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Surgery_Schwartz_10202 | Surgery_Schwartz | with selective embolization. J Trauma. 2004;56(5): 1063-1067. 175. Koconis KG, Singh H, Soares G. Partial splenic emboliza-tion in the treatment of patients with portal hypertension: a review of the english language literature. J Vasc Interv Radiol. 2007;18(4):463-481. 176. Cuker A, Cines DB. Evidence-based mini-review: is indium-labeled autologous platelet scanning predictive of response to splenectomy in patients with chronic immune thrombo-cytopenia? Hematology Am Soc Hematol Educ Program. 2010;2010:385-386. 177. Wu Z, Zhou J, Pankaj P, Peng B. Comparative treatment and literature review for laparoscopic splenectomy alone versus preoperative splenic artery embolization splenectomy. Surg Endosc. 2012;26(10):2758-2766. 178. Mousa A, Armbruster J, Adongay J, AbuRahma AF. Splenic artery embolization as a treatment option for chronic pancyto-penia secondary to hypersplenism: a case report and review of literature. Vasc Endovascular Surg. 2012;46(6):501-503. 179. Williams G, Rosen MP, | Surgery_Schwartz. with selective embolization. J Trauma. 2004;56(5): 1063-1067. 175. Koconis KG, Singh H, Soares G. Partial splenic emboliza-tion in the treatment of patients with portal hypertension: a review of the english language literature. J Vasc Interv Radiol. 2007;18(4):463-481. 176. Cuker A, Cines DB. Evidence-based mini-review: is indium-labeled autologous platelet scanning predictive of response to splenectomy in patients with chronic immune thrombo-cytopenia? Hematology Am Soc Hematol Educ Program. 2010;2010:385-386. 177. Wu Z, Zhou J, Pankaj P, Peng B. Comparative treatment and literature review for laparoscopic splenectomy alone versus preoperative splenic artery embolization splenectomy. Surg Endosc. 2012;26(10):2758-2766. 178. Mousa A, Armbruster J, Adongay J, AbuRahma AF. Splenic artery embolization as a treatment option for chronic pancyto-penia secondary to hypersplenism: a case report and review of literature. Vasc Endovascular Surg. 2012;46(6):501-503. 179. Williams G, Rosen MP, |
Surgery_Schwartz_10203 | Surgery_Schwartz | embolization as a treatment option for chronic pancyto-penia secondary to hypersplenism: a case report and review of literature. Vasc Endovascular Surg. 2012;46(6):501-503. 179. Williams G, Rosen MP, Parker JA, Kolodny GM. Splenic implants detected by SPECT images of Tc-99m labeled damaged red blood cells. Clin Nucl Med. 2006;31(8): 467-469. 180. Lui EH, Lau KK. Intra-abdominal splenosis: how clinical his-tory and imaging features averted an invasive procedure for tissue diagnosis. Australas Radiol. 2005;49(4):342-344. 181. Balague C, Vela S, Targarona EM, et al. Predictive factors for successful laparoscopic splenectomy in immune thrombocy-topenic purpura: study of clinical and laboratory data. Surg Endosc. 2006;20(8):1208-1213. 182. Sweet PH, Khoo T, Nguyen S. Nonalcoholic fatty liver dis-ease. Prim Care. 2017;44(4):599-607. 183. Bolton-Maggs PH, Langer JC, Iolascon A, Tittensor P, King MJ; General Haematology Task Force of the British Committee for Standards in Haematology. | Surgery_Schwartz. embolization as a treatment option for chronic pancyto-penia secondary to hypersplenism: a case report and review of literature. Vasc Endovascular Surg. 2012;46(6):501-503. 179. Williams G, Rosen MP, Parker JA, Kolodny GM. Splenic implants detected by SPECT images of Tc-99m labeled damaged red blood cells. Clin Nucl Med. 2006;31(8): 467-469. 180. Lui EH, Lau KK. Intra-abdominal splenosis: how clinical his-tory and imaging features averted an invasive procedure for tissue diagnosis. Australas Radiol. 2005;49(4):342-344. 181. Balague C, Vela S, Targarona EM, et al. Predictive factors for successful laparoscopic splenectomy in immune thrombocy-topenic purpura: study of clinical and laboratory data. Surg Endosc. 2006;20(8):1208-1213. 182. Sweet PH, Khoo T, Nguyen S. Nonalcoholic fatty liver dis-ease. Prim Care. 2017;44(4):599-607. 183. Bolton-Maggs PH, Langer JC, Iolascon A, Tittensor P, King MJ; General Haematology Task Force of the British Committee for Standards in Haematology. |
Surgery_Schwartz_10204 | Surgery_Schwartz | liver dis-ease. Prim Care. 2017;44(4):599-607. 183. Bolton-Maggs PH, Langer JC, Iolascon A, Tittensor P, King MJ; General Haematology Task Force of the British Committee for Standards in Haematology. Guidelines for the diagnosis and management of hereditary spherocytosis—2011 update. Br J Haematol. 2012;156(1):37-49. 184. Tovo CV, de Mattos AZ, Coral GP, Branco FS, Suwa E, de Mattos AA. Noninvasive imaging assessment of non-alcoholic fatty liver disease: focus on liver scintigraphy. World J Gastro-enterol. 2015;21(15):4432-4439. 185. Rubin LG, Schaffner W. Clinical practice. Care of the asplenic patient. N Engl J Med. 2014;371(4):349-356. 186. Theilacker C, Ludewig K, Serr A, et al. Overwhelming post-splenectomy infection: a prospective multicenter cohort study. Clin Infect Dis. 2016;62(7):871-878. 187. O’Neal HR, Jr, Niven AS, Karam GH. Critical illness in patients with asplenia. Chest. 2016;150(6):1394-1402. 188. Chong J, Jones P, Spelman D, Leder K, Cheng AC. Over-whelming | Surgery_Schwartz. liver dis-ease. Prim Care. 2017;44(4):599-607. 183. Bolton-Maggs PH, Langer JC, Iolascon A, Tittensor P, King MJ; General Haematology Task Force of the British Committee for Standards in Haematology. Guidelines for the diagnosis and management of hereditary spherocytosis—2011 update. Br J Haematol. 2012;156(1):37-49. 184. Tovo CV, de Mattos AZ, Coral GP, Branco FS, Suwa E, de Mattos AA. Noninvasive imaging assessment of non-alcoholic fatty liver disease: focus on liver scintigraphy. World J Gastro-enterol. 2015;21(15):4432-4439. 185. Rubin LG, Schaffner W. Clinical practice. Care of the asplenic patient. N Engl J Med. 2014;371(4):349-356. 186. Theilacker C, Ludewig K, Serr A, et al. Overwhelming post-splenectomy infection: a prospective multicenter cohort study. Clin Infect Dis. 2016;62(7):871-878. 187. O’Neal HR, Jr, Niven AS, Karam GH. Critical illness in patients with asplenia. Chest. 2016;150(6):1394-1402. 188. Chong J, Jones P, Spelman D, Leder K, Cheng AC. Over-whelming |
Surgery_Schwartz_10205 | Surgery_Schwartz | HR, Jr, Niven AS, Karam GH. Critical illness in patients with asplenia. Chest. 2016;150(6):1394-1402. 188. Chong J, Jones P, Spelman D, Leder K, Cheng AC. Over-whelming post-splenectomy sepsis in patients with asplenia and hyposplenia: a retrospective cohort study. Epidemiol Infect. 2017;145(2):397-400. 189. Sinwar PD. Overwhelming post splenectomy infection syndrome—review study. Int J Surg. 2014;12(12):1314-1316. 190. Lynch AM, Kapila R. Overwhelming postsplenectomy infec-tion. Infect Dis Clin North Am. 1996;10(4):693-707.Brunicardi_Ch34_p1517-p1548.indd 154623/02/19 2:37 PM 1547THE SPLEENCHAPTER 34 191. Brigden ML. Overwhelming postsplenectomy infection still a problem. West J Med. 1992;157(4):440-443. 192. Dionne B, Dehority W, Brett M, Howdieshell TR. The asplenic patient: post-insult immunocompetence, infection, and vacci-nation. Surg Infect (Larchmt). 2017;18(5):536-544. 193. Dendle C, Sundararajan V, Spelman T, Jolley D, Woolley I. Splenectomy sequelae: an analysis of | Surgery_Schwartz. HR, Jr, Niven AS, Karam GH. Critical illness in patients with asplenia. Chest. 2016;150(6):1394-1402. 188. Chong J, Jones P, Spelman D, Leder K, Cheng AC. Over-whelming post-splenectomy sepsis in patients with asplenia and hyposplenia: a retrospective cohort study. Epidemiol Infect. 2017;145(2):397-400. 189. Sinwar PD. Overwhelming post splenectomy infection syndrome—review study. Int J Surg. 2014;12(12):1314-1316. 190. Lynch AM, Kapila R. Overwhelming postsplenectomy infec-tion. Infect Dis Clin North Am. 1996;10(4):693-707.Brunicardi_Ch34_p1517-p1548.indd 154623/02/19 2:37 PM 1547THE SPLEENCHAPTER 34 191. Brigden ML. Overwhelming postsplenectomy infection still a problem. West J Med. 1992;157(4):440-443. 192. Dionne B, Dehority W, Brett M, Howdieshell TR. The asplenic patient: post-insult immunocompetence, infection, and vacci-nation. Surg Infect (Larchmt). 2017;18(5):536-544. 193. Dendle C, Sundararajan V, Spelman T, Jolley D, Woolley I. Splenectomy sequelae: an analysis of |
Surgery_Schwartz_10206 | Surgery_Schwartz | immunocompetence, infection, and vacci-nation. Surg Infect (Larchmt). 2017;18(5):536-544. 193. Dendle C, Sundararajan V, Spelman T, Jolley D, Woolley I. Splenectomy sequelae: an analysis of infectious outcomes among adults in Victoria. Med J Aust. 2012;196(9):582-586. 194. Ejstrud P, Kristensen B, Hansen JB, Madsen KM, Schonhey-der HC, Sorensen HT. Risk and patterns of bacteraemia after splenectomy: a population-based study. Scand J Infect Dis. 2000;32(5):521-525. 195. Edgren G, Almqvist R, Hartman M, Utter GH. Splenectomy and the risk of sepsis: a population-based cohort study. Ann Surg. 2014;260(6):1081-1087. 196. Leone G, Pizzigallo E. Bacterial infections following splenec-tomy for malignant and nonmalignant hematologic diseases. Mediterr J Hematol Infect Dis. 2015;7(1):e2015057. 197. Yu RK, Shepherd LE, Rapson DA. Capnocytophaga canimor-sus, a potential emerging microorganism in splenectomized patients. Br J Haematol. 2000;109(4):679. 198. Sica S, Di Mario A, Salutari P, et al. | Surgery_Schwartz. immunocompetence, infection, and vacci-nation. Surg Infect (Larchmt). 2017;18(5):536-544. 193. Dendle C, Sundararajan V, Spelman T, Jolley D, Woolley I. Splenectomy sequelae: an analysis of infectious outcomes among adults in Victoria. Med J Aust. 2012;196(9):582-586. 194. Ejstrud P, Kristensen B, Hansen JB, Madsen KM, Schonhey-der HC, Sorensen HT. Risk and patterns of bacteraemia after splenectomy: a population-based study. Scand J Infect Dis. 2000;32(5):521-525. 195. Edgren G, Almqvist R, Hartman M, Utter GH. Splenectomy and the risk of sepsis: a population-based cohort study. Ann Surg. 2014;260(6):1081-1087. 196. Leone G, Pizzigallo E. Bacterial infections following splenec-tomy for malignant and nonmalignant hematologic diseases. Mediterr J Hematol Infect Dis. 2015;7(1):e2015057. 197. Yu RK, Shepherd LE, Rapson DA. Capnocytophaga canimor-sus, a potential emerging microorganism in splenectomized patients. Br J Haematol. 2000;109(4):679. 198. Sica S, Di Mario A, Salutari P, et al. |
Surgery_Schwartz_10207 | Surgery_Schwartz | RK, Shepherd LE, Rapson DA. Capnocytophaga canimor-sus, a potential emerging microorganism in splenectomized patients. Br J Haematol. 2000;109(4):679. 198. Sica S, Di Mario A, Salutari P, et al. Morganella morganii pericarditis after resolvent splenectomy for immune pan-cytopenia following allogeneic bone marrow transplanta-tion for acute lymphoblastic leukemia. Clin Infect Dis. 1995;21(4):1052-1053. 199. Demar M, Legrand E, Hommel D, Esterre P, Carme B. Plas-modium falciparum malaria in splenectomized patients: two case reports in French Guiana and a literature review. Am J Trop Med Hyg. 2004;71(3):290-293. 200. Rosner F, Zarrabi MH, Benach JL, Habicht GS. Babesiosis in splenectomized adults. Review of 22 reported cases. Am J Med. 1984;76(4):696-701. 201. Okabayashi T, Hanazaki K. Overwhelming postsplenectomy infection syndrome in adults—a clinically preventable disease. World J Gastroenterol. 2008;14(2):176-179.Brunicardi_Ch34_p1517-p1548.indd 154723/02/19 2:37 PM | Surgery_Schwartz. RK, Shepherd LE, Rapson DA. Capnocytophaga canimor-sus, a potential emerging microorganism in splenectomized patients. Br J Haematol. 2000;109(4):679. 198. Sica S, Di Mario A, Salutari P, et al. Morganella morganii pericarditis after resolvent splenectomy for immune pan-cytopenia following allogeneic bone marrow transplanta-tion for acute lymphoblastic leukemia. Clin Infect Dis. 1995;21(4):1052-1053. 199. Demar M, Legrand E, Hommel D, Esterre P, Carme B. Plas-modium falciparum malaria in splenectomized patients: two case reports in French Guiana and a literature review. Am J Trop Med Hyg. 2004;71(3):290-293. 200. Rosner F, Zarrabi MH, Benach JL, Habicht GS. Babesiosis in splenectomized adults. Review of 22 reported cases. Am J Med. 1984;76(4):696-701. 201. Okabayashi T, Hanazaki K. Overwhelming postsplenectomy infection syndrome in adults—a clinically preventable disease. World J Gastroenterol. 2008;14(2):176-179.Brunicardi_Ch34_p1517-p1548.indd 154723/02/19 2:37 PM |
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Surgery_Schwartz_10209 | Surgery_Schwartz | Abdominal Wall, Omentum, Mesentery, and RetroperitoneumScott Kizy and Sayeed Ikramuddin 35chapterABDOMINAL WALLGeneral ConsiderationsIncision and closure of the abdominal wall is among the most common surgical procedures performed. Knowledge of its lay-ered anatomy is critical in the management of surgical patients. Cranially defined by the costal margin and xiphoid process and caudally ending over the pubic bones of the pelvis, the abdomi-nal wall provides support and protection to the peritoneal and retroperitoneal organs.Surgical AnatomyEmbryologically, the abdominal wall is derived from the meso-derm and envelops the future abdominal contents as bilateral migrating layers originating from the paravertebral area. The leading bars of these sheets fuse in the midline as the linea alba at 7 weeks after gestation and reach the umbilicus at 8 weeks.The abdominal wall consists of nine distinct layers: skin, subcutaneous tissue, superficial fascia, external oblique muscle, internal | Surgery_Schwartz. Abdominal Wall, Omentum, Mesentery, and RetroperitoneumScott Kizy and Sayeed Ikramuddin 35chapterABDOMINAL WALLGeneral ConsiderationsIncision and closure of the abdominal wall is among the most common surgical procedures performed. Knowledge of its lay-ered anatomy is critical in the management of surgical patients. Cranially defined by the costal margin and xiphoid process and caudally ending over the pubic bones of the pelvis, the abdomi-nal wall provides support and protection to the peritoneal and retroperitoneal organs.Surgical AnatomyEmbryologically, the abdominal wall is derived from the meso-derm and envelops the future abdominal contents as bilateral migrating layers originating from the paravertebral area. The leading bars of these sheets fuse in the midline as the linea alba at 7 weeks after gestation and reach the umbilicus at 8 weeks.The abdominal wall consists of nine distinct layers: skin, subcutaneous tissue, superficial fascia, external oblique muscle, internal |
Surgery_Schwartz_10210 | Surgery_Schwartz | at 7 weeks after gestation and reach the umbilicus at 8 weeks.The abdominal wall consists of nine distinct layers: skin, subcutaneous tissue, superficial fascia, external oblique muscle, internal oblique muscles, transversus abdominus muscle, trans-versalis fascia, preperitoneal adipose tissue, and peritoneum. The subcutaneous tissue is composed of superficial adipose tis-sue that is contiguous with Camper’s fascia anteriorly. Deep to this, Scarpa’s fascia consists of a fibrous matrix of tissue that fuses with the anterior layer of fascia of the flank and back.The muscles of the abdominal wall consist of the rectus abdominus medially and the external oblique, internal oblique, and transversus abdominis laterally. The rectus abdominus is a paired longitudinal muscle spanning the length of the abdomen. Divided by the linea alba, both rectus muscles originate at the pubic symphysis and crest and insert on the xiphoid process, the fifth and sixth ribs, and the seventh costal cartilage. | Surgery_Schwartz. at 7 weeks after gestation and reach the umbilicus at 8 weeks.The abdominal wall consists of nine distinct layers: skin, subcutaneous tissue, superficial fascia, external oblique muscle, internal oblique muscles, transversus abdominus muscle, trans-versalis fascia, preperitoneal adipose tissue, and peritoneum. The subcutaneous tissue is composed of superficial adipose tis-sue that is contiguous with Camper’s fascia anteriorly. Deep to this, Scarpa’s fascia consists of a fibrous matrix of tissue that fuses with the anterior layer of fascia of the flank and back.The muscles of the abdominal wall consist of the rectus abdominus medially and the external oblique, internal oblique, and transversus abdominis laterally. The rectus abdominus is a paired longitudinal muscle spanning the length of the abdomen. Divided by the linea alba, both rectus muscles originate at the pubic symphysis and crest and insert on the xiphoid process, the fifth and sixth ribs, and the seventh costal cartilage. |
Surgery_Schwartz_10211 | Surgery_Schwartz | the abdomen. Divided by the linea alba, both rectus muscles originate at the pubic symphysis and crest and insert on the xiphoid process, the fifth and sixth ribs, and the seventh costal cartilage. Three ten-dinous insertions cross the rectus muscle along its length. The muscle is contained within an aponeurotic sheath formed from the fusion of differing components of the lateral fascial layers.Laterally, the three muscular layers (external oblique, internal oblique, and transversus abdominis) have obliquely oriented fibers relative to one another. The external oblique arises from the eighth rib and inserts medially into the linea alba and anterior iliac crests. The fibers of this muscular layer travel medial and caudal from its insertion. The internal oblique originates from the thoracolumbar fascia. Its fibers travels cra-nially and anteriorly, inserting on the lower costal margin and the xiphoid process. The deep muscular layer, the transversus abdominis muscle, begins at the | Surgery_Schwartz. the abdomen. Divided by the linea alba, both rectus muscles originate at the pubic symphysis and crest and insert on the xiphoid process, the fifth and sixth ribs, and the seventh costal cartilage. Three ten-dinous insertions cross the rectus muscle along its length. The muscle is contained within an aponeurotic sheath formed from the fusion of differing components of the lateral fascial layers.Laterally, the three muscular layers (external oblique, internal oblique, and transversus abdominis) have obliquely oriented fibers relative to one another. The external oblique arises from the eighth rib and inserts medially into the linea alba and anterior iliac crests. The fibers of this muscular layer travel medial and caudal from its insertion. The internal oblique originates from the thoracolumbar fascia. Its fibers travels cra-nially and anteriorly, inserting on the lower costal margin and the xiphoid process. The deep muscular layer, the transversus abdominis muscle, begins at the |
Surgery_Schwartz_10212 | Surgery_Schwartz | fascia. Its fibers travels cra-nially and anteriorly, inserting on the lower costal margin and the xiphoid process. The deep muscular layer, the transversus abdominis muscle, begins at the costal margin and lumbar fas-cia, runs horizontally and anteriorly, and inserts on the linea alba, xiphoid process, and pubis symphysis (Fig. 35-1).Altogether, these muscular layers provide fascial aponeu-rotic sheaths anteriorly. These fascial layers provide variable contributions to the separate layers of the rectus sheath and ultimately fuse in the midline as the linea alba. The rectus sheath that encloses the rectus muscles has differing composi-tions above and below the arcuate line. The anterior rectus sheath is composed of the external oblique aponeurosis through-out its length. The internal oblique aponeurosis is bilaminar and contributes to the anterior and posterior rectus sheaths above the arcuate line. Below this line, the internal aponeurosis contrib-utes only to the anterior rectus | Surgery_Schwartz. fascia. Its fibers travels cra-nially and anteriorly, inserting on the lower costal margin and the xiphoid process. The deep muscular layer, the transversus abdominis muscle, begins at the costal margin and lumbar fas-cia, runs horizontally and anteriorly, and inserts on the linea alba, xiphoid process, and pubis symphysis (Fig. 35-1).Altogether, these muscular layers provide fascial aponeu-rotic sheaths anteriorly. These fascial layers provide variable contributions to the separate layers of the rectus sheath and ultimately fuse in the midline as the linea alba. The rectus sheath that encloses the rectus muscles has differing composi-tions above and below the arcuate line. The anterior rectus sheath is composed of the external oblique aponeurosis through-out its length. The internal oblique aponeurosis is bilaminar and contributes to the anterior and posterior rectus sheaths above the arcuate line. Below this line, the internal aponeurosis contrib-utes only to the anterior rectus |
Surgery_Schwartz_10213 | Surgery_Schwartz | aponeurosis is bilaminar and contributes to the anterior and posterior rectus sheaths above the arcuate line. Below this line, the internal aponeurosis contrib-utes only to the anterior rectus sheath. The transversus abdomi-nis aponeurosis contributes the posterior rectus sheath above the arcuate line and the anterior rectus sheath below the arcuate line. Therefore, below the arcuate line, all the aponeurotic layers of the lateral musculature form the anterior sheath, leaving the transversalis fascia as the only posterior fascial covering. This layer is a weak fibrous layer separated from the peritoneum by preperitoneal fat (Fig. 35-2).Along the posterior abdominal wall are folds correspond-ing to underlying vasculature and embryologic remnants. The median umbilical fold is formed by the obliterated urachus trav-eling from the dome of the bladder to the umbilicus in the mid-line. The bilateral medial folds are formed by remnants of the umbilical arteries. Lastly, the lateral folds are | Surgery_Schwartz. aponeurosis is bilaminar and contributes to the anterior and posterior rectus sheaths above the arcuate line. Below this line, the internal aponeurosis contrib-utes only to the anterior rectus sheath. The transversus abdomi-nis aponeurosis contributes the posterior rectus sheath above the arcuate line and the anterior rectus sheath below the arcuate line. Therefore, below the arcuate line, all the aponeurotic layers of the lateral musculature form the anterior sheath, leaving the transversalis fascia as the only posterior fascial covering. This layer is a weak fibrous layer separated from the peritoneum by preperitoneal fat (Fig. 35-2).Along the posterior abdominal wall are folds correspond-ing to underlying vasculature and embryologic remnants. The median umbilical fold is formed by the obliterated urachus trav-eling from the dome of the bladder to the umbilicus in the mid-line. The bilateral medial folds are formed by remnants of the umbilical arteries. Lastly, the lateral folds are |
Surgery_Schwartz_10214 | Surgery_Schwartz | urachus trav-eling from the dome of the bladder to the umbilicus in the mid-line. The bilateral medial folds are formed by remnants of the umbilical arteries. Lastly, the lateral folds are associated with the inferior epigastric vessels.The deep blood supply of the abdominal wall is supplied mostly from the inferior and superior epigastric arteries. The superior epigastric artery is the final branch of the internal tho-racic artery. It enters the rectus sheath below the costal margin 1Abdominal Wall 1549General Considerations / 1549Surgical Anatomy / 1549Physiology / 1550Abdominal Surgical Incisions and Closure / 1550Congenital Abnormalities / 1553Acquired Abnormalities / 1554Omentum 1557Surgical Anatomy / 1557Physiology / 1558Acquired Disorders / 1558Mesentery 1559Surgical Anatomy / 1559Sclerosing Mesenteritis / 1559Mesenteric Cysts / 1560Mesenteric Tumors / 1561Retroperitoneum 1561Surgical Anatomy / 1561Retroperitoneal Infections / 1561Retroperitoneal Fibrosis / | Surgery_Schwartz. urachus trav-eling from the dome of the bladder to the umbilicus in the mid-line. The bilateral medial folds are formed by remnants of the umbilical arteries. Lastly, the lateral folds are associated with the inferior epigastric vessels.The deep blood supply of the abdominal wall is supplied mostly from the inferior and superior epigastric arteries. The superior epigastric artery is the final branch of the internal tho-racic artery. It enters the rectus sheath below the costal margin 1Abdominal Wall 1549General Considerations / 1549Surgical Anatomy / 1549Physiology / 1550Abdominal Surgical Incisions and Closure / 1550Congenital Abnormalities / 1553Acquired Abnormalities / 1554Omentum 1557Surgical Anatomy / 1557Physiology / 1558Acquired Disorders / 1558Mesentery 1559Surgical Anatomy / 1559Sclerosing Mesenteritis / 1559Mesenteric Cysts / 1560Mesenteric Tumors / 1561Retroperitoneum 1561Surgical Anatomy / 1561Retroperitoneal Infections / 1561Retroperitoneal Fibrosis / |
