SURGERY I Module No.

- 6

Abdominal wall, omentum, mesentery, and retroperitoneum 6.1

Dr. Merced 8 March 2017
o antero-inferior aspects of the fifth and sixth ribs
Outline o seventh costal cartilages
I. Abdominal Wall o xiphoid process
A. Surgical Anatomy
1. Rectus Abdominis  lateral border - convex shape that gives rise to the surface landmark
2. Muscular Layer of the linea semilunaris
3. Abdominal Incisions
B. Abdominal Wall Abnormalities  Three tendinous intersections or inscriptions:
1. Congenital Abnormalities o level of the xiphoid process
2. Acquired abnormalities o level of the umbilicus
3. Abdominal Wall Hernias
o halfway between the xiphoid process and the umbilicus
4. Rectus Sheath Hematoma
II. Omentum
A. Surgical Anatomy
MUSCULAR LAYER
1. Greater Omentum  three muscular layers w/ oblique fiber orientations relative to one
2. Lesser Omentum another
B. Physiology  derived from the laterally migrating mesodermal tissues during the
C. Omental Infarction sixth to seventh week of fetal development
D. Omental Cyst
E. Omental Neoplasm
III. Mesentery ABDOMINAL WALL
A. Surgical Anatomy LAYERS:
B. Sclerosing Mesenteritis  Skin
C. Mesenteric Cyst o loose except umbilicus
D. Mesenteric Tumor
IV. Retroperitoneum
o Lines of tension = transverse
A. Surgical Anatomy
1. Retroperitoneal Structures  Fascia
B. Retroperitoneal Infection a. Superficial Fascia
C. Retroperitoneal Fibrosis 1] Superficial fatty = CAMPER
D. Diagnostics - blood vessels/nerves ramify
E. Treatment
- represented by Dartos muscle in the scrotum
F. Prognosis
2] Deep membranous = SCARPA
LEGEND - attached to linea alba
Lecture Powerpoint, Audio 2018, Textbook, picture notes - equivalent to Colles’ fascia in the perineum
b. Deep Fascia
OBJECTIVES – very thin
 to revisit the Anatomy of the Abdominal Wall, omentum, mesentery,  Muscles
and retroperitoneum a. External Oblique
 to identify common surgical diseases and abnormalities  Free inferior margin = inguinal ligament (Poupart’s
ligament)
 Lacunar ligament (Gimbernat’s)- reflected downward,
ABDOMINAL WALL
backward and lateral
 superiorly - costal margins  Cooper’s ligament- lateral continuation of lacunar
 inferiorly - symphysis pubis & pelvic bones b. Internal Oblique
 posteriorly - vertebral column  Deep to external oblique
*The abdominal wall is defined  Upward and medial
 Aponeurotic fibers of internal oblique and transversus
 support and protect abdominal and retroperitoneal structures abdominis = conjoint tendon
 muscular functions - enable twisting and flexing motions of the trunk  lower fibers forms the Cremaster muscle in the scrotum
c. Transversus abdominis
 Innermost
 Flat
 Ends in aponeurosis
 Contribute to conjoint tendon
d. Rectus abdominis
 On either side of linea alba
 Segmented = tendinous intersections
 Lateral borders convex = linea semilunaris
e. Pyramidalis
 Not always present
 Tenses linea alba

RECTUS Sheath
 Aponeurosis of 3 muscles: External oblique, internal oblique
and transversus abdominis
1] Anterior layer
 Fused aponeurosis of ext obl + int obl
2] Posterior layer
 Fused aponeurosis of int obl + trans abd
 Absent between the level of the ASIS and pubis w/c is bounded
superiorly by the arcuate line
 Linea alba is the midline aponeurotic demarcation between the
 Arcuate line - cresentic border where posterior layers of rectus
bellies of the rectus abdominis muscles. sheath ends
 The rectus abdominis muscle and its tendinous intersections on
the left are shown deep to the reflected anterior rectus sheath. NERVE SUPPLY
Schwartz  Ventral rami of T6-12, L1 spinal nerves
 Sensory
 End as anterior cutaneous branches w/c emerge thru anterior
SURGICAL ANATOMY rectus sheath
 mesodermal in origin  2 branches of ventral ramus of L1 nerve
 originate in the paravertebral region envelop the future abdominal 1] iliohypogastric – medial location; skin over inguinal location
area 2] ilioinguinal – anterior location; skin over superomedial thigh
 leading edges develop into the rectus abdominis muscles which
eventually meet in the midline of the anterior abdominal wall ARTERIAL BLOOD SUPPLY
 Thoracic and abdominal aorta
RECTUS ABDOMINIS  Superior epigastric artery
 arranged vertically, within aponeurotic sheath o terminal br of internal thoracic a.; supplies rectus abdominis
 anterior and posterior layers fused midline –linea alba  Inferior epigastric artery
 insertions: o branch of external iliac artery; supplies Rectus abdominis
o symphysis pubis and pubic bones ANATOMY HANDOUTS 2018

