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ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM

SURGERY BLOCK
2012

Abdominal Wall, Omentum, Mesentery & Retroperitoneum


Dr. Gerardo R. Wenceslao
ABDOMINAL WALL
Arteries of Abdominal Wall

ANATOMY & PHYSIOLOGY OF

Abdominal Wall

Function of Abdominal Wall


protects and surrounds the abdominal viscera
provide accessory respiratory function
for urination and defecation by increasing intra-abdominal
pressure
Boundaries of Abdominal Wall
SUPERIORLY
Costal margin
Xiphoid process of the sternum
INFERIORLY:
Iliac crest
Inguinal ligaments
pubis
Muscles & Fascia of Abdominal Wall
MUSCLES:
rectus abdominis
external and internal oblique
transversus abdominis
pyramidalis
not always present
lower intercostal muscles
Muscles are enveloped by fascial sheaths and aponeurosis
Transversalis Fascia
found deep to the muscles
continuous
considered to be STRONGEST LAYER of the abdominal
wall and parietal peritoneum

Blood Supply
Superior and Inferior Epigastric arteries
located between the rectus abdominis and posterior
rectus sheath
Lower intercostal arteries
Lumbar arteries
Iliac circumflex arteries
Lymphatic Drainage
UPPER HALF of the abdomen
drains into the Axillary Nodes
LOWER HALF of the abdomen
drains into the Iliac Nodes
PERIUMBILICAL area
ascend around the ligamentum teres into the Porta
Hepatis
Nerve Supply
Lower 6 intercostal nerves
Ilioinguinal nerve
Iliohypogastric nerves
CONGENITAL DISORDERS OF THE

Abdominal Wall
Omphalocele
AKA: Exomphalos
COMMONLY associated with
malformations
Cardiac anomalies
NTD
Chromosomal abnormalities
SAC present
formed from an outpouching of peritoneum
protrudes in the midline, through the umbilicus
MANAGMENT
Surgery
Cover w/ allograft to prevent drying
Gastroschisis
Umbilical cord NOT involved in lesions
NO SAC
Parts of organs may be free in the amniotic fluid

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ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM


Herniated organs are not enclosed in a membranous
(peritoneal) sac
Lesion to the RIGHT of midline
NOT commonly associated w/ defects or chromosomal
abnormalities
Size of defect usually <4 cm
Vitelline Duct Remnants
Forerunner of the development of Meckels Diverticulum
PERSISTENCE of all or portions of the omphalomesenteric duct
can result in
Fistulas
AKA: Persistent Omphalo Mesenteric Duct
Intestinal substance may drain out of the umbilicus
sinus tracts
cysts
congenital bands
mucosal remnants
can present with an umbilical polyp or within an
umbilical cyst
a/w congenital abnormalities
cardiac defects
congenital diaphragmatic hernia
duodenal atresia
imperforate anus
gastroschisis
malrotation
Urachal Remnant
The developing bladder remains connected to the allantois
through the urachus.
Remnants of urachus include a
Patent Urachus
urinary bladder fluids drain out f the umbilicus
urachal sinus
urachal cyst.
Umbilical polyps can also be observed in association with a
urachal remnant

SURGERY BLOCK
2012

Differential Diagnosis
Ventral Abdominal Hernia
Midline Aponeurosis is affected
CAUSES
Advancing age
Obesity
Pregnancy
Lifting Heavy weights
DIAGNOSIS
Physical examination
CT scan
TREATMENT:
Plication Of The Broad Midline Aponeurosis
Rectus Sheath Hematoma
Due to rupture of the Epigastric Artery or Vein
EPIDEMIOLOGY
More frequent in female than male
M<F
rare in children
th
peak incidence in the 5 decade of life
Often SELF-LIMITING
May simulate acute abdomen
ETIOLOGY
Direct trauma to the epigastric blood vessels
Inelasticity of the artery or vein
atheromatous vessel
Debilitating illness
Collagen diseases
Blood dyscrasias
Hemophiliac
Leukemia
Anticoagulant therapy

Umbilical Hernia
result when persistence of a patent umbilical ring
may spontaneously close or many require surgical repair
Congenital Diastasis Recti
Separation of Rectus Abdominis at midline d/t more lateral
insertion of the rectus muscle to the ribs and costochondral
junction
ACQUIRED DISORDERS OF THE

Anatomy of Rectus Sheath

Abdominal Wall

Rectus Abdominis Diastasis


Separation of the pillars of the rectus abdominis muscle
MANIFESTATION
bulging of the abdominal wall in the epigastric area
wide Linea alba

Midline aponeurosis is INTACT

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CLINICAL MANIFESTATIONS
Sudden onset of low abdominal pain
Hypotension (in severe bleeding)
Tender mass on the lower abdomen
Hematoma location varies in relation to Arcuate line of
Douglas
Bleeding ABOVE the line
dont cross the midline
hematoma limited by the linea alba
bleeding is below the line
Hematoma may cross past midline
(+) Fothergill sign
mass in the abdominal wall DOES NOT cross midline
Mass does not change with flexion of the rectus
muscles
Indicates rectus sheath hematoma
Ecchymosis
(+) Cullens Sign
Periumbilical ecchymosis
DIAGNOSIS:
Medical history
Trauma
Sudden exertion

ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM


Ultrasound, CT scan, MRI
Assess cystic or complex mass w/in the rectus sheath
TREATMENT:
Stable with minimal symptoms
Bed rest and analgesic
Severe symptoms, hypotension, or diagnosis is in doubt
Surgery
Paramedian incision
evacuation of hematoma
ligation of bleeding points

BENIGN TUMORS OF

Anterior Abdominal Wall


Benign Cystic Tumors of Abdominal Wall
Epidermal inclusion cyst
Sebaceous Cyst
MC Benign CYSTIC tumor of ANTERIOR abdominal wall

Benign Solid Tumors of Abdominal Wall


Lipoma
MC Benign SOLID tumor of ANTERIOR abdominal wall
nd
2 MC Benign tumor of ANTERIOR abdominal wall
Fibroma
Leiomyoma
Rhabdomyoma
MALIGNANT TUMORS OF

Anterior Abdominal Wall


Malignant Tumors of Abdominal Wall
Liposarcoma
Rhabdomyosarcoma
Fibrosarcoma
DESMOID TUMORS
Classified as a Low Grade Fibrosarcoma
Previously classified as variant of fibromatosis or
fibroma
UNENCAPSULATED
arise from musculoskeletal aponeurotic tissues
very destructive & LOCALLY invasive
ORIGIN of TUMOR
Fibroblast
MORPHOLOGY
tan color
smooth surface.
ETIOLOGY:
Can be Familial or Sporadic
FAMILIAL
a/w Familial Adenomatous Polyposis
abnormality in Chromosome 5q
Spontaneous or Sporadic
Associated with Estrogen
Common in FEMALES
Can be Abdominal or extrabdominal
CATEGORIES:
Juvenile
Predominantly EXTRABDOMINAL
Females
Fertile
Almost exclusively ABDOMINAL
FERTILE Females
Menopausal
equal sex ratio
M=F
Frequently ABDOMINAL
Senescent
equal sex ratio
M=F
equal ABDOMINAL & EXTRAABDOMINAL
PATHOLOGY

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Usually SOLITARY
no true capsule but has a pseudocapsule with
multiple projections into the surrounding tissue
cause of RECURRENCE after its excision
Well-differentiated fibroblast and fibrocyte
with variable degree of cellularity
from moderate to almost acellular
may present w/ few or no mitoses.
Cells infiltrate the surrounding muscle
LOCAL INVASION is common
DOES NOT metastasize to lymph nodes
There are reported cases of metastasis but
very rare
DOES NOT invade the skin.
Symptoms due to compression or invasion of
adjacent muscle, tendon, nerves, periosteum,
bones, lymph nodes and ureters
DIAGNOSIS
Clinical History & Physical Examination
gives some clue as it often interrupts
intramuscular and soft tissue planes
Plain Abdominal Xray
Show visceral displacement or obstruction
Contrast enhanced studies;
Show thinning and even occasional
extravasation of intraluminal material into
the desmoid
Excretory urography
displacement of ureter and compression
Ultrasound
CT scan/MRI
MOST USEFUL diagnostic examination
shows homogenous soft tissue mass that
displaced adjacent viscera
T2 weighted MRI
illustrates relationship of desmoid
tumor to rectus abdominis muscle
T2 Weighted MRI

MANAGEMENT
Surgery
Complete Surgical Extirpation
only form of therapy that can give a
long-term remission.
PRINCIPLE
complete excision with 1-2 cm of
normal margin
RADICAL Excision
Musculocutaneous flap is needed
to close the defect
Exenteration and/or Hemipelvectomy
BEST MANAGEMENT for desmoid that
is located in the pelvis and involves
adjacent organs
Radiation Therapy
INDICATIONS:
UNRESECTABLE Desmoid tumor
Gross disease left at the margin
4.8 to 61.2 Gy dose
given in doses of 1.6 to 1.8 Gy per
fraction
5 fractions per week
Port should be designed to cover the tumor
bed w/ generous overlap margin

ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM

Chemotherapy
VAC Chemotherapy
Vincristine
Actinomycin D
Cyclophosphamide
Success rate
not good
takes up to 27 months for desmoid
tumor to respond
Pharmacology
Indomethacin
Given with high dose of ascorbic acid
effect on cyclic AMP
inhibit of Ornithine decarboxylase
Sulindac and other non-steroidal antiinflammatory drugs
Tamoxifen
because estrogen is thought to be
involved
Dicarbazine and Doxorubicin/Iridium
192 implantation
PROGNOSIS
Intra-abdominal desmoid tumor are difficult to
treat because it is usually located along the
superior mesenteric artery and its branches
Surgery will lead to SHORT BOWEL
SYNDROME

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2012

rapidly remove bacteria of foreign particles


bactericidal and absorptive properties and its ability to form
adhesions
GREATER OMENTUM
attached to the caudal border of the greater curvature of
the stomach
CONSISTS of
Gastrocolic Ligaments
Gastrosplenic ligaments
LESSER OMENTUM
attached to the lesser curvature of the stomach
2 parts
Hepatogastric ligament
Hepatoduodenal ligament
PATHOLOGICAL CONDITIONS OF THE

Omentm

RECURRENCE
If excision is not complete RECURRENCE
FACTORS contributing to local recurrence
AGE
Late teens & 30s
Recurrent disease at presentation
Inadequate incision at the time of 1st
operation
Radiation therapy not administered for
gross residual disease

