V51 - Presacral Schwannoma Excision: An Intra-abdominal Approach

Purpose/Background: Presacral tumors are rare lesions that arise in the space between the rectum and the sacrum. Surgical resection remains the mainstay of treatment, both for diagnosis and management, especially given the risk of malignancy. The choice of surgical approach depends on the size, location, and suspected pathology of the tumor. This video demonstrates an intra-abdominal robotic approach for excision of a large, symptomatic presacral schwannoma in a 76-year-old female.

Methods/Interventions: The patient was brought to the operating room and positioned into a modified lithotomy position with legs elevated. After the urology team performed cystoscopy and bilateral ureteral ICG instillation, a 5mm trocar was inserted into the LUQ via an optiview technique. Four 8 mm robotic trocars were then placed along the lower abdomen, and the robot was docked to the patient left side. The uterus was retracted towards the anterior abdominal wall and the presacral plane was developed starting from the distal aspect of the IMA pedicle towards the sacral promontory. The known presacral mass could be visualized. Dissection was extended both posteriorly and laterally by partially diving the right rectal stalk and right lateral attachments. After posterior dissection, the dissection was continued both laterally and anteriorly. The mass was removed intact. Flexible sigmoidoscopy was performed with a negative leak test.

Results/Outcomes: Patient managed postoperatively on our institutions enhanced recovery after surgery protocol. Diet was progressed and postoperative course was uncomplicated. The patient was discharged home on postoperative day three ambulatory, tolerating a diet, and with normal bowel function. Surgical pathology immunostains demonstrated S100, CD34, desmin, and Ki-67 proliferative index of 2-3%. Pathology ultimately consistent with schwannoma.

Conclusion/Discussion: This video demonstrates a minimally invasive intra-abdominal approach for excision of a large, symptomatic presacral schwannoma.