1460
PART
UNIT II
SPECIFIC CONSIDERATIONS
Figure 35-15. Computed tomography (CT) scan of a mesenteric cyst (left panel). Unilocular appearance without associated solid component
strongly suggests the diagnosis of benign cyst. The operative findings during laparoscopic eploration (right panel) confirm the CT diagnosis
of unilocular cyst, which is then enucleated from the mesentery in a relatively avascular plane adjacent to mesenteric vessels.
have a high propensity to recur after drainage alone. On rare
occasion, adjacent mesentery or bowel may be densely adherent
to the cyst, or mesenteric vessels must be sacrificed in order to
achieve complete excision. In this case, segmental bowel resec-
tion inclusive of the adjacent mesentery is performed.
Mesenteric Tumors
Primary tumors of the mesentery are rare. Benign tumors of the
mesentery include lipoma, cystic lymphangioma, and desmoid
tumors. Primary malignant tumors of the mesentery are similar
to those described for omentum. Liposarcomas, leiomyosar-
comas, malignant fibrous histiocytomas, lipoblastomas, and
lymphangiosarcomas have all been described. Metastatic small
intestinal carcinoid in mesenteric lymph nodes may exceed the
bulk of primary disease and compromise blood supply to the
bowel. Treatment of mesenteric malignancies involves wide
resection of the mass. Because of the proximity to the blood
supply to the intestine, such resections may be technically
unfeasible or involve loss of substantial lengths of bowel.
RETROPERITONEUM
Surgical Anatomy
The retroperitoneum is defined as the space between the poste-
rior envelopment of the peritoneum and the posterior body wall
(Fig. 35-16). The retroperitoneal space is bounded superiorly by
the diaphragm, posteriorly by the spinal column and iliopsoas
muscles, and inferiorly by the levator ani muscles. Although
technically bounded anteriorly by the posterior reflection of the
peritoneum, the anterior border of the retroperitoneum is quite
convoluted, extending into the spaces in between the mesenter-
ies of the small and large intestine. Because of the rigidity of the
superior, posterior, and inferior boundaries, and the compliance
of the anterior margin, retroperitoneal tumors tend to expand
anteriorly toward the peritoneal cavity.
Retroperitoneal Infections
The posterior reflection of the peritoneum limits the spread of
most intra-abdominal infections into the peritoneum. Accordingly,
the source of retroperitoneal infections is usually an organ con-
tained within or abutting the retroperitoneum. Retrocecal appen-
dicitis, contained perforation of duodenal ulcers, iatrogenic
perforation with esophagogastroduodenoscopy or endoscopic
retrograde cholangiopancreatography, and complicated pancre-
atitis may all lead to retroperitoneal infection with or without
abscess formation. The substantial space and rather nondiscrete
boundaries of the retroperitoneum allow some retroperitoneal
abscesses to become quite large prior to diagnosis.
Patients with a retroperitoneal abscess usually present with
pain and fever, but more worrisome signs of sepsis may also be
present depending on clinical severity. The site of pain may be
variable and can include the back, pelvis, or thighs. Erythema
may be observed around the umbilicus or flank. The diagnosis
is best established by CT, which may demonstrate a unilocular
or multilocular collection along with retroperitoneal soft tissue
stranding (Fig. 35-17).
Management of retroperitoneal infections includes identi-
fication and treatment of the underlying condition, intravenous
antibiotics, and drainage of all well-defined collections. Image-
guided percutaneous drainage is strongly favored, but operative
drainage may sometimes be needed for adequate drainage of
complex or multiple collections. The mortality rate of retroperi-
toneal abscess has been reported to be as high as 25%, and even
higher in rare cases of necrotizing fasciitis of the retroperitoneum.
Retroperitoneal Fibrosis
Retroperitoneal fibrosis is a class of disorders characterized by
hyperproliferation of fibrous tissue in the retroperitoneum. This
may be a primary disorder as in idiopathic retroperitoneal fibro-
sis, also known as Ormond’s disease, or a secondary reaction to
an inciting inflammatory process, malignancy, or medication.
Idiopathic retroperitoneal fibrosis is a rare disorder, usually
affecting 0.5 per 100,000 patients annually. Men are twice as
likely to be affected as women, with no predilection for any
particular ethnic group. The disease primarily affects individu-
als in the fourth to the sixth decades of life.
Although allergic or autoimmune mechanisms have been
postulated, the pathogenesis of this condition remains uncertain.
 1461

Lesser
peritoneal
Posterior cavity
wall of liver
Spleen
Right
adrenal gland Left adrenal

CHAPTER 35 ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUM

gland
Duodenum
Phrenocolic
ligament
Right ureter

Right kidney Left kidney

Quadratus Pancreas
lumborum m.

Psoas major m.

Common
iliac a.

Figure 35-16. Anatomy of the retroperitoneum. (Reproduced with permission from Healy JE, Hodge J, eds. Surgical Anatomy. 2nd ed.
Toronto: BC Decker; 1990:201.)