Transcribed by: 5th Street, Avida, Mezza, Kim possible Checked by: R VILA Page 1 of 8
 SURGERY I Abdominal wall, omentum, mesentery, and retroperitoneum Module 6, Lecture 1

ABDOMINAL WALL (cont.) Abdominal Incisions

 Longitudinal (in or off the midline), transverse (lateral to or
VENOUS DRAINAGE
 Superior Vena Cava crossing midline), or oblique (directed either upward or
o superior epigastric vein downward toward the flank) - open peritoneal access
o intercostal vein  Midline incisions are used for the majority of non-
o subcostal vein laparoscopic procedures on the gastrointestinal tract.
 Inferior Vena Cava  Paramedian incisions through the rectus abdominis sheath
o inferior epigastric vein structures have largely been abandoned in favor of midline or
o deep circumflex iliac vein non-longitudinal incisions.
o lumbar vein
o thoracoepigastric vein  Muscle-splitting approach, exemplified by the classic
 Paraumbilical veins McBurney incision for appendectomy, may be less destructive
o connect network of veins through the umbilicus and along the to tissue but offers more limited exposure.
ligamentum teres to the portal vein (portal-systemic venous  Subcostal incisions on the right (Kocher incision for
anastomosis) cholecystectomy) or left (for splenectomy) – archetypal
LYMPHATIC DRAINAGE muscle-dividing incisions that result in transection of
 Axillary nodes – above umbilicus intervening musculoaponeurotic tissues
 Inguinal nodes – below umbilicus  Pfannenstiel incision, used commonly for pelvic procedure.
ANATOMY HANDOUTS 2018 Schwartz

 These are the different incisions na usually ginagawa namin kapag

abdominal surgery. The most common is the MIDLINE incision
kapag gagawa ka ng exploratory laparotomy.
 Then you have the PARAMEDIAN is used to be the area kapag mag-
opera ka ng ruptured appendicitis, but it does not mean na ito palagi.
 Then the RIGHT SUBCOSTAL, usually another term for that is
Upper Incision or Saber Slash, usually for cholecystectomy and
hepatobiliary.
 Then you have BILATERAL SUBCOSTAL, usually ang tawag natin
diyan is Chevron incision. Kapag nag-extend ka pataas, ang tawag
doon is Mercedes Benz, kapag mag-opera ka ng liver, gastric,
especially pancreas.
 ROCKY DAVIS naman sa appendicitis, then kapag inextend mo pa
yung Rocky Davis, that is called WEIR EXTENSION.
 McBURNEYS incision, another one for appendicitis. Kung minsan
kinukuha nila yung creased area para itago yung scar.
 Ang TRANSVERSE incision naman usually for pediatric suturing.
Bakit? Kasi mas malaki yung left to right ng bata kesa up and down.
 PFANNENSTEIL is for Caesarian.

ABDOMINAL WALL ABNORMALITIES

CONGENITAL ABNORMALITIES
 Defects in abdominal wall closure may lead to omphalocele or
gastroschisis
 Omphalocele
o viscera protrude through an open umbilical ring and are covered
by a sac derived from the amnion
 Gastroschisis
o viscera protrude through a defect lateral to the umbilicus and no
sac is present

