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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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LETTER TO EDITOR
Year : 2009  |  Volume : 14  |  Issue : 1  |  Page : 39
 

Sacrococcygeal teratoma: Excision aided by laparocopic ligation of the median sacral artery in a premature neonate


Department of Pediatric Surgery, Norfolk & Norwich University Hospital, Colney Lane, Norwich NR4 7UY, United Kingdom

Date of Web Publication31-Jul-2009

Correspondence Address:
A P Desai
Consultant Paediatric Surgeon, King's College Hopsital, London SE5 9RS
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.54807

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How to cite this article:
Desai A P, Wragg R, Kulkarni M, Tsang T. Sacrococcygeal teratoma: Excision aided by laparocopic ligation of the median sacral artery in a premature neonate. J Indian Assoc Pediatr Surg 2009;14:39

How to cite this URL:
Desai A P, Wragg R, Kulkarni M, Tsang T. Sacrococcygeal teratoma: Excision aided by laparocopic ligation of the median sacral artery in a premature neonate. J Indian Assoc Pediatr Surg [serial online] 2009 [cited 2019 Nov 20];14:39. Available from: http://www.jiaps.com/text.asp?2009/14/1/39/54807


Sir,

Sacrococcygeal teratoma (SCT) is the most common teratoma presenting at birth. It can have variable intrapelvic extension. One of the most immediate risks with sacrococcygeal teratoma is the risk of life threatening hemorrhage, either perinatally or during surgical resection.

In the presence of significant intrapelvic extension, ligation of the median sacral artery during laparotomy has been used to minimise this risk during surgery.[1] Recently, there have been a few reports of the use of laparoscopic ligation of the artery. [2],[3],[4] We report the successful use of this technique in a premature newborn infant.

The diagnosis of sacrococcygeal teratoma had been made antenatally at 22 weeks gestation. The parents were counselled. The mother went into pre- mature labor, and the female infant was delivered by emergency caesarean section at 30+2 weeks. The birth weight was 1.826kg. She required ventilation for 12minutes at birth and was then commenced on continuos positive pressure airway ventillation.

The external component of the teratoma measured 5.7cm in diameter. An ultrasound scan showed that the internal component filled the entire true pelvis with an intra-pelvic extension of 6 cm. It was related to the sacral promontory and displaced the rectum and bladder superiorly. It was mainly solid with some cystic components and foci of calcification. Hence, diagnosis of Type 3 SCT was made according to Altman's classification.

At the beginning of the surgery, the patient was initially placed supine. A laparoscopy surgery was performed using a 5mm, 0 degree laparoscope. The laparoscope was placed at the umbilicus using Hassan's technique. Another 5mm port was placed in the right iliac fossa and a 3mm port was placed in the left iliac fossa. The retroperitoneal space was identified next to the rectum and opened by a sharp and blunt dissection. A single median sacral artery was identified and clipped in continuity using two 5 mm endoclips. The patient was then turned to a prone position and a cruciate, perineal incision was performed. The teratoma was dissected from the surrounding muscles and connective tissue. The tumor was excised en bloc with the tip of the coccyx in a standard surgical technique.

Total estimated blood loss was 15 ml. The dimensions of the teratoma were 9cm 5cm 7cm and weighed 78grams. A penrose drain was left in situ but drained minimally and was removed 48 hours later. Postoperatively the patient remained well and was extubated the same day. She was kept in the neonatal intensive care unit in view of her premature status and was discharged later.

The hemorrhage of a sacrococcygeal teratoma is a life-threatening event and the proper care must be taken to avoid it. The ligation of the median sacral artery has long been a useful technique in controlling the blood supply of these tumors, thus reducing the risk of hemorrhage. [1]

For tumors with significant intrapelvic extension, ligation can be performed by a laparotomy. Laparoscopic ligation of the median sacral artery is an alternative method of controlling the risk, which does not require a laparotomy. This has been reported previously in literature as early as 1998 as a safe and effective procedure. [2],[3],[4]

This report shows that the use of this technique is both possible and safe in a premature infant with low birth weight. Our patient is the smallest infant so far reported where this technique has been used.

 
   References Top

1.Angel CA, Murillo C, Mayhew J. Experience with vascular control before excision of giant, highly vascular sacrococcygeal teratomas in neonates. J Pediatr Surg 1998;33:1840-2.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Bax NM, Van der Zee DC. Laparoscopic clipping of the median sacral artery in huge teratomas. Surg Endosc 1998;12:882-3.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Bax NM, Van der Zee DC. The laparoscopic approach to teratomas. Surg Endosc 2004;18:128-30.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Lukish JR, Powell DM. Laparoscopic ligation of the median sacral artery before resection of a teratoma. J Pediatr Surg 2004;39:1288-90.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]



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