Abdominal - Retroperitoneum by S.

Wichien (SNG KKU)

Anatomy Deep inguinal ring -arise from transversalis F Superficial inguinal ring -arise from med/lat EO aponeurosis Inguinal lig (Poupart lig) -arise from thickening EO -connect ASIS--pubic tubercle Lacunar lig (Gimbernat lig) -medial,fan shape of inguinal lig -join inguinal lig to pectineal line Cooper lig (pectineal lig) -extend from lacunar lig Conjoint tendon (falx inguinalis) -arise from IO+Transversus abdo Cremasteric m -inf most fiber of IO in inguinal canal Blood supply -sup epigastric a<--int thoracic a -inf epigastric a<--ext illiac a deep circumflex illiac a<--ext illiac a -lumbar a Incision -rt subcostal = kocher -extend kocher = saber slash -bilat subcostal = bucket handle (chevron,gable) -extend rockey davis = weir Rectus disease 1.rectus abdominis diastasis -diastasis recti -old,s/p preg -separate of linea alba -bulging epigastrium -mistaken for ventral hernia Tx -plication of midline aponeurosis 2.rectus sheath hematoma -a--post to rectus m,enter post sheath -sudden onset of uni.abdo.pain -below arcuate can bilat pain -abdo.CT--definite study Hx -major/minor blunt trauma -sudden contract m w cough,sneez -coag.drug can spon bleed PE -Fothergill sign Tx 1.small+stable--observe 2.large+stable -coag.factor replacement -reverse anticoagulation 3.expanding hematoma or unstable -as 2 -if stable--observe if enlarging--angiogram+embolize if unstable--OR--evac clot+ligate

Abdominal - Retroperitoneum by S.Wichien (SNG KKU)

Ventral hernia (By anatomic location) Epigastric hernia -locate in midline -btw xiphoid & umbilicus -small defedt -contain omentum,falciform Umbilical hernia congen.hernia -close spon by age 5 -if not = elective sx Adult -sx when symp,enlarge,incarcerate -prosthetic mesh (>2cm) Spigelian hernia -occur anywhere along Spigelian line -lateral border of rectus -most slightly above arcuate line Incisional hernia Tx 1.anatomical suture Simple suture -small defect <3cm -strong interrupted non-ansorb -suture line under tension -hi recur rate Component separate technic -release tension than simple suture -create large subcu.flap lateral to fascial defect -incision EO m -simple suture 2.overlapping suture method -mayo principle -imbricated upper layer 3.Mesh repair -gold std Categorized by relation to abdo fascia 1.extrafascial--onlay 2.subfascial--preperitoneum--underlay 3.sandwish dissect sac from abdo.wall 3-4 cm Type of material 1.prosthesis mesh -ease,low cost,durability 2.bio.mesh -porcine,bovine,human -contaminate field,expensive 4.laparoscopic repair -intraperitoneal technic -transfascial suture 5.myofascial flap -tensor fascia lata flap -gracillis m tranfer -extended latissimus dorsi flap -separation of ant abdo.wall m

Abdominal - Retroperitoneum by S.Wichien (SNG KKU)

Desmoid -unusual soft tissue neoplasm -from fascial or musculoaponeurotic -proliferation of fibroblast,collagen -some consider desmoid to be a form of fibrosarcoma -sx incision(abdo/thorax)have been the site of desmoid development Omental anatomy Greater omentum -double layer -gastrocolic,gastrosplenic Lesser omentum -hepatoduodenal,hepatogastric lig -foramen of winslow Blood supply -rt/lt gastroepiploic a Physiology -abdo.policeman -intrinsic hemostatic -adhere area of inj/inflam 1.Omental infarction 2cause -tortion of omentum -thrombose,vasculitis of omental vv -venous outflow obstruct Clinical -mimic sx condition -localized pain -no intes symptom Tx -not toxic--supportive -controversy dx--lap.explore 2.Omental cyst -less common than mesenteric cyst Clinical -asymp abdo.mass--freely mobile -abdo.pain w, wo mass Tx -resection of all symptomatic cyst 3.Omental neoplasm -benign = lipoma,myxoma,desmoid -1tumor = uncommon ,GIST -2tumor =mmetas tumor

-not metastasis
-significant to recur locally 5-50%, despite complete negative margin Cause -unknown -multiple association :familial polyposis(gardner synd) :inc estrogen(pregnancy) :trauma Clinical -30-40yr -pain,chest wall mass -tumor usually fix to chest wall,but not to overlying skin Ix -no radiographic finding are typical -MRI may delineate m./soft tissue -histo dx from needle bx become of low cellularity -open incision bx for lesion over 3-4cm is necessary Rx -wide local excision with margin of 2-4cm and c intraop assess by frozen -typical,a rib is removed above and below tumor c 4-5 cm margin of ribs -margin of less than 1cm result in much higher local recurrence rate -survival after wide excision c neg margin is 90% at 10yr

Abdominal - Retroperitoneum by S.Wichien (SNG KKU)

Mesentery -develop from mesenchyme -attach gut to post abdo wall -root mesentery--oblique direction :LUQ (lig of treitz) to RLQ (IC valve) 1.Paraduodenal/mesocolic hernia -anatomic anomaly, rotational disorder -abnormal fixation -small bowel into retrocolic hernia sac -post to descending colon -chronic or acute intes obstuction -children /adult 2.Sclerosing mesenteritis (mesenteric panniculitis) (mesenteric lipodystrophy) ->50y -localized or diffuse dz -chronic inflam, fibrotic process -inc tissue density in mesentery -inc inflam component -replace degen fatty component -mesen retract/shorten c scarring :retractile mesentery Clinical -abdo.pain--most common -discrete mass, may up to 40cm -intes obstruct -incidental finding CT -can't ddx from mesen tumor -fat ring sign--hypoden around mass -hyperattenuating stripe Tx -sx--for dx & r/o tumor (PET may r/o tumor) -biopsy or enbloc resection -self limited dz 3.Mesenteric cyst -asymp or symp -chronic intermittent abdo.pain :compress adjacent structure :spon torsion & detorsion -acute pain--rupture,tortion,hmg -mobile only lt<-->rt (Tillaux sign) Tx -surgical excision--open vs lap -deoof/marsupialize--not use--recur 4.Mesenteric tumor 1--rare Benign--lipoma,lymphangio,desmoid Malig--liposarc,leiomyosarc,MFH 2--metas small bowel carcinoid Tx--resection Retroperitonium -space btw post of perito & body wall -ant border--post reflect of perito Structure -KN,ureter,bladder,adrenal -seminal vesicle,vas def -pancreas,2nd&3rd duo -asc,des colon,2/3upper rectum -aorta,IVC,illiac vv -lymphatic (cisterna chyli) -upper vagina,ovary 1.Retroperitoneal infection -retrocecal appendicitis,diverticulitis perforate DU,pancreatitis -retroperitoneal abscess -large space--large size before dx -pain,fever,malaise -retro hmg--cullen,grey turner sign -dx test of choice--CT Tx -Tx cause -percu or open drainage 2.Retroperitoneal fibrosis 1 -idiopathic retroperito fibrosis -Ormand disease 2 -inflam--AAA,pancreatitis -malig--lymphoma,ca,carcinoid -allergic,autoIM--SLE -TB,actinomycosis,histoplassis -drug--ergot,methyldopa Clinical -insidious onset -dull,poor localized abdo.pain -unilat leg swelling -claudication -hematuria,dysuria -abdo.mass Ix -CT--ix of choice -MRI Tx -Bx--r/o tumor -corticosteroid Sx -HDN--ureteolysis,stenting -IVC thrombosis--anticoag