Surgery_Schwartz_10215 | Surgery_Schwartz | Anatomy / 1559Sclerosing Mesenteritis / 1559Mesenteric Cysts / 1560Mesenteric Tumors / 1561Retroperitoneum 1561Surgical Anatomy / 1561Retroperitoneal Infections / 1561Retroperitoneal Fibrosis / 1562Brunicardi_Ch35_p1549-p1566.indd 154912/02/19 9:58 AM 1550Key Points1 There are differences in the anatomic structure in the rectus sheath above and below the arcuate line. Below the arcuate line, all the lateral fascial layers combine and travel anteriorly forming the anterior rectus sheath and leaving the posterior aspect of the lower portion of the rectus muscles without an aponeurotic covering. Above the arcuate line, the posterior rectus sheath is formed by a portion of the internal oblique aponeurosis and the transversus abdominus sheath, and the anterior rectus sheath is formed by the remaining fibers of the internal oblique and the external oblique aponeuroses.2 Two randomized trials have found that closure of midline incisions with small fascial stitches of five to eight mm | Surgery_Schwartz. Anatomy / 1559Sclerosing Mesenteritis / 1559Mesenteric Cysts / 1560Mesenteric Tumors / 1561Retroperitoneum 1561Surgical Anatomy / 1561Retroperitoneal Infections / 1561Retroperitoneal Fibrosis / 1562Brunicardi_Ch35_p1549-p1566.indd 154912/02/19 9:58 AM 1550Key Points1 There are differences in the anatomic structure in the rectus sheath above and below the arcuate line. Below the arcuate line, all the lateral fascial layers combine and travel anteriorly forming the anterior rectus sheath and leaving the posterior aspect of the lower portion of the rectus muscles without an aponeurotic covering. Above the arcuate line, the posterior rectus sheath is formed by a portion of the internal oblique aponeurosis and the transversus abdominus sheath, and the anterior rectus sheath is formed by the remaining fibers of the internal oblique and the external oblique aponeuroses.2 Two randomized trials have found that closure of midline incisions with small fascial stitches of five to eight mm |
Surgery_Schwartz_10216 | Surgery_Schwartz | the remaining fibers of the internal oblique and the external oblique aponeuroses.2 Two randomized trials have found that closure of midline incisions with small fascial stitches of five to eight mm length and five mm width is beneficial in preventing inci-sional hernias of the abdominal wall.3 Primary repair of ventral incisional hernias results in high recurrence rates, and repair utilizing other methods, includ-ing prosthetic mesh and component separation, are preferred techniques of repair.4 Laparoscopic incisional hernia repair results in similar recur-rence rates and wound infections, compared to open repair. Laparoscopic repair may result in a faster recovery and shorter hospitalization; however, there may be an increase in bowel injury when compared to an open repair.5 Desmoid tumors should be monitored for asymptomatic patients as there is a possibility of spontaneous regression. For patients with rapidly growing or symptomatic tumors resection is recommended. If complete | Surgery_Schwartz. the remaining fibers of the internal oblique and the external oblique aponeuroses.2 Two randomized trials have found that closure of midline incisions with small fascial stitches of five to eight mm length and five mm width is beneficial in preventing inci-sional hernias of the abdominal wall.3 Primary repair of ventral incisional hernias results in high recurrence rates, and repair utilizing other methods, includ-ing prosthetic mesh and component separation, are preferred techniques of repair.4 Laparoscopic incisional hernia repair results in similar recur-rence rates and wound infections, compared to open repair. Laparoscopic repair may result in a faster recovery and shorter hospitalization; however, there may be an increase in bowel injury when compared to an open repair.5 Desmoid tumors should be monitored for asymptomatic patients as there is a possibility of spontaneous regression. For patients with rapidly growing or symptomatic tumors resection is recommended. If complete |
Surgery_Schwartz_10217 | Surgery_Schwartz | tumors should be monitored for asymptomatic patients as there is a possibility of spontaneous regression. For patients with rapidly growing or symptomatic tumors resection is recommended. If complete pathologic resection is not achievable without significant morbidity, more modest resection is recommended along with treatment with adju-vant therapies.6 The omentum provides an immunogenic and fibrotic response to foreign stimuli, allowing the abdomen to wall off infections preventing diffuse peritonitis.7 The role of surgery in the treatment of sclerosing mesenteri-tis is minimal and is most often undertaken to obtain tissue for diagnosis. Most cases should be treated medically with surgical interventions reserved for cases of bowel obstruc-tion and ischemia.8 Surgical interventions for retroperitoneal fibrosis include obtaining tissue for pathologic diagnosis, relieving ureteral obstructions via ureterolysis or ureteral stenting, and reliev-ing vascular obstructions via endovascular | Surgery_Schwartz. tumors should be monitored for asymptomatic patients as there is a possibility of spontaneous regression. For patients with rapidly growing or symptomatic tumors resection is recommended. If complete pathologic resection is not achievable without significant morbidity, more modest resection is recommended along with treatment with adju-vant therapies.6 The omentum provides an immunogenic and fibrotic response to foreign stimuli, allowing the abdomen to wall off infections preventing diffuse peritonitis.7 The role of surgery in the treatment of sclerosing mesenteri-tis is minimal and is most often undertaken to obtain tissue for diagnosis. Most cases should be treated medically with surgical interventions reserved for cases of bowel obstruc-tion and ischemia.8 Surgical interventions for retroperitoneal fibrosis include obtaining tissue for pathologic diagnosis, relieving ureteral obstructions via ureterolysis or ureteral stenting, and reliev-ing vascular obstructions via endovascular |
Surgery_Schwartz_10218 | Surgery_Schwartz | fibrosis include obtaining tissue for pathologic diagnosis, relieving ureteral obstructions via ureterolysis or ureteral stenting, and reliev-ing vascular obstructions via endovascular stenting of affected vessels. Most cases are treated successfully with the use of steroids.and travels along the posterior surface of the anterior sheath and forms an anastomosis with the inferior epigastric artery at the umbilicus. The inferior epigastric artery arises from the external iliac artery. These arteries provide a collateral circula-tion between the vasculature of the upper and lower extremities (Fig. 35-3). The abdominal wall is also supplied by branches of the subcostal and lumbar arteries. Superficially, the abdominal wall subcutaneous and skin tissue is supplied by branches of the superficial epigastric arteries, femoral arteries, superficial exter-nal pudendal, and superficial circumflex arteries. Venous drain-age of the abdominal wall is variable but typically follows the | Surgery_Schwartz. fibrosis include obtaining tissue for pathologic diagnosis, relieving ureteral obstructions via ureterolysis or ureteral stenting, and reliev-ing vascular obstructions via endovascular stenting of affected vessels. Most cases are treated successfully with the use of steroids.and travels along the posterior surface of the anterior sheath and forms an anastomosis with the inferior epigastric artery at the umbilicus. The inferior epigastric artery arises from the external iliac artery. These arteries provide a collateral circula-tion between the vasculature of the upper and lower extremities (Fig. 35-3). The abdominal wall is also supplied by branches of the subcostal and lumbar arteries. Superficially, the abdominal wall subcutaneous and skin tissue is supplied by branches of the superficial epigastric arteries, femoral arteries, superficial exter-nal pudendal, and superficial circumflex arteries. Venous drain-age of the abdominal wall is variable but typically follows the |
Surgery_Schwartz_10219 | Surgery_Schwartz | superficial epigastric arteries, femoral arteries, superficial exter-nal pudendal, and superficial circumflex arteries. Venous drain-age of the abdominal wall is variable but typically follows the aforementioned arteries. Above the umbilicus, the lymphatics of the abdominal wall drain into the superficial axillary nodes. Below the umbilicus, these drain into the inguinal nodes. Lym-phatics near the umbilicus can drain along the falciform liga-ment toward the hepatic nodes.Innervation of the abdominal wall is segmental, leading to a dermatomal sensory pattern. Afferent branches of the T4 to L1 nerve roots provide sensation of the abdominal wall (see Fig. 35-3). The muscles of the abdominal wall are inner-vated by the efferent branches of spinal nerves T6 to T12.PhysiologyAside from providing protection of the intraabdominal and retroperitoneal organs, the abdominal wall muscles assist with flexion, extension, and rotation of the torso along with the muscles of the back and trunk. | Surgery_Schwartz. superficial epigastric arteries, femoral arteries, superficial exter-nal pudendal, and superficial circumflex arteries. Venous drain-age of the abdominal wall is variable but typically follows the aforementioned arteries. Above the umbilicus, the lymphatics of the abdominal wall drain into the superficial axillary nodes. Below the umbilicus, these drain into the inguinal nodes. Lym-phatics near the umbilicus can drain along the falciform liga-ment toward the hepatic nodes.Innervation of the abdominal wall is segmental, leading to a dermatomal sensory pattern. Afferent branches of the T4 to L1 nerve roots provide sensation of the abdominal wall (see Fig. 35-3). The muscles of the abdominal wall are inner-vated by the efferent branches of spinal nerves T6 to T12.PhysiologyAside from providing protection of the intraabdominal and retroperitoneal organs, the abdominal wall muscles assist with flexion, extension, and rotation of the torso along with the muscles of the back and trunk. |
Surgery_Schwartz_10220 | Surgery_Schwartz | protection of the intraabdominal and retroperitoneal organs, the abdominal wall muscles assist with flexion, extension, and rotation of the torso along with the muscles of the back and trunk. Working as a unit, the rectus muscles and external/internal obliques activate to flex the trunk anteriorly and laterally. Rotation of the torso is performed by simultaneous stimulation of the contralateral external oblique and ipsilateral internal oblique. To rotate the torso to the right requires simultaneous contraction of the right internal oblique muscle and left external oblique muscle, and vice versa for leftward rotation. Altogether, the muscles of the abdominal wall can act to raise intraabdominal pressure providing assistance with respiration, coughs, defecation, uri-nation, and parturition.Abdominal Surgical Incisions and ClosureKnowledge of the abdominal wall anatomy is an important aspect of safe entry into the abdomen. The goal of an efficacious incision is to provide adequate | Surgery_Schwartz. protection of the intraabdominal and retroperitoneal organs, the abdominal wall muscles assist with flexion, extension, and rotation of the torso along with the muscles of the back and trunk. Working as a unit, the rectus muscles and external/internal obliques activate to flex the trunk anteriorly and laterally. Rotation of the torso is performed by simultaneous stimulation of the contralateral external oblique and ipsilateral internal oblique. To rotate the torso to the right requires simultaneous contraction of the right internal oblique muscle and left external oblique muscle, and vice versa for leftward rotation. Altogether, the muscles of the abdominal wall can act to raise intraabdominal pressure providing assistance with respiration, coughs, defecation, uri-nation, and parturition.Abdominal Surgical Incisions and ClosureKnowledge of the abdominal wall anatomy is an important aspect of safe entry into the abdomen. The goal of an efficacious incision is to provide adequate |
Surgery_Schwartz_10221 | Surgery_Schwartz | Surgical Incisions and ClosureKnowledge of the abdominal wall anatomy is an important aspect of safe entry into the abdomen. The goal of an efficacious incision is to provide adequate exposure to perform the proce-dure with minimal perturbation of the abdominal wall function.Incisions for open abdominal surgery are generally located in proximity to operative targets. There are two general types of incisions: longitudinal or transverse/oblique (Fig. 35-4). There does not appear to be differences in early or late postoperative complications or recovery time between these two types of inci-sions. However, transverse incisions may be associated with lower incisional hernia rates but higher rates of wound infec-tions. Overall, without clear evidence of superiority the choice of incision remains a surgeon-dependent decision. Several retractor systems can be used to provide exposure using these open incisions. Examples include the Bookwalter, Omni-Tract, and Thompson retractors (Fig. | Surgery_Schwartz. Surgical Incisions and ClosureKnowledge of the abdominal wall anatomy is an important aspect of safe entry into the abdomen. The goal of an efficacious incision is to provide adequate exposure to perform the proce-dure with minimal perturbation of the abdominal wall function.Incisions for open abdominal surgery are generally located in proximity to operative targets. There are two general types of incisions: longitudinal or transverse/oblique (Fig. 35-4). There does not appear to be differences in early or late postoperative complications or recovery time between these two types of inci-sions. However, transverse incisions may be associated with lower incisional hernia rates but higher rates of wound infec-tions. Overall, without clear evidence of superiority the choice of incision remains a surgeon-dependent decision. Several retractor systems can be used to provide exposure using these open incisions. Examples include the Bookwalter, Omni-Tract, and Thompson retractors (Fig. |
Surgery_Schwartz_10222 | Surgery_Schwartz | remains a surgeon-dependent decision. Several retractor systems can be used to provide exposure using these open incisions. Examples include the Bookwalter, Omni-Tract, and Thompson retractors (Fig. 35-5).The most common longitudinal incision is the midline incision. Providing access to most intraabdominal organs and some retroperitoneal structures, the midline incision is carried down to the linea alba to allow access to the abdomen with mini-mal injury to skeletal muscles, nerves, and vessels. Paramedian longitudinal incisions are made lateral to the midline through the rectus sheath or in the pararectus location. These incisions restrict access to the contralateral abdomen and pelvis and risk damage to the musculature, vessels, and nerves.Closure of the midline incision requires reapproximation without undue tension or strangulation of the tissue to prevent Brunicardi_Ch35_p1549-p1566.indd 155012/02/19 9:58 AM 1551ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER | Surgery_Schwartz. remains a surgeon-dependent decision. Several retractor systems can be used to provide exposure using these open incisions. Examples include the Bookwalter, Omni-Tract, and Thompson retractors (Fig. 35-5).The most common longitudinal incision is the midline incision. Providing access to most intraabdominal organs and some retroperitoneal structures, the midline incision is carried down to the linea alba to allow access to the abdomen with mini-mal injury to skeletal muscles, nerves, and vessels. Paramedian longitudinal incisions are made lateral to the midline through the rectus sheath or in the pararectus location. These incisions restrict access to the contralateral abdomen and pelvis and risk damage to the musculature, vessels, and nerves.Closure of the midline incision requires reapproximation without undue tension or strangulation of the tissue to prevent Brunicardi_Ch35_p1549-p1566.indd 155012/02/19 9:58 AM 1551ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER |
Surgery_Schwartz_10223 | Surgery_Schwartz | without undue tension or strangulation of the tissue to prevent Brunicardi_Ch35_p1549-p1566.indd 155012/02/19 9:58 AM 1551ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35perioperative dehiscence or incisional hernia formation. Clas-sically, the midline fascia of the incision is closed using sutures placed 1 cm from the edge and a width of 1 cm apart. Two European randomized controlled trials demonstrated reduced rates of incisional hernia with shorter stitch width (5–8 mm) compared to the standard 1 cm stitches. Studies are ongoing in the United States at this time. Several studies have evaluated the use of prophylactic mesh implanta-tion in the closure of the midline incision. While these studies demonstrate reduced incisional hernia formation in the short-term, more long-term data is needed to determine the inci-dence of mesh-related complications. Furthermore, the optimal location of mesh implantation and type of mesh used are still being evaluated.When | Surgery_Schwartz. without undue tension or strangulation of the tissue to prevent Brunicardi_Ch35_p1549-p1566.indd 155012/02/19 9:58 AM 1551ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35perioperative dehiscence or incisional hernia formation. Clas-sically, the midline fascia of the incision is closed using sutures placed 1 cm from the edge and a width of 1 cm apart. Two European randomized controlled trials demonstrated reduced rates of incisional hernia with shorter stitch width (5–8 mm) compared to the standard 1 cm stitches. Studies are ongoing in the United States at this time. Several studies have evaluated the use of prophylactic mesh implanta-tion in the closure of the midline incision. While these studies demonstrate reduced incisional hernia formation in the short-term, more long-term data is needed to determine the inci-dence of mesh-related complications. Furthermore, the optimal location of mesh implantation and type of mesh used are still being evaluated.When |
Surgery_Schwartz_10224 | Surgery_Schwartz | more long-term data is needed to determine the inci-dence of mesh-related complications. Furthermore, the optimal location of mesh implantation and type of mesh used are still being evaluated.When performing a transverse or oblique incision, a sur-geon can either divide or separate the muscle fibers of the abdom-inal wall. The classic McBurney’s incision for appendectomy, an oblique incision performed one-third of the way from the iliac spine to the umbilicus, is an example of a muscle-splitting approach. A subcostal incision can be used to access the upper abdomen, liver, gallbladder, spleen, pancreas, or adrenals. On closure of these incisions, two layers must be approximated. The deep layer includes the internal oblique, transversus abdominus muscle, and the transversalis fascia. The superficial layer includes the anterior aponeurotic tissue of the rectus sheath medially and the external muscle/aponeurosis laterally. A bilateral subcostal incision, or a chevron incision, can be | Surgery_Schwartz. more long-term data is needed to determine the inci-dence of mesh-related complications. Furthermore, the optimal location of mesh implantation and type of mesh used are still being evaluated.When performing a transverse or oblique incision, a sur-geon can either divide or separate the muscle fibers of the abdom-inal wall. The classic McBurney’s incision for appendectomy, an oblique incision performed one-third of the way from the iliac spine to the umbilicus, is an example of a muscle-splitting approach. A subcostal incision can be used to access the upper abdomen, liver, gallbladder, spleen, pancreas, or adrenals. On closure of these incisions, two layers must be approximated. The deep layer includes the internal oblique, transversus abdominus muscle, and the transversalis fascia. The superficial layer includes the anterior aponeurotic tissue of the rectus sheath medially and the external muscle/aponeurosis laterally. A bilateral subcostal incision, or a chevron incision, can be |
Surgery_Schwartz_10225 | Surgery_Schwartz | superficial layer includes the anterior aponeurotic tissue of the rectus sheath medially and the external muscle/aponeurosis laterally. A bilateral subcostal incision, or a chevron incision, can be used to access organs of the upper abdomen and diaphragm. A Mercedes-Benz modification includes a midline incision superiorly, providing further access to the upper abdomen or the lower mediastinum.Pelvic procedures are commonly performed through a Pfannenstiel incision. This incision is performed via a trans-verse skin incision carried down to the anterior rectus sheath. The sheath is also transversely incised and dissected off the underlying rectus muscle. The rectus muscles are separated, and access through the transversalis fascia is performed lon-gitudinally. Closure of this incision requires approximation of the peritoneum and rectus muscles and closure of the anterior rectus sheath.Laparoscopic port site incision placement must be care-fully planned based on approach angles and | Surgery_Schwartz. superficial layer includes the anterior aponeurotic tissue of the rectus sheath medially and the external muscle/aponeurosis laterally. A bilateral subcostal incision, or a chevron incision, can be used to access organs of the upper abdomen and diaphragm. A Mercedes-Benz modification includes a midline incision superiorly, providing further access to the upper abdomen or the lower mediastinum.Pelvic procedures are commonly performed through a Pfannenstiel incision. This incision is performed via a trans-verse skin incision carried down to the anterior rectus sheath. The sheath is also transversely incised and dissected off the underlying rectus muscle. The rectus muscles are separated, and access through the transversalis fascia is performed lon-gitudinally. Closure of this incision requires approximation of the peritoneum and rectus muscles and closure of the anterior rectus sheath.Laparoscopic port site incision placement must be care-fully planned based on approach angles and |
Surgery_Schwartz_10226 | Surgery_Schwartz | requires approximation of the peritoneum and rectus muscles and closure of the anterior rectus sheath.Laparoscopic port site incision placement must be care-fully planned based on approach angles and working distances both to the operative site and between ports. Placement of a 278910789106511L1L2L31010(A) Anterior view(B) Rectus abdominis (RA)(C) External oblique (EO) (layer 1)(D) Internal oblique (IO) (layer 2)(E) Transversus abdominis (layer 3)Lateral viewsEOIliac crestIntertendinousband (IT)RAIOTARSRSRSEOEOEORAITRAITRAITRALinea albaPyramidalisITITFigure 35-1. Muscles of the anterior abdominal wall. A. The anterior abdominal wall musculature is shown with the rectus sheath reflected on the left side. B. Rectus abdominis. C. External oblique. D. Internal oblique. E. Transversus abdominus. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)Brunicardi_Ch35_p1549-p1566.indd | Surgery_Schwartz. requires approximation of the peritoneum and rectus muscles and closure of the anterior rectus sheath.Laparoscopic port site incision placement must be care-fully planned based on approach angles and working distances both to the operative site and between ports. Placement of a 278910789106511L1L2L31010(A) Anterior view(B) Rectus abdominis (RA)(C) External oblique (EO) (layer 1)(D) Internal oblique (IO) (layer 2)(E) Transversus abdominis (layer 3)Lateral viewsEOIliac crestIntertendinousband (IT)RAIOTARSRSRSEOEOEORAITRAITRAITRALinea albaPyramidalisITITFigure 35-1. Muscles of the anterior abdominal wall. A. The anterior abdominal wall musculature is shown with the rectus sheath reflected on the left side. B. Rectus abdominis. C. External oblique. D. Internal oblique. E. Transversus abdominus. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)Brunicardi_Ch35_p1549-p1566.indd |
Surgery_Schwartz_10227 | Surgery_Schwartz | abdominus. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)Brunicardi_Ch35_p1549-p1566.indd 155112/02/19 9:58 AM 1552SPECIFIC CONSIDERATIONSPART IInasogastric tube and Foley catheter may help to decompress the stomach and bladder reducing injury to these structures on entry. Initial entry into the abdomen may be completed using the open Hasson or closed Veress needle techniques. The Hasson tech-nique involves direct visualization and systematic opening of each fascial layer encountered on entry. The closed technique utilizes the Veress needle to access the abdomen in a controlled fashion. Access to the peritoneum is confirmed using one or a combination of several techniques (saline drop method or measurement of intraabdominal pressure), and gas insuffla-tion is begun. The abdomen can then be accessed using either a visual entry port or a nonvisualized entry port at the site of the | Surgery_Schwartz. abdominus. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)Brunicardi_Ch35_p1549-p1566.indd 155112/02/19 9:58 AM 1552SPECIFIC CONSIDERATIONSPART IInasogastric tube and Foley catheter may help to decompress the stomach and bladder reducing injury to these structures on entry. Initial entry into the abdomen may be completed using the open Hasson or closed Veress needle techniques. The Hasson tech-nique involves direct visualization and systematic opening of each fascial layer encountered on entry. The closed technique utilizes the Veress needle to access the abdomen in a controlled fashion. Access to the peritoneum is confirmed using one or a combination of several techniques (saline drop method or measurement of intraabdominal pressure), and gas insuffla-tion is begun. The abdomen can then be accessed using either a visual entry port or a nonvisualized entry port at the site of the |
