SURGERY 2

Anterior Abdominal Wall / Dr. Dr. Gaudencio I. Abratique / 27th October 2017

ANTERIOR ABDOMINAL WALL

 Important board type question: Arcuate line of douglas – As a

surgeon you must know this.
 It is approximately located in the level of ASIS.
 When you do midline incision, may pagkakaiba yung superior and
inferior part of the rectus sheath.
 Above the arcuate line binubuo sya ng aponeurosis of external
oblique, internal oblique and the external lamina of the external
oblique muscle.
 Posterior rectus sheath is made up of internal lamina of the internal
oblique, the aponeurosis of transversus muscle and the transversalis
fascia.  Blood supply of the anterior abdominal wall
 Below the arcuate line, approximately at the level of ASIS, The o Superior epigastric vessels – coming from internal
anterior rectus sheath is made up of external oblique aponeurosis ng thoracic artery
dalawang lamina (external and internal lamina of internal oblique). o Inferior epigastric vessels – coming from external iliac
 Below the arcuate line, Yung posterior rectus sheath wala na syang artery
aponeurosis.
 When you close the abdomen yun yung kinoclose mo yung mga RECTUS SHEATH HEMATOMA
fascia.
• Bleeding into the rectus sheath
• Result of the rupture of the epigastric arteries
• Self-limiting
A. Etiology
• Infectious diseases
• Debilitating diseases
• Collagen diseases
• Blood dyscrasias
• Patients on anticoagulation therapy
You must know this things so that you’ll know what to ask to ask to the
patient
B. Clinical Manifestation
• Three time more common in women than in men
• Peak age incidence at the 5th decade
C. History
• Previous trauma
• Sudden muscular exertion
• Generalized vascular disease
• Anticoagulation post-surgery 4-14 days post-treatment
D. Symptoms
• Pain - first
• Sudden, sharp, progressively severe
• Anorexia, nausea, vomiting, tachycardia, low grade fever,
leukocytosis
E. Signs
• Tenderness/spasm at the site of haemorrhage
• Bowel sounds not altered
• (+) or (-) palpable masses
• (+) Fothergil’s sign – may mass. When you let the patient take a deep
breath or do Valsalva. Not unless sobrang laki na nung mass. If the
mass is intra abdominal positive yun. Hindi sya mawawala. Pero pag
nawala sya
• Bluish discoloration of skin in 3-4 days
F. Diagnostics
• Ultrasound
• Computed tomography (CT scan)
o Cystic or complex mass lesion within the rectus
sheath

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TOPIC: Anterior Abdominal Wall

C. Management
• Surgical treatment
o Adequate tissue biopsy
o Complete surgical extirpation (removal) - Complete
excision with a 1 or 2 cm margin of all tissue
o Extent of excision must be “radical”
• Radiation treatment – unresectable and gross disease left
• Chemotherapy treatment – vincristine, actinomycin D,
cyclophosphamide
• Pharmacologic treatment – polynucleotides, theophyline,
Tip: When you request for this things, Do not rely so much on the readings. In indomethacin with high dose ascorbic acid, sulindac and NSAIDS
general, It is much better if you talk to the radiologist/CT scanner para mas
D. Features contributing to Local Failure
madali yung diagnosis kasi igaguide ka nya.
G. Treatment • Age between the late teens and the third decade
• Recurrent disease at presentation
• Make sure that this is not a surgical abdomen. Make sure that this is • Inadequate excision at time of OR
really an acute hematoma. • Radiation treatment not done for gross residual disease
• Bed rest/analgesics
• Discontinue anticoagulants
• Surgery (occasionally) to relieve symptoms and to rule out other more DISEASES OF THE OMENTUM
serious diseases. Sometimes in surgery kailangan mong irelease • Torsion
yung hematoma or you have to ligate the vessel. Yung epigastric • Idiopathic Segmental Infarction
vessel pwede mong iligate yun. • Cysts
• Solid Tumors
DESMOID TUMORS
• Desmoid: greek meaning “band like appearance” Torsion
o Locally aggressive, tendency to recur, high ultimate • The organ twists on its long axis, casing vascular compromise
mortality • 2 situations must exist:
o Low grade malignant lesions-low grade fibrosarcoma o Redundant and mobile segment
A. Etiology o Fixed point around which the segment can twist
• Spontaneous: 4.4 – 5: 1 ratio
• In patients with FAP
• Incidence: 2-5 cases in one million
• Sporadic – in abdominal wall and extraabdominal sites
• Juvenile/associated with women of childbearing age
B. Diagnosis
• Ultrasound
o Nonspecific, hypoechoic mass with poor enhancement
• Angiography
o Arterial displacement/ stretching, fibrotic reaction
along mesenteric arteries most common early
manifestation
• CT scan/MRI
o Most useful radiologic exam = homogenous soft tissue
mass and adjacent viscera displaced

