title: The posterior midsagittal approach for the surgical excision of intrapelvic malignant tumours.
abstract: OBJECTIVE
  The Posterior Midsagittal Approach (PMA), originally used for the treatment of anorectal malformations, provides a wide exposure of the pelvic floor. Aim of this study is to describe and discuss the PMA in the treatment of intrapelvic malignant tumours which could not be radically excised by laparotomy alone.
  
  
  METHODS
  Since 1997, four children were operated upon for pelvic Ewing's sarcoma, presacral sarcoma, intrapelvic neuroblastoma and prostatic rhabdomyosarcoma, respectively. The age of the patients ranged from two to eleven years. Two of them were males and two were females. In all patients, a laparotomy was performed, but inability to remove the tumour radically using this approach led to PMA. A midline incision extending between the tip of the coccyx and the posterior margin of the anus was made. The rectum was mobilised and retracted to the right side, using traction slings. Exposure of the lower part of the tumours was adequate, thus allowing them to be dissected in the midline anteriorly to the sacrum.
  
  
  RESULTS
  In the patient with neuroblastoma diffuse bleeding was controlled by packing, which was removed on the 3rd postoperative day. Otherwise the postoperative course in all patients was free of complications. The patient with presacral sarcoma died one year after the operation from generalised disease. The remaining three patients are free of disease and continent two to six years postoperatively.
  
  
  CONCLUSIONS
  PMA is a safe procedure enabling radical excision of intrapelvic malignant tumours which are too high to be approached through the perineum and too low to be reached by laparotomy alone. The posterior midsagittal incision and lateral traction of the rectum permits easy access to the tumour and radical excision, without disturbance of the sphincteric function. Colostomy is not necessary.
mesh_terms: D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D008297:Male; D009447:Neuroblastoma / Q000601:surgery*; D010386:Pelvic Neoplasms / Q000601:surgery*; D012509:Sarcoma / Q000601:surgery*; D013514:Surgical Procedures, Operative / Q000379:methods*; D016896:Treatment Outcome