Surgery_Schwartz_10228 | Surgery_Schwartz | method or measurement of intraabdominal pressure), and gas insuffla-tion is begun. The abdomen can then be accessed using either a visual entry port or a nonvisualized entry port at the site of the needle track or an alternative site. Choice of entry method is still controversial and based on surgeon preference. Retrospec-tive reviews suggest that complications may be lower using the Hasson technique, but randomized trials (although small) have not found significant differences in techniques.Abdominal incisions can lead to significant patient mor-bidity. Complications include hematomas/seromas, surgical site infections, fascial dehiscence, incisional hernias, and nerve injuries among others. In general, minimizing opera-tive incision lengths to only that which is necessary for a safe operation is prudent to reduce these complications and morbidity.Right externaloblique muscleFibers of rightexternal obliqueaponeurosisFibers of leftinternal obliqueaponeurosisFibers passing from | Surgery_Schwartz. method or measurement of intraabdominal pressure), and gas insuffla-tion is begun. The abdomen can then be accessed using either a visual entry port or a nonvisualized entry port at the site of the needle track or an alternative site. Choice of entry method is still controversial and based on surgeon preference. Retrospec-tive reviews suggest that complications may be lower using the Hasson technique, but randomized trials (although small) have not found significant differences in techniques.Abdominal incisions can lead to significant patient mor-bidity. Complications include hematomas/seromas, surgical site infections, fascial dehiscence, incisional hernias, and nerve injuries among others. In general, minimizing opera-tive incision lengths to only that which is necessary for a safe operation is prudent to reduce these complications and morbidity.Right externaloblique muscleFibers of rightexternal obliqueaponeurosisFibers of leftinternal obliqueaponeurosisFibers passing from |
Surgery_Schwartz_10229 | Surgery_Schwartz | operation is prudent to reduce these complications and morbidity.Right externaloblique muscleFibers of rightexternal obliqueaponeurosisFibers of leftinternal obliqueaponeurosisFibers passing from superficial to deep(and vice versa) at linea albaLeft internaloblique muscleIntermuscular exchange of fibers between aponeuroses ofcontralateral external and internal oblique muscles.Fibers of left externaloblique aponeurosis,which run deep on theright side and runningsuperficially on the leftsideDeep fibers of left external oblique aponeurosisUmbilical ringDeep fibers of right external oblique aponeurosisIntramuscular exchange of superficial and deepfibers within aponeuroses of contralateralexternal oblique muscles. Transverse sections(B) Anterior view(A) Anterior viewsLineaalbaRectus abdominisAponeurosisof externalobliqueAponeurosisof internalobliqueAponeurosisof transversusabdominisParietal peritoneumSkinTransversus abdominisInternal obliqueExternal obliqueDeep membranous layerof | Surgery_Schwartz. operation is prudent to reduce these complications and morbidity.Right externaloblique muscleFibers of rightexternal obliqueaponeurosisFibers of leftinternal obliqueaponeurosisFibers passing from superficial to deep(and vice versa) at linea albaLeft internaloblique muscleIntermuscular exchange of fibers between aponeuroses ofcontralateral external and internal oblique muscles.Fibers of left externaloblique aponeurosis,which run deep on theright side and runningsuperficially on the leftsideDeep fibers of left external oblique aponeurosisUmbilical ringDeep fibers of right external oblique aponeurosisIntramuscular exchange of superficial and deepfibers within aponeuroses of contralateralexternal oblique muscles. Transverse sections(B) Anterior view(A) Anterior viewsLineaalbaRectus abdominisAponeurosisof externalobliqueAponeurosisof internalobliqueAponeurosisof transversusabdominisParietal peritoneumSkinTransversus abdominisInternal obliqueExternal obliqueDeep membranous layerof |
Surgery_Schwartz_10230 | Surgery_Schwartz | externalobliqueAponeurosisof internalobliqueAponeurosisof transversusabdominisParietal peritoneumSkinTransversus abdominisInternal obliqueExternal obliqueDeep membranous layerof subcutaneoustissueTransversalis fasciaExtraperitoneal fatRectussheathLinea alba(note fibers passingfrom superficial to deep,and vice versa, as inright side of figure A)Superficial fatty layer ofsubcutaneoustissueInvesting (deep) fascia:SuperficialIntermediateDeepFigure 35-2. Fiber direction and cross-sectional anatomy of the abdominal wall. A. Muscular and aponeurosis fiber direction of external and internal obliques. B. Cross-sectional anatomy of the anterior abdominal wall above and below the arcuate line. The posterior leaf of the rectus sheath exists above the arcuate line. Below this line, all aponeurotic sheaths converge and travel anterior to the rectus muscles, leaving the posterior rectus uncovered by a fascial layer. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, | Surgery_Schwartz. externalobliqueAponeurosisof internalobliqueAponeurosisof transversusabdominisParietal peritoneumSkinTransversus abdominisInternal obliqueExternal obliqueDeep membranous layerof subcutaneoustissueTransversalis fasciaExtraperitoneal fatRectussheathLinea alba(note fibers passingfrom superficial to deep,and vice versa, as inright side of figure A)Superficial fatty layer ofsubcutaneoustissueInvesting (deep) fascia:SuperficialIntermediateDeepFigure 35-2. Fiber direction and cross-sectional anatomy of the abdominal wall. A. Muscular and aponeurosis fiber direction of external and internal obliques. B. Cross-sectional anatomy of the anterior abdominal wall above and below the arcuate line. The posterior leaf of the rectus sheath exists above the arcuate line. Below this line, all aponeurotic sheaths converge and travel anterior to the rectus muscles, leaving the posterior rectus uncovered by a fascial layer. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, |
Surgery_Schwartz_10231 | Surgery_Schwartz | converge and travel anterior to the rectus muscles, leaving the posterior rectus uncovered by a fascial layer. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)Brunicardi_Ch35_p1549-p1566.indd 155212/02/19 9:58 AM 1553ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35Congenital AbnormalitiesThe folds of mesodermal cells that form the abdominal wall lay-ers begin to form in the early weeks after gestation. The folds develop in the cephalic, caudal, and right/left lateral directions and converge at the umbilicus around 8 weeks. At around 6 weeks of development the contents of the abdominal cavity outgrow the space allowed by the surrounding layers of the Thoraco-abdominalnerves (T7-T11)Lateral cutaneous branchof subcostal nerve (T12)Anterior cutaneous branchof subcostal nerve (T12)Iliohypogastric nerve (L1)Ilio-inguinal nerve (L1)Xiphoid processAnterior superior iliac | Surgery_Schwartz. converge and travel anterior to the rectus muscles, leaving the posterior rectus uncovered by a fascial layer. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)Brunicardi_Ch35_p1549-p1566.indd 155212/02/19 9:58 AM 1553ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35Congenital AbnormalitiesThe folds of mesodermal cells that form the abdominal wall lay-ers begin to form in the early weeks after gestation. The folds develop in the cephalic, caudal, and right/left lateral directions and converge at the umbilicus around 8 weeks. At around 6 weeks of development the contents of the abdominal cavity outgrow the space allowed by the surrounding layers of the Thoraco-abdominalnerves (T7-T11)Lateral cutaneous branchof subcostal nerve (T12)Anterior cutaneous branchof subcostal nerve (T12)Iliohypogastric nerve (L1)Ilio-inguinal nerve (L1)Xiphoid processAnterior superior iliac |
Surgery_Schwartz_10232 | Surgery_Schwartz | (T7-T11)Lateral cutaneous branchof subcostal nerve (T12)Anterior cutaneous branchof subcostal nerve (T12)Iliohypogastric nerve (L1)Ilio-inguinal nerve (L1)Xiphoid processAnterior superior iliac spine (ASIS)AnteriorcutaneousbranchesLateralcutaneousbranchesInguinal ligamentSuperiorepigastric a.External obliqueInternal oblique TransversusabdominisInferior epigastric a.Deep circumflexiliac a.Superficialepigastric a.Superficialcircumflex iliac a.External iliac a.Femoral a.Transversalis fasciaMusculophrenic a.11th posteriorintercostal a.10th posteriorintercostal a.Subcostal a.Internal thoracic a.Anterior viewFigure 35-3. Neurovascular anatomy of the anterior abdominal wall. The right image demonstrates the arteries of the deep abdominal wall. The superior epigastric and inferior epigastric form an anastomosis along the posterior aspect of the rectus muscle. The image on the left demonstrates the dermatomal distribution of cutaneous nerves of the abdominal wall. (Reproduced with permission | Surgery_Schwartz. (T7-T11)Lateral cutaneous branchof subcostal nerve (T12)Anterior cutaneous branchof subcostal nerve (T12)Iliohypogastric nerve (L1)Ilio-inguinal nerve (L1)Xiphoid processAnterior superior iliac spine (ASIS)AnteriorcutaneousbranchesLateralcutaneousbranchesInguinal ligamentSuperiorepigastric a.External obliqueInternal oblique TransversusabdominisInferior epigastric a.Deep circumflexiliac a.Superficialepigastric a.Superficialcircumflex iliac a.External iliac a.Femoral a.Transversalis fasciaMusculophrenic a.11th posteriorintercostal a.10th posteriorintercostal a.Subcostal a.Internal thoracic a.Anterior viewFigure 35-3. Neurovascular anatomy of the anterior abdominal wall. The right image demonstrates the arteries of the deep abdominal wall. The superior epigastric and inferior epigastric form an anastomosis along the posterior aspect of the rectus muscle. The image on the left demonstrates the dermatomal distribution of cutaneous nerves of the abdominal wall. (Reproduced with permission |
Surgery_Schwartz_10233 | Surgery_Schwartz | an anastomosis along the posterior aspect of the rectus muscle. The image on the left demonstrates the dermatomal distribution of cutaneous nerves of the abdominal wall. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)CDEFHGABFigure 35-4. Various open abdominal wall incisions. A. Mid-line incision. B. Paramedian incision. C. Right subcostal incision and “saber slash” extension (dashed line). D. Bilateral subcostal incision (also chevron incision) with “Mercedes Benz” extension (dashed line). E. Rocky-Davis incision and Weir extension (dashed line). F. McBurney incision. G. Transverse incision. H. Pfannen-stiel incision.Figure 35-5. Thompson retractor for exposure of intra-abdominal structures utilizing an upper midline incision.Brunicardi_Ch35_p1549-p1566.indd 155312/02/19 9:58 AM 1554SPECIFIC CONSIDERATIONSPART IIabdominal wall, resulting in temporary herniation of the abdom-inal | Surgery_Schwartz. an anastomosis along the posterior aspect of the rectus muscle. The image on the left demonstrates the dermatomal distribution of cutaneous nerves of the abdominal wall. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)CDEFHGABFigure 35-4. Various open abdominal wall incisions. A. Mid-line incision. B. Paramedian incision. C. Right subcostal incision and “saber slash” extension (dashed line). D. Bilateral subcostal incision (also chevron incision) with “Mercedes Benz” extension (dashed line). E. Rocky-Davis incision and Weir extension (dashed line). F. McBurney incision. G. Transverse incision. H. Pfannen-stiel incision.Figure 35-5. Thompson retractor for exposure of intra-abdominal structures utilizing an upper midline incision.Brunicardi_Ch35_p1549-p1566.indd 155312/02/19 9:58 AM 1554SPECIFIC CONSIDERATIONSPART IIabdominal wall, resulting in temporary herniation of the abdom-inal |
Surgery_Schwartz_10234 | Surgery_Schwartz | utilizing an upper midline incision.Brunicardi_Ch35_p1549-p1566.indd 155312/02/19 9:58 AM 1554SPECIFIC CONSIDERATIONSPART IIabdominal wall, resulting in temporary herniation of the abdom-inal contents through a central defect. At this time, the vitelline duct (omphalomesenteric duct) and allantois also pass through the central defect. The vitelline duct serves as a conduit to the embryologic midgut and the yolk sac. As the midgut develops outside of the abdomen, it undergoes a 270° counterclockwise rotation and reenters the abdomen at around 12 weeks. Failure of the midgut to reenter the abdomen leads to the congenital abdominal wall defect known as an omphalocele, in which the contents of the defect protrude through an open umbilicus and are covered by an amniotic/peritoneal membrane. Gastroschisis, on the other hand, results from either malformation or disrup-tion of the abdominal wall, either from genetic defects or vas-cular compromise. Gastroschisis presents as protruding | Surgery_Schwartz. utilizing an upper midline incision.Brunicardi_Ch35_p1549-p1566.indd 155312/02/19 9:58 AM 1554SPECIFIC CONSIDERATIONSPART IIabdominal wall, resulting in temporary herniation of the abdom-inal contents through a central defect. At this time, the vitelline duct (omphalomesenteric duct) and allantois also pass through the central defect. The vitelline duct serves as a conduit to the embryologic midgut and the yolk sac. As the midgut develops outside of the abdomen, it undergoes a 270° counterclockwise rotation and reenters the abdomen at around 12 weeks. Failure of the midgut to reenter the abdomen leads to the congenital abdominal wall defect known as an omphalocele, in which the contents of the defect protrude through an open umbilicus and are covered by an amniotic/peritoneal membrane. Gastroschisis, on the other hand, results from either malformation or disrup-tion of the abdominal wall, either from genetic defects or vas-cular compromise. Gastroschisis presents as protruding |
Surgery_Schwartz_10235 | Surgery_Schwartz | Gastroschisis, on the other hand, results from either malformation or disrup-tion of the abdominal wall, either from genetic defects or vas-cular compromise. Gastroschisis presents as protruding viscera through a defect lateral to the umbilicus (usually along the right side) without the amniotic sac covering.The vitelline duct usually involutes at around the eighth to ninth week after gestation. Failure of vitelline duct regression can lead to several abnormalities depending on the spectrum of involution. This spectrum includes total persistence of the vitel-line duct leading to omphalomesenteric fistula causing drainage of intestinal contents at the umbilicus, to partial closure leading to omphalomesenteric cyst. If the vitelline remnant persists at the ileal border, a Meckel’s diverticulum forms. The vitelline duct may also persist as a fibrous attachment of the intestine to the abdominal wall predisposing the patient to bowel obstruc-tions. Fistulas, cysts, and fibrous attachments | Surgery_Schwartz. Gastroschisis, on the other hand, results from either malformation or disrup-tion of the abdominal wall, either from genetic defects or vas-cular compromise. Gastroschisis presents as protruding viscera through a defect lateral to the umbilicus (usually along the right side) without the amniotic sac covering.The vitelline duct usually involutes at around the eighth to ninth week after gestation. Failure of vitelline duct regression can lead to several abnormalities depending on the spectrum of involution. This spectrum includes total persistence of the vitel-line duct leading to omphalomesenteric fistula causing drainage of intestinal contents at the umbilicus, to partial closure leading to omphalomesenteric cyst. If the vitelline remnant persists at the ileal border, a Meckel’s diverticulum forms. The vitelline duct may also persist as a fibrous attachment of the intestine to the abdominal wall predisposing the patient to bowel obstruc-tions. Fistulas, cysts, and fibrous attachments |
Surgery_Schwartz_10236 | Surgery_Schwartz | forms. The vitelline duct may also persist as a fibrous attachment of the intestine to the abdominal wall predisposing the patient to bowel obstruc-tions. Fistulas, cysts, and fibrous attachments should be resected when diagnosed.The urachus is the proximal portion of the allantois form-ing as the bladder descends into its pelvic position. The urachus closes and forms the median umbilical ligament of the abdomi-nal wall as previously described. Failure of the urachus to close results in urinary fistula or cyst. These are treated by urachal excision and closure of the bladder defect.Acquired AbnormalitiesAbdominal Wall Hernias. A protrusion or bulge of abdomi-nal contents through the abdominal wall muscle/fascia repre-sents an abdominal wall hernia. This may be present at birth or acquired from weakening or disruption of the overlying fascia, or from failed healing of a surgical incision. Hernias may present as asymptomatic bulges that increase with Val-salva maneuvers, or with | Surgery_Schwartz. forms. The vitelline duct may also persist as a fibrous attachment of the intestine to the abdominal wall predisposing the patient to bowel obstruc-tions. Fistulas, cysts, and fibrous attachments should be resected when diagnosed.The urachus is the proximal portion of the allantois form-ing as the bladder descends into its pelvic position. The urachus closes and forms the median umbilical ligament of the abdomi-nal wall as previously described. Failure of the urachus to close results in urinary fistula or cyst. These are treated by urachal excision and closure of the bladder defect.Acquired AbnormalitiesAbdominal Wall Hernias. A protrusion or bulge of abdomi-nal contents through the abdominal wall muscle/fascia repre-sents an abdominal wall hernia. This may be present at birth or acquired from weakening or disruption of the overlying fascia, or from failed healing of a surgical incision. Hernias may present as asymptomatic bulges that increase with Val-salva maneuvers, or with |
Surgery_Schwartz_10237 | Surgery_Schwartz | from weakening or disruption of the overlying fascia, or from failed healing of a surgical incision. Hernias may present as asymptomatic bulges that increase with Val-salva maneuvers, or with significant discomfort. On physical exam, the patient’s abdominal wall should be evaluated with the patient both standing and in the recumbent position. Her-nias may reduce spontaneously or with manual pressure. If a hernia is incarcerated, it cannot be reduced and generally requires surgical correction. If intestine is incarcerated in the hernia defect, bowel obstruction may ensue, which represents a surgical emergency. Incarcerated hernias present with sig-nificant pain, nausea, and vomiting. A hernia is considered strangulated if blood supply to its contents is compromised. Localized ischemia may lead to infarction and eventual perfo-ration if left untreated.Nonincisional hernias are named based on their location on the abdominal wall. Epigastric hernias are defects in the abdominal wall | Surgery_Schwartz. from weakening or disruption of the overlying fascia, or from failed healing of a surgical incision. Hernias may present as asymptomatic bulges that increase with Val-salva maneuvers, or with significant discomfort. On physical exam, the patient’s abdominal wall should be evaluated with the patient both standing and in the recumbent position. Her-nias may reduce spontaneously or with manual pressure. If a hernia is incarcerated, it cannot be reduced and generally requires surgical correction. If intestine is incarcerated in the hernia defect, bowel obstruction may ensue, which represents a surgical emergency. Incarcerated hernias present with sig-nificant pain, nausea, and vomiting. A hernia is considered strangulated if blood supply to its contents is compromised. Localized ischemia may lead to infarction and eventual perfo-ration if left untreated.Nonincisional hernias are named based on their location on the abdominal wall. Epigastric hernias are defects in the abdominal wall |
Surgery_Schwartz_10238 | Surgery_Schwartz | may lead to infarction and eventual perfo-ration if left untreated.Nonincisional hernias are named based on their location on the abdominal wall. Epigastric hernias are defects in the abdominal wall located between the umbilicus and the xiphoid process. These hernias are usually small but may be associ-ated with multiple defects. They result from multiple factors, including muscle weakness, congenitally weakened epigastric fascia, or increases in intra-abdominal pressure. Epigastric hernias rarely contain bowel and usually contain portions of the omentum or falciform ligament. Given the rarity of incarcera-tion, repair of an epigastric hernia is indicated for symptomatic patients only. Laparoscopic repair can be attempted, but this type of hernia usually can be managed with a small incision where the defect is closed with interrupted sutures.Umbilical hernias may be congenital or acquired. Umbili-cal hernias are common in newborns, especially in premature infants. Closure of an | Surgery_Schwartz. may lead to infarction and eventual perfo-ration if left untreated.Nonincisional hernias are named based on their location on the abdominal wall. Epigastric hernias are defects in the abdominal wall located between the umbilicus and the xiphoid process. These hernias are usually small but may be associ-ated with multiple defects. They result from multiple factors, including muscle weakness, congenitally weakened epigastric fascia, or increases in intra-abdominal pressure. Epigastric hernias rarely contain bowel and usually contain portions of the omentum or falciform ligament. Given the rarity of incarcera-tion, repair of an epigastric hernia is indicated for symptomatic patients only. Laparoscopic repair can be attempted, but this type of hernia usually can be managed with a small incision where the defect is closed with interrupted sutures.Umbilical hernias may be congenital or acquired. Umbili-cal hernias are common in newborns, especially in premature infants. Closure of an |
Surgery_Schwartz_10239 | Surgery_Schwartz | incision where the defect is closed with interrupted sutures.Umbilical hernias may be congenital or acquired. Umbili-cal hernias are common in newborns, especially in premature infants. Closure of an umbilical defect occurs after birth as the muscles of the rectus abdominis grow toward one another. Most umbilical hernias close spontaneously by 5 years of age and can be monitored as they will spontaneously resolve. Indications for repair include incarceration, symptomatic hernia, failure to decrease in size or if the defect fails to close by the age of 5 years.In adults, umbilical hernias form because of increased abdominal pressure due to pregnancy, obesity, or ascites. Females are at higher risk for this type of hernia than men. Small, asymptomatic hernias may be followed clinically. How-ever, if an umbilical hernia enlarges in size, causes symptoms, or incarcerates surgical treatment should be offered. Hernias can be repaired laparoscopically or with an open procedure. Mesh should | Surgery_Schwartz. incision where the defect is closed with interrupted sutures.Umbilical hernias may be congenital or acquired. Umbili-cal hernias are common in newborns, especially in premature infants. Closure of an umbilical defect occurs after birth as the muscles of the rectus abdominis grow toward one another. Most umbilical hernias close spontaneously by 5 years of age and can be monitored as they will spontaneously resolve. Indications for repair include incarceration, symptomatic hernia, failure to decrease in size or if the defect fails to close by the age of 5 years.In adults, umbilical hernias form because of increased abdominal pressure due to pregnancy, obesity, or ascites. Females are at higher risk for this type of hernia than men. Small, asymptomatic hernias may be followed clinically. How-ever, if an umbilical hernia enlarges in size, causes symptoms, or incarcerates surgical treatment should be offered. Hernias can be repaired laparoscopically or with an open procedure. Mesh should |
