Abdominal Wall and Hernias,

Omentum, Mesentery, and

Retroperitoneum:
Surgical Considerations
Credits: Townsend: Sabiston Textbook of Surgery, 18th Ed.
Scwhartz, Textbook of Surgery, 11e
GABRIEL L. MARTINEZ, MD, FPCS, FPSGS Bates, A Guide to Physical Examination
Professor of Surgery American College of Surgeons Textbook of Surgery
Sandalakis, Surgical Anatomy and Technique
Norton, Surgery: Basic Science and Evidence
Intended Learning Outcomes
At the end of the session, the student will be able to:

1. Relate the pertinent surgical anatomy of the Abdominal wall,

Omentum, Mesentery and Retroperitoneum to surgical procedures and
maneuvers.
2. Recognize and compare the clinical presentations of the surgical
conditions associated with the diseases of the abdominal wall,
omentum, mesentery and retroperitoneum.
3. Design a management plan for surgical conditions of the abdominal
wall, omentum, mesentery and retroperitoneum
 Surgical Anatomy – Abdominal Wall
Nine distinct layers:
>skin,
>subcutaneous tissue,
>superficial fascia,
>external oblique
muscle,
>internal oblique
muscles,
>transversus abdominis
muscle,
>transversalis fascia,
>preperitoneal adipose
tissue/fat pad
>peritoneum
Muscles
- protect the intra-abdominal and
retroperitoneal organs
- Assist in flexion, extension and
rotation of the torso (via action
of contralateral external oblique
and ipsilateral internal oblique
Blood supply
- Inferior and superior epigastric
vessels (superficial & deep)
Lymphatics above the umbilicus
drain toward the superficial
axillary nodes; below the
umbilicus, to the inguinal nodes
Surface Anatomy
Considerations:

Midscapular line
Tip of Scapula
Costovertebral angle
Lumbar Triangle of
Petit (inferior) and
Grynfeltt-Lesshaft
(superior)
Goldflam test
 Incision Description

Kocher RUQ subcostal incision for biliary tract surgery

Kehr Subcostal incision with midline cephalad extension for

biliary tract or splenic surgery

Rocky-Davis RLQ muscle-splitting incision going thru McBurney’s

aka Gridiron Point for appendectomy

pfannenstiehl Lower infraumbilical transverse skin incision with

midline fascial opening used in caesarean section

Midline Division of linea alba vertically to allow rapid access to

abdominal cavity

Bilateral Subcostal For hepatic, pancreatic and complex biliary surgery

aka Chevron/Rooftop

Thoracoabdominal Extension of laparotomy incision into chest

Coller aka Saber Slash Oblique LUQ to RLQ (from Univ of Michigan)

