4.1.

2
20 January 2014
Abdominal Wall,
Dr. Norberto Bibera
Omentum and
“I cannot fix on the hour, or the look, or the words, which laid the foundation. It is
too long ago. I was in the middle before I knew that I had begun” - Mr. Darcy
Retroperitoneum
Schwartz-based trans  Lateral to the rectus sheath are three
TOPIC PAGE muscular layers with oblique fiber
ABDOMINAL WALL orientations relative to one another.
General Considerations 1 o External oblique, internal oblique and
Surgical Anatomy 1 tranversus abdominis
Physiology 2 o these layers are derived from the
Abdominal Anatomy and 2 laterally migrating mesodermal tissues
Surgical Incisions during the 6th to 7th week of fetal
Congenital Abnormalities 3 development, before fusion of the
Acquired Abnormalities 3-6 developing rectus abdominis muscles in
OMENTUM the midline
Surgical Anatomy 6-7  runs inferiorly and medially, arising
from the margins of the lowest eight ribs
Physiology 7
and costal cartilages
Omental Infarction 7
 originates laterally on the latissimus dorsi
Omental Cyst 7
EXTERNAL and serratus anterior muscles & iliac crest
Omental Neoplasms 7 OBLIQUE  medially it forms a tendinous
MESENTERY (EO) aponeurosis, which is contiguous with the
Surgical Anatomy 7-8 anterior rectus sheath
Sclerosing Mesenteritis 8  inguinal ligament is the inferior-most
Mesenteric Cysts 8-9 edge of the external oblique aponeurosis,
Mesenteric Tumors 9 reflected posteriorly in the area between
RETROPERITONEUM anterior superior iliac spine & pubic
Surgical Anatomy 9 tubercle
Retroperitoneal Infections 9-10  lies immediately deep to the external
Retroperitoneal Fibrosis 10-11 oblique muscle and arises from the lateral
aspect of the inguinal ligament, the iliac
ABDOMINAL WALL crest, and the thoracolumbar fascia
GENERAL CONSIDERATIONS INTERNAL  its fibers course superiorly and medially
 abdominal wall is defined: OBLIQUE and form a tendinous aponeurosis that
o superiorly by the costal margins (IO) contributes components to both the
o inferiorly by the symphysis pubis and pelvic bones anterior and posterior rectus sheath
o posteriorly by the vertebral column  the lower medial and inferior-most fibers
 it serves to support and protect abdominal and of the internal oblique course may fuse
retroperitoneal structures, and its complex muscular with the lower fibers of the transversus
functions enable twisting and flexing motions of the trunk. abdominis muscle (the conjoined area)
 the inferior-most fibers of the internal
oblique muscle are contiguous with the
SURGICAL ANATOMY
cremasteric muscle in the inguinal canal
 It is mesodermal in origin and develops as bilateral TRANSVERS  deepest of the three lateral muscles
migrating sheets that originate in the paravertebral US  runs transversely from the bilateral lowest
region and envelop the future abdominal area ABDOMINIS six ribs, lumbosacral fascia, and iliac crest
 The leading edges of these structures develop into the (TA) to the lateral border of the rectus
rectus abdominis muscles, which eventually meet in the abdominis musculoaponeurotic structures
midline of the anterior abdominal wall.
MUSCLE DESCRIPTION
 muscle fibers are arranged vertically and
are encased within an aponeurotic sheath,
the anterior and posterior layers of which
are fused in the midline at the linea alba
 has insertions on the:
o symphysis pubis and pubic bones
o anteroinferior aspects of 5th & 6th ribs
RECTUS o 7th costal cartilages
ABDOMINIS o xiphoid process
 the lateral border of the rectus muscles
assumes a convex shape that gives rise to
the surface landmark of the linea
semilunaris
 there usually are three tendinous
intersections or inscriptions that cross the
rectus muscles:
o one at the level of xiphoid process
o one at the level of umbilicus
o one halfway between xiphoid process
and the umbilicus Fig 1. Anterior abdominal wall.

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 Abdominal Wall, Omentum and Retroperitoneum

