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T E C H N I C A L I N N O V A T I O N

Posterior sagittal approach for resection of sacrococcygealteratomas

Iftikhar Ahmad Jan Ejaz A. Khan

Nuzhat Yasmeen Hazratullah Orakzai

Jahria Saeed

Accepted: 9 February 2011 / Published online: 23 February 2011

Springer-Verlag 2011

Abstract The aim is to evaluate the ease of access, sur-

gical trauma and cosmetic results of posterior sagittalapproach for sacrococygeal teratomas (SCTs). From Jan-

uary 2002 to June 2010, we operated 19 cases of SCT

exclusively through posterior sagittal approach. Patients

were placed in knee chest position. An elliptical incision

was made for the excision of the tumor. Care was taken to

preserve all the muscles and other vital tissue in this area.

Coccygectomy was performed in all patients. Closure was

performed in layers. It was possible to resect all tumors

from this approach and none of the patients required

revision of the incision. Complete resection was possible in

17 patients while two had residual disease due to local

extension. Minimal wound dehiscence was noted in four

patients that healed spontaneously. It was possible to per-

form excision even in very large masses. Wound scar was

satisfactory in most patients with preservation of gluteal

folds. It is therefore concluded that posterior sagittal

approach for SCT is feasible, with good access and cos-

metic results.

Keywords Sacrococcygeal teratoma Posterior sagittal

approach Resection Surgery

Introduction

Sacrococcygeal teratomas (SCTs) are common tumors of

infancy but may be seen at any age depending upon the

type of the tumor and social setup. Historically, SCT are

treated by a Chevron incision, which leaves a transverse

scar causing significant cosmetic and functional concerns

[1]. Posterior sagittal approach (PSA) is now gold standard

for surgical correction of anorectal malformations and

similar conditions in this area. PSA for SCT has been used

with caution due to the belief that it gives poor access for

surgery and may cause more tissue damage [2]. On the

contrary this is a natural approach for lesions in this area

and shall cause minimal tissue damage due to the sagittal

orientation of muscles and other structures in this area [3].

We prospectively reviewed our patients who had resection

of SCT through PSA, with reference to the ease of access,

surgical trauma and cosmetic results and shall share our

experience.

Materials and methods

All patients presenting with SCT were fully evaluated by

Ultrasonography, CT scan, MRI scan, and serum tumor

markers (alpha-fetoprotein and BHCG). Investigations

were also performed for proper staging of the tumors.

Inclusion criteria included all patients with resectable

masses. Exclusion criteria included patients having

advance disease and were referred for chemotherapy. PSA

was used in all patients who had tumor resection. This was

achieved by placing the patients in jack knife or knee chest

position with perineum elevated. An elliptical incision was

made taking an island of redundant skin with the tumor

mass. Excision was achieved by preserving muscle fibers

I. A. Jan (&) H. Orakzai J. Saeed

National Institute of Rehabilitation Medicine,

Islamabad, Pakistan

e-mail: iftikarjan@gmail.com

E. A. Khan

Shifa International Hospital, Islamabad, Pakistan

N. Yasmeen

The Childrens Hospital, PIMS, Islamabad, Pakistan

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using pencil point diathermy tip. Bipolar diathermy wasused for hemostasis. Care was taken to avoid injury to the

adjacent structure like rectum. Aim was to remove the

whole tumor without residual disease, however, in patients

with local tumor invasion major bulk of the tumor was

excised. Coccygectomy was performed in all patients to

prevent recurrence. Cavity was then washed with normal

saline and muscle repair was performed in layers using 5/0

polyglycolate sutures. Muscle stimulator was used when

necessary. Subcutaneous tissue and skin were closed with

5/0 or 6/0 polydiaoxanone sodium (PDS) depending upon

the size of the incision. A transparent dressing was used

and usually removed on the first postoperative day. Patientswere started to feed few hours after surgery.

Data were collected on a prescribed Performa, which

included the type of SCT, resectability of the mass whether

complete or incomplete, ease of access, and cosmetic and

functional results at 6 weeks follow-up. Pre and post

operative photographs of all patients were recorded after

informed consent for evaluation purpose.

Patients were discharged when on full oral feeds with

1-week follow-up in out patients clinics. Cosmetic and

functional results were evaluated after 6 weeks of surgery.

Results

Twenty-four patients were managed during this period. Of

these, two patients died before surgery and three had

advance disease and were referred for chemotherapy. 19

patients were operated. Of these, 14 were female and 5

were male. Age ranged from newborn period to 8 years.