 Persistent vitelline duct fistulas & cysts should be excised along

Physiology with any accompanying fibrous cord.
 The rectus abdominis, external oblique and internal oblique  Persistence of urachal remnants can result in cysts as well as
muscles work as a unit to flex the trunk anteriorly and fistulas to the urinary bladder should also be excised; urachus is a
laterally. fibromuscular, tubular extension of the allantois that develops with
 Rotation of the trunk is achieved by contraction of the external the descent of the bladder to its pelvic position.
oblique and the contralateral internal oblique muscle.
 All 4 muscles are involved in raising the intraabdominal Meckel’s diverticulum
pressure.  Result of a persistent vitelline duct remnant on the ileal border
Schwartz Vitelline duct fistula
 Complete failure of the vitelline duct to regress, which is
ABDOMINAL INCISIONS associated with drainage of small intestinal contents from the
umbilicus
 Various anterior abdominal wall incisions for exposure of peritoneal
structures.  If both the intestinal and umbilical ends of the vitelline duct
regress into fibrous cords, a central vitelline duct
A. Midline incision;
B. paramedian incision; (omphalomesenteric) cyst may occur.
C. right subcostal incision and  Persistent vitelline duct remnants between the GIT and the
"saber slash" extension to costal anterior abdominal wall may be associated with small intestinal
margin (dashed line); volvulus in neonates.
D. bilateral subcostal (also  When diagnosed, vitelline duct fistulas and cysts should be
bucket handle, chevron, gable) excised along with any accompanying fibrous cord.
incision, and "Mercedes Benz" Schwartz
extension (dashed line);
E. Rocky-Davis incision and
Weir extension (dashed line);  So ano ang mas delikado? Omphalocele or gastrochisis?
F. McBurney incision; OMPHALOCELE. Kasi usually meron siyang kasamang other
G. transverse incision and congenital anomalies, most common is yung associated cardiac
extension across midline (dashed pathology. Gastroschisis kasi abdominal wall lang ang defect mo.
line); and  Vitelline duct is the connection between the umbilicus and the
H. Pfannenstiel incision. abdominal wall to the small intestine, more particular is the ileum.
 Abdominal incisions are injuries inflicted under controlled Urachal naman ay sa bladder.
circumstances that can lead to short- and long-term complications

Transcribed By: 5th Street, Avida, Mezza, Kim possible Checked by: R VILA Page 2 of 8
 SURGERY I Abdominal wall, omentum, mesentery, and retroperitoneum Module 6, Lecture 1

ACQUIRED ABNORMALITIES RECTUS SHEATH HEMATOMA

 Rectus abdominis diastasis
o This results in a characteristic bulging of the abdominal wall in the
epigastrium that is sometimes mistaken for a ventral hernia

 Rectus abdominis diastasis (or diastasis recti)

o a clinically evident separation of the rectus abdominis muscle
pillars
o midline aponeurosis is intact and no hernia defect is present
*please read rectus abdominis diastasis book part under Acquired
abnormalities