ARCUATE LINE  If the diaphragm is relaxed when the abdominal

 semicircular line of Douglas musculature is contracted, the pressure exerted by the
 lies roughly at the level of the anterior superior iliac spines abdominal muscles results in expiration of air from the
ABOVE THE BELOW THE lungs or a cough if this contraction is forceful. Thus, these
ARCUATE LINE ARCUATE LINE abdominal muscles are the primary muscles of
ANTERIOR  EO aponeurosis  EO aponeurosis expiration.
RECTUS  external lamina of  laminae of the IO  If the diaphragm is contracted when the abdominal
SHEATH IO aponeurosis aponeurosis musculature is contracted (Valsalva maneuver) the
 TA aponeurosis increased abdominal pressure aids in processes such as
micturition, defecation, and childbirth.
POSTERIOR  internal lamina of  no aponeurotic
RECTUS IO aponeurosis posterior covering
SHEATH  TA aponeurosis  transversalis fascia ABDOMINAL ANATOMY AND SURGICAL INCISIONS
 transversalis fascia  Incisions for open surgery generally are located in proximity
to the principal operative targets.
 Laparoscopic port site incisions might be remote from the
site of interest and are carefully planned based on the
anticipated instrument approach angles and necessary
working distances both to operative site & between ports
 Orientation of line of incision may be determined based on:
o expected quality of exposure
o closure considerations, including cosmesis
o avoidance of previous incision sites
o simple surgeon preference
 the incision for open peritoneal access can be:
o longitudinal (in or off the midline)
o transverse (lateral to or crossing the midline)
o oblique (directed either upward or downward toward the
flank)
INCISION DESCRIPTION
Fig 2. Cross-sectional anatomy of the abdominal wall above and below
 used for the majority of
the arcuate line of Douglas
MIDLINE nonlaparoscopic procedures on the
INCISIONS GI tract because of the flexibility
BLOOD SUPPLY offered by this approach in establishing
 majority of the blood supply to the muscles of the anterior adequate exposure
abdominal wall is derived from the superior and inferior  incision in the fused midline aponeurotic
epigastric arteries tissue (linea alba) is simple and requires
SUPERIOR arises from internal thoracic no division of skeletal muscle
EPIGASTRIC ARTERY artery PARAMEDIAN  made longitudinally 3cm off the midline,
INFERIOR arises from the external iliac INCISIONS through the rectus abdominis sheath
EPIGASTRIC ARTERY artery structures
 a collateral network of branches of subcostal and lumbar  have largely been abandoned in favor of
arteries also contributes to the abdominal wall blood supply midline or nonlongitudinal access
 the lymphatic drainage of the abdominal wall is methods
predominantly to the major nodal basins in the INCISION  if made with transverse or oblique
superficial inguinal and axillary areas LATERAL TO orientations may divide the successive
 Innervation of the anterior abdominal wall is segmentally THE MIDLINE muscular layers or bluntly split them in
related to specific spinal levels. the direction of their fibers
 The motor nerves to the rectus muscles, the internal OBLIQUE  exemplified by classic McBurney incision
oblique muscles, and the transversus abdominis muscles MUSCLE- for appendectomy
run from the anterior rami of spinal nerves at the T6 to SPLITTING  may be less destructive to tissue
T12 levels. APPROACH  allow healing with less scarring and
 The overlying skin is innervated by afferent branches of the tissue distortion
T4 to L1 nerve roots, with the nerve roots of T10  offers more limited exposure than other
subserving sensation of the skin around the umbilicus methods
SUBCOSTAL  subcostal incisions on the right (Kocher
PHYSIOLOGY INCISIONS incision for cholecystectomy)
 rectus muscles, the external oblique muscles, and the  subcostal incisions on the left (for
internal oblique muscles work as a unit to flex the trunk splenectomy)
anteriorly or laterally  archetypal muscle-dividing incisions that
 Rotation of the trunk is achieved by the contraction of generally result in transection of some
the external oblique muscle and the contralateral internal or all of the rectus abdominis muscle
oblique muscle fibers and investing aponeuroses
o Rotation of the trunk to the right is produced by PFANNENSTIEL  used commonly for pelvic procedures
contraction of the left external oblique muscle and the INCISION  distinguished by transverse skin and
right internal oblique muscle anterior rectus sheath incisions,
 Raising intra-abdominal pressure, all four muscle followed by rectus muscle retraction &
groups are involved in longitudinal incision of the peritoneum

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 Abdominal Wall, Omentum and Retroperitoneum

CONGENITAL ABNORMALITIES  congenital condition  as a result of a more lateral

 abdominal wall layers begin to form in the first weeks after insertion of the rectus muscles to the ribs and
conception costochondral junctions
 prominent in the early embryonic abdominal wall is a large  more typically an acquired condition  occurring with
central defect through which pass the vitelline advancing age, in obesity, or after pregnancy
(omphalomesenteric) duct and allantois  in postpartum setting, it tends to occur in women who are
 vitelline duct connects the embryonic and fetal midgut to of advanced maternal age, who have a multiple or twin
the yolk sac pregnancy, or who deliver a high-birth-weight infant
 during the 6th week of development, the abdominal  usually easily identified on physical examination
contents grow too large for the abdominal wall to  computed tomographic (CT) scanning
completely contain and the embryonic midgut herniates into o provides an accurate means of measuring the distance
the umbilical cord between the rectus pillars
 although outside the confines of the developing abdomen, it o can differentiate rectus diastasis from a true ventral
undergoes a 270-degree counterclockwise rotation and, at hernia if clarification is required
the end of the 12th week, returns to the abdominal cavity  surgical correction of rectus diastasis by plication of the
 defects in abdominal wall closure may lead to omphalocele broad midline aponeurosis has been described for
or gastroschisis cosmetic indications and for alleviation of impaired
 during the third trimester, the vitelline duct regresses abdominal wall muscular function
CONGENITAL DESCRIPTION o however, these approaches introduce the risk of an
ABNORMALITIES actual ventral hernia and are of questionable value in
OMPHALOCELE  viscera protrude through an open addressing pathology
umbilical ring and are covered by
a sac derived from the amnion RECTUS SHEATH HEMATOMA
GASTROSCHISIS  viscera protrude through a defect  terminal branches of superior and inferior epigastric arteries
lateral to the umbilicus and no course deep to the posterior aspect of left and right rectus
sac is present abdominis muscles and enter the posterior rectus sheath
MECKEL’S  persistence of a vitelline duct  hemorrhage from any of the network of
DIVERTICULUM remnant on the ileal border collateralizing vessels within the rectus sheath and
VITELLINE DUCT  complete failure of the vitelline muscles can result in a rectus sheath hematoma
FISTULA duct to regress  although a history of major or minor blunt trauma may be
 associated with drainage of small elicited, less obvious events also have been reported to
intestine contents from umbilicus cause this condition, such as sudden contraction of the
CENTRAL VITELLINE  may occur if both intestinal and rectus muscles with coughing, sneezing, or any vigorous
DUCT (OMPHALO- umbilical ends of vitelline duct physical activity
MESENTERIC) CYST regress into fibrous cords  spontaneous rectus sheath hematomas have been
SMALL INTESTINE  associated with persistent vitelline described in the elderly and in those receiving
VOLVULUS IN duct remnants between GI tract anticoagulation therapy
NEONATES and anterior abdominal wall  patients frequently describe the sudden onset of
unilateral abdominal pain that may be confused with
 When diagnosed, vitelline duct fistulas and cysts should be lateralized peritoneal disorders such as appendicitis
excised along with any accompanying fibrous cord.  below the arcuate line, a hematoma may cross the
 URACHUS midline and cause bilateral lower quadrant pain
o a fibromuscular, tubular extension of the allantois that
develops with the descent of the bladder to its pelvic HISTORY AND PHYSICAL EXAMINATION
position  alone may be diagnostic
o persistence of urachal remnants can result in cysts as  pain typically increases with contraction of the rectus
well as fistulas to the urinary bladder with drainage of muscles and a tender mass may be palpated
urine from the umbilicus  the ability to appreciate an intra-abdominal mass is
o these are treated by urachal excision and closure of ordinarily degraded with contraction of the rectus muscles
any bladder defect that may be present  FOTHERGILL’S SIGN
o a palpable abdominal mass that remains unchanged
with contraction of the rectus muscles
ACQUIRED ABNORMALITIES
o classically associated with rectus hematoma
 Rectus Abdominis Diastasis  hemoglobin level and hematocrit should be measured
 Rectus Sheath Hematoma and coagulation studies should be performed
 Abdominal Wall Hernias  ABDOMINAL ULTRASOUND may show a solid or cystic
 Incisional Hernias mass within the abdominal wall depending on the chronicity
of the bleeding
RECTURS ABDOMINIS DIASTASIS  CT is the most definitive study to establish the correct
 diastasis recti diagnosis and to exclude other disorders
 a clinically evident separation of the rectus abdominis  MRI also has been used for this purpose
muscle pillars
 results in a characteristic bulging of the abdominal wall SPECIFIC TREATMENT
in the epigastrium that is sometimes mistaken for a  depends on the severity of the hemorrhage
ventral hernia despite the fact that the midline aponeurosis  small, unilateral, and stable hematomas may be
is intact and no hernia defect is present observed without patient hospitalization
 may be congenital or acquired