Surgery_Schwartz_10240 | Surgery_Schwartz | if an umbilical hernia enlarges in size, causes symptoms, or incarcerates surgical treatment should be offered. Hernias can be repaired laparoscopically or with an open procedure. Mesh should be employed for large defects where the fascial edges cannot be approximated without tension. In this case, mesh should be placed as a sublay technique (below the fascia) and sutured in place to prevent migration.Patients with cirrhosis and associated ascites with an umbilical hernia pose a significant clinical dilemma. Umbilical defects enlarge in these patients because of high intra-abdominal pressure associated with uncontrolled ascites. With severe liver disease, these patients are at high risk of operative complica-tions. Most hernias contain ascites; however, omentum and bowel may also enter the defect. Given the high pressure, skin breakdown may ensue leading to hernia rupture or weeping as well as risk of spontaneous bacterial peritonitis. All attempts should be made to control the | Surgery_Schwartz. if an umbilical hernia enlarges in size, causes symptoms, or incarcerates surgical treatment should be offered. Hernias can be repaired laparoscopically or with an open procedure. Mesh should be employed for large defects where the fascial edges cannot be approximated without tension. In this case, mesh should be placed as a sublay technique (below the fascia) and sutured in place to prevent migration.Patients with cirrhosis and associated ascites with an umbilical hernia pose a significant clinical dilemma. Umbilical defects enlarge in these patients because of high intra-abdominal pressure associated with uncontrolled ascites. With severe liver disease, these patients are at high risk of operative complica-tions. Most hernias contain ascites; however, omentum and bowel may also enter the defect. Given the high pressure, skin breakdown may ensue leading to hernia rupture or weeping as well as risk of spontaneous bacterial peritonitis. All attempts should be made to control the |
Surgery_Schwartz_10241 | Surgery_Schwartz | the defect. Given the high pressure, skin breakdown may ensue leading to hernia rupture or weeping as well as risk of spontaneous bacterial peritonitis. All attempts should be made to control the patient’s ascites prior to repair. Therefore, asymptomatic patients should be managed conserva-tively with aggressive management of ascites. Liver transplant candidates should undergo repair at the time of transplanta-tion as pretransplant repair has high morbidity and mortality. Patients with incarcerated hernias or with thinning or ruptured skin overlying the hernia should be treated emergently.Hernias that occur along the arcuate line are known as Spigelian hernias. While rare, these hernias form due to the anatomic weakness of lack of a posterior rectus sheath below the arcuate line. As the hernia develops, peritoneum that passes through the arcuate line will pass laterally toward the external oblique muscle given the overlying aponeurosis (Fig. 35-6). Most patients present with pain and | Surgery_Schwartz. the defect. Given the high pressure, skin breakdown may ensue leading to hernia rupture or weeping as well as risk of spontaneous bacterial peritonitis. All attempts should be made to control the patient’s ascites prior to repair. Therefore, asymptomatic patients should be managed conserva-tively with aggressive management of ascites. Liver transplant candidates should undergo repair at the time of transplanta-tion as pretransplant repair has high morbidity and mortality. Patients with incarcerated hernias or with thinning or ruptured skin overlying the hernia should be treated emergently.Hernias that occur along the arcuate line are known as Spigelian hernias. While rare, these hernias form due to the anatomic weakness of lack of a posterior rectus sheath below the arcuate line. As the hernia develops, peritoneum that passes through the arcuate line will pass laterally toward the external oblique muscle given the overlying aponeurosis (Fig. 35-6). Most patients present with pain and |
Surgery_Schwartz_10242 | Surgery_Schwartz | develops, peritoneum that passes through the arcuate line will pass laterally toward the external oblique muscle given the overlying aponeurosis (Fig. 35-6). Most patients present with pain and swelling in the mid to lower abdomen. Incarceration is common as up to 20% of patients present with a nonreducible hernia. Given the high rate of incar-ceration, surgical repair is usually recommended. Either open or laparoscopic repair can be performed. The defect is closed by approximating the medial and lateral edges of the transversalis fascia to the rectus sheath.Incisional Hernias. Hernias that develop at sites of pre-vious abdominal incisions are known as incisional hernias. Hernias can develop at the site of any previous abdominal incision. Up to 20% of midline incisions will develop her-nias eventually. Vertical incisions may have a higher risk of hernia formation than transverse or oblique incisions. Upper Brunicardi_Ch35_p1549-p1566.indd 155412/02/19 9:58 AM 1555ABDOMINAL WALL, | Surgery_Schwartz. develops, peritoneum that passes through the arcuate line will pass laterally toward the external oblique muscle given the overlying aponeurosis (Fig. 35-6). Most patients present with pain and swelling in the mid to lower abdomen. Incarceration is common as up to 20% of patients present with a nonreducible hernia. Given the high rate of incar-ceration, surgical repair is usually recommended. Either open or laparoscopic repair can be performed. The defect is closed by approximating the medial and lateral edges of the transversalis fascia to the rectus sheath.Incisional Hernias. Hernias that develop at sites of pre-vious abdominal incisions are known as incisional hernias. Hernias can develop at the site of any previous abdominal incision. Up to 20% of midline incisions will develop her-nias eventually. Vertical incisions may have a higher risk of hernia formation than transverse or oblique incisions. Upper Brunicardi_Ch35_p1549-p1566.indd 155412/02/19 9:58 AM 1555ABDOMINAL WALL, |
Surgery_Schwartz_10243 | Surgery_Schwartz | eventually. Vertical incisions may have a higher risk of hernia formation than transverse or oblique incisions. Upper Brunicardi_Ch35_p1549-p1566.indd 155412/02/19 9:58 AM 1555ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35abdominal incisions are also at higher risk than lower inci-sions. Laparoscopic port sites may also develop hernias. The etiology of incisional hernias is complex. Several patient-derived factors increase the risk of hernia, including diabe-tes, immunosuppressant use, obesity, smoking, malnutrition, and connective tissue disorders. Local operative factors may also be implicated, including technique, wound infection, or high tension at the time of closure. Hernias can develop up to 10 years after surgery but normally occur in the early postop-erative period. Incisional hernias can present as asymptom-atic bulges or with severe discomfort. Multiple hernias can be present along the length of the incision. Elective surgery should be recommended in | Surgery_Schwartz. eventually. Vertical incisions may have a higher risk of hernia formation than transverse or oblique incisions. Upper Brunicardi_Ch35_p1549-p1566.indd 155412/02/19 9:58 AM 1555ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35abdominal incisions are also at higher risk than lower inci-sions. Laparoscopic port sites may also develop hernias. The etiology of incisional hernias is complex. Several patient-derived factors increase the risk of hernia, including diabe-tes, immunosuppressant use, obesity, smoking, malnutrition, and connective tissue disorders. Local operative factors may also be implicated, including technique, wound infection, or high tension at the time of closure. Hernias can develop up to 10 years after surgery but normally occur in the early postop-erative period. Incisional hernias can present as asymptom-atic bulges or with severe discomfort. Multiple hernias can be present along the length of the incision. Elective surgery should be recommended in |
Surgery_Schwartz_10244 | Surgery_Schwartz | period. Incisional hernias can present as asymptom-atic bulges or with severe discomfort. Multiple hernias can be present along the length of the incision. Elective surgery should be recommended in patients who are symptomatic. Small defects pose a higher risk of incarceration and should be repaired. To improve operative outcome, patient associated factors, including smoking and obesity, should be remedied prior to surgical repair.Surgical management of incisional hernias include either primary tissue or mesh repairs. Hernias can also be repaired via a laparoscopic or open approach. Simple suture repair is associ-ated with recurrence rates as high as 54%. A Cochrane review of several randomized controlled trials found that open mesh repair improved hernia recurrence rates when compared to simple closure (33% with simple repair vs. 16% with mesh repair). Mesh repairs are, however, associated with a higher rate of infections.To reduce tension at the suture line associated with pri-mary | Surgery_Schwartz. period. Incisional hernias can present as asymptom-atic bulges or with severe discomfort. Multiple hernias can be present along the length of the incision. Elective surgery should be recommended in patients who are symptomatic. Small defects pose a higher risk of incarceration and should be repaired. To improve operative outcome, patient associated factors, including smoking and obesity, should be remedied prior to surgical repair.Surgical management of incisional hernias include either primary tissue or mesh repairs. Hernias can also be repaired via a laparoscopic or open approach. Simple suture repair is associ-ated with recurrence rates as high as 54%. A Cochrane review of several randomized controlled trials found that open mesh repair improved hernia recurrence rates when compared to simple closure (33% with simple repair vs. 16% with mesh repair). Mesh repairs are, however, associated with a higher rate of infections.To reduce tension at the suture line associated with pri-mary |
Surgery_Schwartz_10245 | Surgery_Schwartz | simple closure (33% with simple repair vs. 16% with mesh repair). Mesh repairs are, however, associated with a higher rate of infections.To reduce tension at the suture line associated with pri-mary suture repair Ramirez described the components separa-tion technique in 1990. This procedure entails dividing portions of the bilateral external oblique aponeuroses forming musculo-fascial advancement flaps. The posterior rectus sheath can also be incised, allowing up to 10 cm of medial mobilization and ten-sionless approximation of the midline fascia. This technique can cause large skin flaps and initially had high rates of infection. Overtime, techniques have been developed to decrease flap for-mation and decreased rates of surgical site infection. Endoscopic component separation can also be used to mobilize flaps with minimal ischemia to overlying subcutaneous and skin tissue, theoretically decreasing infection rates. Mobilization of midline fascia is reduced with endoscopic methods. | Surgery_Schwartz. simple closure (33% with simple repair vs. 16% with mesh repair). Mesh repairs are, however, associated with a higher rate of infections.To reduce tension at the suture line associated with pri-mary suture repair Ramirez described the components separa-tion technique in 1990. This procedure entails dividing portions of the bilateral external oblique aponeuroses forming musculo-fascial advancement flaps. The posterior rectus sheath can also be incised, allowing up to 10 cm of medial mobilization and ten-sionless approximation of the midline fascia. This technique can cause large skin flaps and initially had high rates of infection. Overtime, techniques have been developed to decrease flap for-mation and decreased rates of surgical site infection. Endoscopic component separation can also be used to mobilize flaps with minimal ischemia to overlying subcutaneous and skin tissue, theoretically decreasing infection rates. Mobilization of midline fascia is reduced with endoscopic methods. |
Surgery_Schwartz_10246 | Surgery_Schwartz | be used to mobilize flaps with minimal ischemia to overlying subcutaneous and skin tissue, theoretically decreasing infection rates. Mobilization of midline fascia is reduced with endoscopic methods. Mesh can also be utilized to reinforce the repair. Overall, component separation without mesh compares to standard mesh repair with respect to hernia recurrence, but precludes the risk of mesh implantation. When mesh is added to component separation, recurrence rates may be as low as 4% to 10% depending on follow up period.Mesh repair has become the standard for elective manage-ment of most incisional hernias. Position of mesh placement is controversial. Mesh can be placed above the midline fascia (overlay), bridged across fascial defects (interlay), underneath fascia (sublay), or within the abdominal cavity (underlay). A systematic review found that sublay placement of mesh may reduce hernia recurrence and prevent wound related compli-cations. The sublay technique is performed by | Surgery_Schwartz. be used to mobilize flaps with minimal ischemia to overlying subcutaneous and skin tissue, theoretically decreasing infection rates. Mobilization of midline fascia is reduced with endoscopic methods. Mesh can also be utilized to reinforce the repair. Overall, component separation without mesh compares to standard mesh repair with respect to hernia recurrence, but precludes the risk of mesh implantation. When mesh is added to component separation, recurrence rates may be as low as 4% to 10% depending on follow up period.Mesh repair has become the standard for elective manage-ment of most incisional hernias. Position of mesh placement is controversial. Mesh can be placed above the midline fascia (overlay), bridged across fascial defects (interlay), underneath fascia (sublay), or within the abdominal cavity (underlay). A systematic review found that sublay placement of mesh may reduce hernia recurrence and prevent wound related compli-cations. The sublay technique is performed by |
Surgery_Schwartz_10247 | Surgery_Schwartz | the abdominal cavity (underlay). A systematic review found that sublay placement of mesh may reduce hernia recurrence and prevent wound related compli-cations. The sublay technique is performed by developing the plane between the rectus muscle and the posterior sheath, and affixing mesh in this space. The anterior sheath can be approxi-mated if there is no tension.Material used for mesh manufacturing can be classified into two classes: synthetic and biologic. Synthetic meshes can be either permanent or degradable, while all biologic meshes are degradable. Permanent mesh is currently made of either poly-propylene, polyethylene terephthalate polyester, or expanded polytetrafluoroethylene. Permanent mesh is durable and of rel-atively low cost. Degradable synthetic mesh, including Vicryl mesh, is eventually eliminated and loses structural support, but it does offer the advantage of lower mesh infection rates. Degrad-able mesh is associated with high recurrence rates, but it can be used | Surgery_Schwartz. the abdominal cavity (underlay). A systematic review found that sublay placement of mesh may reduce hernia recurrence and prevent wound related compli-cations. The sublay technique is performed by developing the plane between the rectus muscle and the posterior sheath, and affixing mesh in this space. The anterior sheath can be approxi-mated if there is no tension.Material used for mesh manufacturing can be classified into two classes: synthetic and biologic. Synthetic meshes can be either permanent or degradable, while all biologic meshes are degradable. Permanent mesh is currently made of either poly-propylene, polyethylene terephthalate polyester, or expanded polytetrafluoroethylene. Permanent mesh is durable and of rel-atively low cost. Degradable synthetic mesh, including Vicryl mesh, is eventually eliminated and loses structural support, but it does offer the advantage of lower mesh infection rates. Degrad-able mesh is associated with high recurrence rates, but it can be used |
Surgery_Schwartz_10248 | Surgery_Schwartz | is eventually eliminated and loses structural support, but it does offer the advantage of lower mesh infection rates. Degrad-able mesh is associated with high recurrence rates, but it can be used for temporary abdominal wall closure in contaminated or infected fields. Newer synthetic biomaterial meshes, includ-ing Gore BioA or Phasix, degrade over a longer period of time and may reduce recurrence rates, but long-term effectiveness is unknown. Biologic meshes are decellularized, collagen-rich porcine, bovine, or human tissue. These meshes are designed to allow host cellular ingrowth, promoting incorporation and eventual replacement of the mesh with host tissue. Biologic meshes are a high cost alternative to synthetic degradable mesh and can be used in infected fields. However, their efficacy in preventing recurrence is unclear. Composite products contain two components and are used during intraperitoneal repair. One side of composite mesh, which is placed on the abdominal wall side of | Surgery_Schwartz. is eventually eliminated and loses structural support, but it does offer the advantage of lower mesh infection rates. Degrad-able mesh is associated with high recurrence rates, but it can be used for temporary abdominal wall closure in contaminated or infected fields. Newer synthetic biomaterial meshes, includ-ing Gore BioA or Phasix, degrade over a longer period of time and may reduce recurrence rates, but long-term effectiveness is unknown. Biologic meshes are decellularized, collagen-rich porcine, bovine, or human tissue. These meshes are designed to allow host cellular ingrowth, promoting incorporation and eventual replacement of the mesh with host tissue. Biologic meshes are a high cost alternative to synthetic degradable mesh and can be used in infected fields. However, their efficacy in preventing recurrence is unclear. Composite products contain two components and are used during intraperitoneal repair. One side of composite mesh, which is placed on the abdominal wall side of |
Surgery_Schwartz_10249 | Surgery_Schwartz | in preventing recurrence is unclear. Composite products contain two components and are used during intraperitoneal repair. One side of composite mesh, which is placed on the abdominal wall side of implantation, is made of typical nondegradable synthetic material and promotes integration of host tissue. The other side is covered in a synthetic or biologic material, allowing contact with viscera and preventing adhesion formation. These materi-als include polyglactin, collagen, cellulose, titanium, omega-3, and hyaluronate. This allays concerns of direct mesh contact 3Figure 35-6. Computed tomography scan imaging of Spigelian hernia. Hernia contents traverse through the arcuate line but remain covered by the external oblique aponeurosis. (Reproduced with permission from Martin M, Paquette B, Badet N, et al: Spigelian hernia: CT findings and clinical relevance, Abdom Imaging. 2013 Apr;38(2):260-264.)Brunicardi_Ch35_p1549-p1566.indd 155512/02/19 9:58 AM 1556SPECIFIC | Surgery_Schwartz. in preventing recurrence is unclear. Composite products contain two components and are used during intraperitoneal repair. One side of composite mesh, which is placed on the abdominal wall side of implantation, is made of typical nondegradable synthetic material and promotes integration of host tissue. The other side is covered in a synthetic or biologic material, allowing contact with viscera and preventing adhesion formation. These materi-als include polyglactin, collagen, cellulose, titanium, omega-3, and hyaluronate. This allays concerns of direct mesh contact 3Figure 35-6. Computed tomography scan imaging of Spigelian hernia. Hernia contents traverse through the arcuate line but remain covered by the external oblique aponeurosis. (Reproduced with permission from Martin M, Paquette B, Badet N, et al: Spigelian hernia: CT findings and clinical relevance, Abdom Imaging. 2013 Apr;38(2):260-264.)Brunicardi_Ch35_p1549-p1566.indd 155512/02/19 9:58 AM 1556SPECIFIC |
Surgery_Schwartz_10250 | Surgery_Schwartz | M, Paquette B, Badet N, et al: Spigelian hernia: CT findings and clinical relevance, Abdom Imaging. 2013 Apr;38(2):260-264.)Brunicardi_Ch35_p1549-p1566.indd 155512/02/19 9:58 AM 1556SPECIFIC CONSIDERATIONSPART IIwith viscera that may cause adhesions, erosion, and eventual fistula formation. Pore size and mesh weight are also important aspects of mesh design. Recently, large-pore, lightweight mesh has been developed. This was initially thought to delay incorpo-ration, but that has not been seen in practice. They do allow the theoretical advantage of increased incorporation of host tissue and potentially better elasticity and improved postoperative pain when compared to microporous heavier meshes. There is also initial data which suggests lower rates of mesh infection with the use of large pore mesh.Initially described by LeBlanc and Booth in 1993, laparo-scopic repair is now an accepted modality for treatment of inci-sional hernias. Several studies have found that laparoscopic | Surgery_Schwartz. M, Paquette B, Badet N, et al: Spigelian hernia: CT findings and clinical relevance, Abdom Imaging. 2013 Apr;38(2):260-264.)Brunicardi_Ch35_p1549-p1566.indd 155512/02/19 9:58 AM 1556SPECIFIC CONSIDERATIONSPART IIwith viscera that may cause adhesions, erosion, and eventual fistula formation. Pore size and mesh weight are also important aspects of mesh design. Recently, large-pore, lightweight mesh has been developed. This was initially thought to delay incorpo-ration, but that has not been seen in practice. They do allow the theoretical advantage of increased incorporation of host tissue and potentially better elasticity and improved postoperative pain when compared to microporous heavier meshes. There is also initial data which suggests lower rates of mesh infection with the use of large pore mesh.Initially described by LeBlanc and Booth in 1993, laparo-scopic repair is now an accepted modality for treatment of inci-sional hernias. Several studies have found that laparoscopic |
Surgery_Schwartz_10251 | Surgery_Schwartz | large pore mesh.Initially described by LeBlanc and Booth in 1993, laparo-scopic repair is now an accepted modality for treatment of inci-sional hernias. Several studies have found that laparoscopic repair has a lower incidence of surgical site and mesh infections compared to open repair. It also seems that lapa-roscopic repair allows faster recovery with less postoperative pain. A meta-analysis of 11 studies comparing laparoscopic and open ventral hernia repair found no difference in hernia recur-rence and lower rates of wound infection and wound drainage. There was however, a higher risk of bowel injury in the laparo-scopic group. Another meta-analysis of six randomized con-trolled trials had similar findings. Follow-up in these studies is relatively short, and more long-term data is needed at this time to compare these two modalities of repair.Laparoscopic hernia repair is performed by initially plac-ing lateral ports for midline defects and contralaterally placed ports for lateral | Surgery_Schwartz. large pore mesh.Initially described by LeBlanc and Booth in 1993, laparo-scopic repair is now an accepted modality for treatment of inci-sional hernias. Several studies have found that laparoscopic repair has a lower incidence of surgical site and mesh infections compared to open repair. It also seems that lapa-roscopic repair allows faster recovery with less postoperative pain. A meta-analysis of 11 studies comparing laparoscopic and open ventral hernia repair found no difference in hernia recur-rence and lower rates of wound infection and wound drainage. There was however, a higher risk of bowel injury in the laparo-scopic group. Another meta-analysis of six randomized con-trolled trials had similar findings. Follow-up in these studies is relatively short, and more long-term data is needed at this time to compare these two modalities of repair.Laparoscopic hernia repair is performed by initially plac-ing lateral ports for midline defects and contralaterally placed ports for lateral |
Surgery_Schwartz_10252 | Surgery_Schwartz | at this time to compare these two modalities of repair.Laparoscopic hernia repair is performed by initially plac-ing lateral ports for midline defects and contralaterally placed ports for lateral defects. Adhesions between the abdominal wall and intestine are carefully taken down, and the hernia contents are completely reduced. The sac is normally left in situ. Once the fascial defect is defined, a mesh is properly shaped and fash-ioned over the hernia. Transfascial sutures are placed circum-ferentially to position the mesh with sufficient overlap (4–5 cm) with healthy abdominal wall. Spiral tacks may be placed accord-ing to surgeon preference. Even more recently, robotic surgery has been established as another surgical modality in the treat-ment of ventral hernias. The theoretical advantage of improved visualization and articulating instruments may improve out-comes, but the cost-effectiveness of robotic repair is unclear. Overall, more studies are needed to evaluate the role of | Surgery_Schwartz. at this time to compare these two modalities of repair.Laparoscopic hernia repair is performed by initially plac-ing lateral ports for midline defects and contralaterally placed ports for lateral defects. Adhesions between the abdominal wall and intestine are carefully taken down, and the hernia contents are completely reduced. The sac is normally left in situ. Once the fascial defect is defined, a mesh is properly shaped and fash-ioned over the hernia. Transfascial sutures are placed circum-ferentially to position the mesh with sufficient overlap (4–5 cm) with healthy abdominal wall. Spiral tacks may be placed accord-ing to surgeon preference. Even more recently, robotic surgery has been established as another surgical modality in the treat-ment of ventral hernias. The theoretical advantage of improved visualization and articulating instruments may improve out-comes, but the cost-effectiveness of robotic repair is unclear. Overall, more studies are needed to evaluate the role of |