Battle Vertical incision lateral to linea semilunaris

Tri-star Bilateral subcostal and cephalad vertical trans-sternal

aka Mercedez Benz incision for hepatectomy
Abdominal wall Non-incisional hernias
• A protrusion of abdominal
contents through a defect or
weakness in the abdominal wall
muscle/fascia
• May be congenital or acquired
• Bulging increases with Valsalva’s
maneuver
• May be reducible, incarcerated
or strangulated
Hernias -
Clinical Classification
2.1. Obstructed – hernia
1. Reducible – hernia can be causing intestinal obstruction
pushed back into the
abdomen 2.2. Strangulated - the blood
supply of the herniating organ
2. Irreducible/Incarcerated – is cut off, thus, leading to
hernia can’t be pushed ischemia. The lumen of the
back into the abdominal intestine may be patent or
cavity. For urgent surgery not.
Non-incisional Abdominal Wall Hernias
Epigastric hernias Diastasis Recti
Located between the umbilicus > Separation of the rectus abdominis
and the xiphoid process (≥ 2.0 cm) at the linea alba.
May be due to muscle More common
weakness, weakened epigastric among women.
fascia or increases in intra- Patient is obese.
abdominal pressure.
Rarely incarcerated Mesh applied over
primary repair
Repaired if symptomatic (overlay); lately, a
subrectus repair
has been done
 Non-incisional Abdominal Wall Hernias
Umbilical Hernia Spigelian Hernia
a hernia through the Spigelian fascia, which is
May be congenital or acquired; the aponeurotic layer between the rectus
common among prematures abdominis muscle medially, and the semilunar
Most close spontaneously by 5 line laterally. Common in the “Spigelian Belt”
years of age.
Indication for repair include
incarceration, symptomatic
hernia, failure to close by 5 yrs;
increase in size
Processus Vaginalis Testis – role in pathogenesis of groin hernias
>a “coat” of peritoneum that
precedes (processus) testicular
descent from the
retroperitoneal area thru the
internal inguinal ring, thru the
inguinal canal up to the scrotum;
this “coat” becomes the tunica
vaginalis.
>if this peritoneal “coat”
remains patent, abdominal
contents can pass thru toward
the scrotum – this is the indirect
inguinal hernia.
Groin Hernias The deep inguinal ring, which is the beginning of
the inguinal canal, remains as an opening in the
fascia transversalis. When the opening is larger
than necessary (>13mm) for passage of the
spermatic cord, plus a patent processus vaginalis,
the stage is set for an indirect inguinal hernia; the
protrusion is located lateral to the deep inferior
epigastric artery and anteromedial to the cord.
Types:
Bubonocele – hernia in inguinal canal
Funicular - processus vaginalis is closed at its
lower end just above the epididymis
Complete (or vaginal) - processus vaginalis is
patent throughout. The hernial sac is continuous
with the tunica vaginalis of the testis.
Groin Hernias
Direct Inguinal Hernia – protrusion into the
weakened Hesselbach’s triangle, medial to
the deep inferior epigastric vessel.
When both Indirect and Direct inguinal
hernias occur on the same side, (looks like a
pair of pants with the epigastric vessels as
the crotch), this is called a “pantaloon”
hernia (Romberg’s hernia, dual hernia, or
saddle bag hernia). Hernia sacs are present
on both sides of the inferior epigastric
vessels, and separated by the posterior wall
of the inguinal canal brought down by the
direct hernia.
Groin Hernias Amyand's hernia, appendix contained
within an incarcerated inguinal
hernia.
Littre's hernia, hernial sac contains a
Meckel's diverticulum.
Obturator hernia, protrusion through
the obturator canal, passageway of
the obturator artery, vein, and nerve.
Patients usually thin or with multiple
pregnancies
Groin Hernias
Sliding hernia (hernia-en-glissade),
when the herniating organ (usually
partially peritonialized) forms part of
the sac.
Richter hernia (partial enterocele) is
the protrusion and/or strangulation
of only part of the circumference of
the intestine's antimesenteric border
through a rigid small defect of the
abdominal wall.
Groin Hernias Femoral hernia – protrusion through
the femoral canal.

The femoral canal is located below the

inguinal ligament on the lateral aspect of
the pubic tubercle. It is bounded by the
iliopubic tract anteriorly, pectineal
ligament posteriorly, lacunar ligament
medially, and the femoral vein laterally. It
normally contains a few lymphatics, loose
areolar tissue, and occasionally a lymph
node called Cloquet's node. It allows the
femoral vein to expand when necessary to
accommodate increased venous return
from the leg during periods of activity.
Groin Hernias Subtypes of Femoral hernia

'Retrovascular hernia (Narath’s hernia)' The hernial

sac emerges from the abdomen within the femoral
sheath but lies posteriorly to the femoral vein and
artery, visible only if the hip is congenitally dislocated.
'Serafini's hernia' The hernial sac emerges behind
femoral vessels.
'Velpeau hernia' The hernial sac lies in front of the
femoral blood vessels in the groin.
'External femoral hernia of Hesselbach and Cloquet'
The neck of the sac lies lateral to the femoral vessels.
Groin Hernias Subtypes of Femoral hernia