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 bilateral or large hematomas will likely require
hospitalization and possibly resuscitation
 need for transfusion or coagulation factor
replacement is determined by the clinical circumstances
 reversal of warfarin (Coumadin) anticoagulation in
the acute setting is frequently, but not always, necessary
 emergent operative intervention or angiographic
embolization is required infrequently but may be
necessary if hematoma enlargement, free bleeding, or
clinical deterioration occur
 surgical therapy is used in the rare situations of failed
angiographic treatment or hemodynamic instability that
precludes any other options
 operative goals are evacuation of the hematoma and
ligation of any bleeding vessel identified
Fig 4. Algorithm of Rectus Sheath Hematoma
ABDOMINAL WALL HERNIAS
 hernias of the anterior abdominal wall or ventral hernias,
 defects in the parietal abdominal wall fascia and muscle
through which intra-abdominal or preperitoneal contents
can protrude
 ventral hernias may be congenital or acquired
 acquired hernias may develop through slow architectural
deterioration of the muscular aponeuroses or they may
develop from failed healing of an anterior abdominal wall
incision (incisional hernia)
 most common finding is a mass or bulge on the anterior
abdominal wall, (may increase in size with a Valsalva
maneuver)
 ventral hernias may be asymptomatic or cause a
considerable degree of discomfort, and generally enlarge
over time
 physical examination reveals a bulge on the anterior
abdominal wall that may reduce spontaneously, with
recumbency, or with manual pressure
HERNIA DESCRIPTION
 hernia that cannot be reduced
INCARCERATED  requires emergent surgical
HERNIA correction
 incarceration of an intestinal segment
may be accompanied by nausea,
vomiting, and significant pain
 when the blood supply to the
STRANGULATED incarcerated bowel is compromised
HERNIA  the localized ischemia may lead to
infarction and perforation
Agatep, Dela Fuente, Detera, Leynes, Rodriguez, Tejano
Abdominal Wall, Omentum and Retroperitoneum
PRIMARY  also termed true ventral hernias
VENTRAL  are more properly named according to
HERNIA (NON- their anatomic location
INCISIONAL)
 located in the midline between the
xiphoid process and the umbilicus
 generally small, may be multiple, and
EPIGASTRIC at elective repair are usually found to
HERNIA contain omentum or a portion of the
falciform ligament
 may be congenital and due to defective
midline fusion of developing lateral
abdominal wall element
 occur at the umbilical ring
 may either be present at birth or
develop gradually during the life of the
individual
 present in approx. 10% of all newborns
 more common in premature infants
 most congenital umbilical hernias
UMBILICAL close spontaneously by age 5 years
HERNIA (if closure does not occur by this time,
elective surgical repair usually is
advised)
 adults with small, asymptomatic
umbilical hernias may be followed
clinically
 surgical treatment is offered if a hernia
is observed to enlarge, if it is associated
with symptoms, or if incarceration
occurs
 surgical treatment can consist of
primary sutured repair or placement of
prosthetic mesh for larger defects (>2
cm) using open or laparoscopic
methods
 can occur anywhere along the length
SPIGELIAN of the Spigelian line or zone—an
HERNIA aponeurotic band of variable width at
the lateral border of the rectus
abdominis
 the most frequent location of these rare
hernias is at or slightly above the
level of the arcuate line
 these are not always clinically evident
as a bulge and may come to medical
attention because of pain or
incarceration
 Patients with advanced liver disease, ascites, and umbilical
hernia require special consideration.
 Enlargement of the umbilical ring usually occurs in this
clinical situation as a result of increased intra-
abdominal pressure from uncontrolled ascites.
 FIRST LINE OF THERAPY is aggressive medical correction
of the ascites:
o diuretics
o dietary management
o paracentesis for tense ascites with respiratory
compromise
 These hernias usually are filled with ascitic fluid, but
omentum or bowel may enter the defect after large-volume
paracentesis.
 Uncontrolled ascites may lead to skin breakdown on the
protuberant hernia and eventual ascitic leak, which
can predispose the patient to bacterial peritonitis.
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 Abdominal Wall, Omentum and Retroperitoneum