Surgery_Schwartz_10253 | Surgery_Schwartz | of improved visualization and articulating instruments may improve out-comes, but the cost-effectiveness of robotic repair is unclear. Overall, more studies are needed to evaluate the role of robotics in ventral hernia surgery.Although still rare, given the increase in laparoscopic procedures, the incidence of laparoscopic port site hernias is becoming more common. Given the size of the hernias, there is a substantial risk of bowel strangulation and ischemia. These hernias commonly present as Richter’s hernia, or a hernia con-taining only a portion of bowel wall. A recent meta-analysis found that the incidence of port site hernia after laparoscopic procedure was less than 1%. Patients can present either early or several years after surgery. Risk factors are similar to other incisional hernias. The most common site of herniation is at an umbilical incision, but it may be found elsewhere. In adults, hernias usually occur in ports that are greater than 5 mm in size, but they can occur in | Surgery_Schwartz. of improved visualization and articulating instruments may improve out-comes, but the cost-effectiveness of robotic repair is unclear. Overall, more studies are needed to evaluate the role of robotics in ventral hernia surgery.Although still rare, given the increase in laparoscopic procedures, the incidence of laparoscopic port site hernias is becoming more common. Given the size of the hernias, there is a substantial risk of bowel strangulation and ischemia. These hernias commonly present as Richter’s hernia, or a hernia con-taining only a portion of bowel wall. A recent meta-analysis found that the incidence of port site hernia after laparoscopic procedure was less than 1%. Patients can present either early or several years after surgery. Risk factors are similar to other incisional hernias. The most common site of herniation is at an umbilical incision, but it may be found elsewhere. In adults, hernias usually occur in ports that are greater than 5 mm in size, but they can occur in |
Surgery_Schwartz_10254 | Surgery_Schwartz | The most common site of herniation is at an umbilical incision, but it may be found elsewhere. In adults, hernias usually occur in ports that are greater than 5 mm in size, but they can occur in any size ports in children. Depending on the timing of presentation, these are usually repaired via an open approach by increasing the size of the skin incision, reducing the hernia, and approximating all layers of fascia.Rectus Abdominis Diastasis. Rectus abdominis diastasis (diastasis recti) is an anatomic term referring to an abnormal separation of rectus muscles and a laxity at the linea alba. Although there is controversy regarding normal separation dis-tances between rectus muscles, a distance of two centimeters is usually considered abnormal in the midline abdomen above the umbilicus. This can either be a congenital or acquired abnor-mality. This is not a true hernia as the midline fascia is intact, and as such incarceration and strangulation do not occur. Risk factors for acquired | Surgery_Schwartz. The most common site of herniation is at an umbilical incision, but it may be found elsewhere. In adults, hernias usually occur in ports that are greater than 5 mm in size, but they can occur in any size ports in children. Depending on the timing of presentation, these are usually repaired via an open approach by increasing the size of the skin incision, reducing the hernia, and approximating all layers of fascia.Rectus Abdominis Diastasis. Rectus abdominis diastasis (diastasis recti) is an anatomic term referring to an abnormal separation of rectus muscles and a laxity at the linea alba. Although there is controversy regarding normal separation dis-tances between rectus muscles, a distance of two centimeters is usually considered abnormal in the midline abdomen above the umbilicus. This can either be a congenital or acquired abnor-mality. This is not a true hernia as the midline fascia is intact, and as such incarceration and strangulation do not occur. Risk factors for acquired |
Surgery_Schwartz_10255 | Surgery_Schwartz | can either be a congenital or acquired abnor-mality. This is not a true hernia as the midline fascia is intact, and as such incarceration and strangulation do not occur. Risk factors for acquired rectus abdominis diastasis include condi-tions that elevate intraabdominal pressure, including obesity and pregnancy, as well as conditions which weaken the abdominal wall, including connective tissue disorders or prior abdominal surgery. Risk factors of developing a diastasis recti after preg-nancy include older age at the time of pregnancy, multiple preg-nancies, and recurrent ceasarean sections. Postpartum exercise reduces the risk of developing diasthesis recti. Most patients with diastasis recti can be diagnosed based on physical exam where a fusiform bulge is usually apparent. This bulge worsens with contraction of the rectus muscles or Valsalva maneuver. If imaging is needed, ultrasonography can be used to confirm dia-thesis and rule out hernia. CT scan can also be used to confirm | Surgery_Schwartz. can either be a congenital or acquired abnor-mality. This is not a true hernia as the midline fascia is intact, and as such incarceration and strangulation do not occur. Risk factors for acquired rectus abdominis diastasis include condi-tions that elevate intraabdominal pressure, including obesity and pregnancy, as well as conditions which weaken the abdominal wall, including connective tissue disorders or prior abdominal surgery. Risk factors of developing a diastasis recti after preg-nancy include older age at the time of pregnancy, multiple preg-nancies, and recurrent ceasarean sections. Postpartum exercise reduces the risk of developing diasthesis recti. Most patients with diastasis recti can be diagnosed based on physical exam where a fusiform bulge is usually apparent. This bulge worsens with contraction of the rectus muscles or Valsalva maneuver. If imaging is needed, ultrasonography can be used to confirm dia-thesis and rule out hernia. CT scan can also be used to confirm |
Surgery_Schwartz_10256 | Surgery_Schwartz | worsens with contraction of the rectus muscles or Valsalva maneuver. If imaging is needed, ultrasonography can be used to confirm dia-thesis and rule out hernia. CT scan can also be used to confirm diagnosis and measure distance between muscle pillars. Rectus diastasis does not require surgical repair and may be improved via weight loss and exercise. Indications for repair include dis-ability of abdominal wall muscular function or cosmesis. Sur-gical repair includes both open and laparoscopic plication of the rectus sheath. Mesh can also be used to bridge the muscle; however, complication rates increase with mesh usage. These procedures do, unfortunately, have a high risk of recurrence long term and introduce a new risk of incisional hernia.Rectus Sheath Hematoma. Disruption of one of the branches of the inferior epigastric artery as well as an inability to tampon-ade the hemorrhage results in a rectus sheath hematoma. This occurs commonly around the arcuate line where the artery and | Surgery_Schwartz. worsens with contraction of the rectus muscles or Valsalva maneuver. If imaging is needed, ultrasonography can be used to confirm dia-thesis and rule out hernia. CT scan can also be used to confirm diagnosis and measure distance between muscle pillars. Rectus diastasis does not require surgical repair and may be improved via weight loss and exercise. Indications for repair include dis-ability of abdominal wall muscular function or cosmesis. Sur-gical repair includes both open and laparoscopic plication of the rectus sheath. Mesh can also be used to bridge the muscle; however, complication rates increase with mesh usage. These procedures do, unfortunately, have a high risk of recurrence long term and introduce a new risk of incisional hernia.Rectus Sheath Hematoma. Disruption of one of the branches of the inferior epigastric artery as well as an inability to tampon-ade the hemorrhage results in a rectus sheath hematoma. This occurs commonly around the arcuate line where the artery and |
Surgery_Schwartz_10257 | Surgery_Schwartz | branches of the inferior epigastric artery as well as an inability to tampon-ade the hemorrhage results in a rectus sheath hematoma. This occurs commonly around the arcuate line where the artery and its branches are relatively fixed causing vulnerability to shearing forces. Several risk factors are associated with rectus hematoma formation via either proclivity to disruption of blood vessels or by inability to cease bleeding. Trauma to the abdominal wall, including iatrogenic trauma with laparoscopic trocar placement, can lead to disruption of blood vessels. Vigorous contraction of the rectus muscle, either with coughing, sneezing, or exercise, can also induce hemorrhage formation. Chronic pulmonary dis-ease can lead to hemorrhage because of coughing fits. Patients on anticoagulation also present with higher risk of hematoma formation. This condition presents with acute abdominal pain and a palpable abdominal wall mass. Rectus sheath hematoma may be mistaken with intraperitoneal | Surgery_Schwartz. branches of the inferior epigastric artery as well as an inability to tampon-ade the hemorrhage results in a rectus sheath hematoma. This occurs commonly around the arcuate line where the artery and its branches are relatively fixed causing vulnerability to shearing forces. Several risk factors are associated with rectus hematoma formation via either proclivity to disruption of blood vessels or by inability to cease bleeding. Trauma to the abdominal wall, including iatrogenic trauma with laparoscopic trocar placement, can lead to disruption of blood vessels. Vigorous contraction of the rectus muscle, either with coughing, sneezing, or exercise, can also induce hemorrhage formation. Chronic pulmonary dis-ease can lead to hemorrhage because of coughing fits. Patients on anticoagulation also present with higher risk of hematoma formation. This condition presents with acute abdominal pain and a palpable abdominal wall mass. Rectus sheath hematoma may be mistaken with intraperitoneal |
Surgery_Schwartz_10258 | Surgery_Schwartz | also present with higher risk of hematoma formation. This condition presents with acute abdominal pain and a palpable abdominal wall mass. Rectus sheath hematoma may be mistaken with intraperitoneal pathology, including appendicitis if on the right side. However, in patients with rec-tus sheath hematomas, pain usually increases with contraction of the rectus muscles as opposed to intraperitoneal conditions. In addition, palpation of a mass that does not change during contraction of the rectus muscle, known as Fothergill’s sign, is also associated with rectus sheath pathology. The diagnosis should be confirmed via ultrasound or CT scan with intravenous contrast. Obtaining a type and screen, hemoglobin/hematocrit, and coagulation factors are critical in the management of these patients.Treatment of patients with rectus sheath hematoma depends on the hemodynamic stability of the patient as well as the size of the hematoma. Hemodynamically stable patients with small hematomas, stable | Surgery_Schwartz. also present with higher risk of hematoma formation. This condition presents with acute abdominal pain and a palpable abdominal wall mass. Rectus sheath hematoma may be mistaken with intraperitoneal pathology, including appendicitis if on the right side. However, in patients with rec-tus sheath hematomas, pain usually increases with contraction of the rectus muscles as opposed to intraperitoneal conditions. In addition, palpation of a mass that does not change during contraction of the rectus muscle, known as Fothergill’s sign, is also associated with rectus sheath pathology. The diagnosis should be confirmed via ultrasound or CT scan with intravenous contrast. Obtaining a type and screen, hemoglobin/hematocrit, and coagulation factors are critical in the management of these patients.Treatment of patients with rectus sheath hematoma depends on the hemodynamic stability of the patient as well as the size of the hematoma. Hemodynamically stable patients with small hematomas, stable |
Surgery_Schwartz_10259 | Surgery_Schwartz | of patients with rectus sheath hematoma depends on the hemodynamic stability of the patient as well as the size of the hematoma. Hemodynamically stable patients with small hematomas, stable serial hemoglobin/hematocrits, and normal coagulation factors may be observed without hospital-ization. Hemodynamically stable patients with larger or bilateral hematomas and decreases in hemoglobin should be monitored in the hospital setting, with serial hemoglobin levels, compres-sion of the hematoma, and bedrest. If anticoagulated, reversal is necessary and transfusions of packed red blood cells may 4Brunicardi_Ch35_p1549-p1566.indd 155612/02/19 9:58 AM 1557ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35be required in some situations. Patients in hypovolemic shock should be aggressively resuscitated with the use of blood prod-ucts and treated via angiographic embolization. Angiographic intervention may also be required if the hematoma increases in size or if clinical | Surgery_Schwartz. of patients with rectus sheath hematoma depends on the hemodynamic stability of the patient as well as the size of the hematoma. Hemodynamically stable patients with small hematomas, stable serial hemoglobin/hematocrits, and normal coagulation factors may be observed without hospital-ization. Hemodynamically stable patients with larger or bilateral hematomas and decreases in hemoglobin should be monitored in the hospital setting, with serial hemoglobin levels, compres-sion of the hematoma, and bedrest. If anticoagulated, reversal is necessary and transfusions of packed red blood cells may 4Brunicardi_Ch35_p1549-p1566.indd 155612/02/19 9:58 AM 1557ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35be required in some situations. Patients in hypovolemic shock should be aggressively resuscitated with the use of blood prod-ucts and treated via angiographic embolization. Angiographic intervention may also be required if the hematoma increases in size or if clinical |
Surgery_Schwartz_10260 | Surgery_Schwartz | be aggressively resuscitated with the use of blood prod-ucts and treated via angiographic embolization. Angiographic intervention may also be required if the hematoma increases in size or if clinical deterioration occurs. Surgical therapy can be performed if angiographic intervention has failed. Surgical treatment includes operative evacuation of hematoma and liga-tion of bleeding vessels.Desmoid Tumors. Also known as aggressive fibromatosis, desmoid tumors are fibroblastic neoplasms with aggressive infiltrative behavior but no metastatic potential. These tumors can occur anywhere in the body but commonly occur in the abdomen or abdominal wall. Desmoid tumors are rare and usu-ally occur sporadically. They are, however, also associated with familial adenomatous polyposis (FAP), with an even greater risk in patients with Gardner’s syndrome. Of patients with FAP, 10% to 15% develop desmoid tumors. After prophylactic col-ectomy, desmoid tumors becomes the primary cause of death in | Surgery_Schwartz. be aggressively resuscitated with the use of blood prod-ucts and treated via angiographic embolization. Angiographic intervention may also be required if the hematoma increases in size or if clinical deterioration occurs. Surgical therapy can be performed if angiographic intervention has failed. Surgical treatment includes operative evacuation of hematoma and liga-tion of bleeding vessels.Desmoid Tumors. Also known as aggressive fibromatosis, desmoid tumors are fibroblastic neoplasms with aggressive infiltrative behavior but no metastatic potential. These tumors can occur anywhere in the body but commonly occur in the abdomen or abdominal wall. Desmoid tumors are rare and usu-ally occur sporadically. They are, however, also associated with familial adenomatous polyposis (FAP), with an even greater risk in patients with Gardner’s syndrome. Of patients with FAP, 10% to 15% develop desmoid tumors. After prophylactic col-ectomy, desmoid tumors becomes the primary cause of death in |
Surgery_Schwartz_10261 | Surgery_Schwartz | an even greater risk in patients with Gardner’s syndrome. Of patients with FAP, 10% to 15% develop desmoid tumors. After prophylactic col-ectomy, desmoid tumors becomes the primary cause of death in patients with FAP. Risk factors for sporadic development of desmoid tumors include previous surgical incision, pregnancy, hormonal exposure, and trauma. Females have a higher pre-dilection for formation of desmoid tumors. Diagnosis can be performed via core-needle or incisional biopsy. Larger tumor size, young patient age, and extra-abdominal tumor location all predict poor recurrence free survival.The gold standard of treatment of abdominal wall desmoid tumors, historically, is margin-negative resection with immedi-ate mesh reconstruction. However, more recently there has been controversy as to whether complete microscopic resection is necessary. It is now commonly agreed that while complete microscopic resection is ideal, with the emergence of adjuvant therapy a positive margin may not | Surgery_Schwartz. an even greater risk in patients with Gardner’s syndrome. Of patients with FAP, 10% to 15% develop desmoid tumors. After prophylactic col-ectomy, desmoid tumors becomes the primary cause of death in patients with FAP. Risk factors for sporadic development of desmoid tumors include previous surgical incision, pregnancy, hormonal exposure, and trauma. Females have a higher pre-dilection for formation of desmoid tumors. Diagnosis can be performed via core-needle or incisional biopsy. Larger tumor size, young patient age, and extra-abdominal tumor location all predict poor recurrence free survival.The gold standard of treatment of abdominal wall desmoid tumors, historically, is margin-negative resection with immedi-ate mesh reconstruction. However, more recently there has been controversy as to whether complete microscopic resection is necessary. It is now commonly agreed that while complete microscopic resection is ideal, with the emergence of adjuvant therapy a positive margin may not |
Surgery_Schwartz_10262 | Surgery_Schwartz | to whether complete microscopic resection is necessary. It is now commonly agreed that while complete microscopic resection is ideal, with the emergence of adjuvant therapy a positive margin may not require additional surgery, especially if re-resection would cause high morbidity. There is also some evidence to suggest a period of close watchful wait-ing, as some tumors appear to remain stable or even regress over time. In one cohort of 106 abdominal wall desmoids managed initially without surgery, 16% of patients went on to require surgery in a follow-up period of three years. Interestingly, 29 patients had spontaneous regression of their tumors over that time. The National Comprehensive Cancer Network (NCCN) now suggests initial close observation for patients with asymptomatic, non–life-threatening tumors. Surgery is indicated in patients with symptomatic disease, risk of invasion of surrounding structures, or enlarging tumors. There may be a role for adjuvant or neoadjuvant | Surgery_Schwartz. to whether complete microscopic resection is necessary. It is now commonly agreed that while complete microscopic resection is ideal, with the emergence of adjuvant therapy a positive margin may not require additional surgery, especially if re-resection would cause high morbidity. There is also some evidence to suggest a period of close watchful wait-ing, as some tumors appear to remain stable or even regress over time. In one cohort of 106 abdominal wall desmoids managed initially without surgery, 16% of patients went on to require surgery in a follow-up period of three years. Interestingly, 29 patients had spontaneous regression of their tumors over that time. The National Comprehensive Cancer Network (NCCN) now suggests initial close observation for patients with asymptomatic, non–life-threatening tumors. Surgery is indicated in patients with symptomatic disease, risk of invasion of surrounding structures, or enlarging tumors. There may be a role for adjuvant or neoadjuvant |
Surgery_Schwartz_10263 | Surgery_Schwartz | tumors. Surgery is indicated in patients with symptomatic disease, risk of invasion of surrounding structures, or enlarging tumors. There may be a role for adjuvant or neoadjuvant radiation therapy, although the data are unclear at this time. Primary radiation therapy may be an option for patients who are not surgical candidates. There may also be a role for systemic therapy, especially if tumors are unre-sectable. Options include hormonal therapy, nonsteroidal anti-inflammatory agents, cytotoxic chemotherapies (doxorubicin or carboplatin), or imatinib.Other Abdominal Wall Tumors. Various tumors may also be found within the abdominal wall including lipomas and neu-rofibromas (Fig. 35-7). Surgical resection is recommended for symptomatic or enlarging lesions. Abdominal wall malignancies are exceedingly rare and include several histologic subtypes of sarcomas, dermatofibrosarcoma protuberans, schwannomas, and melanomas. Workup of abdominal wall tumors should include core needle biopsy | Surgery_Schwartz. tumors. Surgery is indicated in patients with symptomatic disease, risk of invasion of surrounding structures, or enlarging tumors. There may be a role for adjuvant or neoadjuvant radiation therapy, although the data are unclear at this time. Primary radiation therapy may be an option for patients who are not surgical candidates. There may also be a role for systemic therapy, especially if tumors are unre-sectable. Options include hormonal therapy, nonsteroidal anti-inflammatory agents, cytotoxic chemotherapies (doxorubicin or carboplatin), or imatinib.Other Abdominal Wall Tumors. Various tumors may also be found within the abdominal wall including lipomas and neu-rofibromas (Fig. 35-7). Surgical resection is recommended for symptomatic or enlarging lesions. Abdominal wall malignancies are exceedingly rare and include several histologic subtypes of sarcomas, dermatofibrosarcoma protuberans, schwannomas, and melanomas. Workup of abdominal wall tumors should include core needle biopsy |
Surgery_Schwartz_10264 | Surgery_Schwartz | exceedingly rare and include several histologic subtypes of sarcomas, dermatofibrosarcoma protuberans, schwannomas, and melanomas. Workup of abdominal wall tumors should include core needle biopsy or excisional biopsy if the tumor is small enough. Magnetic resonance imaging (MRI) or CT scan with IV contrast should be utilized to define local extent of disease. MRI is preferred as this modality provides more detail on extent of disease. Chest CT should also be obtained to rule out pulmo-nary metastasis in high-grade tumors. Chest X-ray may be suf-ficient to stage tumors that are low grade, given the lower risk of distant disease. Surgical resection is the mainstay of treatment for nonmetastatic disease. For most soft tissue sarcomas, 1 cm margins are usually sufficient, but 2 cm margins may be needed for dermatofibrosarcoma protuberans. Tumors of the superficial abdominal wall should be resected with the underlying fascia, which may require use of mesh to prevent abdominal wall laxity | Surgery_Schwartz. exceedingly rare and include several histologic subtypes of sarcomas, dermatofibrosarcoma protuberans, schwannomas, and melanomas. Workup of abdominal wall tumors should include core needle biopsy or excisional biopsy if the tumor is small enough. Magnetic resonance imaging (MRI) or CT scan with IV contrast should be utilized to define local extent of disease. MRI is preferred as this modality provides more detail on extent of disease. Chest CT should also be obtained to rule out pulmo-nary metastasis in high-grade tumors. Chest X-ray may be suf-ficient to stage tumors that are low grade, given the lower risk of distant disease. Surgical resection is the mainstay of treatment for nonmetastatic disease. For most soft tissue sarcomas, 1 cm margins are usually sufficient, but 2 cm margins may be needed for dermatofibrosarcoma protuberans. Tumors of the superficial abdominal wall should be resected with the underlying fascia, which may require use of mesh to prevent abdominal wall laxity |