In the closely related condition of chronic perioaortitis, an asso-
ciation with the HLA-DRB1*03 allele, which has been linked to
autoimmune diseases such as systemic lupus erythematosus, type
1 diabetes mellitus, and myasthenia gravis, is of particular interest
Figure 35-17. Computed tomography scan of retroperitoneal
abscess complicating complex, surgically treated retroperitoneal
infection that had resulted from ampullary perforation at the time
of endoscopic retrograde cholangiopancreatography. This pattern
of infection may be difficult to treat and result in multiple interven-
tions such as percutaneous drainage before resolution.
in defining an autoimmune cause of retroperitoneal fibrosis. Cir-
culating antibodies to ceroid, a lipoproteinaceous by-product of
vascular atheromatous plaque oxidation, are present in more than
90% of patients with retroperitoneal fibrosis. The relationship of
these finding to the occurrence of fibrosis remains uncertain. The
early inflammatory reaction is predominated by T-helper cells,
plasma cells, and macrophages, but is subsequently replaced by
collagen-synthesizing fibroblasts. Microscopically, the infiltrate
is indistinguishable from the periadventitial involvement of aortic
aneurysmal disease, Reidel’s thyroiditis, sclerosing cholangitis,
and Peyronie’s disease. The fibrotic process begins in the ret-
roperitoneum just below the level of the renal arteries. Fibrosis
gradually expands, encasing the ureters, inferior vena cava, aorta,
mesenteric vessels, or sympathetic nerves. Bilateral involvement
is noted in 67% of cases.
Retroperitoneal fibrosis may also appear secondarily with
a variety of inflammatory conditions including abdominal aortic
aneurysm, pancreatitis, histoplasmosis, tuberculosis, or actino-
mycosis. It also is associated with a variety of malignancies,
including prostate, pancreas, and gastric cancer, as well as non-
Hodgkin’s lymphoma, stromal tumors, and carcinoid tumors.
Retroperitoneal fibrosis has been described in association with
autoimmune disorders including ankylosing spondylitis, sys-
temic lupus erythematosus, Wegener’s granulomatosis, and
polyarteritis nodosa.
There is strong evidence that methysergide, a semisyn-
thetic ergot alkaloid used in the treatment of migraine head-
aches, plays a causal role in some cases of retroperitoneal
1462 fibrosis. Other medications that have been linked to retroperi-
toneal fibrosis include β-blockers, hydralazine, α-methyldopa,
and entacapone, which inhibits catechol-O-methyltransferase
and is used as an adjunct with levodopa in the treatment of Par-
kinson’s disease. The retroperitoneal fibrosis regresses upon
discontinuation of these medications.
Presenting symptoms depend on the structure or structures
affected by the fibrotic process. Initially, patients complain of
the insidious onset of dull, poorly localized abdominal pain.
Sudden-onset or severe abdominal pain may signify acute mes-
enteric ischemia. Other symptoms of retroperitoneal fibrosis
may include unilateral leg swelling, intermittent claudication,
PART
UNIT II
oliguria, hematuria, or dysuria.
As with the patient’s symptomatology, findings on physi-
cal examination vary with the retroperitoneal structure involved.
Consequently, findings may include hypertension, the palpation
of an abdominal or flank mass, lower-extremity edema (uni-
SPECIFIC CONSIDERATIONS
lateral or bilateral), or diminished lower-extremity pulses (uni-
lateral or bilateral). Laboratory evaluation may reveal elevated
blood urea nitrogen and/or creatinine levels. As with many auto-
immune inflammatory processes, the erythrocyte sedimentation
rate almost always is elevated in patients with retroperitoneal
fibrosis.
Many imaging modalities have been used with various
sensitivities to diagnose retroperitoneal fibrosis. Abdominal/
lower-extremity ultrasonography is the least invasive imag-
ing procedure but is technician dependent. It may be useful
if iliocaval compressive or renal symptoms predominate. A
lower-extremity ultrasound may show deep venous thrombosis,
whereas abdominal ultrasonography may identify a mass lesion
or hydronephrosis. Once the diagnostic procedure of choice,
intravenous pyelography (IVP) is less commonly used today. If
the ureters are involved, IVP findings include ureteral compres-
sion, ureteral deviation toward the midline, and hydronephrosis.
Abdominopelvic CT with oral and intravenous contrast
is the imaging procedure of choice and will generally allow
the extent of the fibrotic process to be determined. If there is
diminished renal function, avoidance of the use of intravenous
contrast will reduce the ability to characterize retroperitoneal
tissue planes. In this case, MRI may be used, since the signal
intensity of the fibrotic process is discrete from muscle or fat.
Additionally, magnetic resonance angiography will generally
provide a good assessment of the degree of iliocaval involve-
ment. Once a mass lesion is identified, the mass should be biop-
sied to rule out a retroperitoneal malignancy. The specimen may
be retrieved using image-guided techniques or surgical retro-
peritoneal biopsy, which may be performed laparoscopically or
during open laparotomy.
Once malignancy, drug-induced, and infectious etiologies
are ruled out, treatment of the retroperitoneal fibrotic process
is instituted. Corticosteroids, with or without surgery, are the
mainstay of medical therapy. Surgical treatment consists primar-
ily of ureterolysis or ureteral stenting and is required in patients
who present with significant hydronephrosis. Laparoscopic ure-
terolysis has been shown to be as efficacious as open the open
procedure. Patients with iliocaval thrombosis require anticoag-
ulation, although appropriate duration of therapy is uncertain.
Endovascular interventions for iliocaval occlusion have also
been shown to be effective in small numbers of patients.
8 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
based on patient symptoms and interval imaging studies. Cyclo-
sporin, tamoxifen, and azathioprine have also been used to treat
patients who respond poorly to corticosteroids.
The overall prognosis in idiopathic retroperitoneal fibrosis
is good, with 5-year survival rates of 90% to 100%. Because
long-term recurrences have been described, lifelong follow-up
is warranted.
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