 Patients with refractory ascites may be candidates for o interlay either bridging the gap between the defect
transjugular intrahepatic portocaval shunting or edges or within the abdominal wall musculoaponeurotic
eventual liver transplantation. layers (intraparietal)
 Umbilical hernia repair should be deferred until after o onlay (superficial to the fascial defect).
the ascites is controlled.  laparoscopic repairs use an intraperitoneal underlay
technique
INCISIONAL HERNIAS  meshes can be characterized by:
 abdominal operations that develop to hernias at the o type of material
abdominal incision sites  specified density
 can be regarded as a wound healing failure  porosity
 may contribute to the cause of hernia:  strength
o obesity o can be prosthetic or biologic
o primary wound healing defects  made of materials that do not degrade
o multiple prior procedures PERMANENT over time
o prior incisional hernias PROSTHETIC  PRINCIPAL ADVANTAGES OF
o technical errors during repair MESH PROSTHETIC MESHES
 hernias can occur at sites of defective healing within IMPLANTS o ease of use
the approximated incision or at the suture puncture o relatively low cost
sites created during the closure, or both o durability
 the most important distinctions in describing surgical  Degraded primarily by hydrolytic enzyme
management of incisional hernias are: activity
o primary vs. mesh repair  composed of the same materials as
o open vs. laparoscopic repair polysaccharide-derived synthetic
ABSORBABLE absorbable suture
PRIMARY REPAIR METHODS MESHES  provide relatively inexpensive solutions
 Open procedure for temporary abdominal wall support in
o simple suture closure highly contaminated or infected fields
o components separation  use of these meshes leaves patients with
 Primary repair, even of small hernias (defects <3 recurrent ventral hernias that can be
cm), is associated with high reported hernia definitively repaired when permitted by
recurrence rates. improved local wound conditions
 Identified risk factors for recurrence of primary repair:  prepared from collagen-rich porcine,
o primary suture repair bovine, or human tissues from which all
o postoperative wound infection antigenic cellular materials are removed
o prostatism  these mesh materials can be chemically
o surgery for abdominal aortic aneurysm BIOLOGIC treated to cross-link collagen molecules,
 investigators concluded that mesh repair was superior to MESHES which increases strength and durability at
primary repair the cost of some impairment in host
SIMPLE  Simple suture approximation of fascial cellular ingrowth
SUTURE defect edges predictably results in a  biologic mesh–derived collagen can be
CLOSURE suture line under tension incorporated into the host tissue,
COMPONENTS  entails creation of large subcutaneous remodeled, and eventually replaced by
SEPARATION flaps lateral to the fascial defect followed host collagen
by incision of the external oblique  early in their use, biologic meshes were
muscles and, if necessary, incision of the felt to represent a potentially definitive
posterior rectus sheath bilaterally solution when used to bridge an
 these fascial releases allow for primary abdominal wall defect (however, more
apposition of the fascia under far less recent reports show that hernia
tension than in simple primary repair recurrence rates are excessive in this
 assoc with a high wound infection risk application)
 are useful in the setting of
(20%)&a recurrence rate of 18.2% at 1yr
contaminated or potentially
 most applicable for the repair of incisional
contaminated fields
hernias when there are converging needs
 very expensive
to:
 do not offer the durability of permanent
o avoid the use of prosthetic materials
prosthetic meshes unless combined with a
o achieve a definitive repair
primary repair
MESH REPAIR
 has become the gold standard in the elective Table 35-1 Meshes Used in Incisional Hernia Repair
management of most incisional hernias Proprietary Name Composition
 can be categorized according to the way in which mesh is
placed & as its relationship to the abdominal wall fascia Prosthetic meshes
 mesh can be placed as an:
o underlay deep to the fascial defect (intraperitoneal or Parietex Polyester/collagen film
preperitoneal) Composix Polypropylene/ePTFE
DualMesh, Dulex, ePTFE

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 Abdominal Wall, Omentum and Retroperitoneum

