Laparoscopic Resection of Pararectal Space Mass

Our patient is a 68-year-old female with a history of Stage 1B high-grade serous ovarian cancer, which was first diagnosed in March, 2018. In 2018, the patient underwent total abdominal hysterectomy, bilateral salpingo-ophorectomy, infracolic omentectomy, pelvic and para-aortic lymph node sampling followed by six cycles of carboplatin and paclitaxel.

The patient subsequently underwent routine screening, and in November 2022, was noted to have a 1.59 cm × 0.7 cm × 1 cm left-sided solid mass continuous and inseparable from the vaginal cuff on the left on a transvaginal sonogram. Additional positron emission tomography (PET) imaging demonstrated no additional lesions concerning for recurrence. The patient underwent laparoscopic resection of this isolated recurrence demonstrated in Supplementary Video S1.

On laparoscopic survey of the pelvic sidewall, it was noted that the mass was located in the pararectal space, which is bound medially by the ureter (in the case of uterus in-situ, would also be bound medially by the ureterosacral ligaments and posterior leaf of the broad ligament), laterally by the internal iliac artery, posteriorly by the sacral fascia, and anteriorly by the uterine vessels. The pararectal space was dissected using gentle blunt and sharp dissection. On additional dissection, the mass was noted to be invading into the Okabayashi space, which is defined laterally by the ureter, anteriorly by the deep uterine vein, and posteriorly by the sacral fascia. It was noted that the ureter was closely adherent to the surrounding peritoneum requiring careful dissection to allow access to the mass, which was noted to span from the pararectal space to the level of the vaginal cuff. Blunt and cautery dissection were utilized to completely resect the mass from surrounding tissue. An unavoidable defect in the vaginal cuff was noted and repaired.

Final pathology demonstrated that the pelvic mass was morphologically compatible with high-grade, pelvic-type serous carcinoma, therefore confirming the patient’s recurrence. Recurrence rates of early-stage ovarian cancer remain high at approximately 25%, even after optimal primary treatment with primary debulking and adjuvant chemotherapy. ¹ Previous studies have demonstrated improved outcomes, including overall survival, in patients with recurrent disease who underwent secondary cytoreductive surgery to zero residual disease. ²

This case showcases the total laparoscopic resection of an ovarian recurrence within the pelvic sidewall. The laparoscopic approach allows for adequate visualization throughout dissection into the pelvic sidewall and resection of the mass from surrounding tissue including nervous and vascular structures. The laparoscopic approach was especially beneficial in this case of a patient with adhesive disease, most notably of the ureter, secondary to previous surgical management. Furthermore, the laparoscopic approach decreases length of hospital stay and patient recovery time. This case also exemplifies the need for thorough knowledge of the avascular spaces within the pelvis to minimize surgical complications.