A. Etiology
• Primary or idiopathic – cause is obscure
• Secondary – associated with adhesions of free end of the omentum
(ex. Previous surgeries)
B. Clinical Signs and Symptoms
• Occurs in the 4th or 5th decade of life
• M:F – 2:1
• Initial predominant symptom: PAIN
• Nausea and vomiting, fever,
• Tenderness and rebound tenderness and voluntary spasm (it may
present as surgical abdomen)
• Mass may be palpable
C. Differential Diagnosis
Halos same sya sa CT scan ng rectus sheath hematoma pero notice nyo hindi
sya masyadong smooth unlike sa rectus sheath hematoma smooth sya. • Acute appendicitis
Character kasi sya ng tumor pag yug borders nya hindi masyadong smooth. • Acute cholecystitis
• Twisted ovarian cyst
D. Treatment
• Resection of involved omentum (tie it)
• Secondary torsion (hernia, cysts, adhesions etc) should be connected
(secondary problem involved e.g. hernia, remove the cysts or lyse the
adhesions)

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IDIOPATHIC SEGMENTAL INFARCTION SOLID TUMORS

• Acute vascular disturbance of the omentum • Most common: metastatic carcinoma (solid tumor coming from
• Precipitated by thrombosis of the omental veins secondary to neighboring tissues or organs that have carcinoma)
endothelial injury • Primary source of metastasis: colon, stomach, pancreas or ovaries
• common in young or middle aged adults • Mean age of occurrence: 5th decade
• 3:1 predilection to males A. Diagnosis
Clinical Signs and Symptoms • CT scan findings – soft tissue mass “omental cake”
• Associated with anorexia and nausea frequent vomiting is rare B. Tumor Types
• Tenderness and rebound tenderness and voluntary guarding is a • Primary Solid tumor: Rare
common symptom • Benign Tumors: Lipomas, leiomyomas, fibromas and neurofibromas
• Moderate leucocytosis • Ending in –oma are benign
A. Treatment
• Treatment resection of the infarcted area

Nangigitim = infracted area

Yellowish = tumors
CYSTS • Malignant tumors: leiomyosarcomas, and hemangiopericytomas
B. Signs and Symptoms
• Rare
• Small cysts – asymptomatic/incidental findings at laparotomy and • Mean age of patients: 5th decade
autopsy • Asymptomatic or vague abdominal pain, palpable abdominal mass
• Large cysts – palpable mass or diffuse swelling C. Treatment
• Incidental finding during laparotomy; if small cysts you can just • Treatment will be surgical excision (remove all the omentum)
remove it; usually benign
A. Diagnosis
• Plain Radiographs – circumscribed soft tissue haziness (cyst is fluid MESENTERY
filled that’s why it’s haze unlike mass which is solid)
• Acute Occlusive Visceral Ischemia
• Barium meal – displacement of intestinal loops (seen in xray)
• Nonspecific Mesenteric Lymphadenitis
• UTZ or Ct scan – fluid filled mass
B. Differential Diagnosis
ACUTE OCCLUSIVE VISCERAL ISCHEMIA
• Cysts and solid tumors of the mesentery, peritoneum and
retroperitoneal region • Incidence and Risk Factors for Acute Mesenteric Ischemia
C. Treatment • Mesentery has lots of blood vessels (arteries & veins)  thrombus
• Local excision (benign condition only) from other blood vessels may lodge in these mesenteric vessels
(embolus )  ischemia
Etiology Incidence (%) Risk Factors
SMA embolus 40 – 50 Atrial or
ventricular
thrombus,
arrhythmia
synchronus
emboli
SMA 20 – 35 History of chronic
thrombosis mesenteric
ischemia, diffuse
atherosclerotic
vascular disease
NOMI 20 - 30 Use of vasospastic
medications,
myocardial
depression,
hypotension
MVT 5 History of DVT or
hypercoagulability