MotifMESH LAPAROSCOPIC INCISIONAL HERNIA REPAIR

 was first described by LeBlanc and Booth in 1993
Prolene, Surgipro, Polypropylene  these procedures have become a new gold standard for
ProLite abdominal wall reconstruction for ventral hernia
 use of the laparoscopic technique was associated with
Proceed Polypropylene/polydioxanone
statistically:
Sepramesh IP Polypropylene/hyaluronate gel o fewer wound complications
o fewer overall complications
C-Qur Polypropylene/omega-3 fatty acid o lower recurrence rate than use of the open technique
TiMESH Polypropylene/titanium  these benefits of the minimally invasive technique are
achieved by eliminating the requisite large abdominal
Biologic meshes incision at a location where the abdominal wall blood supply
has previously been compromised
Surgisis Gold Porcine small intestine submucosa  with this technique, the entire undersurface of the
AlloDerm Human dermis abdominal wall can be examined, which often reveals
multiple secondary defects that might not otherwise be
SurgiMend Fetal bovine dermis appreciated
 involves laterally placed ports for midline defects and
CollaMend Porcine dermis
contralaterally placed ports for lateral defects
AlloMax Human dermis  all adhesions to the anterior abdominal wall are divided,
with great care taken not to injure the intestine either
Absorbable meshes directly or with thermal or electrical energy
 contents of the hernial sac are completely reduced,
Gore Bio-A Poly(glycolide:trimethylene carbonate)
but in contrast to open repairs, the sac itself is left in
Vicryl Polyglactin situ
 once the area encompassing all fascial defects is defined, a
Dexon Polyglycolate mesh is fashioned to allow for sufficient overlap (minimum
ePTFE = expanded polytetrafluoroethylene. of 3 to 4 cm) under the healthy abdominal wall
 after insertion into the abdomen, the mesh is fixed into
OPEN MESH REPAIR position with transfascial sutures placed circumferentially
 generally requires incision or excision of the previous around the mesh and spiral tacks placed according to
laparotomy scar, with care taken to avoid injury to the surgeon preference
underlying abdominal contents  it has been proposed that transfascial sutures contribute to
 the peritoneum and hernial sac are then dissected free from excessive postoperative pain, and some surgeons have
the abdominal wall fascia so that at least 3 to 4 cm of fascia eliminated them from the aforementioned technique,
is circumferentially exposed relying solely on spiral tacks for the strength of the repair
 the mesh can then be sutured into place using an  LeBlanc reviewed the usefulness of transfascial sutures and
underlay, onlay, interlay, or "sandwich-style" (both cautiously recommended a minimum 5-cm overlap of mesh
underlay and onlay) method from defect edge if transfascial sutures are not used
 the most successful method is to extensively develop a
preperitoneal space to accommodate a large sheet of OMENTUM
polypropylene or woven polyester mesh
 the mesh, which is isolated from the peritoneal contents, is SURGICAL ANATOMY
then secured to the musculoaponeurotic tissues using
 greater omentum and lesser omentum are fibro-fatty
interrupted nonabsorbable sutures
aprons that provide support, coverage, and protection
 tissue ingrowth within the interstices of these mesh types
for peritoneal contents
results in dense attachment to whatever tissues the mesh
 these structures begin to develop during the fourth week
comes into contact with
of gestation
o this effect is desirable when the mesh is located in the
preperitoneal position
o however, exposure to the underlying bowel ought to be GREATER OMENTUM
avoided whenever possible  develops from the dorsal mesogastrium, which begins as
 problems attributed to adherence of peritoneal contents to a double-layered structure
mesh:  the spleen develops in between the two layers, and later in
o chronic pain development the two layers fuse, giving rise to the
o bowel obstruction intraperitoneal spleen and the gastrosplenic ligament
o fistulization to bowel  the fused layers then hang from the greater curvature of
 Polytetrafluoroethylene (PTFE) the stomach and drape over the transverse colon, to which
o doesn’t become incorporated into the surrounding their posterior surface becomes fixed
tissues  gastrocolic ligament and the gastrosplenic ligament
o not associated with dense adhesions to the are those segments of the greater omental apron that
intraperitoneal structures connect the named structures
o it is therefore commonly used for intraperitoneal  greater omentum in adults
applications o lies in between the anterior abdominal wall and the
 irrespective of technique, the recurrence rate after open hollow viscera
incisional hernia repair can be high o usually extends into the pelvis to the level of the
symphysis pubis

