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Life-threatening bleeding is a hazard of major tumor excision in children. However, fatalities from inadvertent arterial ligation should not be overlooked. Sacrococcygeal teratoma is the commonest neonatal tumor. Laparotomy to ligate the median sacral artery has been used to preempt potentially fatal resectional bleeding. Use of laparoscopy to achieve the same is an evolving technique, with only 7 neonatal cases described. As such, the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) guidelines on surgical innovation recommend case reports addressing proof of concept, technical factors and safety tips. Fortunately, mistaken arterial division is so far unreported during laparoscopic median sacral artery ligation. However, as uptake widens, anatomical distortion by tumor and surgeon disorientation at endosurgery are risk factors for even such inconceivable complications. We report a successful case of laparoscopic vascular control for neonatal sacrococcygeal teratoma and demonstrate an observation that serves as a useful safety check for this procedure (as well as the open alternative)., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Surgical resections of massive sacrococcygeal teratomas (SCTs) carry significant risk due to baseline hemodynamic instability and the potential for significant hemorrhage. In this case report, a fetus with sacrococcygeal teratoma developed high-output cardiac instability at 32 weeks' gestation. After urgent cesarian delivery, a damage-control operation using Teflon-pledgeted mattress sutures allowed for hemodynamic control of bleeding into the tumor. One week later, after subsequent fluid resuscitation and stabilization, an elective staged resection of the complete mass including the pelvic portion was performed. The patient was discharged home on postoperative day 30 and was doing well at her most recent clinic visit at 30 months of age., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Resection of a large vascular sacrococcygeal teratoma (SCT) in a newborn has the potential to be a fatal procedure caused by hemolysis, rupture, or bleeding of the tumor. Usually, most blood supply of an SCT is derived from the middle sacral artery. As soon as these arteries have been ligated, further blood loss is minimal. There is only one previous presentation about preoperative embolization of these arteries. We present a case in which the feeding arteries of a giant SCT were embolized in an infant born at 30 weeks and 3 days of gestation. Although bleeding during the surgery was minimal, continuous need of transfusions and life-threatening hyperkalemia created severe problems during surgery, until tumor resection was completed. This is the smallest reported patient in whom SCT was preoperatively treated by embolization., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Reports about giant, highly vascular sacrococcygeal teratoma (GHV-SCT) are uncommon. A boy with a prenatally diagnosed GHV-SCT was born at 34 weeks' gestation weighing 3,716 g. At birth, the GHV-SCT was 20 x 17 x 14 cm. After initial devascularization using an aortic snare, excision of the GHV-SCT was started using monopolar diathermy, but hemorrhage from cutaneous collateral vessels was difficult to control, and individual ligation of vessels was extremely time consuming. The authors then used the LigaSure (LS) vessel sealing system (Valleylab, Boulder, CO) to control intraoperative hemorrhage. Hemostasis was achieved easily with LS, without any need for vessel ligation; the operative field was dry and the efficiency of excision enhanced. Total operating time was 255 minutes, but excision of the GHV-SCT itself took only 16 minutes. The GHV-SCT weighed 1,208 g or 325.1 g/kg body weight. Total blood loss was 77 mL or 20.7 mL/kg body weight, which was minimal compared with other cases in the literature. At the last follow-up examination, 7 months after surgery, he remains well with no evidence of recurrence. LS was extremely useful for controlling intraoperative hemorrhage in this case, and we strongly recommend its selective use for excising highly vascular SCT.

To minimize the risk of exsanguinating hemorrhage, the authors describe a technique of laparoscopic ligation of the median sacral artery before posterior sagittal resection of type I sacrococcygeal teratoma (SCT). Two female infants with antenatally diagnosed SCT underwent postnatal evaluation and preoperative imaging and were taken to the operating room. In both patients, pneumoperitoneum was established via an epigastic 5-mm trocar. Two additional trocars were inserted in the right and left lower quadrants. The peritoneal reflection was opened to the right of the sigmoid colon, and the presacral space was explored. A large median sacral artery was identified easily, isolated, and divided. The children then were placed in a prone position, and the tumors underwent en bloc resection via a Chevron incision with minimal blood loss. The laparoscopic portion of the procedure was performed in an average of 15 minutes. This is the first report of laparoscopic ligation of the median sacral artery before posterior resection of a sacrococcygeal tumor in an infant. This technique can be performed easily with minimal morbidity. Division of this artery is a logical preventative measure and may reduce the risk of hemorrhage during operative resection.

Background: A subset of fetuses with sacrococcygeal teratoma (SCT) develops hydrops caused by high-output heart failure. Identification of fetuses at risk for hydrops is important because fetal intervention may reverse the pathophysiology of the disease. To date, no reliable sonographic prognostic factors have been identified., Methods: An experienced sonologist reviewed the sonographic records of 17 fetuses with SCT referred to the authors' institution. Size of the tumor was measured and corrected for fetal size. The appearance of the tumor (solid versus cystic) and its vascularity were graded on a subjective scale of 1 to 5., Results: Only 4 of 12 fetuses that had hydrops survived; of the survivors, 3 had undergone fetal intervention. All nonhydropic fetuses survived. Fetuses with hydrops had tumors that were mainly solid and highly vascular, whereas nonhydropic fetuses had predominantly cystic tumors with comparatively less vascularity. There was no significant difference in tumor size between these 2 groups., Conclusions: Fetuses with SCT that are mainly solid in appearance and are highly vascularized have a higher risk of getting hydrops in utero. Tumor size is not an independent prognostic factor.

Sacrococcygeal teratomas (SCT) are the most common neoplasms in newborns with a reported occurrence of 1 in 35,000 live births. Highly vascularized tumors in which the ratio of tumor weight to patient weight approaches 1:1 are frequently associated with hyperdynamic states, prenatal hydrops, placentamegaly, postnatal high-output cardiac failure, and carry a high perinatal mortality rate. Operative management of giant, highly-vascular sacrococcygeal teratomas in neonates can be complicated by life-threatening hemorrhage. Laparotomy, control of the aorta, and the arterial blood supply to these tumors before resection has been advocated as a safer alternative. The authors report their experience with three infants successfully treated using this approach. Hemodynamic stability was maintained during the operations. All tumors were resected successfully. The patients are alive without evidence of recurrence, 8.5 months to 18 months (average, 14.3 months) after the operation. Alpha-fetoprotein levels dropped to normal range after the removal of SCT and have remained normal in follow-up. Vascular control before excision of giant, highly-vascular SCT in neonates is safe, decreases intraoperative blood loss, and postoperative morbidity.

Sacrococcygeal teratoma identified in utero is associated with 50% fetal demise, which is caused by hyperdynamic cardiac failure, hemorrhage, and polyhydramnios-induced preterm labor. A premature infant (26 weeks' gestation) with prenatally diagnosed sacrococcygeal teratoma was managed successfully with initial devascularization to control the hyperdynamic state, followed by staged resection.

The authors report on three infants who had an unusual variant of sacrococcygeal teratoma--a highly vascularized tumor. All three patients had major problems perioperatively, which resulted in cardiac arrest in all three and the death of one. Several suggestions are made concerning diagnosis as well as preoperative and intraoperative management of this rare tumor variant.

A method of emergency hemostasis and continuous intraoperative control of hemorrhage in giant sacrococcygeal teratoma, using an aortic snare, is described. A baby weighing 1,700 g with a 1,300-g sacrococcygeal teratoma was successfully operated using this technique.