Excision of Coccyx
Two different incisions for coccygectomy have been described by surgeons; some prefer a median longitudinal incision starting above the sacrococcygeal joint and extending down to the coccyx (see the image below). Care should be taken not to extend the incision near perianal skin. The incision is deepened through the fascia and gluteus muscles until the bone is felt. With blunt dissection, the tip of the coccyx is located.
After the posterior surface of bone is exposed, the intervertebral disk between the sacrum and the coccyx is excised with the scalpel. The coccygeal vessels on each side are ligated or cauterized. The anococcygeal ligament is incised, and the tip of the coccyx is elevated. The coccygeus and the ileococcygeus are dissected through muscle attachments and incised carefully in such a way as to protect the rectum. All segments and layers of the coccyx, including the periosteum, are excised.
Some surgeons prefer to create a subperiosteal plane on both sides of the tip by means of sharp dissection and to leave the ligamentous and muscular attachments behind, along with the periosteum. Periosteum preservation and closure have been shown to result in a low risk of postoperative infection.
Because the coccyx lies close to the rectum, care must be taken in excising it. Gardener described a technique for mobilizing the rectum and dense fascia deep to the sacrococcygeal joint that has the advantages of protecting the rectum, reducing the risk of infection, and leading to more rapid healing. [20]
After the coccyx is removed (see the image below), the distal prominent end of the sacrum is beveled. The dead space is obliterated by drawing the cut ends of aponeurotic tissues in the midline and applying two to four mattress stitches with absorbable sutures. The subcutaneous tissue and skin are closed in layers. Usually, a small drain is placed if the dead space is left, and a small dressing is applied.
Coccygectomy. After coccyx is removed, distal prominent end of sacrum is beveled.
Minimally invasive approaches to coccygectomy have also been described. [21, 22]
Postoperative Care
After the procedure, patients are usually continued on oral antibiotics for 4-6 days. Some authorities recommend two or three more intravenous doses postoperatively. [23]
Patients are discharged from hospital within 3-5 days, provided that there are no immediate complications. Sutures are removed as appropriate in 2 weeks. Dressings are changed every 3 days. Patients should be educated accordingly; often, improvement in symptoms after coccygectomy is appreciated only after a period of several months. Patients are followed for a period of 12-36 months to assess clinical and functional outcome.
Complications
The most common complication of coccygectomy is postoperative infection. The literature has indicated an infection rate as high as 30%.
Rectal injury can occur as a result if the dissection plane strays from the subperiosteal region.
Some authors have also documented fecal incontinence following the procedure as a result of damage to the sphincter ani externus.
The ganglion impar is located just anterior to the coccyx (the last ganglion of the paravertebral sympathetic nervous system). Therefore, a potential risk of damage to the sympathetic nerve supply exists during coccygectomy.
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Transverse process of coccyx provides attachment to lateral sacrococcygeal ligaments.
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Intercoccygeal angle is angle between midline of first coccygeal segment and last (fourth) coccygeal segment. This serves as objective measurement of forward angulation of coccyx.
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Coccygectomy: surgical technique.
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Coccygectomy. After coccyx is removed, distal prominent end of sacrum is beveled.