ABDOMINAL WALL HERNIAS

 Hernias of the anterior abdominal wall, or ventral hernias,
represent defects in the parietal abdominal wall fascia and muscle
through which intra-abdominal or pre-peritoneal contents can Computed tomographic scan showing a medium-sized right rectus sheath hematoma.
protrude The hematoma occurred in an elderly patient without a clear history of trauma who was receiving
 Ventral hernias may be congenital or acquired anticoagulation therapy. Because of its size and the patient's slender body habitus, this hematoma
o Epigastric was palpable and could be followed clinically.
o Umbilical
o Spigelian Acquired Abnormalities
o Petit Rectus abdominis diastasis
o Incisional Hernia  separation of the two rectus abdominis muscle pillars
 results in the characteristic epigastric bulging of the
abdominal wall; can be mistaken for a ventral hernia despite
the fact that the midline aponeurosis is intact and no hernia
defect is present
 an acquired condition with advancing age, obesity, or
following pregnancy (in women of advanced maternal age,
after multiple or twin pregnancies, or in women who deliver
high-birth-weight infants)
Rectus Sheath Hematoma
 Can result from hemorrhage from the network of
collateralizing vessels within the rectus sheath and muscles
 Causes:
o history of trauma
o sudden contraction of the rectus muscles with
coughing, or sneezing
o any vigorous physical activity
Intraperitoneal view of polytetrafluoroethylene mesh used for laparoscopic ventral incisional hernia
repair. The mesh is in place on the posterior aspect of the abdominal wall without apparent laxity  Spontaneous rectus sheath hematomas occur most frequently
due to the ongoing CO2 insufflation. Once pneumoperitoneum is released, sufficient laxity is in the elderly and in those on anticoagulation therapy.
introduced to relieve any pull at the fixation points and to permit good apposition of mesh to the  sudden onset of unilateral abdominal pain that may be
abdominal wall surface.
confused with lateralized peritoneal disorders
 Fothergill’s sign – palpable abdominal mass that remains
 most common finding: mass or bulge; may increase in size unchanged with contraction of the rectus muscles
with Valsalva
 Incarcerated hernia – hernia that cannot be reduced; Desmoid Tumors
generally requires surgical correction.  fibrous neoplasms originating from the musculoaponeurotic
 If the blood supply to the incarcerated bowel is structures of the anterior abdomen
compromised, the hernia is described as strangulated, and  aka “aggressive fibrosis” – aggressive and infiltrative local
the localized ischemia may lead to infarction and behavior
perforation.  do not have metastatic potential; although there’s marked
cellularity in biopsy specimens, there are no specific
Primary Ventral Hernias histologic characteristics that suggest malignancy
Epigastric hernias Schwartz
 midline between the xiphoid process and the umbilicus
 generally small and may be multiple OMENTUM
 usually contain omentum or a portion of the falciform
ligament SURGICAL ANATOMY
 congenital and due to defective midline fusion of developing
 The greater omentum and
lateral abdominal wall element
lesser omentum
Umbilical Hernias  Provide support,
 occur at the umbilical ring and may be present at birth or coverage, and protection
develop later in life for peritoneal contents
 approx. 10% of all NB; more common in premature infant  develop during the fourth
 Most congenital umbilical hernias close spontaneously by 5 week of gestation
years; if closure does not occur, elective surgical repair is
usually advised.
Spigelian Hernia
 can occur anywhere along the length of the Spigelian line or
zone—an aponeurotic band of variable width at the lateral GREATER OMENTUM
border of the rectus abdominis  develops from the dorsal mesogastrium begins as a double-layered
 the most frequent location of these rare hernias is at or structure spleen develops in between the two layers
slightly above the level of the arcuate line  blood supply:
Incisional Hernias o from the right and left gastroepiploic arteries
 10% to 20% of patients may eventually develop hernias at  venous drainage parallels the arterial
incision sites following open abdominal surgery  left and right gastroepiploic veins ultimately draining into the portal
 Obesity, primary wound healing defects, multiple prior vein
procedures, prior incisional hernias, and technical errors
LESSER OMENTUM
during repair may all be contributory.
Schwartz  known as the hepatoduodenal and hepatogastric ligaments
 develops from the mesoderm of the septum transversum

Transcribed By: 5th Street, Avida, Mezza, Kim possible Checked by: R VILA Page 3 of 8
 SURGERY I Abdominal wall, omentum, mesentery, and retroperitoneum Module 6, Lecture 1

PERITONEAL FORMATION OMENTAL CYST

GREATER OMENTUM
 hangs down like an apron from the greater curvature of the
stomach and proximal part of the duodenum
 connects the greater curvature of the stomach to the transverse
colon
 prevents the visceral peritoneum from adhering to the parietal
peritoneum
 cushions the abdominal organs against injury
 forms insulation against the loss of body heat
LESSER OMENTUM
 connects the lesser curvature of the stomach and proximal part of
the duodenum to the liver
ANATOMY HANDOUTS 2018
 Cystic lesions of the omentum and mesentery are related disorders
 from either peritoneal inclusions or degeneration of lymphatic
structures
 Omental cysts less common than mesenteric cysts
 Present as an asymptomatic abdominal mass
 Or cause abdominal pain with or without appreciable mass or
distention
 Physical examination:
o A freely mobile intra-abdominal mass
 CT and abdominal ultrasound:
o a well circumscribed, cystic mass lesion arising from the greater
omentum

 Treatment:
o resection of all symptomatic omental cysts
o benign lesions is readily accomplished using laparoscopic
techniques

SOURCE: https://www.studyblue.com/notes/note/n/abdomen-1/deck/12601188 OMENTAL NEOPLASM