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 BLOOD SUPPLY to the greater omentum is derived from
the right and left gastroepiploic arteries
 VENOUS DRAINAGE parallels the arterial supply to a great
extent, with the left and right gastroepiploic veins
ultimately draining into the portal system
LESSER OMENTUM
 otherwise known as the hepatoduodenal and
hepatogastric ligaments
 develops from the mesoderm of the septum transversum,
which connects the embryonic liver to the foregut
 the common bile duct, portal vein, and hepatic artery are
located in the inferolateral margin of the lesser omentum,
which also forms the anterior margin of the foramen of
Winslow
PHYSIOLOGY
 abdominal policeman
 omentum tended to wall off areas of infection and limit
the spread of intraperitoneal contamination
 the concentration of tissue factor in omentum is over twice
the amount per gram of that found in muscle
o this facilitates activation of coagulation at sites of
inflammation, ischemia, infection, or trauma within the
peritoneal cavity
o the consequent local production of fibrin contributes to
the ability of the omentum to adhere to areas of injury
or inflammation
OMENTAL INFACTION
 interruption of the blood supply to the omentum is a rare
cause of an acute abdomen that may be secondary to
torsion of the omentum around its vascular pedicle,
thrombosis or vasculitis of the omental vessels, or omental
venous outflow obstruction
 depending on the location of the infarcted omental tissue,
this disease process may mimic appendicitis,
cholecystitis, diverticulitis, perforated peptic ulcer, or
ruptured ovarian cyst
 patients typically present with localized right lower
quadrant, right upper quadrant, or left lower
quadrant pain
 although a mild degree of nausea may be present, patients
do not usually have concomitant intestinal symptoms
 physical examination typically reveals a mild tachycardia
and a low-grade fever
 abdominal examination may demonstrate a tender,
palpable mass associated with guarding and rebound
tenderness
 the diagnosis is rarely made before abdominal imaging
studies are performed
 either abdominal CT or ultrasonography will show a
localized, inflammatory mass of fat density
 treatment of omental infarction depends on the certainty
with which the diagnosis is made
 in patients who are not toxic and whose abdominal imaging
results are convincing, supportive care is sufficient
 many cases are indistinguishable from surgical conditions
with immediate surgical implications so laparoscopic
exploration offers the opportunity to establish an accurate
diagnosis and determine the most appropriate treatment
 resection of the infarcted tissue results in rapid
resolution of symptoms
Agatep, Dela Fuente, Detera, Leynes, Rodriguez, Tejano
Abdominal Wall, Omentum and Retroperitoneum
OMENTAL CYSTS
 cystic lesions of the omentum and mesentery are related
disorders, likely resulting from either peritoneal inclusions
or degeneration of lymphatic structures
 omental cysts are far less common than mesenteric
cysts
 may present as an asymptomatic abdominal mass or
may cause abdominal pain with or without
appreciable mass or distention
 physical examination may reveal a freely mobile intra-
abdominal mass
 both CT and abdominal ultrasound reveal a well-
circumscribed, cystic mass lesion arising from the greater
omentum
 treatment involves resection of all symptomatic
omental cysts
 resection of these benign lesions is readily accomplished
using laparoscopic techniques
OMENTAL NEOPLASMS
 primary tumors of the omentum are uncommon
 benign tumors of the omentum include:
o lipomas
o myxomas
o desmoid tumors
 primary malignant tumors of the omentum are
considered mesodermally derived stromal tumors, in
which some of the associated immunohistochemical
characteristics of GI stromal tumors have been described,
including c-kit immunopositivity
 metastatic tumors of the omentum are common, with
metastatic ovarian cancer showing the highest
preponderance of omental involvement
 malignant tumors of the stomach, small intestine, colon,
pancreas, biliary tract, uterus, and kidney may also
metastasize to the omentum
MESENTERY
SURGICAL ANATOMY
 mesentery develops from mesenchyme that attaches the
foregut, midgut, & hindgut to the posterior abdominal wall
 during embryonic maturation, this mesenchyme forms the
dorsal mesentery
 in the stomach region, the dorsal mesentery becomes the
greater omentum
 in the jejunum and ileum region, the dorsal mesentery
becomes the mesentery proper
 in the colon region, the dorsal mesentery is known as the
mesocolon
 during embryonic development, after the 270-degree
counterclockwise rotation of the herniated midgut, the
reduced mesentery achieves its final fixation state
o segments at the duodenum, ascending colon, and
descending colon become fixed to the
retroperitoneum
o small intestine mesentery, transverse colon
mesentery, and, to a variable extent, the sigmoid
colon mesentery remain mobile
 defects in the normal developmental steps of intestinal
rotation result in malrotation disorders
 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
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 the small and large intestine mesenteries serve as the
major pathway for arterial, venous, lymphatic, and neural
structures coursing to and from the bowel
 anatomic anomalies of the mesentery related to rotational
disorders can lead to paraduodenal or mesocolic hernias,
which can present as chronic or acute intestinal obstruction
in children or adults
SCLEROSING MESENTERITIS
 also referred to as mesenteric panniculitis or
mesenteric lipodystrophy
 a chronic inflammatory and fibrotic process that
involves a portion of the intestinal mesentery
 there is no gender or race predominance
 most commonly diagnosed in individuals >50 yrs of age
 etiology of this process is unknown
 its cardinal feature is increased tissue density within
the mesentery
o this can be localized and associated with a discrete non-
neoplastic mesenteric mass or more diffuse, sometimes
involving large swaths of mesentery without well-
defined borders
 there may be varying relative degrees of fat tissue
degeneration, inflammation, and fibrosis on histologic
examination, which gives rise to the various terms used to
describe this condition.
MESENTERIC  used when the inflammatory and
LIPODYSTROPHY fibrotic components are small
 signifies an increased
MESENTERIC inflammatory component with
PANNICULITIS replacement of degenerative
fatty elements
 signifies a major fibrotic
component
SCLEROSING  sometimes referred to as
MESENTERITIS retractile mesenteritis to
describe mesenteric retraction
and shortening associated with
scarring
o it is not clear if these represent stages in a sequential
process or variations in disease severity
 a discrete mass may be up to 40 cm in diameter, and
patients typically present with symptoms of a mass lesion
 ABDOMINAL PAIN is the most frequent presenting
symptom, followed by the presence of a nonpainful mass
or, more rarely, intestinal obstruction
IMAGING
 many cases are discovered incidentally when imaging
studies (most frequently abdominal CT scanning) are
performed for unrelated reasons
 CT of the abdomen can verify the presence of a mass
lesion or area of the mesentery with a higher density than
found in normal mesenteric tissue
 although CT cannot definitively distinguish sclerosing
mesenteritis from a primary or secondary mesenteric
tumor, identification of a "fat ring sign" or hypodense
zone around the mass area has been suggested as a
means of distinguishing sclerosing mesenteritis from
lymphoma
 presence of a hyperattenuating stripe also has been
suggested as a radiologic finding that would favor a
diagnosis of mesenteritis
 the recent use of positron emission tomography (PET)
with CT scanning has proven effective in ruling out
neoplasia for focal mesenteric masses, which leaves the
sclerosing mesenteritis diagnosis as one of exclusion
Agatep, Dela Fuente, Detera, Leynes, Rodriguez, Tejano
Abdominal Wall, Omentum and Retroperitoneum
SURGERY
 surgery has been used most frequently to establish a
diagnosis and to rule out a neoplastic process
 the extent and location of mesenteric involvement defines,
and in some cases limits, the options for surgical
intervention
 in addition to simple biopsy, bowel and mesenteric
resection can be considered, particularly in cases in which
it is technically feasible based on mass size and the ability
to avoid injury to the small intestine blood supply
 the involvement of the vascular structures at the
mesenteric root makes resection unfeasible
 in rare cases, an ostomy of some type for fecal diversion in
the face of obstruction can be considered
OVERALL
 in most cases of sclerosing mesenteritis the process
appears to be self-limited and may even demonstrate
regression if followed with interval imaging studies
 clinical symptoms are very likely to improve without
intervention, and therefore aggressive surgical treatments
are generally not indicated
 in clinically problematic cases that are not amenable to
resection because of widespread mesenteric involvement or
unfavorable location, medical treatment has been given to
alleviate severe symptoms
 among the agents that have been used are corticosteroids,
colchicine, tamoxifen, and cyclophosphamide
MESENTERIC CYSTS
 cysts of the mesentery are benign lesions with an
incidence of <1 in 100,000
 etiology of cysts remains unknow but several theories
regarding their development have been put forward,
including that they are caused by degeneration of the
mesenteric lymphatics and that they simply arise as a
congenital anomaly
 may be asymptomatic or may cause symptoms of a mass
lesion
 symptoms may be acute or chronic
o acute abdominal pain secondary to a mesenteric cyst
is generally caused by rupture or torsion of the cyst or
by acute hemorrhage into the cyst
o may also cause chronic intermittent abdominal pain
secondary to compression of adjacent structures or
spontaneous torsion followed by detorsion of the cyst.
 can be the cause of nonspecific symptoms such as
anorexia, nausea, vomiting, fatigue, and weight loss
 physical examination may reveal a mass lesion that is
mobile only from the patient's right to left or left to
right (Tillaux's sign) [in contrast to the findings with
omental cysts, which should be freely mobile in all
directions]
 CT, abdominal ultrasound, and MRI all have been used
to evaluate patients with mesenteric cysts
o each imaging modalities reveals a cystic structure
without a solid component in the central abdomen
o these structures are generally unilocular but may on
occasion be multiple or multilocular
o irrespective of the imaging method used, it may be
difficult to distinguish these cystic masses from rare
solid mesenteric tumors with cystic components, such as
a cystic stromal tumor or mesothelioma
 mesenteric cystic lymphangioma may present as
numerous, often large cysts in the setting of abdominal
pain (These can be difficult to treat and almost invariably
recur after excision)
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 Abdominal Wall, Omentum and Retroperitoneum