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TOPIC: Anterior Abdominal Wall
Clinical Signs and Symptoms
• Pain out of proportion to physical findings (sobrang aray pero on PE
the abdomen is soft)
• Abdominal pain – acute, intense and diffuse
• Vomiting
• Pain unresponsive to narcotics
• Occult blood on stool or frank bloody diarrhea hematochezia or
melena
• Early abdominal examination – remarkable for paucity (konti) or
absence of findings (requires high index of suspicion, continue
diagnosing because you don’t want to catch this late.)
• Late findings – localization of pain and development of peritoneal
signs (board-like abdomen)
• Board exam question: common in the elderly (those living in home for
the aged)
A. Diagnosis
• Laboratory investigation too non specific
• Diagnosis must be done on clinical grounds and requires a high index
of suspicion
• Leukocytosis >20,000/mm3, hemoconcentration, metabolic acidosis,
elevated serum lactate and amylase levels
• Plain films of the abdomen, UTZ, CT, MRI
• Contrast arteriography, including lateral aortography and selective
injection of SMA – the single most important diagnostic maneuver
(karamihan din a umaabot dito namamatay na yung patient or
unstable na yung patient you need to go to surgery immediately)
D. Treatment
A.
D.
E.
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NONSPECIFIC MESENTERIC LYMPHADENITIS
• Common cause of abdominal pain in children and young adults,
under 18 y/o, no sex predilection
• Self-limiting
• Most common cause of inflammatory enlargement of abdominal
lymph glands  may cause abdominal pain that mimics appendicits
• Similarity to several abdominal conditions
• Common ddx for acute appendicitis
• Namamagang kulani tapos with abdominal pain
Clinical Signs and Symptoms
• Signs and symptoms are non-characteristic
• Recent sore throat or upper respiratory tract infection
• pain is the first symptom and initial pain on upper abdomen on Right
lower quadrant or generalized and localized on the right side
• patient unable to indicate exact site of most intense pain (di niya
maturo)
• between spasms of colic, patient feels well (meron, wala, meron,
wala, meron uli, wala uli, meron then wala) (crescendo like)
• nausea, vomiting, malaise and anorexia inconsistent symptoms
• patient appears flushed with associated URTI
• 20% lymphadenopahty most often cervical
• Tenderness on lower aspect of right side (higher and more medial
and less severe than acute appendicitis)
• Rebound tenderness may or may not be present
• Voluntary guarding maybe present
• Early part temperature elevated 38 to 38.5C
• At least have leukocytosis over 10,000
• (ask the patient for previous or associated cough and cold because it
is usually assoc with URTI; Very impt so you won’t miss the right dx)
Differential Diagnosis
• Acute appendicitis
• Regional enteritis
• Intussusceptions
• Specific bacterial and granulomatous adenitis
• Lymphoma
• Infectious mononucleosis
Treatment
• Prognosis excellent
• Complete recovery expected without specific treatment
RETROPERITONEUM
• Idiopathic Retroperitoneal Fibrosis
• Retroperitoneal Tumors
IDIOPATHIC RETROPERITONEAL FIBROSIS
• Non-specific, non-suppurative inflammation of fibro-adipose tissue of
unknown cause that produces symptoms by the gradual compression
of tubular structures on the retroperitoneal space
• Tubular structures in the retroperitoneal space: aorta, ureter
• Sinasakal yung mga tubular structures
• Retroperitoneal area napupuno ng inflammation  titigas (fibrosis)
• 2-3x more common in men
• 40 to 60 years of age
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A. Etiology C. Diagnosis/ Treatment

• Obscure etiology theories
• Extravasated urine cause a fibrotic reaction
• Abortive infection elsewhere
• Hypersensisitivity to anti serotonian drug methysergide
• Immune basis as cause
B. Pathology
• Gross appearance plaque of woody, white fibrous tissue along the
course of periaortic lymphatics
• 1/3 bilateral; 2-12 cm thick from sacral promontory to renal pedicles to
iliopsoas muscle
• Mass surrounds and constricts but not invade regional structures
C. Clinical Signs and Symptoms
• Early signs /symptoms vague and specific
• First complaint: Pain
• Anorexia, nausea, diarrhea , malaise, weight loss
• Lower abdominal or costovertebral tenderness, fever and
leukocytosis
• Signs and symptoms of compression from tubular retroperitoneal
structures ureters>aorta and IVC
• Dysuria, frequency, fever, secondary infection of a hydronephrotic
kidney (nasasakal yung ureter and kidney)
• Lower extremity edema (blockade of vena cava), arterial insufficiency
(blockade of aorta)
D. Diagnosis
• CT scan – a homogenous soft tissue mass enveloping the ureters,
aorta and the IVC; no anterior displacement of the great vessels (di
napupush; sasakalin niya papuntang medial side)
• Intravenous pylelography – most definitive noninvasive diagnostic test
(inject contrast)
o Hydronephrosis with dilated tortuous upper ureter
(lumu-lobo yung kidney and ureter)
o Medial deviation of the ureter
o Extrinsic ureteral compression
E. Treatment
• Surgical treatment directed toward relief of tubular obstruction usually
urinary
• Mid-transabdominal approach – several deep
• biopsies of the mass
• Ureterolysis with intraperitoneal transplantation – most effective
means of relieving obstruction of ureter (done by a urologist)
• Arteriolysis or bypass with synthetic vascular graft – aortic or iliac
artery obstruction
RETROPERITONEAL TUMORS
• Rare
• Most common malignancies – sarcomas/lymphomas
• Cause unclear
• Associated with history of therapeutic radiation, exposure to vinyl
chloride, thorium dioxide
• Occurring in the 5th or 6th decade of life
• Differential diagnosis of unknown abdominal mass
A. Pathology
• Lymphoma/sarcoma – most common
• Liposarcoma and leiomyosarcoma most frequent
• Hisotlogic grade – most important characteristic to determine
prognosis --------- END OF TRANS---------
• Metastasis occurs hematogenously to liver and lungs. Lymph node
mets are rare (very poor prognosis) Dark green fonts – from recordings
B. Clinical Signs and Symptoms Yung mga nakahighlight yun yung mga inemphasize ni doc.
• Symptoms produced by compression or obstruction of adjacent
tissues
• History of enlarging mass on abdomen, vague abdominal discomfort
or sense of fullness or heaviness (mass is more pronounced)
• Abdominal mass – non tender, firm and rubbery

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