Surgery_Schwartz_10265 | Surgery_Schwartz | be needed for dermatofibrosarcoma protuberans. Tumors of the superficial abdominal wall should be resected with the underlying fascia, which may require use of mesh to prevent abdominal wall laxity or hernia.Given the rarity of these tumors, the efficacy of adjuvant or neoadjuvant chemoradiation is unclear. Adjuvant or neo-adjuvant therapy may be recommended in patients with large (>5 cm) or high-grade tumors. Some centers administer neoad-juvant radiation therapy to patients with high-risk tumors to monitor response. Chemotherapy may also be used in certain situations. If tumors involve underlying viscera, en bloc resec-tion may be required. Primary closure may be feasible, but pros-thetic mesh use (even in the setting of bowel resection) may be required. Options for abdominal wall closure after resection include absorbable or biologic mesh reinforcement, and myocu-taneous flap reconstruction.OMENTUMSurgical AnatomyThe omentum is a fibrous adipose apron providing support and | Surgery_Schwartz. be needed for dermatofibrosarcoma protuberans. Tumors of the superficial abdominal wall should be resected with the underlying fascia, which may require use of mesh to prevent abdominal wall laxity or hernia.Given the rarity of these tumors, the efficacy of adjuvant or neoadjuvant chemoradiation is unclear. Adjuvant or neo-adjuvant therapy may be recommended in patients with large (>5 cm) or high-grade tumors. Some centers administer neoad-juvant radiation therapy to patients with high-risk tumors to monitor response. Chemotherapy may also be used in certain situations. If tumors involve underlying viscera, en bloc resec-tion may be required. Primary closure may be feasible, but pros-thetic mesh use (even in the setting of bowel resection) may be required. Options for abdominal wall closure after resection include absorbable or biologic mesh reinforcement, and myocu-taneous flap reconstruction.OMENTUMSurgical AnatomyThe omentum is a fibrous adipose apron providing support and |
Surgery_Schwartz_10266 | Surgery_Schwartz | closure after resection include absorbable or biologic mesh reinforcement, and myocu-taneous flap reconstruction.OMENTUMSurgical AnatomyThe omentum is a fibrous adipose apron providing support and protection of the intraabdominal viscera. Embryologically, the omentum originated from the dorsal mesogastrium. Anatomi-cally, the omentum is divided into the greater and lesser omen-tums. The greater omentum begins to form during the fourth week of gestation. Initially, the omentum forms as a double-layered structure, with the spleen developing between the two layers. As development proceeds, the layers of mesentery fuse, the spleen assumes its position in the peritoneum, and the gas-trosplenic ligament forms. The greater omentum, therefore, is a double-layered sheet of visceral fibroadipose tissue descending from the greater curvature of the stomach, covering the small intestines. The omentum folds back on itself and attaches onto the anterior peritoneum of the transverse colon (Fig. | Surgery_Schwartz. closure after resection include absorbable or biologic mesh reinforcement, and myocu-taneous flap reconstruction.OMENTUMSurgical AnatomyThe omentum is a fibrous adipose apron providing support and protection of the intraabdominal viscera. Embryologically, the omentum originated from the dorsal mesogastrium. Anatomi-cally, the omentum is divided into the greater and lesser omen-tums. The greater omentum begins to form during the fourth week of gestation. Initially, the omentum forms as a double-layered structure, with the spleen developing between the two layers. As development proceeds, the layers of mesentery fuse, the spleen assumes its position in the peritoneum, and the gas-trosplenic ligament forms. The greater omentum, therefore, is a double-layered sheet of visceral fibroadipose tissue descending from the greater curvature of the stomach, covering the small intestines. The omentum folds back on itself and attaches onto the anterior peritoneum of the transverse colon (Fig. |
Surgery_Schwartz_10267 | Surgery_Schwartz | tissue descending from the greater curvature of the stomach, covering the small intestines. The omentum folds back on itself and attaches onto the anterior peritoneum of the transverse colon (Fig. 35-8). 5Figure 35-7. Abdominal wall lipoma.Brunicardi_Ch35_p1549-p1566.indd 155712/02/19 9:59 AM 1558SPECIFIC CONSIDERATIONSPART IIIn an adult, the greater omentum lies between the abdominal wall and the hollow viscera, usually extending into the pelvis. The greater omental tissue connecting the stomach to transverse colon, as well as the stomach to the spleen, are known as the gastrocolic and gastrosplenic ligaments, respectively. The blood supply to the greater omentum is derived from the right and left gastroepiploic arteries. The venous system parallels the arterial supply and ultimately drains into the portal system. Lymphatic drainage of the greater omentum occurs via the subpyloric or splenic nodes depending on laterality ultimately culminating in the celiac nodes and subsequently | Surgery_Schwartz. tissue descending from the greater curvature of the stomach, covering the small intestines. The omentum folds back on itself and attaches onto the anterior peritoneum of the transverse colon (Fig. 35-8). 5Figure 35-7. Abdominal wall lipoma.Brunicardi_Ch35_p1549-p1566.indd 155712/02/19 9:59 AM 1558SPECIFIC CONSIDERATIONSPART IIIn an adult, the greater omentum lies between the abdominal wall and the hollow viscera, usually extending into the pelvis. The greater omental tissue connecting the stomach to transverse colon, as well as the stomach to the spleen, are known as the gastrocolic and gastrosplenic ligaments, respectively. The blood supply to the greater omentum is derived from the right and left gastroepiploic arteries. The venous system parallels the arterial supply and ultimately drains into the portal system. Lymphatic drainage of the greater omentum occurs via the subpyloric or splenic nodes depending on laterality ultimately culminating in the celiac nodes and subsequently |
Surgery_Schwartz_10268 | Surgery_Schwartz | drains into the portal system. Lymphatic drainage of the greater omentum occurs via the subpyloric or splenic nodes depending on laterality ultimately culminating in the celiac nodes and subsequently the thoracic duct.Forming the anterior boundary of the lesser sac, the lesser omentum extends between the liver and lesser curvature of the stomach. Also known as the hepatoduodenal and hepatogastric ligaments, the portal triad (including the common bile duct, por-tal vein, and hepatic artery) is located within the inferolateral margin of the lesser omentum. This free edge of lesser omentum forms the foramen of Winslow, which is used to encircle the portal triad during a pringle maneuver (see Fig. 35-8).PhysiologyInitially described by the British surgeon Rutherford Morison as the “policeman of the abdomen,” the greater omentum is under-stood as a peritoneal defense organ. The omentum forms fibrin adhesions at sites of inflammation, effectively attempting to wall off peritoneal | Surgery_Schwartz. drains into the portal system. Lymphatic drainage of the greater omentum occurs via the subpyloric or splenic nodes depending on laterality ultimately culminating in the celiac nodes and subsequently the thoracic duct.Forming the anterior boundary of the lesser sac, the lesser omentum extends between the liver and lesser curvature of the stomach. Also known as the hepatoduodenal and hepatogastric ligaments, the portal triad (including the common bile duct, por-tal vein, and hepatic artery) is located within the inferolateral margin of the lesser omentum. This free edge of lesser omentum forms the foramen of Winslow, which is used to encircle the portal triad during a pringle maneuver (see Fig. 35-8).PhysiologyInitially described by the British surgeon Rutherford Morison as the “policeman of the abdomen,” the greater omentum is under-stood as a peritoneal defense organ. The omentum forms fibrin adhesions at sites of inflammation, effectively attempting to wall off peritoneal |
Surgery_Schwartz_10269 | Surgery_Schwartz | of the abdomen,” the greater omentum is under-stood as a peritoneal defense organ. The omentum forms fibrin adhesions at sites of inflammation, effectively attempting to wall off peritoneal infections. The greater omentum is known to respond to a foreign stimulus by expanding stro-mal tissue that expresses chemotactic, inflammatory, and hemo-static factors, which promote tissue inflammation and subsequent repair. Forming a fibrin bridge between omental tis-sue and the injured site allows passage of inflammatory factors and immune cells. The Graham Patch repair of a perforated ulcer utilizes the complex inflammatory interactions of the omentum to improve leak rates after repair.The visceral fat of the greater omentum is also involved in metabolic functions of the body. Increased visceral fat, including the greater omentum, is an independent risk factor for insulin resistance and high triglyceride levels. This may be, in part, mediated by the increase in visceral inflammation seen in | Surgery_Schwartz. of the abdomen,” the greater omentum is under-stood as a peritoneal defense organ. The omentum forms fibrin adhesions at sites of inflammation, effectively attempting to wall off peritoneal infections. The greater omentum is known to respond to a foreign stimulus by expanding stro-mal tissue that expresses chemotactic, inflammatory, and hemo-static factors, which promote tissue inflammation and subsequent repair. Forming a fibrin bridge between omental tis-sue and the injured site allows passage of inflammatory factors and immune cells. The Graham Patch repair of a perforated ulcer utilizes the complex inflammatory interactions of the omentum to improve leak rates after repair.The visceral fat of the greater omentum is also involved in metabolic functions of the body. Increased visceral fat, including the greater omentum, is an independent risk factor for insulin resistance and high triglyceride levels. This may be, in part, mediated by the increase in visceral inflammation seen in |
Surgery_Schwartz_10270 | Surgery_Schwartz | fat, including the greater omentum, is an independent risk factor for insulin resistance and high triglyceride levels. This may be, in part, mediated by the increase in visceral inflammation seen in intra-abdominal obesity. Several adipokines, or cell-signaling molecules secreted by adipose tissue, are secreted by the greater omentum and act on peripheral tissues, affecting metabolic health throughout the body.Acquired DisordersOmental Infarction. Omental infarction is a rare cause of acute abdominal pain. Omental infarction may be primary or 6DiaphragmGastrohepaticligamentRight colic (hepatic)flexureAscending colonGreater omentum(gastrocolic ligament)Falciform ligamentRound ligamentof liverHepatoduodenalligament (containingportal triad)Arrow passingthrough omentalforamen intoomental bursaGastrophrenicligamentCoronaryligament (cut)StomachSpleenDescending colonPhrenicocolicligamentInferior recess ofomental bursa(between layers ofgreater omentum)GastrocolicligamentTransverse | Surgery_Schwartz. fat, including the greater omentum, is an independent risk factor for insulin resistance and high triglyceride levels. This may be, in part, mediated by the increase in visceral inflammation seen in intra-abdominal obesity. Several adipokines, or cell-signaling molecules secreted by adipose tissue, are secreted by the greater omentum and act on peripheral tissues, affecting metabolic health throughout the body.Acquired DisordersOmental Infarction. Omental infarction is a rare cause of acute abdominal pain. Omental infarction may be primary or 6DiaphragmGastrohepaticligamentRight colic (hepatic)flexureAscending colonGreater omentum(gastrocolic ligament)Falciform ligamentRound ligamentof liverHepatoduodenalligament (containingportal triad)Arrow passingthrough omentalforamen intoomental bursaGastrophrenicligamentCoronaryligament (cut)StomachSpleenDescending colonPhrenicocolicligamentInferior recess ofomental bursa(between layers ofgreater omentum)GastrocolicligamentTransverse |
Surgery_Schwartz_10271 | Surgery_Schwartz | bursaGastrophrenicligamentCoronaryligament (cut)StomachSpleenDescending colonPhrenicocolicligamentInferior recess ofomental bursa(between layers ofgreater omentum)GastrocolicligamentTransverse colon(sectioned)GastrosplenicligamentLeft colic (splenic)flexureTransversemesocolonLiver: Diaphragmatic surface Visceral surfaceAnterior view** Parts of greater omentum* Parts of lesser omentum********Figure 35-8. Greater and lesser omentum. The greater omentum begins along the greater curvature of the stomach, drapes over the transverse colon into the pelvis, and folds back on itself inserting along the posterior wall of the transverse colon. The greater omentum includes the gastrophrenic and gastro splenic ligament. The lesser omentum includes the gastrohepatic and hepatoduodenal ligaments, covering the lesser sac of the abdomen. The free lateral edge of the lesser omentum includes the portal triad, forming the foramen of Winslow below. (Reproduced with permission from Moore KL, Agur AM: | Surgery_Schwartz. bursaGastrophrenicligamentCoronaryligament (cut)StomachSpleenDescending colonPhrenicocolicligamentInferior recess ofomental bursa(between layers ofgreater omentum)GastrocolicligamentTransverse colon(sectioned)GastrosplenicligamentLeft colic (splenic)flexureTransversemesocolonLiver: Diaphragmatic surface Visceral surfaceAnterior view** Parts of greater omentum* Parts of lesser omentum********Figure 35-8. Greater and lesser omentum. The greater omentum begins along the greater curvature of the stomach, drapes over the transverse colon into the pelvis, and folds back on itself inserting along the posterior wall of the transverse colon. The greater omentum includes the gastrophrenic and gastro splenic ligament. The lesser omentum includes the gastrohepatic and hepatoduodenal ligaments, covering the lesser sac of the abdomen. The free lateral edge of the lesser omentum includes the portal triad, forming the foramen of Winslow below. (Reproduced with permission from Moore KL, Agur AM: |
Surgery_Schwartz_10272 | Surgery_Schwartz | the lesser sac of the abdomen. The free lateral edge of the lesser omentum includes the portal triad, forming the foramen of Winslow below. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)Brunicardi_Ch35_p1549-p1566.indd 155812/02/19 9:59 AM 1559ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35secondary depending on the etiology. Primary infarction may be caused by torsion of the omentum from sudden or force-ful movements, thrombosis or vasculitis of omental vessels, or omental venous outflow obstruction. Secondary causes of torsion are most often due to hernias, tumors, or adhesions. Only about 250 cases of primary omental infarction have been reported in the literature. This occurs most often in male and obese patients. Omental infarction may mimic other intra-abdominal pathologies such as appendicitis, cholecystitis, or diverticulitis. Abdominal exam usually | Surgery_Schwartz. the lesser sac of the abdomen. The free lateral edge of the lesser omentum includes the portal triad, forming the foramen of Winslow below. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)Brunicardi_Ch35_p1549-p1566.indd 155812/02/19 9:59 AM 1559ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35secondary depending on the etiology. Primary infarction may be caused by torsion of the omentum from sudden or force-ful movements, thrombosis or vasculitis of omental vessels, or omental venous outflow obstruction. Secondary causes of torsion are most often due to hernias, tumors, or adhesions. Only about 250 cases of primary omental infarction have been reported in the literature. This occurs most often in male and obese patients. Omental infarction may mimic other intra-abdominal pathologies such as appendicitis, cholecystitis, or diverticulitis. Abdominal exam usually |
Surgery_Schwartz_10273 | Surgery_Schwartz | This occurs most often in male and obese patients. Omental infarction may mimic other intra-abdominal pathologies such as appendicitis, cholecystitis, or diverticulitis. Abdominal exam usually demonstrates perito-neal tenderness, with a possible palpable mass. Ultrasonogra-phy (US) and abdominal CT scan are used to assist diagnosis. US may demonstrate a hyperechoic, noncompressible intra-abdominal mass attached to the abdominal wall. CT scan demonstrates a streaking whirling pattern of fatty tissue in the anterior abdomen (Fig. 35-9). Regardless, only a small percent-age of patients are preoperatively diagnosed. Omental infarction can be treated conservatively, but this leads to several possible complications, including abscess or adhesion formation. Lapa-roscopic exploration and resection of infarcted tissue is the usual treatment of choice and leads to rapid resolution of symptoms.Omental Cysts. Cystic lesions of the omentum are rare dis-orders, related in pathogenesis to mesenteric | Surgery_Schwartz. This occurs most often in male and obese patients. Omental infarction may mimic other intra-abdominal pathologies such as appendicitis, cholecystitis, or diverticulitis. Abdominal exam usually demonstrates perito-neal tenderness, with a possible palpable mass. Ultrasonogra-phy (US) and abdominal CT scan are used to assist diagnosis. US may demonstrate a hyperechoic, noncompressible intra-abdominal mass attached to the abdominal wall. CT scan demonstrates a streaking whirling pattern of fatty tissue in the anterior abdomen (Fig. 35-9). Regardless, only a small percent-age of patients are preoperatively diagnosed. Omental infarction can be treated conservatively, but this leads to several possible complications, including abscess or adhesion formation. Lapa-roscopic exploration and resection of infarcted tissue is the usual treatment of choice and leads to rapid resolution of symptoms.Omental Cysts. Cystic lesions of the omentum are rare dis-orders, related in pathogenesis to mesenteric |
Surgery_Schwartz_10274 | Surgery_Schwartz | of infarcted tissue is the usual treatment of choice and leads to rapid resolution of symptoms.Omental Cysts. Cystic lesions of the omentum are rare dis-orders, related in pathogenesis to mesenteric cysts. Most are thought to form through degeneration or inclusion of lymphatic structures. Case reports described these lesions presenting as vague abdominal pain or nausea or vomiting. Cysts may also present as a lead point for omental torsion and infarction. Physi-cal exam may or may not reveal evidence of an intra-abdominal mass. Cysts may also be diagnosed incidentally on imaging exams performed for other reasons. CT scan and US are largely diagnostic and reveal a well-circumscribed cystic appearing lesion arising from the greater omentum. A very small percent-age may transform to malignancy. Most are resected, especially if symptomatic, via open or laparoscopic approaches. Cysts may relapse if treated conservatively via laparoscopic unroofing or percutaneous drainage.Omental | Surgery_Schwartz. of infarcted tissue is the usual treatment of choice and leads to rapid resolution of symptoms.Omental Cysts. Cystic lesions of the omentum are rare dis-orders, related in pathogenesis to mesenteric cysts. Most are thought to form through degeneration or inclusion of lymphatic structures. Case reports described these lesions presenting as vague abdominal pain or nausea or vomiting. Cysts may also present as a lead point for omental torsion and infarction. Physi-cal exam may or may not reveal evidence of an intra-abdominal mass. Cysts may also be diagnosed incidentally on imaging exams performed for other reasons. CT scan and US are largely diagnostic and reveal a well-circumscribed cystic appearing lesion arising from the greater omentum. A very small percent-age may transform to malignancy. Most are resected, especially if symptomatic, via open or laparoscopic approaches. Cysts may relapse if treated conservatively via laparoscopic unroofing or percutaneous drainage.Omental |
Surgery_Schwartz_10275 | Surgery_Schwartz | malignancy. Most are resected, especially if symptomatic, via open or laparoscopic approaches. Cysts may relapse if treated conservatively via laparoscopic unroofing or percutaneous drainage.Omental Neoplasms. Most omental neoplasms are meta-static disease. Ovarian cancer is the most common cancer to have omental involvement. Other metastatic cancers include gastrointestinal tract tumors, melanoma, endometrial cancer, and kidney cancer.Primary tumors of the omentum are exceedingly rare. Benign masses may include lipomas, myxomas, and desmoid tumors. Extra gastrointestinal stromal tumors are a rare malig-nant tumor of the omentum that have been described in several case series. These tumors share many genetic and immuno-phenotypic similarities to classical GISTS, including c-kit and PDGFRA mutations. In one review of case reports, the median age of diagnosis was noted to be 65 years and had equal predi-lection for male and female patients.MESENTERYSurgical AnatomyThe mesentery is a | Surgery_Schwartz. malignancy. Most are resected, especially if symptomatic, via open or laparoscopic approaches. Cysts may relapse if treated conservatively via laparoscopic unroofing or percutaneous drainage.Omental Neoplasms. Most omental neoplasms are meta-static disease. Ovarian cancer is the most common cancer to have omental involvement. Other metastatic cancers include gastrointestinal tract tumors, melanoma, endometrial cancer, and kidney cancer.Primary tumors of the omentum are exceedingly rare. Benign masses may include lipomas, myxomas, and desmoid tumors. Extra gastrointestinal stromal tumors are a rare malig-nant tumor of the omentum that have been described in several case series. These tumors share many genetic and immuno-phenotypic similarities to classical GISTS, including c-kit and PDGFRA mutations. In one review of case reports, the median age of diagnosis was noted to be 65 years and had equal predi-lection for male and female patients.MESENTERYSurgical AnatomyThe mesentery is a |
Surgery_Schwartz_10276 | Surgery_Schwartz | mutations. In one review of case reports, the median age of diagnosis was noted to be 65 years and had equal predi-lection for male and female patients.MESENTERYSurgical AnatomyThe mesentery is a contiguous structure suspending and fix-ing bowel to the abdominal wall providing housing for arterial, venous, nervous, and lymphatic structures connecting hollow viscera with the body. The mesentery is derived from the meso-dermal germ layer becoming the dorsal mesentery. Previous theories of development included sliding and regression models of mesenteric development. However, with a new contiguous model of development of the mesentery, several key simple steps are proposed to take place. Initially, the mesentery provides a point of suspension from vascular connections. As the intestine and mesentery elongate, they undergo a 270° counterclockwise rotation leaving the primordial abdominal cavity. Eventually, the duodenum and ascending/descending colon flatten against the posterior abdominal | Surgery_Schwartz. mutations. In one review of case reports, the median age of diagnosis was noted to be 65 years and had equal predi-lection for male and female patients.MESENTERYSurgical AnatomyThe mesentery is a contiguous structure suspending and fix-ing bowel to the abdominal wall providing housing for arterial, venous, nervous, and lymphatic structures connecting hollow viscera with the body. The mesentery is derived from the meso-dermal germ layer becoming the dorsal mesentery. Previous theories of development included sliding and regression models of mesenteric development. However, with a new contiguous model of development of the mesentery, several key simple steps are proposed to take place. Initially, the mesentery provides a point of suspension from vascular connections. As the intestine and mesentery elongate, they undergo a 270° counterclockwise rotation leaving the primordial abdominal cavity. Eventually, the duodenum and ascending/descending colon flatten against the posterior abdominal |