 Primary tumors of the omentum
are uncommon
PHYSIOLOGY
 Benign tumors of the omentum
 Rutherford Morison – 20th Century termed the omentum as the o Lipomas
abdominal policeman o Myxomas
o wall off areas of infection and limit the spread of intraperitoneal o Desmoid tumors
contamination
 several reports suggested intrinsic hemostatic characteristics  Primary malignant are
 1996, researchers in the Netherlands considered mesodermally
o tissue factor in omentum is over twice the amount of that found derived stromal tumors
in muscle  associated
o facilitates activation of coagulation at sites of inflammation, immunohistochemical characteristics of GI stromal tumors including
ischemia, infection, or trauma within the peritoneal cavity c-kit immunopositivity
o production of fibrin contributes to the ability to adhere to areas of
injury or inflammation  Metastatic tumors are
common
OMENTAL INFARCTION o ovarian cancer -
highest
preponderance
o stomach
o small intestine
o colon
o pancreas
o biliary tract
o Uterus
o kidney

 Interruption of the blood supply MESENTERY

 secondary to torsion
 rare cause of an acute abdomen
 <100 cases reported
 most likely in male adults
 typically present with:
o localized right lower quadrant, right upper quadrant, or left lower
quadrant pain
o mild degree of nausea may be present,
o patients do not usually have concomitant intestinal symptoms
 Physical examination SURGICAL ANATOMY
o mild tachycardia and a low-grade fever  mesentery develops from mesenchyme that attaches the foregut,
o a tender, palpable mass associated with guarding and rebound midgut, and hindgut to the posterior abdominal wall
tenderness  In the region of the colon, the dorsal mesentery is known as the
 Abdominal CT or ultrasonography mesocolon
o show a localized, inflammatory mass of fat density  The segments that became fixed to the retroperitoneum: duodenum,
ascending and descending colon
 Depending on the location of the infarcted omental tissue, this  The segments that remain mobile:
disease process may mimic appendicitis, cholecystitis, diverticulitis, o small intestine mesentery
perforated peptic ulcer, or ruptured ovarian cyst. o transverse colon mesentery
 Treatment: o sigmoid mesentery remain mobile
o patients who are not toxic, abdominal imaging results are  MESENTERY: major pathway for arterial, venous, lymphatic, and
convincing - supportive care is sufficient neural structures coursing to and from the bowel.
o indistinguishable from surgical conditions with immediate surgical
implications - laparoscopic exploration
o Resection of the infarcted tissue - rapid resolution of symptoms

Transcribed By: 5th Street, Avida, Mezza, Kim possible Checked by: R VILA Page 4 of 8
 SURGERY I Abdominal wall, omentum, mesentery, and retroperitoneum Module 6, Lecture 1

MESENTERY
 Layer of peritoneum w/c encloses an organ and connects it to
abdominal wall
 Contains fat, lymph nodes, blood vessels, nerves
 Named after viscus it attaches
 Most mobile parts of intestine
o transverse colon
o small intestine
 None in retroperitoneal viscus
o parts of duodenum
o ascending colon
o kidney
ARTERIAL SUPPLY
 Superior Mesenteric Artery Mesocolic hernia of small bowel into a retrocolichernial sac posterior to the descending colon
 Branches: mesentery.
o Jejunal artery Hernias of this type, as well as hernias into paraduodenal recesses, result from abnormal fixation of
o Ileal artery mesenteric structures during the course of intestinal rotation; a. = artery; v. = vein.
 Arterial arcades
o Arteries unite (refer to the images above under surgical anatomy)
 Vasa recta  During fetal development, after the herniated and 270 o rotated
o Straight vessels which arise from arterial arcades midgut returns to its intraperitoneal location, the reduced
o Longer in jejunum mesentery achieves its final fixation state.
o More complex in ileum
 The duodenum and lateral colon segments become fixed to the
VENOUS DRAINAGE retroperitoneum, whereas the small intestinal mesentery,
 Superior Mesenteric Vein transverse colon mesentery, and sigmoid colon mesentery
o Accompanies SMA remain mobile.
o Crosses duodenum (horizontal part) and unicinate process
o Unites with splenic vein  Defects in these normal developmental steps starting with
midgut rotation result in the spectrum of disorders associated
LYMPHATIC DRAINAGE with midgut malrotation.
 Mesenteric Lymph nodes
 The related anatomic anomalies of the mesentery include
 3 locations:
o Close to the intestinal wall
paraduodenal or mesocolic hernias, which can present as
o Amongst the arterial arcades chronic or acute intestinal obstruction in children or adults.
o Along proximal SMA Schwartz
INNERVATION
 Parasympathetic
o Vagus
SCLEROSING MESENTERITIS
o On stimulation:
 increase motility of the bowel
 increase secretion of intestinal gland
 vasodilation of blood vessels
 Sympathetic
o Superior mesenteric ganglion
o On stimulation:
 reduce motility of the bowel
 reduce secretion of intestinal gland
 vasoconstriction of blood vessels
ANATOMY HANDOUTS 2018