Omental Torsion
The omentum twist on its long axis, causing vascular
compromise which varies from mild vascular constriction
(edema) to complete strangulation (infarction and gangrene)
Two situations that must exist to cause torsion
Redundant and mobile segment
Fixed point around which the segment can twist
2 TYPES
PRIMARY (IDIOPATHIC) OMENTAL TORSION
PREDISPOSING factors:
Anatomic variation
tonguelike projections from
the free
edge of the omentum
bifid omentum
accessory omentum
Large and bulky omentum with a narrow pedicle
Obesity
Venous redundancy relative to the omental
arterial blood supply

OMENTUM
Omentum w/ TONGUE-like
projection

ANATOMY & PHYSIOLOGY OF

Omentm

Omentum
Consist of a DOUBLE SHEET of flattened endothelium
AKA
Police Officer of the Abdomen.
Has no spontaneous or ameboid activity
Displacement occur as a result of
intestinal peristalsis
diaphragmatic excursion
postural change of the individual.
Rich in macrophages

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PRECIPITATING factors
Factos that cause omental displacement
Heavy exertion
Sudden change in body position

ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM

Coughing, straining and hyperperistalsis


with over-eating
PRESENTATION
Normal-Appearing Omentum Can Be Seen Above
The Torsion Point.
Omentum below the torsion is edematous and
congested
HISTOLOGY
Vascular congestion
Parenchymal hemorrhage
SECONDARY OMENTAL TORSION
Associated with adhesion of the free end of the
omentum to
Cysts
Tumors
foci of intra-abdominal inflammation
postoperative wounds
internal or external hernia.
2/3 due to hernias
MORE COMMON than primary torsion
EPIDEMIOLOGY
th
th
4 to 5 decade of life
male > female (2:1)
CLINICAL MANIFESTATIONS
Pain
initial and predominant symptoms
sudden, constant and gradually increase in severity.
usually on the right side of the abdomen but
sometimes it can be peri-umbilical or generalized.
Movement intensifies the pain
Nausea & vomiting
moderate leukocytosis
fever
DIAGNOSIS
Physical examination
direct and rebound tenderness
voluntary muscle spasm
abdominal mass
if torsion is large
CT scan
Useful
show an omental mass but it is non-specific for
making a diagnosis since it can also be seen in
metastatic lesion
Exploratory laparotomy
Makes Definitive diagnosis
DIFFERENTIAL DIAGNOSIS:
Acute Appendicitis
Acute Cholecystitis
Twisted Ovarian Cyst
TREATMENT
RESECTION of the involved omentum
In patients with secondary torsion
underlying condition should be corrected
Idiopathic Segmental Infarction
an acute vascular disturbance of the omentum
CRITERIA FOR THE DIAGNOSIS:
No accompanying omental torsion
No associated cardiovascular disease
No local intra-abdominal pathologic condition
No history of external abdominal trauma
ETIOLOGY:
Precipitated by thrombosis of omental vessels secondary
to endothelial injury
Usually affects the right lower segment of the omentum
Causes of endothelial damage and thrombosis
Stretching or primary rupture of the omental vein
d/t sudden increase in intra-abdominal pressure like
coughing
sneezing
Gravitational pull of an extremely fatty omentum
Anatomic peculiarity of venous drainage
EPIDEMIOLOGY
Young or middle aged adults
male predominates (3:1)

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CLINICAL MANIFESTATIONS:
Right abdominal pain
Steady pain
direct and rebound tenderness
Fever
leukocytosis
TREATMENT:
Resection of the infarcted area
to prevent the possible complication of
gangrene
adhesion formation
TUMORS OF THE

Omentum
Cystic Tumors of the Omentum
TRUE CYST
Are BENIGN
Lymphatic Cyst
caused by
obstruction of lymphatic channels
growth of congenitally misplaced lymphatic
Dermoid Cyst
Rare
lined by squamous epithelium
contains hair, teeth and sebaceous material
X-ray
Mass w/ smooth rim of calcification
CT Scan
Multiloculated cyst
PSEUDOCYST
Results from
fat necrosis
trauma with hematoma
foreign body reaction.
Has fibrous and inflammatory lining
contain cloudy, blood tinged or pus in fluid
walls are thin & translucent w/ septations
CLINICAL MANIFESTATIONS
Small cyst
asymptomatic
Large cyst
palpable abdominal mass
symptoms
heaviness
pain
manifestations of possible complications
torsion
infection
rupture
intestinal obstruction
Complicated cyst may present as an acute abdomen
DIAGNOSIS
Ultrasonography
CT scan
Exploratory Laparotomy
Makes Absolute diagnosis
TREATMENT:
Local excision
Solid Tumors of the Omentum
METASTATIC TUMOR
MC SOLID tumor of the omentum
Primary source:
Colon
Stomach
Pancreas
Ovary
MANIFESTATION
Epigastric pain
CT scan:
omental cake separating the colon and the small
bowel from the anterior abdominal wall

ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM

SURGERY BLOCK
2012

can show Peritoneal carcinomatosis from the


Stomach w/
large amounts of ascites
omental cake
diffuse nodular omental infiltration
abnormal gastric wall thickening
PRIMARY SOLID TUMOR OF THE OMENTUM
rare
50% are malignant
th
Mean age is 5 decade of life
MANIFESTATIONS
have vague abdominal pain
some are asymptomatic
Benign Solid Tumors Of The Omentum
Lipoma
MC benign SOLID tumor
MORPHOLOGY
soft tissue composed of big mature adipose
cells with the laterally displaced nuclei.
macrophages and giant cells with several
nuclei are located near necrotic lipocytes
Leiomyoma
Fibroma
Neurofibroma
Malignant Solid Tumors Of The Omentum
most common malignant tumors are:
Leiomyosarcoma
Hemangiopericytoma
solid and encapsulated
without central necrosis or hemorrhage
oval-shaped, red-brown tumor with soft-cut
surface
vascular spaces of varying size
TREATMENT
Surgical excision
resection of adjacent organ
total omentectomy in malignant tumor
Resection of benign tumors
curative
Palliative omentectomy
for metastatic tumor implant in the omentum
suggested to control any associated ascites
PROGNOSIS
POOR Prognosis
metastatic tumors
primary malignant tumors of the omentum
MESENTERY
ANATOMY & PHYSIOLOGY OF

Mesentery
Mesentery
Reflection of anterior peritoneum to the surface of the
intestine
Connects the intestine to the posterior abdominal wall
Transmits vessels and nerves
Congenital defects
usually found in
Lower ileum
Sigmoid mesocolon
Transverse mesocolon
space of Riolan
can cause INTERNAL Abdominal Hernias
LOCATION
A: paraduodenal
B: foramen of Winslow
C: intersigmoid
D: pericecal
E: transmesenteric
F: retroanastomotic
Can lead to
Small Intestine Infarction

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INTERNAL Abdominal
Hernias

FUNCTION of Mesentery
bactericidal and absorptive properties
Like the omentum
ability to form adhesions
Mesenteric Circulation
Contains 1/3 of the total blood volume
Receives 25-30% of cardiac output
Helps maintain body homeostasis by serving as reservoir in
periods of hypovolemia by autotransfusion
MAIN ARTERIES
CELIAC ARTERY
Stomach
Duodenum
SUPERIOR MESENTERIC ARTERY
rd
3 portion of duodenum to mid transverse colon
BRANCHES
Middle colic artery
Right colic artery
Ileocolic arteries
Jejunal arteries
Ileal arteries
Inferior Pancreaticoduodenal
INFERIOR MESENTERIC ARTERY
Left transverse colon to proximal rectum
BRANCHES
Left Colic Artery
Superior Hemorrhoidal Artery
COLLATERAL CIRCULATION
Between Celiac and Superior mesentery Artery
Superior Pancreaticoduodenal art (from Celiac)
Inferior Pancreaticoduodenal ( frm Sup mesentery)
Between Superior and Inferior mesentery Artery
Middle Colic and left colic (ascending branch)
Between Inferior mesentery and Internal iliac Artery
Superior hemorrhoidal (frm. Inf mesentery)
Inferior hemorrhoidal ( frm Int. Iliac)
Mesentery Response to Pharmacologic Agents
Vasodilatation
Nitroglycerine
Tolazoline
Papaverine
Vasoconstriction
Digitalis
Norepinephrine (alpha adrenergic)
Epinephrine-dose dependent
High dose (alpha adrenergic)
vasoconstrction
Low dose (beta adrenergic)
Vasodilatation

ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM

OCLUSIVE DISEASES OF THE

Mesentery
Occlusive Diseases
Acute mesenteric ischemia
Emboli
thrombosis
Chronic mesenteric ischemia
Long standing atherosclerosis
Involves at least 2 of the three mesenteric arteries
Non-occlusive mesenteric ischemia
Acute Mesenteric Ischemia
SMA most common involved vessel.
Based on ETIOLOGY
Acute Thrombotic Mesenteric Ischemia
With underlying atherosclerosis
Typically involves the origin of SMA.
Spares the collateral branches
Acute Embolic Ischemia
Emboli usually is of cardiac in origin.
Commonly seen in patients with atrial fibrillation or
after MI
Typically lodge the origin of the middle colic artery

Based on ARTERY Involved


ACUTE SUPERIOR MESENTERIC ARTERY OCCLUSION
Occlusion to the origin of SMA
Ischemia from the level of the ligament of Treitz
to the proximal 2/3 of the transverse colon
If celiac artery is patent-proximal 10-12cm of the
jejunum will be viable
Occlusion of the distal branches of SMA
Segmental intestinal ischemia
May infarct depending on the status of the
collateral circulation
EPIDEMIOLOGY
More in males
50 60 years old
CLINICAL Manifestations
Abdominal pain
out of proportion to the physical findings
CLASSIC PRESENTATION
Sudden onset of crampy abdominal pain in
patient with underlying cardiac or
atherosclerotic disease
Bloody diarrhea
Fever
nausea & vomiting
abdominal distention
Rebound, rigidity & diffuse tenderness
DIAGNOSIS
Leukocytosis
> 20,000/cubic mm
Hemoconcentration
due to
fluid accumulation in extravascular
compartment
vomiting