Surgery_Schwartz_10277 | Surgery_Schwartz | elongate, they undergo a 270° counterclockwise rotation leaving the primordial abdominal cavity. Eventually, the duodenum and ascending/descending colon flatten against the posterior abdominal wall returning the bowel back into the abdomen and taking its normal shape. The resultant develop-ment of the white line of Toldt along the lateral border of the ascending and descending large bowel provides an avascular fascial plan between the colon, its mesentery, and the underlying retroperitoneal space. The small intestine mesentery, transverse colon mesentery, and sigmoid colon mesentery remain mobile.Defects in the proper rotation and fixation of the bowel results in the spectrum of congenital disorders known as intesti-nal malrotation. In this scenario, the intestine and mesentery are simply suspended from vascular connection, making intestinal volvulus common. Defects that form in anatomical positions may act as routes for intestinal herniation. Common sites of her-niation include the | Surgery_Schwartz. elongate, they undergo a 270° counterclockwise rotation leaving the primordial abdominal cavity. Eventually, the duodenum and ascending/descending colon flatten against the posterior abdominal wall returning the bowel back into the abdomen and taking its normal shape. The resultant develop-ment of the white line of Toldt along the lateral border of the ascending and descending large bowel provides an avascular fascial plan between the colon, its mesentery, and the underlying retroperitoneal space. The small intestine mesentery, transverse colon mesentery, and sigmoid colon mesentery remain mobile.Defects in the proper rotation and fixation of the bowel results in the spectrum of congenital disorders known as intesti-nal malrotation. In this scenario, the intestine and mesentery are simply suspended from vascular connection, making intestinal volvulus common. Defects that form in anatomical positions may act as routes for intestinal herniation. Common sites of her-niation include the |
Surgery_Schwartz_10278 | Surgery_Schwartz | suspended from vascular connection, making intestinal volvulus common. Defects that form in anatomical positions may act as routes for intestinal herniation. Common sites of her-niation include the paraduodenal or mesocolic areas, leading to either acute or chronic intestinal obstruction in pediatric or adult populations. Areas where mesenteric attachment is incomplete may predispose patients to volvulus. Attachments of the cecum may degrade overtime leading to an area of laxity and possible twisting. The sigmoid mesentery can also increase in size over time also leading to possible sigmoid volvulus. Rarely, other areas of the colon can develop volvulus if differential mesen-teric lengths form.Sclerosing MesenteritisSclerosing mesenteritis is a rare disorder characterized by idio-pathic fibrosis of the mesentery, affecting hollow viscera as well as mesenteric vessels. The disease is part of a spectrum of inflammation and fibrosis, which when localized is known as mesenteric | Surgery_Schwartz. suspended from vascular connection, making intestinal volvulus common. Defects that form in anatomical positions may act as routes for intestinal herniation. Common sites of her-niation include the paraduodenal or mesocolic areas, leading to either acute or chronic intestinal obstruction in pediatric or adult populations. Areas where mesenteric attachment is incomplete may predispose patients to volvulus. Attachments of the cecum may degrade overtime leading to an area of laxity and possible twisting. The sigmoid mesentery can also increase in size over time also leading to possible sigmoid volvulus. Rarely, other areas of the colon can develop volvulus if differential mesen-teric lengths form.Sclerosing MesenteritisSclerosing mesenteritis is a rare disorder characterized by idio-pathic fibrosis of the mesentery, affecting hollow viscera as well as mesenteric vessels. The disease is part of a spectrum of inflammation and fibrosis, which when localized is known as mesenteric |
Surgery_Schwartz_10279 | Surgery_Schwartz | fibrosis of the mesentery, affecting hollow viscera as well as mesenteric vessels. The disease is part of a spectrum of inflammation and fibrosis, which when localized is known as mesenteric lipodystrophy and when diffuse is known as mes-enteric panniculitis. The cause of this disease is unknown, but it may be instigated by antecedent abdominal surgery, an auto-immune disease, a paraneoplastic syndrome, a previous infec-tion (including typhoid, tuberculosis, influenza, and rheumatic fever), or vascular insult. This disease most commonly effects Figure 35-9. Computed tomography scan findings indicative of omental infarction. The area demonstrated by the bold arrow appears congested with a streaking whirling pattern of fatty tissue in the anterior abdomen. (Reproduced with permission from Barai KP, Knight BC: Diagnosis and management of idiopathic omental infarc-tion: A case report, Int J Surg Case Rep. 2011;2(6):138-140.)Brunicardi_Ch35_p1549-p1566.indd 155912/02/19 9:59 AM | Surgery_Schwartz. fibrosis of the mesentery, affecting hollow viscera as well as mesenteric vessels. The disease is part of a spectrum of inflammation and fibrosis, which when localized is known as mesenteric lipodystrophy and when diffuse is known as mes-enteric panniculitis. The cause of this disease is unknown, but it may be instigated by antecedent abdominal surgery, an auto-immune disease, a paraneoplastic syndrome, a previous infec-tion (including typhoid, tuberculosis, influenza, and rheumatic fever), or vascular insult. This disease most commonly effects Figure 35-9. Computed tomography scan findings indicative of omental infarction. The area demonstrated by the bold arrow appears congested with a streaking whirling pattern of fatty tissue in the anterior abdomen. (Reproduced with permission from Barai KP, Knight BC: Diagnosis and management of idiopathic omental infarc-tion: A case report, Int J Surg Case Rep. 2011;2(6):138-140.)Brunicardi_Ch35_p1549-p1566.indd 155912/02/19 9:59 AM |
Surgery_Schwartz_10280 | Surgery_Schwartz | from Barai KP, Knight BC: Diagnosis and management of idiopathic omental infarc-tion: A case report, Int J Surg Case Rep. 2011;2(6):138-140.)Brunicardi_Ch35_p1549-p1566.indd 155912/02/19 9:59 AM 1560SPECIFIC CONSIDERATIONSPART IIwhite patients between 50 and 70 years of age, although it has been rarely described in children. Most studies report a predi-lection for male patients. Most patients with this disease pres-ent with abdominal pain. Other symptoms include nausea and vomiting, weight loss, anorexia, and altered bowel habits. This may appear as a chronic or acute disorder. On physical exam, patients may be found to have tenderness and distension. Up to 50% of patients are found to have an abdominal mass that often transmits aortic pulsations.Abdominal CT with IV contrast is used to assist in diag-nosis (Fig. 35-10). The most common finding is that of a soft tissue mass with a higher density than normal mesenteric tis-sue. Although it is sometimes difficult to distinguish | Surgery_Schwartz. from Barai KP, Knight BC: Diagnosis and management of idiopathic omental infarc-tion: A case report, Int J Surg Case Rep. 2011;2(6):138-140.)Brunicardi_Ch35_p1549-p1566.indd 155912/02/19 9:59 AM 1560SPECIFIC CONSIDERATIONSPART IIwhite patients between 50 and 70 years of age, although it has been rarely described in children. Most studies report a predi-lection for male patients. Most patients with this disease pres-ent with abdominal pain. Other symptoms include nausea and vomiting, weight loss, anorexia, and altered bowel habits. This may appear as a chronic or acute disorder. On physical exam, patients may be found to have tenderness and distension. Up to 50% of patients are found to have an abdominal mass that often transmits aortic pulsations.Abdominal CT with IV contrast is used to assist in diag-nosis (Fig. 35-10). The most common finding is that of a soft tissue mass with a higher density than normal mesenteric tis-sue. Although it is sometimes difficult to distinguish |
Surgery_Schwartz_10281 | Surgery_Schwartz | to assist in diag-nosis (Fig. 35-10). The most common finding is that of a soft tissue mass with a higher density than normal mesenteric tis-sue. Although it is sometimes difficult to distinguish mesen-teric fibrosis from a mesenteric tumor, two CT findings may add specificity. The “tumor pseudocapsule” refers to a hypodense zone around the associated fibrotic mass, and the “fat ring sign” refers to an area of preserved fat near mesenteric vessels cours-ing through areas of fibrosis. These lesions may also be calcified on CT scan.Pathologic confirmation is required to confirm the diagno-sis. This usually requires laparoscopic or open biopsy to provide adequate tissue for confirmation. Treatment of sclerosing mesenteritis is complex, with surgery having a mini-mal role. Patients who present with bowel ischemia may require bowel and mesenteric resection; however, the extent and loca-tion of mesenteric involvement may preclude complete resec-tion. If obstructive symptoms are dominant, | Surgery_Schwartz. to assist in diag-nosis (Fig. 35-10). The most common finding is that of a soft tissue mass with a higher density than normal mesenteric tis-sue. Although it is sometimes difficult to distinguish mesen-teric fibrosis from a mesenteric tumor, two CT findings may add specificity. The “tumor pseudocapsule” refers to a hypodense zone around the associated fibrotic mass, and the “fat ring sign” refers to an area of preserved fat near mesenteric vessels cours-ing through areas of fibrosis. These lesions may also be calcified on CT scan.Pathologic confirmation is required to confirm the diagno-sis. This usually requires laparoscopic or open biopsy to provide adequate tissue for confirmation. Treatment of sclerosing mesenteritis is complex, with surgery having a mini-mal role. Patients who present with bowel ischemia may require bowel and mesenteric resection; however, the extent and loca-tion of mesenteric involvement may preclude complete resec-tion. If obstructive symptoms are dominant, |
Surgery_Schwartz_10282 | Surgery_Schwartz | with bowel ischemia may require bowel and mesenteric resection; however, the extent and loca-tion of mesenteric involvement may preclude complete resec-tion. If obstructive symptoms are dominant, intestinal bypass may be indicated. Aggressive surgical treatment is not indicated because in many cases symptoms may improve with medical treatment or even without intervention. Steroids, hormonal ther-apy, colchicine, thalidomide, and cyclophosphamide have all been reported to be beneficial.Mesenteric CystsMesenteric cysts are a rare benign disorder with an incidence ranging from 1 in 27,000 to 1 in 250,000 admissions. Cysts are thought to be caused by disruption of the lymphatics in the mes-entery either by traumatic disruption, mechanical obstruction, or congenital lymphatic malformations. Most cysts are unilocular, but they also may have multiple loculations. They are usually lined with a single layer of columnar epithelial cells. Presenta-tion of mesenteric cyst is varied, with some | Surgery_Schwartz. with bowel ischemia may require bowel and mesenteric resection; however, the extent and loca-tion of mesenteric involvement may preclude complete resec-tion. If obstructive symptoms are dominant, intestinal bypass may be indicated. Aggressive surgical treatment is not indicated because in many cases symptoms may improve with medical treatment or even without intervention. Steroids, hormonal ther-apy, colchicine, thalidomide, and cyclophosphamide have all been reported to be beneficial.Mesenteric CystsMesenteric cysts are a rare benign disorder with an incidence ranging from 1 in 27,000 to 1 in 250,000 admissions. Cysts are thought to be caused by disruption of the lymphatics in the mes-entery either by traumatic disruption, mechanical obstruction, or congenital lymphatic malformations. Most cysts are unilocular, but they also may have multiple loculations. They are usually lined with a single layer of columnar epithelial cells. Presenta-tion of mesenteric cyst is varied, with some |
Surgery_Schwartz_10283 | Surgery_Schwartz | Most cysts are unilocular, but they also may have multiple loculations. They are usually lined with a single layer of columnar epithelial cells. Presenta-tion of mesenteric cyst is varied, with some being found inciden-tally on imaging exams and others causing acute abdominal pain because of cyst rupture or bowel torsion. Chronic symptoms are usually nonspecific, including abdominal pain or discomfort, anorexia, distension, nausea, vomiting, or changes in bowel habits. Symptoms are due to local compression of abdominal structures. Up to 45% of cysts are found incidentally.Physical exam revels an abdominal mass in up to 60% of patients. The classic Tillaux’s sign is an abdominal mass lesion that is only mobile laterally, contrasting omental cysts which are usually freely mobile in all directions. CT scan and ultra-sound can be used to make an accurate diagnosis. Cystic lesions usually appear as a fluid filled mass without solid components (Fig. 35-11). It can sometimes be difficult to | Surgery_Schwartz. Most cysts are unilocular, but they also may have multiple loculations. They are usually lined with a single layer of columnar epithelial cells. Presenta-tion of mesenteric cyst is varied, with some being found inciden-tally on imaging exams and others causing acute abdominal pain because of cyst rupture or bowel torsion. Chronic symptoms are usually nonspecific, including abdominal pain or discomfort, anorexia, distension, nausea, vomiting, or changes in bowel habits. Symptoms are due to local compression of abdominal structures. Up to 45% of cysts are found incidentally.Physical exam revels an abdominal mass in up to 60% of patients. The classic Tillaux’s sign is an abdominal mass lesion that is only mobile laterally, contrasting omental cysts which are usually freely mobile in all directions. CT scan and ultra-sound can be used to make an accurate diagnosis. Cystic lesions usually appear as a fluid filled mass without solid components (Fig. 35-11). It can sometimes be difficult to |
Surgery_Schwartz_10284 | Surgery_Schwartz | CT scan and ultra-sound can be used to make an accurate diagnosis. Cystic lesions usually appear as a fluid filled mass without solid components (Fig. 35-11). It can sometimes be difficult to differentiate cystic masses from solid tumors based on imaging. Mesenteric cys-tic lymphangioma may present as numerous cysts on imaging. Up to 3% of mesenteric cysts contain malignancy, mostly as a sarcomatous lesion. In one recently published series, 19% of patients harbored malignancy. Solid components within the cystic structure are associated with higher rates of malignancy.Most mesenteric cysts are treated surgically. Marsupial-ization and simple aspiration have high rates of recurrence and 7Figure 35-11. Computed tomography scan demonstrating a mes-enteric cyst. White arrow points to a homogenous cystic structure located in the mesentery of the small bowel. (Reproduced with per-mission from Jain V, DeMuro JP, Geller M, et al. A case of laparo-scopic mesenteric cyst excision. Case Rep Surg. | Surgery_Schwartz. CT scan and ultra-sound can be used to make an accurate diagnosis. Cystic lesions usually appear as a fluid filled mass without solid components (Fig. 35-11). It can sometimes be difficult to differentiate cystic masses from solid tumors based on imaging. Mesenteric cys-tic lymphangioma may present as numerous cysts on imaging. Up to 3% of mesenteric cysts contain malignancy, mostly as a sarcomatous lesion. In one recently published series, 19% of patients harbored malignancy. Solid components within the cystic structure are associated with higher rates of malignancy.Most mesenteric cysts are treated surgically. Marsupial-ization and simple aspiration have high rates of recurrence and 7Figure 35-11. Computed tomography scan demonstrating a mes-enteric cyst. White arrow points to a homogenous cystic structure located in the mesentery of the small bowel. (Reproduced with per-mission from Jain V, DeMuro JP, Geller M, et al. A case of laparo-scopic mesenteric cyst excision. Case Rep Surg. |
Surgery_Schwartz_10285 | Surgery_Schwartz | cystic structure located in the mesentery of the small bowel. (Reproduced with per-mission from Jain V, DeMuro JP, Geller M, et al. A case of laparo-scopic mesenteric cyst excision. Case Rep Surg. 2012;2012:594095.)ABFigure 35-10. Computed tomography scan findings of sclerosing mesenteritis in (A) coronal view and (B) cross-sectional view. The area demonstrated with arrows depicts an area of higher density and edema representing inflamed mesentery. (Reproduced with per-mission from Daumas A, Agostini S, Villeret J, et al. Spontaneous resolution of severe, symptomatic mesocolic panniculitis: a case report, BMC Gastroenterol. 2012 Jun 6;12:59.)Brunicardi_Ch35_p1549-p1566.indd 156012/02/19 9:59 AM 1561ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35are generally discouraged. Benign lesions should be enuclu-ated, and malignant cysts should be resected with clear margins. Intestines or surrounding viscera may require resection if the associated vasculature is excised. | Surgery_Schwartz. cystic structure located in the mesentery of the small bowel. (Reproduced with per-mission from Jain V, DeMuro JP, Geller M, et al. A case of laparo-scopic mesenteric cyst excision. Case Rep Surg. 2012;2012:594095.)ABFigure 35-10. Computed tomography scan findings of sclerosing mesenteritis in (A) coronal view and (B) cross-sectional view. The area demonstrated with arrows depicts an area of higher density and edema representing inflamed mesentery. (Reproduced with per-mission from Daumas A, Agostini S, Villeret J, et al. Spontaneous resolution of severe, symptomatic mesocolic panniculitis: a case report, BMC Gastroenterol. 2012 Jun 6;12:59.)Brunicardi_Ch35_p1549-p1566.indd 156012/02/19 9:59 AM 1561ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35are generally discouraged. Benign lesions should be enuclu-ated, and malignant cysts should be resected with clear margins. Intestines or surrounding viscera may require resection if the associated vasculature is excised. |
Surgery_Schwartz_10286 | Surgery_Schwartz | Benign lesions should be enuclu-ated, and malignant cysts should be resected with clear margins. Intestines or surrounding viscera may require resection if the associated vasculature is excised. Resection can be performed either via a laparoscopic or open procedure.Mesenteric TumorsPrimary mesenteric tumors are rare but represent several histo-logic patterns. Benign tumors include desmoid tumors, lipomas, and cystic lymphangiomas. The most common malignant neo-plasm of the mesentery is lymphoma. On imaging, lymphoma may appear as bulky adenopathy, usually surrounding and not obstructing nearby structures. Lymphomas should not be resected, but they may require operative biopsy for diagnosis. Other malignant tumors of the mesentery include gastrointesti-nal stromal tumors, carcinoids, liposarcoma, leiomyosarcoma, malignant fibrous histiocytomoas, lipoblastomas, or lymphan-giosarcoma. Treatment of malignant mesenteric masses usually involves wide resection; however, given the proximity | Surgery_Schwartz. Benign lesions should be enuclu-ated, and malignant cysts should be resected with clear margins. Intestines or surrounding viscera may require resection if the associated vasculature is excised. Resection can be performed either via a laparoscopic or open procedure.Mesenteric TumorsPrimary mesenteric tumors are rare but represent several histo-logic patterns. Benign tumors include desmoid tumors, lipomas, and cystic lymphangiomas. The most common malignant neo-plasm of the mesentery is lymphoma. On imaging, lymphoma may appear as bulky adenopathy, usually surrounding and not obstructing nearby structures. Lymphomas should not be resected, but they may require operative biopsy for diagnosis. Other malignant tumors of the mesentery include gastrointesti-nal stromal tumors, carcinoids, liposarcoma, leiomyosarcoma, malignant fibrous histiocytomoas, lipoblastomas, or lymphan-giosarcoma. Treatment of malignant mesenteric masses usually involves wide resection; however, given the proximity |
Surgery_Schwartz_10287 | Surgery_Schwartz | leiomyosarcoma, malignant fibrous histiocytomoas, lipoblastomas, or lymphan-giosarcoma. Treatment of malignant mesenteric masses usually involves wide resection; however, given the proximity to mes-enteric vessels, resection may not be feasible or require removal of large portions of bowel.RETROPERITONEUMSurgical AnatomyThe retroperitoneum is bound by the peritoneum anteriorly, the iliopsoas and lumbar muscles posteriorly, the diaphragm superiorly, and the levator ani muscles inferiorly. It is divided into the three spaces: the anterior pararenal space, the perirenal space, and the posterior pararenal space (Fig. 35-12). The ante-rior pararenal space refers to the area anterior to the renal fascia but posterior to the peritoneum. This area contains the ascend-ing and descending colon, the duodenum, and the pancreas. Posterior to this space is the perirenal space, which houses the inferior vena cava, the aorta, kidneys, and adrenal glands. The posterior pararenal space is in continuity | Surgery_Schwartz. leiomyosarcoma, malignant fibrous histiocytomoas, lipoblastomas, or lymphan-giosarcoma. Treatment of malignant mesenteric masses usually involves wide resection; however, given the proximity to mes-enteric vessels, resection may not be feasible or require removal of large portions of bowel.RETROPERITONEUMSurgical AnatomyThe retroperitoneum is bound by the peritoneum anteriorly, the iliopsoas and lumbar muscles posteriorly, the diaphragm superiorly, and the levator ani muscles inferiorly. It is divided into the three spaces: the anterior pararenal space, the perirenal space, and the posterior pararenal space (Fig. 35-12). The ante-rior pararenal space refers to the area anterior to the renal fascia but posterior to the peritoneum. This area contains the ascend-ing and descending colon, the duodenum, and the pancreas. Posterior to this space is the perirenal space, which houses the inferior vena cava, the aorta, kidneys, and adrenal glands. The posterior pararenal space is in continuity |
Surgery_Schwartz_10288 | Surgery_Schwartz | duodenum, and the pancreas. Posterior to this space is the perirenal space, which houses the inferior vena cava, the aorta, kidneys, and adrenal glands. The posterior pararenal space is in continuity with preperitoneal fat of the anterior abdomen. Given the compliance of the anterior boundary of the retroperitoneum and the rigidity of other mar-gins, tumors, hematomas, and abscesses tend to expand anteri-orly toward the peritoneal cavity.With the expansion of minimally invasive techniques in surgery, the retroperitoneoscopic approach has emerged as a potential modality for access to retroperitoneal organs. Patients are positioned in the prone or lateral decubitus positions. The retroperitoneoscopic approach allows access to the kidneys, adrenal glands, and retroperitoneal lymph nodes. One system-atic review found no difference when comparing laparoscopic to retroperitoneoscopic adrenalectomy in terms of operative outcomes, complications, or postoperative recovery. | Surgery_Schwartz. duodenum, and the pancreas. Posterior to this space is the perirenal space, which houses the inferior vena cava, the aorta, kidneys, and adrenal glands. The posterior pararenal space is in continuity with preperitoneal fat of the anterior abdomen. Given the compliance of the anterior boundary of the retroperitoneum and the rigidity of other mar-gins, tumors, hematomas, and abscesses tend to expand anteri-orly toward the peritoneal cavity.With the expansion of minimally invasive techniques in surgery, the retroperitoneoscopic approach has emerged as a potential modality for access to retroperitoneal organs. Patients are positioned in the prone or lateral decubitus positions. The retroperitoneoscopic approach allows access to the kidneys, adrenal glands, and retroperitoneal lymph nodes. One system-atic review found no difference when comparing laparoscopic to retroperitoneoscopic adrenalectomy in terms of operative outcomes, complications, or postoperative recovery. |
Surgery_Schwartz_10289 | Surgery_Schwartz | lymph nodes. One system-atic review found no difference when comparing laparoscopic to retroperitoneoscopic adrenalectomy in terms of operative outcomes, complications, or postoperative recovery. Retroperi-toneoscopic approach did, however, lead to shorter hospital stay likely because of reduced postoperative pain. The majority of the studies evaluating the retroperitoneoscopic approach are retrospective, and more randomized trials are needed to provide further guidance.Retroperitoneal InfectionsInfections of the retroperitoneum can be due to primary hema-togenous spread of microbes or due to secondary infection from retroperitoneal or nearby organs. Examples include abscesses due to a perforated retrocecal appendix, diverticulitis, a con-tained perforated duodenal ulcer, iatrogenic perforation of the gastrointestinal tract, or pancreatitis. Patients may develop back, Inferiorvena cavaDiaphragmEsophagusAbdominal aortaSplenorenal ligamentPancreasRoot of | Surgery_Schwartz. lymph nodes. One system-atic review found no difference when comparing laparoscopic to retroperitoneoscopic adrenalectomy in terms of operative outcomes, complications, or postoperative recovery. Retroperi-toneoscopic approach did, however, lead to shorter hospital stay likely because of reduced postoperative pain. The majority of the studies evaluating the retroperitoneoscopic approach are retrospective, and more randomized trials are needed to provide further guidance.Retroperitoneal InfectionsInfections of the retroperitoneum can be due to primary hema-togenous spread of microbes or due to secondary infection from retroperitoneal or nearby organs. Examples include abscesses due to a perforated retrocecal appendix, diverticulitis, a con-tained perforated duodenal ulcer, iatrogenic perforation of the gastrointestinal tract, or pancreatitis. Patients may develop back, Inferiorvena cavaDiaphragmEsophagusAbdominal aortaSplenorenal ligamentPancreasRoot of |