 also referred to as
o mesenteric panniculitis – signifies an increased inflammatory
component with replacement of degenerative fatty elements
o mesenteric lipodystrophy – inflammatory and fibrotic
components are small
 a chronic inflammatory and fibrotic process that involves a portion of
the intestinal mesentery
 Sclerosing mesenteritis signifies a major fibrotic component and is
sometimes referred to as retractile mesenteritis to describe
mesenteric retraction and shortening associated with scarring
 >50 years of age
 no gender or race predominance
 etiology is unknown
 cardinal feature - increased tissue density within the mesentery
 presentation:
o pain – most frequent presenting symptom
o mass – non-painful
o intestinal obstruction –rare
 incidental cases are discovered on imaging studies

Anatomic relationships of intestinal mesentery to the retroperitoneum after completion of intestinal

rotation during fetal development; art. = artery; sup. = superior; transv. = transverse.

 The root of the small intestine mesentery wall normally courses in

an oblique direction, from the left upper quadrant at the ligament of
Treitz to the right lower quadrant at the ileocecal valve and the fixed
cecum.
Computed tomographic coronal section of a focus of sclerosingmesenteritis at the mesenteric root,
straddlingmajorproximal branches of the superior mesenteric artery.The location of the mass
restricted surgical options to biopsy andconfirmation of diagnosis.

Transcribed By: 5th Street, Avida, Mezza, Kim possible Checked by: R VILA Page 5 of 8
 SURGERY I Abdominal wall, omentum, mesentery, and retroperitoneum Module 6, Lecture 1

 Asymptomatic
 May cause symptoms of a mass lesion.
 Nonspecific symptoms (may be acute or chronic)
o anorexia
o nausea
o vomiting
o fatigue
o weight loss

Computed tomographic scan of sclerosingmesenteritis (mesenteric lipodystrophy). This condition

cannot easily be distinguished from a neoplasm of the mesentery on radiologic study. In this case,
the study showed "fatty mesenteric tumor with involvement of mesenteric vessels," and "mesenteric
lipodystrophy" was demonstrated by biopsy findings at exploration. The finding of a hyperattenuating
stripe around the lesion, as seen in this image, has been associated with the diagnosis of
 Acute pain generally caused by rupture or torsion of the cyst or by
mesenteritis.
acute hemorrhage into the cyst
 Surgery:  Chronic intermittent abdominal pain secondary to compression of
o establish a diagnosis adjacent structures or spontaneous torsion followed by detorsion of
o rule out a neoplastic process the cyst
 Simple biopsy
 Bowel and mesenteric resection  Physical examination:
o a mass lesion that is mobile only from the patient's right to left or
left to right (Tillaux's sign)
 (PET) positron emission tomography with CT scan - effective in ruling
o Tillaux was the first to record this physical finding and, in 1850, the
out neoplasia for focal mesenteric masses
first to successfully remove a mesenteric cyst
o in contrast to the findings with omental cysts, which should be
freely mobile in all directions

 Operative findings at the time of resection of what was believed to be

a mesenteric tumor but which proved to be a focus of mesenteric
lipodystrophy. In this case, the relatively small site of involvement and  CT, abdominal ultrasound, and MRI
the peripheral location in the small intestine mesentery permitted o cystic structure without a solid component in the central abdomen;
management by resection en bloc with a segment of adjacent small these structures are generally unilocular but may on occasion be
bowel. multiple or multilocular

 most cases of the process appears to be self-limited and may even

demonstrate regression
 Clinical symptoms are very likely to improve without intervention
 aggressive surgical treatments are generally not indicated
 clinically problematic cases that are not amenable to resection
o widespread mesenteric involvement or
o unfavorable location

 medical treatment
o to alleviate severe symptoms
o corticosteroids, colchicine, tamoxifen, and
cyclophosphamide