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Elevation of serum amylase


indicative of bowel necrosis
Plain film
findings occur late
Thumbprinting
submucosal edema
Air filled loops of small intestine
Gas in the colon wall
late radiographic sign
multiple air fluid
levels,
suggestive
of
intestinal
obstruction
Duplex ultrasound
non invasive imaging study
Bi planar arteriography
single MOST IMPORTANT diagnostic tool.
Can be therapeutic
Can distinguish between emboli and
thrombosis
Emboli-occlusion
at the origin of branch middle
colic artery
(+) meniscus sign
thrombosis-occlusion
at the origin of superior
mesenteric artery
TREATMENT
Emboli
CONSERVATIVE Management
Fluid resuscitation
Systemic anticoagulation
heparin
Sodium bicarbonate
For metabolic acidosis
Antibiotics
SURGERY
Laparotomy & embolectomy +/resection
Intraoprative IV fluorescein w/ Woods
lamp
to asses viabilty of the intestine
Second look OR
24-48 hrs after
Thrombi
severely atherosclerotic vessel-Ca and SMA
Laparotomy and arterial reconstruction
+/- resection
Saphenous vein
graft material of choice
Prosthetic material
must be avoided in pt. with
non viable bowel
By-pass may originate in the aorta
or iliac
Types of SMA Bypass
Iliac artery SMA bypass w/ Prosthetic
Graft
Suitable for SMA thrombosis w/
salvageable bowels
Iliac artery SMA bypass w/ Saphenous
Vein
Suitable for SMA thrombosis w/
necrotic or perforated bowels

PROGNOSIS
Mortality rate
85%- due to delay with diagnosis
Thrombosis
higher mortality rate than emboli

Chronic Vischeral Ischemia


AKA: Intestinal Angina
CAUSES
95% d/t atherosclerosis involving

ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM


Celiac artery
SMA
Other Causes
Takayasus arteritis
Periarteritis nodosa
Thromboangitis obliterans
Median Arcuate ligament syndrome
Due to extrinsic compression of the CA by fibers
from the diaphragm
Gradual occlusion allows the development of collateral vessels
that prevent the manifestation of acute ischemia
Blood flow is insufficient to meet the high post-prandial oxygen
requirement
Epidemiology:
More common in women
th th
6 -7 decade
Clinical manifestations
+ risk factors and stigmata of atherosclerosis
PAIN
Dull , persistent epigastric and periumbilical pain
Occurs 20 mins after eating
exacerbated by large meal and solid foods
Severe weight loss
Malabsorption syndrome
DIAGNOSTIC STUDIES
Bi-planar contrast arteriography
Definitive diagnostic method
Typically demonstrates collateral circulation
Non invasive Tests
Duplex ultrasound
TREATMENT
Mesenteric revascularization
Ante grade aorto visceral bypass
EXAMPLE
Supraceliac aorta to Celiac
Supraceliac aorta to SMA
occlusion 1-2cm distal to the origin of the
mesenteric vessel
Less
demanding
technically
than
endarterectomy
Transaortic visceral endarterectomy ostial lesions/patent CA or SMA
Transect the medial arcuate ligament
For Median Arcuate Ligament Syndrome
Endovascular Treatment
Chronic Mesenteric ischemia
Stent
angioplasty
Acute mesenteric Ischemia
Catheterdirected thrombolytic therapy ( CDT )
Best if done within 12 hours of the onset of symptoms
Drawbacks:
Doesnt allow inspection of the intestine
Takes time
Delayed operative revascularization
Non-Occlusive Mesenteric Infarction
Etiology:
Low Cardiac output (C.O.)
History of digitalis intake
Associated with
Septicemia
CHF
Dehydration
Arrhythmia
acute myocardial infarction
Pathology:
Hemorrhagic necrosis
Clinical manifestations:
Malaise
vague abdominal discomfort
Associated CHF w/ or w/o arrythmia
Over digitalization

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Infarction
preceded by sudden and severe abdominal pain and
vomiting
Hypotension
rapid pulse
Watery diarrhea
grossly bloody stools
Diagnostic aid:
Angiography
segmental mesenteric vasospasm w/ normal SMA
Treatment:
Correct the underlying disorder producing the low flow
state
Infusion of vasodilator (Papaverine) thru the catheter
Improvement OBSERVE
No improvement SURGERY
segmental resection with end to end anastomosis
Mortality = 80 %
Colonic Ischemia
Etiology:
chronic obstruction of the inferior mesenteric artery
Causes of obstruction
Atherosclerosis
Cholesterol emboli
Inflammatory arteriopathies
Iatrogenic
Produces symptoms only if collaterals are compromised
Middle colic (from SMA) and ascending limb of left
colic
Superior
hemorrhoidal
and
middle/inferior
hemorrhoidal (branch of internal iliac)
Distribution of blood flow to the colon
originating from the inferior mesenteric artery
branches
left colic
marginal
sigmoid arteries
superior hemorrhoidal
supply the
left colon
superior portion of the rectum
Clinical manifestations:
Descending and sigmoid colon
most commonly affected
Non-specific crampy left lower quadrant mild abdominal
pain
Urge to defecate followed in 24 hours by melena or
hematochezia
Maybe reversible
outcome ranging from complete healing to stricture
formation with obstruction, infarction and perforation
Diagnosis:
Bi-Planar mesenteric angiogram
TREATMENT:
50%- responds to supportive measures
Resection of ischemic segment and temporary colostomy
(Hartmanns )
Mesenteric Venous Occlusion
Etiology:
Thrombosis of the mesenteric venous circulation
Idiopathic-25%
Secondary-75%
80%-jejenum and ileum are involved
Predisposing conditions:
Previous deep vein thrombosis
Intrabdominal infections
Oral contraceptive
Post-operative state
Hypercoagulable disorders
Polycytemia vera
thrombocytosis
Clinical manifestations:
Acute form

ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM


abdominal pain disproportionate to physical findings
Pain not relieved by narcotics
Anorexia
Diarrhea with occult or frank blood
Chronic form
Persistence of mild symptoms w/o progression to
infarction
Diagnosis:
contrast-enhanced CT scan
most useful dx modality
Treatment:
Intravenous heparin
cornerstone of therapy
Correct fluid and electrolyte imbalance
Decompress the stomach
Antibiotic
X-lap & resection of infarcted bowel
Lifelong anticoagulation with Coumadin
prevents recurrence

TUMORS OF

Mesentery
Tumors of Mesentery
Most are benign
Most are cystic
Benign tumors
more common in female patients
Malignant tumors
more common in males
2/3 are located in the mesentery of the small bowel
mostly in the ileum
Cystic Lesions
Benign Cystic lesions
Chylous or lymphatic cyst:
developmental defects in mesenteric lymphatics
unilocular or multilocular
Traumatic cysts
lined by fibrous tissue
contains body fluid
Enteric cyst:
lined by intestinal mucosa
duplication of the intestinal tract that do not
communicate with the bowel lumen
Dermoid cyst:
cystic lesion of embryonal tissue
Malignant cystic tumors
Lymphangiosarcoma
Malignant teratom
Solid Tumors
Benign
more common
Develop in the periphery near the intestine
Can recur if incompletely excised
Can degenerate to malignant variety
Common Benign tumors
Lipoma
Fibroma
leiomyoma
Malignant solid tumors
Arise near the root of the mesentery
Spread by
local extension
peritoneal implants
COMMON malignant tumors
Liposarcoma
leiomyosarcoma
Clinical manifestations:
Most are asymptomatic

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The mobility of the mesentery permits the tumors to grow


to very large size before causing symptoms
Symptoms appear sooner those tumors that near the
periphery
Sensation of fullness in abdomen after eating
Diagnosis:
Ultrasound
CT scan
Contrast enhanced radiograph
Helpful only is the tumor is of sufficient size to cause
compression or displacement of bowel
TILLAUX Sign
presence of a resonant area between the pubic bone
and a tumor is an indication of a mesenteric tumor
Treatment:
Benign cystic tumors
Enucleation or excision
Resection in continuity with the small bowel
Benign solid tumors
Wide excision with resection of adjacent bowel
Malignant tumors
Often involve the great vessels and vessels to the
large and small bowel
Few are totally resectable
INFLAMMATORY CONDITIONS OF

Mesentery
Nonspecific Mesenteric Lympadenitis
Self-limiting disease
diagnosed only at laparotomy
Most common inflammatory enlargement of the abdominal LN
surpassing T.B.
Usually affects LN at the ileocecal area
due to decrease intestinal transit at this area
MANIFESTATIONS
similar to acute appendicitis
Mesenteric Panniculitis
AKA: Retractile Mesenteritis
Extensive thickening of the mesentery of the small bowel by a
non-specific inflammatory process
Affects male more
M>F
rare in children
Etiology:
Unknown:
could be due to insult of the fatty tissue of the
mesentery
Treatment:
Laparotomy is done to rule out carcinoma or sarcoma
Steroid
radiotherapy

ANEURYSM OF

Splanchnic Arteries
Visceral Artery Aneurysm
Uncommon
Splenic artery
involved in 60%
Hepatic artery
second most common at 20%
May occur spontaneously w/o known cause
Etiology:
Recognized causes are:
Connective tissue disorder
Mycotic Infection
Pancreatitis
Trauma

ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM

multiparity

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Pelvic Diaphragm
LATERAL
Trasversalis Fascia
Inner aspects of lateral abdominal muscles
POSTERIOR
Body Wall
Organs
Secondary Retroperitoneal Structures
Portions of duodenum: segment 2
Pancreas
Ascending & descending colon
Primary Retroperitoneal Structures
Kidneys
Renal pelves
Ureters
Adrenal glands
Large nerves
IVC
Aorta
Diagnostics
Physical Examination
Radiologic procedures
Pyelography
Venography
Arteriography
Ultrasonography
CTscan/MRI

TUMORS OF

Retroperitoneum
Splenic artery aneurysm
More common in female
Most are asymptomatic
Some presents as left upper quadrant pain radiating to the
left clavicle
Diagnosis is usually incidental
X-ray of the abdomen
Left upper quadrant ring like calcification
Rate of rupture
Non-pregnant-2%
Pregnant-90%
Treatment:
Observation
Resection or ligation w/ or w/o splenectomy
Indications for surgical intervention
Presence of symptoms
Pregnancy
Intention to become pregnant
>2cm size of the aneurysm
Other aneurysms
Surgical correction
high incidence of spontaneous rupture
Celiac artery
excision without reconstruction
Hepatic and SMA
excision with reconstruction with autogenous
venous graft
RETROPERITONEUM
ANATOMY & PHYSIOLOGY OF

