Laparoscopic-Assisted Combined Transabdominal-Transsacral Resection of a Presacral Epidermoid Cyst: A Case Report

Epidermoid cysts of the presacral space are rare congenital lesions with a potential for malignant transformation, necessitating complete surgical resection with negative margins.The selection of an appropriate surgical approach should be guided not only by tumor size but also by anatomical complexity, particularly the proximity of the tumor to critical structures such as the rectum and pelvic autonomic nerves.A 48-year-old woman was referred to our department after a cystic lesion anterior to the coccyx was incidentally identified on whole-body computed tomography (CT).Pelvic magnetic resonance imaging (MRI) revealed a 49-mm cystic lesion in close proximity to the lower rectum and coccyx, with no evidence of invasion.As malignancy could not be excluded, complete surgical resection was planned.Given the intimate anatomical relationship of the tumor with the lower rectum, coccyx, and pelvic splanchnic nerves, we selected a laparoscopic-assisted combined transabdominal-transsacral approach despite the tumor measuring less than 5 cm.Laparoscopic rectal mobilization facilitated precise dissection between the tumor and the rectum under magnified visualization, with reliable preservation of the pelvic splanchnic nerves.The tumor was subsequently excised en bloc with the coccyx via a gluteal incision.The postoperative course was uneventful, and the patient was discharged on postoperative day 8 without complications.Pathological examination confirmed a diagnosis of epidermoid cyst with negative resection margins.At eight months postoperatively, there are no signs of recurrence or bowel and bladder dysfunction.This case demonstrates that anatomical complexity should take precedence over tumor size in selecting a surgical approach for presacral tumors.The laparoscopic-assisted combined transabdominal-transsacral approach enabled safe and complete resection with preservation of pelvic autonomic nerve function and represents a valuable surgical strategy for presacral tumors presenting complex anatomical relationships.