'Transpectineal femoral hernia of Laugier' The

hernial sac transverses the lacunar ligament or
the pectineal ligament of Cooper.
'Callisen’s or Cloquet's hernia' The hernial
sac descends deep to the femoral vessels
through the pectineal fascia.
'Béclard's hernia' The hernial sac emerges
through the saphenous opening carrying the
cribriform fascia with it.
'De Garengeot's hernia' Vermiform appendix
is trapped within the femoral hernial sac.
 Principles of Hernia Management
1. Control of co-morbidities
2. Precise knowledge of the
anatomy and
pathophysiology of the
disease
3. Avoid injuries to important
and vital structures
4. Ligation/closure of the
hernia sac
5. Precise, tension-free
closure/repair of the
defect
6. Meticulous and gentle
surgical technique.
7. Avoid surgical site
infections
8. Engage/Educate
patients
Lumbar Hernias Lumbar hernia is a protrusion of
either extraperitoneal fat or
intraperitoneal contents through
either of the lumbar triangles.
Primary lumbar hernias are
extremely rare

Petit’s Hernia – protrusion through

the inferior lumbar triangle

Hernia of Grynfeltt-Lesshaft –
protrusion through the superior
lumbar triangle
Incisional Hernias Bulging that develop at sites of previous
abdominal incisions.
Risk factors – diabetes, obesity,
immunosuppression, smoking,
malnutrition, connective tissue disorders;
wound infection, poor operative technique
Tension-free (component separation,
mesh) open or laparoscopic repair
advised
Mesh repair
Overlay – above midline fascia
Interlay – bridged across fascial defects
Sublay – underneath fascia
Underlay – within abdominal cavity
Rectus Hematoma
>Due to disruption of the
branches of the inferior epigastric
artery as well as the inability to
tamponade the hemorrhage.
>Occurs around the arcuate line
where the artery and its branches
are relatively fixed thus vulnerable
to shearing forces
>Causes include trauma, vigorous
coughing or exercise
>Presents as acute abdominal pain
and palpable abdominal mass. Pain
usually increases with contraction of
rectus muscle
>Palpation of a mass that does not
change during contraction of the
rectus muscle (Fothergill’s sign)
>Ultrasound or CT scan with contrast
are confirmatory
>Management: Angiographic
intervention; evacuation of
hematoma and ligation of bleeders
 Desmoid Tumors (Aggressive Fibromatosis)
Aggressively infiltrative
fibroblastic neoplasms
with NO metastatic
potential
Associated with familial
adenomatous polyposis
and Gardner’s syndrome
Females have higher risk
Larger tumor size, younger
age and extra-abdominal
location predict poor
recurrence-free survival
Gold standard of
treatment is margin-
negative resection with
reconstruction
Surgery is indicated for
invasive, enlarging,
symptomatic disease
Adjuvant treatment
options include: Radiation
Tx, NSAIDs, Hormonal Tx,
Chemotherapy, Targetted
Tx (Imatinib)
 Other Abdominal Wall Tumors
Work-up
Benign Tumors
Biopsy – needle, excision
Lipoma MRI is preferred modality
Fibroma Treatment
Malignant Tumors Wide excision with free
Sarcoma margins
Dermatofibrosarcoma Adjuvant/Neoadjuvant
protuberans RadioTx
Schwannomas Chemotherapy
Melanomas Reconstruction
The Omentum – policeman of the abdomen
Omental Infarction
primarily due to torsion,
vasculitis or thrombosis. Causes
abdominal tenderness with
possible palpable mass; US/CT
scan are used to assist diagnosis.
Laparoscopic exploration and
resection of infarcted tissue
leads to rapid resolution of
symptoms
Ometal Cysts
Thought to form through
degeneration or inclusion of
lymphatic structures
May present as lead point for
omental torsion and infarction
Omental Neoplasm
Most are due to metastatic
disease (ovarian Ca)
Primary tumors are rare
 Mesentery – diagonally divides abdominal cavity
Sclerosing Mesenteritis
Idiopathic fibrosis of the
mesentery affecting hollow viscera
as well as mesenteric vessel; when
localized is known as mesenteric
lipodystrophy
May be instigated by previous
abdominal insult
Mostly male patient 50-70 yrs old
Presents as abdominal pain,
tenderness and distention
Sclerosing Mesenteritis
Abdominal CT with contrast reveal
soft tissue mass with a higher
density showing “tumor
pseudocapsule” and “fat ring sign”
Aggressive surgical treatment NOT
indicated as symptoms may
improve with steroids, colchicine,
hormonal therapy or
cyclophosphamide
 Mesentery – diagonally divides abdominal cavity
Mesenteric Cysts
Rare benign disorder thought to be
due to disruption of the lymphatics
in the mesentery
Abdominal mass that is only
mobile laterally (Tillaux’s sign)
causing abdominal pain/discomfort
Benign lesions should be
enucleated, malignant cysts should
be resected with clear margins
Mesenteric Tumors
Benign tumors include desmoids,
lipomas and cystic lymphangiomas
Most common malignant tumor is
lymphoma (not resected but will
require operative biopsy)
Others: GIST, carcinoids, sarcomas,
fibrous histiocytomas
Treatment of malignant
mesenteric masses usually involves
wide resection
Retroperitoneum Surgical Anatomy
Anterior – peritoneum,
Posterior – iliopsoas and lumbar muscles,
Superior – diaphragm,
Inferior – levator ani muscle