Sclerosing Mesenteritis Computed tomographic scan of a mesenteric cyst. The unilocular appearance without
 Its cardinal feature is increased tissue density within the an associated solid component strongly suggests the diagnosis of benign cyst.
mesentery  it may be difficult to distinguish these cystic masses from rare solid
 can be localized and associated with a discrete non-neoplastic mesenteric tumors with cystic components, such as a cystic stromal
mesenteric mass, or it can be more diffuse, sometimes involving tumor or mesothelioma
large swaths of mesentery without well-defined borders  Mesenteric cystic lymphangioma may present as numerous, often
Schwartz large cysts in the setting of abdominal pain. These can be difficult to
treat and almost invariably recur after excision.
 Symptomatic:
MESENTERIC CYST o simple mesenteric cysts are surgically excised
o open or laparoscopic
o Adherent vessels - complete excision w/ segmental bowel
resection

 Cyst unroofing or marsupialization is not recommended, because

mesenteric cysts have a high propensity to recur after drainage
alone.
 On rare occasion, adjacent mesentery may be densely adherent to
the cyst or mesenteric vessels must be sacrificed to achieve
complete excision, in which case segmental bowel resection is
performed.
 incidence of <1 in 100,000
 etiology remains unknown  Omental Cyst – freely mobile in all directions
o Theory: degeneration of the mesenteric lymphatics and that they  Mesenteric Cyst – only left to right ang movement
simply arise as a congenital anomaly

Transcribed By: 5th Street, Avida, Mezza, Kim possible Checked by: R VILA Page 6 of 8
 SURGERY I Abdominal wall, omentum, mesentery, and retroperitoneum Module 6, Lecture 1

MESENTERIC TUMOR  The retroperitoneal space is bounded by:

o SUPERIOR: Diaphragm
o POSTERIOR: Spinal column and iliopsoas muscles
o INFERIOR: Levator ani muscles
 Although technically bounded anteriorly by the posterior
reflection of the peritoneum, the anterior border of the
retroperitoneum is quite convoluted, extending into the
spaces in between the mesenteries of the small and large
intestine
 Because of the rigidity of boundaries and the compliance of
 Primary tumors of the mesentery are rare
the anterior margin, retroperitoneal tumors tend to expand
 Benign tumors of the mesentery:
o Lipoma anteriorly toward the peritoneal cavity.
o cystic lymphangioma Schwartz
o desmoid tumors
 Primary malignant tumors of the mesentery: RETROPERITONEAL INFECTION
o Liposarcomas  source of retroperitoneal infections is usually an organ contained
o Leiomyosarcomas within or abutting the retroperitoneum
o Malignant fibrous histiocytomas  e.i. Retrocecal appendicitis, perforated duodenal ulcers, pancreatitis,
o Lipoblastomas and diverticulitis
o Lymphangiosarcomas
 are similar to those described for the omentum

 Metastatic small intestine carcinoid in mesenteric lymph nodes

may exceed the bulk of primary disease and compromise blood
supply to the bowel.
 Treatment of mesenteric malignancies involves wide resection of
the mass.
 Proximity to the blood supply to the intestine - resections may be
technically unfeasible or involve loss of substantial lengths of bowel.

RETROPERITONEUM  Retroperitoneal abscess

o pain, fever, and malaise
SURGICAL ANATOMY
 Clinical findings can include:
 embryonic mesoderm predominates in the developing retroperitoneal o tachypnea and tachycardia
space
o Erythema may be observed around the umbilicus or flank
 parietal and the visceral layer o A palpable flank or abdominal mass may be present.
 Retroperitoneum is defined as the space between the posterior
envelopment of the peritoneum and the posterior body wall  Laboratory evaluation
o elevated white blood cell count
 Diagnostic imaging, modality of choice
o CT, which may demonstrate stranding of the retroperitoneal soft
tissues and/or a unilocular or multilocular collection

Computed tomographic scan of a retroperitoneal abscess complicating complex, surgically treated

retroperitoneal infection that had resulted from ampullary perforation at the time of endoscopic
retrograde cholangiopancreatography. This pattern of infection may be difficult to treat and may
result in multiple interventions, such as percutaneous drainage, before resolution.

