Retrorectal tailgut cysts, also known as retrorectal cystic hamartomas, are rare congenital lesions, located in the retrorectal space, which is bounded anteriorly by the rectum, posteriorly by the sacrum, superiorly by the peritoneal reflection, inferiorly by the levator ani and coccygeus muscles, and laterally by the ureters and iliac vessels [3
]. Tailgut cyst is most prevalent in middle-aged women, arising from postnatal primitive gut remnants, but can be found in a wide range of age groups including infancy [2
]. Most tailgut cysts are asymptomatic, and they often are discovered incidentally or presented as a compressive effect of a growing mass within the pelvis such as change in stool caliber, a palpable rectal mass, urinary frequency, and frequently as infected tailgut cyst with rectal fistula or anal fistula [3
CT showed a retrorectal mass and transrectal ultrasound and rectal MRI are good diagnostic tools. A diagnostic biopsy is not recommended due to the risk of spillage of malignant cells or spread of infection into the abdominal cavity [5
]. Although malignant transformation is known to be rare, the important factors for a good prognosis are the time of diagnosis and surgical radicality [6
Complete surgical resection is the traditional treatment of choice, eliminating the potential of recurrence, hemorrhage, infection, compression, and malignant changes [2
]. Several surgical approaches are proposed for the resection of retrorectal tumors: anterior (abdominal), posterior, and combined anterior and posterior pelvic approach [5
]. The posterior approach of perianal intersphincteric excision or the parasacrococcygeal approach are recommended for a low-lying tumor under the promontory or below the level of S4 [9
]. Perianal intersphincteric excision preserves good sphincter function, whereas the parasacrococcygeal approach is preferred in lesions with a suspicion of malignancy. In addition, transanal endoscopic microsurgery is used for the resection of retrorectal tumors and allows accurate excision through the rectal wall under excellent view [10
]. The laparoscopic approach is reported as a safe and effective option for low-lying retrorectal tumors with the advantage of a magnifying effect in the narrow pelvis [11
In the present case, we dissected the specimen meticulously, preserving the pelvic plexus without entering the cysts and avoiding rectal injury in magnification of the surgical field. Comparatively short operative time, less than estimated blood loss, and a short postoperative hospital stay were achieved by taking benefits of the laparoscopic approach.
Before performing this laparoscopic tailgut cyst excision, 1,101 resections of patients out of a total of 1,584 cases of laparoscopic colorectal cancer surgery, including low-lying rectal cancer, were performed between January 2004 and September 2010 by a single colorectal surgeon (H.R. Kim) in our institution. With the advancement in laparoscopic technique and an experienced colorectal surgeon, we could perform excision of the tailgut cysts laparoscopically at the level of S4 and the levator ani muscles.