MODIFIED KRASKE APPROACH FOR RESECTION OF A GIANT RETRORECTAL CYST

Case Presentation A young woman noticed a bulge in the right gluteal region, asymptomatic but progressively growing. Magnetic resonance imaging revealed a large retrorectal cystic formation (450 cm³) communicating with an exophytic component (2750 cm³) extending into the gluteal region through the right parasacral musculature. While awaiting elective surgery, she presented to the emergency department in septic shock due to cyst infection. After clinical management, cyst drainage, and debridement, she showed good progress. Tissue culture revealed infection by *E. faecalis* and multi-drug-resistant *E. coli*. Following prolonged antibiotic therapy, she proceeded to definitive surgical treatment, as discussed in a multidisciplinary meeting involving colorectal and plastic surgery teams. The patient was positioned prone under general anesthesia. Access to the pelvic cavity was achieved through a posterior approach, starting with a spindle-shaped incision encompassing the gluteal tumor and continuing with marginal dissection along the cyst capsule. The coccyx was resected to improve pelvic access. The dissection remained extraperitoneal, preserving adjacent structures, including nerves, rectum, sphincter apparatus, and vagina. The cyst was removed en bloc. A “water leak test” confirmed rectal wall integrity. Closure was performed in layers, with pelvic drainage using a Blake drain and a prophylactic vacuum dressing applied to the incision. The patient had a favorable postoperative recovery, and pathological examination excluded malignancy.

Discussion Retrorectal cystic tumors are rare, primarily congenital, and often represent embryological remnants of the hindgut or neuroectoderm. The main types include dermoid cysts, epidermoid cysts, rectal duplication cysts, hamartomas, and teratomas. These tumors are generally asymptomatic and incidentally diagnosed through imaging, with extrinsic bulging detectable on digital rectal examination. Due to the risk of infection (30%), as in this case, or malignancy (7–45%), surgical treatment is indicated. Complete resection during surgery is essential to reduce the recurrence risk, reported in up to 15% of cases. Posterior approaches such as Kraske and York-Mason are preferred for low lesions (below S3). In this patient, the Kraske approach was modified to address the gluteal component of the lesion, as demonstrated in the accompanying video.

Final Comments Retrorectal cystic tumors are rare pathologies that can pose significant challenges to the surgical team. A multidisciplinary approach is crucial for achieving successful outcomes in complex cases.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025