Retroperitoneum
Retroperitoneum
Anatomy
Boundaries
SUPERIOR
Diaphragm
ANTERIOR
Posterior Parietal Peritoneum
INFERIOR

10 Schwartzs Principle of Surgery 8th edition

Primary Tumors of Retroperitoneum


Neoplasms arising from tissue that occupy the potential space
(soft tissue, nerve element and blood vessels)
Developed independently and have no connection with any
organs and major vessels
Malignant tumors out number benign tumors (4:1)
Benign Tumors
Lipoma
most common
Lymphatic or chylous cyst
Cyst of urogenital origin
Dermoid
Enterogenous cyst
Malignant Tumors
Lymphomas & Sarcomas
most common
Liposarcoma & Leiomyosarcoma
most common sarcomas
Undifferentiated sarcoma
Rhabdomyosarcoma
Neurogenic sarcoma
Clinical Manifestations:
Symptoms:
Tumor growth
unrestricted
only produces symptoms when it compresses on
adjacent structures (after attaining a large size)
Early symptoms is absent or very vague
Enlarging abdomen, sense of fullness or heaviness,
vague pain and backaches, loss of weight
Bowel involvement:
nausea and vomiting
anorexia
bowel changes
weakness
hematemesis
GUT:
Hematuria
Dysuria
Urgency
frequency of urination
signs and symptoms of uremia
Nerve root:

ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM


radiating pain to both thighs
Major vessels:
swelling and varicosities of lower extremities
hypertension
MI
cardiomegaly
Physical Examination:
Abdominal mass, non-tender
Fixed hard malignant
Soft, ballotable benign
Ascites
due to compression of portal vein or hepatic vein
Edema of lower extremities
scrotal varicosities
dilated superficial abdominal veins
Enlarged hemorrhoidal vessels
Diagnosis:
Clinical history and physical examination
UGIS and Barium enema
Intravenous Pyelography
Ultrasonography
CT scan
Aortography
Needle Biopsy (Histologic Diagnosis)

Treatment:
Surgical
1/3 Inoperable (Distant Metastasis)
Operable Cases (Biopsy Frozen Section)
Malignant
wide excision
transperitoneal approach
Benign
complete resection
recur liposarcomtous change
OUTCOME
< 25 % can be completely resected with
anticipated cure
10 25 % operative mortality
30 50 % recurrence rate
Tumors become more malignant with each
recurrence
re-operation becomes more hazardous
Long term survival reported after multiple
resection
Irradiation
Palliative
rarely curative
affords relief of pain and obstruction
Indications:
Inoperative tumors
Tumor recurrence following previous resection
Radiosensitive tumors
Lymphoma
Adjunct to surgery
Neuroblastoma
Liposarcoma
Rhabdomyosarcoma
Undifferentiated Anaplastic Sacrcoma
Radiotherapy and/or Chemotherapy
treatment of choice for malignant lymphomas
Overall prognosis: POOR
5 Year survival- less than 10%
Chemotherapy (Lymphoma)
FIBROSIS OF

Retroperitoneum
Retroperitoneal Fibrosis
Non-specific non-suppurative inflammation of the fibroadipose
tissue
More common in MALES

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Produces symptoms of gradual compression of retroperitoneal


tubular structures
Ormonds disease
Primary,idiopathic
Allergic or autoimmune
Akylosing spondylitis
SLE
Polyarteritis Nodosa
Secondary reaction to an inciting inflammatory process,
malignancy or medication.
Methysergide
Beta blockers
Alpha- methyldopa
Signs and symptoms
Dull poorly localized abdominal pain
Unilateral leg swelling
Intermittrent claudication
Oliguria, hematuria and dysuria
Physical examination:
Hypertension
Abdominal or flank mass
Diminished lower extremity pulses
Lower extremity edema
Laboratory examination:
Elevated ESR
Elevated BUN/ Creatinine
Imaging modalities
Lower extremity ultrasound
Useful for
iliocaval compression
renal symptoms
Abdominopelvic CT w/ oral and IV contrast
Imaging procedure of choice
Shows the extent of fibrotic process
MRI
for those with impaired renal function
Treatment:
Discontinue medication causing the lesion
Biopsy of the mass lesion
image guided laparoscopicaly
Corticosteroids with or W/O surgery
mainstay
Prednisone 60mg every other day-2 months
Cyclosporin, tamoxifen,azathioprine
for those with poor response to steroids
Lap ureterolysis/ureteral stenting
Arteriolysis/ bypass with vascular graft

ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM


Q&A
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.
12.

13.

14.

15.

16.