 when symptomatic, simple mesenteric cysts are

surgically excised either openly or laparoscopically when
feasible
 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

MESENTERIC TUMORS
 primary tumors of the mesentery are rare.
 benign tumors of the mesentery include:
o lipoma
o cystic lymphangioma
o desmoid tumors
 primary malignant tumors of the mesentery are similar to
those described for the omentum
 liposarcomas, leiomyosarcomas, malignant fibrous
histiocytomas, lipoblastomas, and lymphangiosarcomas all
have been described Fig 5. Anatomy of the retroperitoneum.
 metastatic small intestine carcinoid in mesenteric lymph
nodes may exceed the bulk of primary disease and LIST OF ORGANS & STRUCTURES THAT RESIDE WITHIN
compromise blood supply to the bowel THE RETROPERITONEUM
 treatment of mesenteric malignancies involves wide Kidney Ureters Bladder
resection of the mass Pancreas Duodenum (D2 & D3) Adrenal glands
 because of the proximity to the blood supply to the Ascending Descending colon Rectum (upper
intestine, such resections may be technically unfeasible or colon 2/3s)
involve loss of substantial lengths of bowel Aorta Inferior vena cava Iliac vessels
Seminal Vas deferens Lymphatics
RETROPERITONEUM vesicles (cistern chili)
Vagina Ovaries Nerves (lumbar
SURGICAL ANATOMY (uppermost) sympathetic)
 although there are ectodermal, mesodermal, and
endodermal contributions to the contents of the RETROPERITONEAL INFECTIONS
retroperitoneum, embryonic mesoderm predominates  the posterior reflection of the peritoneum limits the spread
in the developing retroperitoneal space of most intra-abdominal infections to the peritoneum
 from the intermediate mesoderm arise the organs of the  the source of retroperitoneal infections is usually an organ
urinary and genital systems contained within or abutting the retroperitoneum
 the lateral plate mesoderm eventually divides into two  conditions which may all lead to retroperitoneal infection
layers, the parietal layer and the visceral layer with or without abscess formation
o these layers eventually become the pleura, pericardium, o retrocecal appendicitis
peritoneum, and retroperitoneum o perforated duodenal ulcers
 retroperitoneum is defined as the space between the o pancreatitis
posterior envelopment of the peritoneum and the o diverticulitis
posterior body wall  the substantial space and rather nondiscrete boundaries of
 boundary of retroperitoneal space: the retroperitoneum allow some retroperitoneal abscesses
o superiorly by the diaphragm to become quite large before diagnosis
o posteriorly by the spinal column and iliopsoas muscles  a patient with a retroperitoneal abscess usually
o inferiorly by the levator ani muscles presents with pain, fever, and malaise
 although the retroperitoneum is technically bounded  the site of the patient's pain may be variable and can
anteriorly by the posterior reflection of the peritoneum, the include the back, pelvis, or thighs
anterior border of the retroperitoneum is quite convoluted,  clinical findings can include tachypnea and tachycardia
extending into the spaces in between the mesenteries of  erythema may be observed around the umbilicus or flank
the small and large intestine o this is analogous to the ecchymosis seen in these
 because of the rigidity of the superior, posterior, and locations after massive retroperitoneal hemorrhage
inferior boundaries, and the compliance of the anterior (Cullen's sign and Grey Turner's sign, respectively).
margin, retroperitoneal tumors tend to expand anteriorly  a palpable flank or abdominal mass may be present
toward the peritoneal cavity  laboratory evaluation usually reveals an elevated white
blood cell count
 diagnostic imaging modality of choice is CT, which may
demonstrate stranding of the retroperitoneal soft tissues
and/or a unilocular or multilocular collection
 MANAGEMENT of retroperitoneal infections includes:
o identification and treatment of the underlying condition
o IV administration of antibiotics