 Management
o identification and treatment of the underlying condition
o IV administration of antibiotics
o drainage of all well-defined collections
o Unilocular abscesses may be drained percutaneously under CT
guidance
RETROPERITONEAL STRUCTURES o Multilocular collections usually require operative intervention for
 Kidneys adequate drainage
 Ureters
 Bladder  large size of the retroperitoneal space, patients with retroperitoneal
 Adrenal glands abscesses usually do not seek treatment until the abscess is
advanced
 Pancreas
 Consequently, the mortality rate for retroperitoneal abscess, even
 Duodenum (D2 & D3)
when the abscess is drained, has been reported to be as high as
 Ascending colon
25%
 Descending colon
 higher in rare cases of necrotizing fasciitis
 Rectum (upper 2/3)
 Aorta
 Inferior VenaCava RETROPERITONEAL FIBROSIS
 Iliac vessels  Hyperproliferation of fibrous tissue
 Lymphatics (cisterna chyli) in the retroperitoneum
 Seminal vesicles  Ormond’s disease – primary
 Vas deferens disorder; an idiopathic
 Vagina (uppermost) retroperitoneal fibrosis.
 Ovaries  A secondary disorder – i.e. A
 Nerves (lumbar sympathetics) reaction to inciting inflammatory
process malignancy or medication

Transcribed By: 5th Street, Avida, Mezza, Kim possible Checked by: R VILA Page 7 of 8
 SURGERY I Abdominal wall, omentum, mesentery, and retroperitoneum Module 6, Lecture 1

 a rare disorder  Mass lesion is identified

 0.5 in 100,000 patients annually  Biopsy of the mass should be performed to rule out a retroperitoneal
 Men twice as likely to be affected as women, malignancy.
 no predilection for any ethnic group  Image-guided techniques or a surgical retroperitoneal biopsy
 fourth to the sixth decades of life procedure, which may be performed laparoscopically or open
laparotomy
 An allergic or autoimmune mechanism has been postulated
 fibrotic process begins in the retroperitoneum below the level of the  If there is diminished renal function, avoidance of the use of
renal arteries
intravenous contrast will reduce the ability to characterize
 Associated with inflammatory conditions: retroperitoneal tissue planes. In this case, MRI may be used,
o abdominal aortic aneurysm since the signal intensity of the fibrotic process is discrete from
o pancreatitis muscle or fat.
o histoplasmosis  Additionally, magnetic resonance angiography will generally
o tuberculosis provide a good assessment of the degree of iliocaval
o actinomycosis involvement.
 Associated with malignancies: Schwartz
o prostate
o pancreatic
o gastric cancers TREATMENT
o non-Hodgkin's lymphoma  Corticosteroids: Prednisone
o stromal tumors  Patients with poor response, use:
o carcinoid tumors o Cyclosporin
o Tamoxifen
 Association with autoimmune disorders: o Azathioprine
o ankylosing spondylitis
o systemic lupus erythematosus
o Wegener's granulomatosis  Once malignancy, drug-induced, and infectious etiologies are
o Polyarteritis nodosa ruled out, treatment of the retroperitoneal fibrotic process is
instituted.
 Corticosteroids, with or without surgery, are the mainstay of
medical therapy.
 Prednisone is initially administered at a relatively high dose (60
mg every other day for 2 months) and then gradually tapered
over the next 2 months. Therapeutic efficacy is assessed on the
basis of patient symptoms and interval imaging
 Cyclosporin, tamoxifen, and azathioprine also have been used to
treat patients who respond poorly to corticosteroids.
 Surgical treatment consists primarily of ureterolysis or ureteral
stenting and is required in patients who present with significant
hydronephrosis.
Schwartz

PROGNOSIS
 The overall prognosis in idiopathic retroperitoneal fibrosis is good.
 5-year survival rates of 90 to 100%.
 Lifelong follow-up is warranted
o Long-term recurrences have been described
 Allergic reaction medications:
o strongest case for a causal relationship with medication is made REFERENCES
for methylsergide, a semisynthetic ergot alkaloid used in the
Schwartz’s Principles of Surgery
treatment of migraine
Batch 2019 Dr Merced’s ppt
o Other medications beta blockers, hydralazine, methyldopa, and
Anatomy handouts batch 2018
entacapone
o The retroperitoneal fibrosis regresses on discontinuation of these
medications. DISCLAIMER: audio trans from 2018 were used because there is no
video lecture given
DIAGNOSTICS
 Ultrasonography is the least invasive imaging procedure, but results
are technician dependent

 Abdominopelvic CT with oral and IV contrast agents is the imaging

procedure of choice and generally will allow the extent of the fibrotic
process to be determined

Transcribed By: 5th Street, Avida, Mezza, Kim possible Checked by: R VILA Page 8 of 8