Anterior pararenal space contains the

ascending and descending colon,
duodenum and pancreas
Perirenal space houses the inferior vena
cava, aorta, kidneys and adrenal glands
Posterior pararenal space is in
continuity with the preperitoneal fat of
the anterior abdomen
 Retroperitoneum
Retroperitoneal Infections
Due to primary
hematogenous spread or
to secondary infection
from nearby organs e.g.
pancreatitis, diverticulitis,
perforated duodenal ulcer
Image-guided drainage is
preferred but if
multiloculated or
inaccessible, open
operative drainage may be
required
Retroperitoneal Fibrosis
Inflammation and fibrosis
which may be idiopathic or
due to a secondary cause
(aneurysm, pancreatitis) or
certain drugs (ergot-
derivatives, methyldopa),
malignancies or infections
Surgical treatment aimed at
relieving ureteral obstruction
(ureterolysis or stenting)
If idiopathic, corticosteroids
or immunosuppressants are
used
 Diagnose and design a management plan for this case
• A 30-year-old male construction • One year PTC he noticed that the
worker presented to the ER with mass has increased in size and is
history of pain and swelling in the now occupying the lower portion of
right inguinoscrotal region his RLQ and right scrotum
• Condition started about 9 years ago as associated with bearable pain.
a small soft right inguinal mass that
appears upon heavy exertion. Worried
about his occupation, he kept this to • One day PTC, he experienced right
himself. He learned to reduce the inguinoscrotal pain after lifting a
mass, how to place a plastic truss and heavy metal pipe. He noticed that
supporter over the area. Over the the scrotal mass has gone out of his
years, the mass slowly grew often truss and has become irreducible
occupying his right scrotum. and increasingly tender.
 Inguinoscrotal mass…
• T=37.7*C PR=102 bpm, RR=19 cpm;
pain score 7/10
• HEENT and Chest: No findings of note
• Abdomen: soft with diffuse tenderness
in the lower abdomen.
• There was 6x4 cm tender, swollen, firm
mass in right inguinoscrotal region.
The overlying skin is erythematous,
stretched, and shiny.
• Both testes are descended
• The rest of the examination was within
normal limits.
 Your tasks
• What is your complete preoperative • If upon opening the hernia sac that
diagnosis? entered the inguinal canal you found
• What are your differential diagnoses? an inflamed appendix, how will you
proceed to manage this case?
• If you decide to operate on this patient,
how will you prepare the patient? • What is the complete postoperative
diagnosis of this patient?
• If upon surgical exploration, one hernia
was found within Hesselbach’s triangle • What will you advice the patient?
and another hernia sac was entering the
inguinal canal. How will you resolve and
repair this condition?
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THANK YOU!!