Surgery_Schwartz_10290 | Surgery_Schwartz | duodenal ulcer, iatrogenic perforation of the gastrointestinal tract, or pancreatitis. Patients may develop back, Inferiorvena cavaDiaphragmEsophagusAbdominal aortaSplenorenal ligamentPancreasRoot of transversemesocolonDuodenojejunaljunctionLeft kidneyPsoas majorInferior mesenteric arterySite of descending mesocolonRoot of sigmoidmesocolonRectumSite of barearea of liverHepatic portalveinDuodenumSuperiormesenteric vein and arterySite of ascending colonRoot of mesenteryTesticular (or ovarian) vesselsUreterAnterior viewRight kidneyRightparacolic gutterFigure 35-12. Anatomy of the retroperitoneum. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)Brunicardi_Ch35_p1549-p1566.indd 156112/02/19 9:59 AM 1562SPECIFIC CONSIDERATIONSPART IIflank, or groin pain and suffer from fevers or chills. Depend-ing on severity, patients may present with fulminant sepsis. Abscesses may become quite large | Surgery_Schwartz. duodenal ulcer, iatrogenic perforation of the gastrointestinal tract, or pancreatitis. Patients may develop back, Inferiorvena cavaDiaphragmEsophagusAbdominal aortaSplenorenal ligamentPancreasRoot of transversemesocolonDuodenojejunaljunctionLeft kidneyPsoas majorInferior mesenteric arterySite of descending mesocolonRoot of sigmoidmesocolonRectumSite of barearea of liverHepatic portalveinDuodenumSuperiormesenteric vein and arterySite of ascending colonRoot of mesenteryTesticular (or ovarian) vesselsUreterAnterior viewRight kidneyRightparacolic gutterFigure 35-12. Anatomy of the retroperitoneum. (Reproduced with permission from Moore KL, Agur AM: Essential Clinical Anatomy, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.)Brunicardi_Ch35_p1549-p1566.indd 156112/02/19 9:59 AM 1562SPECIFIC CONSIDERATIONSPART IIflank, or groin pain and suffer from fevers or chills. Depend-ing on severity, patients may present with fulminant sepsis. Abscesses may become quite large |
Surgery_Schwartz_10291 | Surgery_Schwartz | 9:59 AM 1562SPECIFIC CONSIDERATIONSPART IIflank, or groin pain and suffer from fevers or chills. Depend-ing on severity, patients may present with fulminant sepsis. Abscesses may become quite large given the substantial retro-peritoneal space. On physical exam, patients may present with erythema of the umbilicus or flank. Abscesses are usually found easily on CT scan of the abdomen with IV contrast, which can also show if the collection is loculated. Treatment of retroperi-toneal abscesses includes source control via treatment of the underlying condition, drainage of well-defined collections, and IV antibiotics. Image guided drainage is preferred, but it may be unsuccessful if the abscess is multiloculated or in an inacces-sible area. For these cases, operative drainage may be required. Given the insidious nature of this disease and a lack of abdomi-nal findings on physical exam, recognition of a retroperitoneal abscess may be delayed. Delays in diagnosis and insufficient drainage | Surgery_Schwartz. 9:59 AM 1562SPECIFIC CONSIDERATIONSPART IIflank, or groin pain and suffer from fevers or chills. Depend-ing on severity, patients may present with fulminant sepsis. Abscesses may become quite large given the substantial retro-peritoneal space. On physical exam, patients may present with erythema of the umbilicus or flank. Abscesses are usually found easily on CT scan of the abdomen with IV contrast, which can also show if the collection is loculated. Treatment of retroperi-toneal abscesses includes source control via treatment of the underlying condition, drainage of well-defined collections, and IV antibiotics. Image guided drainage is preferred, but it may be unsuccessful if the abscess is multiloculated or in an inacces-sible area. For these cases, operative drainage may be required. Given the insidious nature of this disease and a lack of abdomi-nal findings on physical exam, recognition of a retroperitoneal abscess may be delayed. Delays in diagnosis and insufficient drainage |
Surgery_Schwartz_10292 | Surgery_Schwartz | Given the insidious nature of this disease and a lack of abdomi-nal findings on physical exam, recognition of a retroperitoneal abscess may be delayed. Delays in diagnosis and insufficient drainage may lead to high morbidity and mortality. Depending on severity, mortality of retroperitoneal abscess can be as high as 25%. Rarely, patients may develop necrotizing fasciitis of the retroperitoneum, a condition with high mortality.Retroperitoneal FibrosisRetroperitoneal fibrosis is a rare disease characterized by inflammation and fibrosis of the tissue of the retroperitoneum. It exists as a spectrum of disease with chronic periaortitis, which affects the retroperitoneal tissue near large arteries of the retro-peritoneum. Fibrosis gradually expands, encasing the ureters, inferior vena cava, aorta, mesenteric vessels, or sympathetic nerves. Bilateral involvement is noted in up to 70% of cases. The condition may either be idiopathic or due to a secondary cause, including aortic aneurysms, | Surgery_Schwartz. Given the insidious nature of this disease and a lack of abdomi-nal findings on physical exam, recognition of a retroperitoneal abscess may be delayed. Delays in diagnosis and insufficient drainage may lead to high morbidity and mortality. Depending on severity, mortality of retroperitoneal abscess can be as high as 25%. Rarely, patients may develop necrotizing fasciitis of the retroperitoneum, a condition with high mortality.Retroperitoneal FibrosisRetroperitoneal fibrosis is a rare disease characterized by inflammation and fibrosis of the tissue of the retroperitoneum. It exists as a spectrum of disease with chronic periaortitis, which affects the retroperitoneal tissue near large arteries of the retro-peritoneum. Fibrosis gradually expands, encasing the ureters, inferior vena cava, aorta, mesenteric vessels, or sympathetic nerves. Bilateral involvement is noted in up to 70% of cases. The condition may either be idiopathic or due to a secondary cause, including aortic aneurysms, |
Surgery_Schwartz_10293 | Surgery_Schwartz | aorta, mesenteric vessels, or sympathetic nerves. Bilateral involvement is noted in up to 70% of cases. The condition may either be idiopathic or due to a secondary cause, including aortic aneurysms, pancreatitis, certain drugs (Ergot-derivatives, β-blockers, hydralazine, methyldopa, among others), malignancies (including lymphoma, carcinoids, sarco-mas, colorectal, breast, and others), infections such as tuber-culosis, radiation, retroperitoneal hematoma, surgery, asbestos, or tobacco use. Retroperitoneal fibrosis has been described in association with several autoimmune disorders including anky-losing spondylitis, systemic lupus erythematosus, Wegener’s granulomatosis, and polyarteritis nodosa.Idiopathic retroperitoneal fibrosis accounts for 70% of cases and is thought to be an immune-mediated disorder. Theo-ries regarding the pathogenesis of idiopathic fibrosis of the retro-peritoneum include exaggerated local reactions to aortic or iliac atherosclerosis or autoimmune deposition of | Surgery_Schwartz. aorta, mesenteric vessels, or sympathetic nerves. Bilateral involvement is noted in up to 70% of cases. The condition may either be idiopathic or due to a secondary cause, including aortic aneurysms, pancreatitis, certain drugs (Ergot-derivatives, β-blockers, hydralazine, methyldopa, among others), malignancies (including lymphoma, carcinoids, sarco-mas, colorectal, breast, and others), infections such as tuber-culosis, radiation, retroperitoneal hematoma, surgery, asbestos, or tobacco use. Retroperitoneal fibrosis has been described in association with several autoimmune disorders including anky-losing spondylitis, systemic lupus erythematosus, Wegener’s granulomatosis, and polyarteritis nodosa.Idiopathic retroperitoneal fibrosis accounts for 70% of cases and is thought to be an immune-mediated disorder. Theo-ries regarding the pathogenesis of idiopathic fibrosis of the retro-peritoneum include exaggerated local reactions to aortic or iliac atherosclerosis or autoimmune deposition of |
Surgery_Schwartz_10294 | Surgery_Schwartz | disorder. Theo-ries regarding the pathogenesis of idiopathic fibrosis of the retro-peritoneum include exaggerated local reactions to aortic or iliac atherosclerosis or autoimmune deposition of fibroinflammatory cytokines. Retroperitoneal fibrosis is also a manifestation of IgG4-related disease, a multisystem disease characterized by lymphocytic infiltrate and variable degrees of fibrosis of sev-eral affected organs. One study has associated retroperitoneal fibrosis with the HLA-DRB1*03 allelle, which has been linked to autoimmune diseases such as systemic lupus erythematosus, type 1 diabetes mellitus, and myasthenia gravis.Idiopathic retroperitoneal fibrosis is rare, with an incidence of 1.3 per 100,000 people per year. It most commonly affects individuals in the fourth to sixth decades of life. Some studies suggest a 2:1 male-to-female predominance, but others have not found a gender predilection. Patients with this condition present with nonspecific findings. Most patients are | Surgery_Schwartz. disorder. Theo-ries regarding the pathogenesis of idiopathic fibrosis of the retro-peritoneum include exaggerated local reactions to aortic or iliac atherosclerosis or autoimmune deposition of fibroinflammatory cytokines. Retroperitoneal fibrosis is also a manifestation of IgG4-related disease, a multisystem disease characterized by lymphocytic infiltrate and variable degrees of fibrosis of sev-eral affected organs. One study has associated retroperitoneal fibrosis with the HLA-DRB1*03 allelle, which has been linked to autoimmune diseases such as systemic lupus erythematosus, type 1 diabetes mellitus, and myasthenia gravis.Idiopathic retroperitoneal fibrosis is rare, with an incidence of 1.3 per 100,000 people per year. It most commonly affects individuals in the fourth to sixth decades of life. Some studies suggest a 2:1 male-to-female predominance, but others have not found a gender predilection. Patients with this condition present with nonspecific findings. Most patients are |
Surgery_Schwartz_10295 | Surgery_Schwartz | of life. Some studies suggest a 2:1 male-to-female predominance, but others have not found a gender predilection. Patients with this condition present with nonspecific findings. Most patients are diagnosed after ure-teral obstruction. Patients may complain of dull or acute back or flank pain. Systemic complaints include anorexia, weight loss, nausea, vomiting, fever, and malaise. Decreased urinary out-put may ensue if the ureters become fibrotic. Because of renal artery impingement, patients are commonly hypertensive on exam. Other physical exam findings include lower extremity edema and diminished lower extremity pulses if the vessels of the lower extremities are compressed. New hydrocele or varico-cele can also be associated with fibrosis of the retroperitoneum. Laboratory analysis is also nonspecific. If there is renal obstruc-tion, patients may have elevated serum blood urea nitrogen and creatinine. Erythrocyte sedimentation rate and C-reactive pro-tein is elevated in most | Surgery_Schwartz. of life. Some studies suggest a 2:1 male-to-female predominance, but others have not found a gender predilection. Patients with this condition present with nonspecific findings. Most patients are diagnosed after ure-teral obstruction. Patients may complain of dull or acute back or flank pain. Systemic complaints include anorexia, weight loss, nausea, vomiting, fever, and malaise. Decreased urinary out-put may ensue if the ureters become fibrotic. Because of renal artery impingement, patients are commonly hypertensive on exam. Other physical exam findings include lower extremity edema and diminished lower extremity pulses if the vessels of the lower extremities are compressed. New hydrocele or varico-cele can also be associated with fibrosis of the retroperitoneum. Laboratory analysis is also nonspecific. If there is renal obstruc-tion, patients may have elevated serum blood urea nitrogen and creatinine. Erythrocyte sedimentation rate and C-reactive pro-tein is elevated in most |
Surgery_Schwartz_10296 | Surgery_Schwartz | is also nonspecific. If there is renal obstruc-tion, patients may have elevated serum blood urea nitrogen and creatinine. Erythrocyte sedimentation rate and C-reactive pro-tein is elevated in most patients with retroperitoneal fibrosis. Antinuclear antibodies may also be elevated, highlighting the autoimmune nature of this disease.Contrast-enhanced CT scan is the modality of choice to visualize the extent of disease. On CT scan, fibrotic ret-roperitoneum appears to have similar attenuation to muscle tissue (Fig. 35-13). The fibrotic mass can appear to encase the aorta and often compresses the inferior vena cava. If renal insufficiency precludes the use of IV contrast, MRI can be used to clarify the extent of fibrosis. Renal US can also be used to document ureteral compression and hydronephrosis. In some cases, a compressing mass lesion can also be found on abdominal US. Lower-extremity US may show deep venous thrombosis.Pathologic examination of tissue is necessary to confirm the | Surgery_Schwartz. is also nonspecific. If there is renal obstruc-tion, patients may have elevated serum blood urea nitrogen and creatinine. Erythrocyte sedimentation rate and C-reactive pro-tein is elevated in most patients with retroperitoneal fibrosis. Antinuclear antibodies may also be elevated, highlighting the autoimmune nature of this disease.Contrast-enhanced CT scan is the modality of choice to visualize the extent of disease. On CT scan, fibrotic ret-roperitoneum appears to have similar attenuation to muscle tissue (Fig. 35-13). The fibrotic mass can appear to encase the aorta and often compresses the inferior vena cava. If renal insufficiency precludes the use of IV contrast, MRI can be used to clarify the extent of fibrosis. Renal US can also be used to document ureteral compression and hydronephrosis. In some cases, a compressing mass lesion can also be found on abdominal US. Lower-extremity US may show deep venous thrombosis.Pathologic examination of tissue is necessary to confirm the |
Surgery_Schwartz_10297 | Surgery_Schwartz | In some cases, a compressing mass lesion can also be found on abdominal US. Lower-extremity US may show deep venous thrombosis.Pathologic examination of tissue is necessary to confirm the diagnosis and to rule out malignancy. Differential of ret-roperitoneal masses include lymphomas or sarcomas, desmoid Figure 35-13. Computed tomography findings of retroperitoneal fibrosis. Arrows point to a soft tissue mass surrounding the aorta and common iliac arteries. Also present is hydronephrosis of the right kidney because of ureteral compression. (Reproduced with permission from Vagilo A. Salvarani C, Buzio C. Retroperitoneal Fibrosis, Lancet. 2006 Jan 21;367(9506):241-251.)Brunicardi_Ch35_p1549-p1566.indd 156212/02/19 9:59 AM 1563ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35tumors, and infections such as tuberculosis. Biopsy can be obtained either via image-guided or surgical techniques, which may be performed laparoscopically or during an open procedure.Once the | Surgery_Schwartz. In some cases, a compressing mass lesion can also be found on abdominal US. Lower-extremity US may show deep venous thrombosis.Pathologic examination of tissue is necessary to confirm the diagnosis and to rule out malignancy. Differential of ret-roperitoneal masses include lymphomas or sarcomas, desmoid Figure 35-13. Computed tomography findings of retroperitoneal fibrosis. Arrows point to a soft tissue mass surrounding the aorta and common iliac arteries. Also present is hydronephrosis of the right kidney because of ureteral compression. (Reproduced with permission from Vagilo A. Salvarani C, Buzio C. Retroperitoneal Fibrosis, Lancet. 2006 Jan 21;367(9506):241-251.)Brunicardi_Ch35_p1549-p1566.indd 156212/02/19 9:59 AM 1563ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUMCHAPTER 35tumors, and infections such as tuberculosis. Biopsy can be obtained either via image-guided or surgical techniques, which may be performed laparoscopically or during an open procedure.Once the |
Surgery_Schwartz_10298 | Surgery_Schwartz | 35tumors, and infections such as tuberculosis. Biopsy can be obtained either via image-guided or surgical techniques, which may be performed laparoscopically or during an open procedure.Once the diagnosis of retroperitoneal fibrosis is estab-lished, treatment is initiated. Surgical treatment is aimed at relieving ureteral obstruction either by ureterolysis or stenting. Surgery is reserved for patients who develop renal insufficiency as any surgical intervention in these patients car-ries several associated risks. In patients with secondary fibro-sis, treatment is aimed at the underlying etiology or discontinuation of the causative medication. For patients with idiopathic retroperitoneal fibrosis, corticosteroids are the mainstay of treatment. Patients are usually started on one month of high-dose prednisone, followed by maintenance therapy and subsequent taper. Alternatively, tamoxifen can be used if patients have contraindications to steroids. Within days of instituting therapy, | Surgery_Schwartz. 35tumors, and infections such as tuberculosis. Biopsy can be obtained either via image-guided or surgical techniques, which may be performed laparoscopically or during an open procedure.Once the diagnosis of retroperitoneal fibrosis is estab-lished, treatment is initiated. Surgical treatment is aimed at relieving ureteral obstruction either by ureterolysis or stenting. Surgery is reserved for patients who develop renal insufficiency as any surgical intervention in these patients car-ries several associated risks. In patients with secondary fibro-sis, treatment is aimed at the underlying etiology or discontinuation of the causative medication. For patients with idiopathic retroperitoneal fibrosis, corticosteroids are the mainstay of treatment. Patients are usually started on one month of high-dose prednisone, followed by maintenance therapy and subsequent taper. Alternatively, tamoxifen can be used if patients have contraindications to steroids. Within days of instituting therapy, |
Surgery_Schwartz_10299 | Surgery_Schwartz | of high-dose prednisone, followed by maintenance therapy and subsequent taper. Alternatively, tamoxifen can be used if patients have contraindications to steroids. Within days of instituting therapy, symptoms and inflammatory markers should improve. Over the course of a few weeks, renal func-tion should improve. Interval imaging studies are usually obtained after 1 month to evaluate for efficacy. If steroids fail to cause regression of disease, patients can be started on immunosuppressant medications including methotrexate, aza-thioprine, cyclophosphamide, or mycophenolate mofetil. Recurrence of retroperitoneal fibrosis varies between studies from 10% to 30%. In patients who respond to steroid therapy, 5-year survival is as high as 90%.BIBLIOGRAPHYEntries highlighted in bright blue are key references.Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall her-nias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. RadioGraphics. | Surgery_Schwartz. of high-dose prednisone, followed by maintenance therapy and subsequent taper. Alternatively, tamoxifen can be used if patients have contraindications to steroids. Within days of instituting therapy, symptoms and inflammatory markers should improve. Over the course of a few weeks, renal func-tion should improve. Interval imaging studies are usually obtained after 1 month to evaluate for efficacy. If steroids fail to cause regression of disease, patients can be started on immunosuppressant medications including methotrexate, aza-thioprine, cyclophosphamide, or mycophenolate mofetil. Recurrence of retroperitoneal fibrosis varies between studies from 10% to 30%. In patients who respond to steroid therapy, 5-year survival is as high as 90%.BIBLIOGRAPHYEntries highlighted in bright blue are key references.Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall her-nias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. RadioGraphics. |
Surgery_Schwartz_10300 | Surgery_Schwartz | bright blue are key references.Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall her-nias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. RadioGraphics. 2005;25:1501-1520.Ahmad G, Gent D, Henderson D, O’Flynn H, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Data-base Syst Rev. 2015;8:CD006583. doi: 10.1002/14651858.CD006583.pub4Awaiz A, Rahman F, Hossain MB, et al. Meta-analysis and system-atic review of laparoscopic versus open mesh repair for elec-tive incisional hernia. Hernia. 2015;19:449-463. doi: 10.1007/s10029-015-1351-zBagade S, Khanna G. Imaging of omphalomesenteric duct remnants and related pathologies in children. Curr Probl Diagn Radiol. 2015;44:246-255.Beer GM, Schuster A, Seifert B, et al. The normal width of the linea alba in nulliparous women. Clin Anat. 2009;22(6):706-711. doi: 10.1002/ca.20836Berrevoet F, Vanlander A, Sainz-Barriga M, et al. Infected large pore meshes may be salvaged by topical negative | Surgery_Schwartz. bright blue are key references.Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall her-nias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. RadioGraphics. 2005;25:1501-1520.Ahmad G, Gent D, Henderson D, O’Flynn H, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Data-base Syst Rev. 2015;8:CD006583. doi: 10.1002/14651858.CD006583.pub4Awaiz A, Rahman F, Hossain MB, et al. Meta-analysis and system-atic review of laparoscopic versus open mesh repair for elec-tive incisional hernia. Hernia. 2015;19:449-463. doi: 10.1007/s10029-015-1351-zBagade S, Khanna G. Imaging of omphalomesenteric duct remnants and related pathologies in children. Curr Probl Diagn Radiol. 2015;44:246-255.Beer GM, Schuster A, Seifert B, et al. The normal width of the linea alba in nulliparous women. Clin Anat. 2009;22(6):706-711. doi: 10.1002/ca.20836Berrevoet F, Vanlander A, Sainz-Barriga M, et al. Infected large pore meshes may be salvaged by topical negative |
Surgery_Schwartz_10301 | Surgery_Schwartz | linea alba in nulliparous women. Clin Anat. 2009;22(6):706-711. doi: 10.1002/ca.20836Berrevoet F, Vanlander A, Sainz-Barriga M, et al. Infected large pore meshes may be salvaged by topical negative pressure ther-apy. Hernia. 2013;17:67-73. doi: 10.1007/s10029-012-0969-3Bhangu A, Fitzgerald JE, Singh P, Battersby N, Marriott P, Pinkney T. Systematic review and meta-analysis of prophylactic mesh placement for prevention of incisional hernia follow-ing midline laparotomy. Hernia. 2013;17(4):445-455. doi: 10.1007/s10029-013-1119-2Bickenbach KA, Karanicolas PJ, Ammori JB, et al. Development of the ventral body wall in the human embryo. Ann Surg. 2013;227:276-281. doi: 10.1053/j.sempedsurg.2014.09.009Bickenbach KA, Karanicolas PJ, Ammori JB, et al. Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery. Am J Surg. 2013;206:400-409. doi: 10.1016/j.amjsurg.2012.11.008Bilsel Y, Abci I. The search for ideal hernia | Surgery_Schwartz. linea alba in nulliparous women. Clin Anat. 2009;22(6):706-711. doi: 10.1002/ca.20836Berrevoet F, Vanlander A, Sainz-Barriga M, et al. Infected large pore meshes may be salvaged by topical negative pressure ther-apy. Hernia. 2013;17:67-73. doi: 10.1007/s10029-012-0969-3Bhangu A, Fitzgerald JE, Singh P, Battersby N, Marriott P, Pinkney T. Systematic review and meta-analysis of prophylactic mesh placement for prevention of incisional hernia follow-ing midline laparotomy. Hernia. 2013;17(4):445-455. doi: 10.1007/s10029-013-1119-2Bickenbach KA, Karanicolas PJ, Ammori JB, et al. Development of the ventral body wall in the human embryo. Ann Surg. 2013;227:276-281. doi: 10.1053/j.sempedsurg.2014.09.009Bickenbach KA, Karanicolas PJ, Ammori JB, et al. Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery. Am J Surg. 2013;206:400-409. doi: 10.1016/j.amjsurg.2012.11.008Bilsel Y, Abci I. The search for ideal hernia |
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