Surgical diseases of abdominal wall


A. Infection
B. Desmoid Tumors
C.Hernia
D.All
Strongest layer of abdominal wall
A.transversalis fascia
B.Linea alba
C. Transverse abdominal muscle
D.Rectus abdominus
Failure of desmoids tumors surgery
A.Adequate incision
B.Radition therapy
C.Age between late teen and 30 years
D.Primary diseases and presentation
Etiology of rectus sheaths of hematoma
A.Direct trauma of epigastric
B.Coughing and sneezing
C.Both
D.None
True of omentum
A.Double sheet of flat endothelium
B. Police officer of abdominal
C.Both
D.None
Predisposing factor or PRIMARY OR IDIOPATHIC omential
torsion
A.Heavy exercisoin
B.Anatomical variation
C.Hyperperistalsis with pvereating
D.Coughing and straining
Most common tumor of ommentum
A. Metastatic carcinoma
B. Liomyosarcoma
C. Hemangiopericitoma
D. Neurofibroma
intestinal angina :
A. acute occlusion of superior mesenteric artery
C. mesenteric venous occlusion
D. nonocclusive mesenteric infarction
D. chronic occlusion of visceral arteries
most common benign tumor of retroperitoneal
A. desmoids
B. lipoma
C. chylous cyst
D. lymphatic cyst
Idiopathic retroperitoneal fibrosis
A. nonsupparative inflammation of fibroadipose tissue of
unknown cause
B. produce symptom of gradual compression
C. both of the above
D. none
Anterior boundary of retropertoneum: peritoneal
Content of retroperitoneum, EXCEPT
A.kidneys
B. pancreas
C.abdominal aorta
D.stomach
treatment of dermoid cysts:
A.incision
B.excision
C.both
D.none
Most common primary malignant solid tumor of omentum
A.leiomyoma
B.fibroma
C.neurofubroma
D.hemangiopericytomas
CT scan finding of metastatic tumor of omentum
A.omental cake
B. smudgedappearance
Periods of natural history idiopathic retropentional fibrosis
a. Period of activity
b. Period of incident and development
c.
Both

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d. None
17. Most common malignant retroperitoneal tumors
a. Sarcoma
b. squamous cell CA
c. Adeno CA
d. Lymphoma
18. Benign retroperitoneal tumors
a. Mesenchal tyhoma
b. Sinouoma
c. Cyst of Urogential origin
d. Lipoma
19. True of omentum
a. double sheet of flattened endothelium
b. police officer of the abdomen
c. both of the above
d. none of the above
20. Predisposing factor of primary or idiopathic omental torsion:
a. heavy exertion
b. anatomic variations
c. hyperperistalsis with overeating
d. coughing and straining
21. Most common tumor of omentum:
a. Leiomyosarcoma
b. metastatic carcinoma
c. hemangiopericytoma
d. None

22. most common malignant retroperitoneal tumor:


a. sarcoma
b. squamous cell CA
c. adenocarcinoma
d. lymphoma
23. Intestinal angina
a. acute occlusion of superior mesenteric artery
b. acute mesenteric venous occlusion
c. nonocclusive mesenteric infarction
d. chronic occlusion of visceral arteries
24. Idiopathic retroperitoneal fibrosis
a. nonsuppurative inflammation of fibroadipose tissue of
unknown cause
b. produce symptom of gradual compression of tubular
structure in the retroperitoneum
c. both of the above
d. none of the above
25. Most common benign tumor of retroperitoneum:
a. desmoid tumor
b. Lipoma
c. Chylous cyst
d. lymphatic cyst
26. Anterior boundary of Retroperitoneum:
a. Peritoneum
b. Spine
c. brim of pelvis
d. psoas muscle
27. Contents of retroperitoneum, EXCEPT:
a. Kidneys
b. Pancreas
c. abdominal aorta
d. stomach
28. Periods in the natural history of idiopathic retroperitoneal
fibrosis
a. period of activity
b. period of incidence and development
c. both of the above
d. none of the above
29. Treatment of omental torsion
a. supportive
b. resection
c. both of the above
d. none of the above
30. Primary malignant tumor of the omentum are the following,
EXCEPT:
a. Myxoma
b. Leiomyosarcomas
c. Liposarcomas

ABDOMINAL WALL, OMENTUM, MESENTERY, RETROPERITONEUM


d. Rhabdomyosarcomes
31. Most common primary malignant solid tumor of omentum:
a. leiomyoma
b. fibroma
c. neurofibroma
d. hemangiopericytomas
32. Etiology of idiopathic segmental infarction:
a. thrombosis of omental veins
b. embolism of omental veins
c. both of the above
d. none of the above
33. The most common site for visceral artery aneurysm is:
a. Hepatic Artery
b. Coeliac Artery
c. Splenic Artery
d. Superior Mesentery Artery
34. Predisposing factors for primary Idiopathic Infarction, EXCEPT:
a. Malnutrition
b. Anatomic Variation
c. Large and Bulky Omentum w/ narrow pedicle
d. Venous redundancy
e. NONE of the above
35. Omental Infarction is described by:
a. Interruption of blood supply to omentum
b. Torsion of omentum around vascular pedicle
c. Thrombosis or Vasculitis of Omental vessels
d. Omental venous outflow obstruction
e. All of the above

36. Clinical Manifestations of Omental Torsion, EXCEPT:


a. Sudden, Constant & gradually severe pain at Right
Abdomen, sometimes periumbilical or generalized
b. Female to Male preponderance ratio of 2:1
c. PE- Direct rebound tenderness, palpable mass if enlarged
d. Movement intensifies pain
37. Criteria for DIAGNOSIS of Idiopathic segmental Infarction,
EXCEPT:
a. No accompanying Omental Torsion
b. No local intra-abdominal pathology
c. No associated Pulmonary disease
d. No history of external Abdominal Trauma
38. Differential Diagnosis for Idiopathic segmental Infarction,
EXCEPT:
a. Amoebic Colitis
b. Cholecystitis
c. Appendicitis
d. Perforated peptic ulcer

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