Among these there were nine neonates, seven infants and

three patients were more than 1 year of age. Three patients

had type-I (16%), 6 had type-II (31%), 7 had type-III(37%) and 3 had type-IV (16%) SCT. Complete tumor

excision was possible in 17 of the 19 patients. In two

patients, complete excision was not possible due to the

presacral extension of the tumor and debulking was per-

formed excising most of the tumour bulk. Midline muscle

repair was achieved in most patients. Skin closure was

possible in all patients with out causing significant disfig-

urement of the area. Complications included urinary

retention in five patients, minor wound dehiscence in four

patients, which responded to conservative treatment. There

were no deaths in immediate postoperative period. His-

tology suggested malignant teratoma in 5 of the 19 patients(26%), 2 cases qualified as fetus in fetu were having

rudimentary spine and limb buds. Cosmetic results were

satisfactory in 17 of the 19 patients (Fig. 1). The shape of

the buttocks were well preserved even in very large lesions

(Fig. 2). In two patients, lateral extension of the incisions

were required (Fig. 3). Comparing with the chevron inci-

sion, the cosmetic results were better with PSA (Fig. 4).

When asked about the scar, none of the parents complaint

about the bad scar and most were happy with the cosmetic

results of surgery. Temporary soiling or constipation was

noted in five patients who improved with time. Long-term

fecal continence results were needed to be evaluated.

Discussion

The aim of surgery in SCT is to have good access for

complete tumor resection, coccygectomy to prevent

recurrence, reconstruction of the perineal muscles for

achieving continence and restoration of normal perineal

and gluteal appearance. Chevron incision has proved to be

Fig. 1 Early results of posterior

sagittal approach for SCT

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Fig. 4 Comparative post-

operative appearance of

posterior sagittal approach (our

patient) and Chevrons incision

(operated elsewhere)

Fig. 3 Lateral extension of the

incision in large asymmetrical

SCT

Fig. 2 Pre and post-operative

cosmetic appearance in a large

SCT by posterior sagittal

approach

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a satisfactory approach in achieving most of the goals of

surgery, however, the orientation of the incision is against

the line of muscles and other vital structures giving sub-

optimal access, muscles repair and poor cosmetic appear-

ance. Steven et al. [4] showed in a study highlighted the

problems of dog ear formation with Chevron incision and

proposed a new technique to solve this problem. The PSA

is a natural approach for excision of masses in this area.Pena used this for anorectal malformations and the out-

come of surgery for ano-rectal malformations is signifi-

cantly improved after PSA. Studies have shown the

advantages of PSA for sacral and presacral masses [4, 5]

including SCT, however, PSA is not widely used for sur-

gery for SCT. Our experience with PSA has been most

satisfactory and helped in achieving all the goals of surgery

for SCT. In tumors with large presacral extension, PSA

helped in getting a better view and line of cleavage for

complete tumor excision. In PSA, the anatomy of the

pelvic floor and perineal muscles is more defined as the

incisions are made in the direction of muscles fibers. It laterhelps in proper orientation and repair of perineal muscles

and skin. Some modification of incision was needed in two

patients with asymmetrical masses. Minor wound dehis-

cence was noted in four patients and all these patients

responded to the conservative treatment. One of the

patients had recurrent SCT with multiple sinuses in the area

and was operated thrice in another hospital. PSA helped in

identifying the extension of the tumor mass and it was

possible to have complete tumor excision along with the

fibrous tissue. One of the patients having fetus in fetu had a

large presacral mass. It was possible to excise the whole

mass with excellent cosmetic appearance and achieved a

curative resection.

On follow-up, we interviewed all parents about the scar.

None of the family showed concern about disfigurement of

the buttocks and were satisfied with the scar of surgery but

this may be due to the fact that the main concern of the

family was complete tumor removal and scar was not the

main concern. In the studies by Derikx et al. [1] scar was

the main concern in long-term follow-up of patients oper-

ated through Chevron incision reported in 40% cases. We

have also noticed the dissatisfaction by the family after

Chevron incision operated elsewhere (Fig. 4).

Fecal continence and constipation may be a concern

after surgery for SCT. Draper et al. [6] showed that con-

stipation was noted in nearly 50% patients in long-term

follow-up with 10% having severe constipation. Some ofour patients had fecal soiling in the initial period after

surgery, which improved significantly after few months. In

small babies, it was not possible to access the continence

properly. Constipation was reported in two patients on

short-term follow-up.

It may be concluded that PSA is a safe, feasible and

practical approach for excision of SCT. It causes minimal

disfigurement in this area and better cosmetic appearance

after surgery. The functional results of perineal muscle

repair, however, need long-term follow-up and evaluation.

References

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Feasibility of perineal sagittal approaches in patients without

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