Pre-sacral tumours

Anterior/abdominal approach

• For lesions at S4 or above
• Open approach
• Dissect rectum from anterior aspect of tumour then dissect lesion from sacrum

Posterior (Kraske) approach

• For small lesions below S4
• Prone or jack-knife position with buttocks taped apart
• Longitudinal incision down to anoderm (avoid damage to sphincter complex)
• Divide anococcygeal ligament and retract levator ani muscles laterally
• Disarticulae +/- excise coccyx +/- detach gluteus maximus if required
• Dissect lesion from surrounding tissue and rectal wall
• Disadvantages - no control over pelvic vessels, potential injury to lateral pelvic nerves

Combined approach

• For large lesions or above and below S4