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 Abdominal Wall, Omentum and Retroperitoneum

o drainage of all well-defined collections  the strongest case for a causal relationship between
 unilocular abscesses may be drained percutaneously medication and retroperitoneal fibrosis is made for
under CT guidance methysergide, a semisynthetic ergot alkaloid used in the
 multilocular collections usually require operative treatment of migraine headaches
intervention for adequate drainage  other medications that have been linked to retroperitoneal
 because of the large size of the retroperitoneal space, fibrosis include:
patients with retroperitoneal abscesses usually do not seek o beta blockers
treatment until the abscess is advanced o hydralazine
 mortality rate for retroperitoneal abscess, even when the o –methyldopa
abscess is drained, has been reported to be as high as o entacapone
25%, or even higher in rare cases of necrotizing fasciitis of  inhibits catechol-O-methyltransferase
the retroperitoneum  used as an adjunct with levodopa in the treatment of
Parkinson's disease
RETROPERITONEAL FIBROSIS  retroperitoneal fibrosis regresses on discontinuation of
 a class of disorders characterized by hyperproliferation of these medications
fibrous tissue in the retroperitoneum  presenting symptoms depend on the structure or structures
 It may be a primary disorder as in idiopathic affected by the fibrotic process
retroperitoneal fibrosis, also known as Ormond disease  initially, patients complain of the insidious onset of dull,
 It may be a secondary reaction to an inciting poorly localized abdominal pain
inflammatory process, malignancy, or medication  sudden-onset or severe abdominal pain may signify acute
 Idiopathic retroperitoneal fibrosis is a rare disorder, mesenteric ischemia
usually affecting 0.5 in 100,000 patients annually  other symptoms of retroperitoneal fibrosis include:
 men are twice as likely to be affected as women o unilateral leg swelling
 no predilection for any particular ethnic group is seen o intermittent claudication
 the disease primarily affects individuals in the fourth to o oliguria, hematuria
the sixth decades of life o dysuria
 an allergic or autoimmune mechanism has been postulated  findings on physical examination vary with the
for this condition retroperitoneal structure involved
 circulating antibodies to ceroid, a lipoproteinaceous by-  findings may include:
product of vascular atheromatous plaque oxidation, are o hypertension
present in >90% of patients with retroperitoneal fibrosis o palpation of an abdominal or flank mass
 the relationship of this finding to the occurrence of fibrosis o lower extremity edema (unilateral or bilateral)
remains uncertain o diminished lower extremity pulses (unilateral or
 early inflammatory reaction involves predominately helper T bilateral)
cells, plasma cells, and macrophages, but these are  laboratory evaluation may reveal an elevated blood urea
subsequently replaced by collagen-synthesizing fibroblasts nitrogen and/or creatinine level
 microscopically, the infiltrate is indistinguishable from that  as with many autoimmune inflammatory processes, the
seen with periadventitial involvement in aortic aneurysmal erythrocyte sedimentation rate almost always is
disease, Riedel's thyroiditis, sclerosing cholangitis, and elevated in patients with retroperitoneal fibrosis
Peyronie's disease
 the fibrotic process begins in the retroperitoneum just IMAGING DESCRIPTION
below the level of the renal arteries ABDOMINAL &  is the least invasive imaging
 fibrosis gradually expands, encasing the ureters, inferior LOWER procedure, but results are technician
vena cava, aorta, mesenteric vessels, or sympathetic EXTREMITY dependent
nerves. Bilateral involvement is noted in 67% of cases ULTRASOUND  It may be useful if iliocaval
 retroperitoneal fibrosis may also occur secondary to a compressive or renal symptoms
variety of inflammatory conditions or as an allergic reaction predominate.
to a medication  LOWER  may show deep vein thrombosis
o abdominal aortic aneurysm EXTREMITY UTZ
o pancreatitis  ABDOMINAL  may identify a mass lesion or
o histoplasmosis ULTRASOUND hydronephrosis
o tuberculosis  once the diagnostic procedure of
o actinomycosis choice, is less commonly used today
 it is also associated with a variety of malignancies:  if the ureters are involved, the
o prostate cancer IV PYELOGRAPHY findings of IV pyelography will
o pancreatic cancer include ureteral compression,
o gastric cancers ureteral deviation toward the
o non-Hodgkin's lymphoma midline, and hydronephrosis
o stromal tumors ABDOMINO-  the imaging procedure of choice
o carcinoid tumors PELVIC CT WWITH  generally will allow the extent of the
 has been described in association with autoimmune ORAL & IV fibrotic process to be determined
disorders including: CONTRAST
o ankylosing spondylitis AGENTS
o systemic lupus erythematosus  if renal function is diminished so that
o Wegener's granulomatosis MRI the use of IV contrast agents must
o polyarteritis nodosa be avoided, the ability to
characterize retroperitoneal tissue

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 Abdominal Wall, Omentum and Retroperitoneum

planes will be reduced, MRI can be

used because the signal intensity of
the fibrotic process is discrete from
that of muscle or fat
MAGNETIC  generally provides a good
RESONANCE assessment of the degree of
ANGIOGRAPHY iliocaval involvement
 once a mass lesion is identified, biopsy of the mass should
be performed to rule out a retroperitoneal malignancy
 the specimen may be obtained using image-guided
techniques or a surgical retroperitoneal biopsy procedure,
which may be performed laparoscopically or during open
laparotomy
 once malignancy, drug effects, and infectious causes are
ruled out, treatment of the retroperitoneal fibrotic process
is instituted
 corticosteroids, with or without surgery, are the
mainstay of medical therapy
 surgical treatment
o consists primarily of ureterolysis or ureteral stenting
o required in patients who present with moderate or
massive hydronephrosis
 laparoscopic ureterolysis has been shown to be as
efficacious as open surgery in addressing this problem
 patients with iliocaval thrombosis require anticoagulation,
although the required duration of this therapy is unclear
 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 studies
 cyclosporin, tamoxifen, and azathioprine also have been
used to treat patients who respond poorly to corticosteroids
 overall prognosis in idiopathic retroperitoneal fibrosis is
good, with 5-year survival rates of 90 to 100%
 vecause long-term recurrences have been described,
lifelong follow-up is warranted

Agatep, Dela Fuente, Detera, Leynes, Rodriguez, Tejano Page 11 of 11