Total Laparoscopic Excision of an Altman Type IV Sacrococcygeal Teratoma with the Assistance of Intraoperative Transrectal Sonography.

Objective: To present the case of a young patient with an Altman type IV sacrococcygeal teratoma (Fig 1) managed exclusively with laparoscopy.

Design: A step-by-step demonstration of the technique.

Setting: A 24-year-old patient complaining of dysmenorrhea, deep dyspareunia, chronic constipation, dyschezia, and bladder atony was diagnosed with a 5-cm cystic tumor compressing the low rectum and overlying the left levator ani muscle.

Interventions: Laparoscopic excision of the tumor. At laparoscopy, significant bilateral pelvic venous congestion was found. The left medial and lateral pararectal fossa and the rectovaginal space were developed to the level of the pelvic floor. Several branches of the left internal artery and vein were dissected. The left hypogastric nerve and deep hypogastric plexus were dissected in an effort to preserve ipsilateral autonomic nerve supply to the rectum. Owing to the tumor's soft consistency and dense adherence to the surrounding structures, transrectal sonography facilitated dissection, which was performed medially to the mesorectal fascia and anteriorly to the presacral fascia. The middle sacral artery and peripheral branches of the internal iliac vasculature supplying the tumor were ligated. Part of the left levator ani had to be excised. The rectum was injured during the effort to detach the tumor from its lateral wall. The injury was repaired laparoscopically. The cut edge of the levator ani was used as a flap to reinforce the repair.

Conclusion: Sacrococcygeal teratomas lying entirely in the pelvis (Altman type IV) are extremely rare [1,2]. Complete laparoscopic excision is challenging and potentially dangerous [3-5], but it is feasible with careful dissection.