1460

PART
UNIT II
SPECIFIC CONSIDERATIONS

Figure 35-15. Computed tomography (CT) scan of a mesenteric cyst (left panel). Unilocular appearance without associated solid component
strongly suggests the diagnosis of benign cyst. The operative findings during laparoscopic eploration (right panel) confirm the CT diagnosis
of unilocular cyst, which is then enucleated from the mesentery in a relatively avascular plane adjacent to mesenteric vessels.

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

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

CHAPTER 35 ABDOMINAL WALL, OMENTUM, MESENTERY, AND RETROPERITONEUM

gland
Duodenum
Phrenocolic
ligament
Right ureter

Right kidney Left kidney

Quadratus Pancreas
lumborum m.

Psoas major m.

Common
iliac a.

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

In the closely related condition of chronic perioaortitis, an asso- in defining an autoimmune cause of retroperitoneal fibrosis. Cir-
ciation with the HLA-DRB1*03 allele, which has been linked to culating antibodies to ceroid, a lipoproteinaceous by-product of
autoimmune diseases such as systemic lupus erythematosus, type vascular atheromatous plaque oxidation, are present in more than
1 diabetes mellitus, and myasthenia gravis, is of particular interest 90% of patients with retroperitoneal fibrosis. The relationship of
these finding to the occurrence of fibrosis remains uncertain. The
early inflammatory reaction is predominated by T-helper cells,
plasma cells, and macrophages, but is subsequently replaced by
collagen-synthesizing fibroblasts. Microscopically, the infiltrate
is indistinguishable from the periadventitial involvement of aortic
aneurysmal disease, Reidel’s thyroiditis, sclerosing cholangitis,
and Peyronie’s disease. The fibrotic process begins in the ret-
roperitoneum just below the level of the renal arteries. Fibrosis
gradually expands, encasing the ureters, inferior vena cava, aorta,
mesenteric vessels, or sympathetic nerves. Bilateral involvement
is noted in 67% of cases.
Retroperitoneal fibrosis may also appear secondarily with
a variety of inflammatory conditions including abdominal aortic
aneurysm, pancreatitis, histoplasmosis, tuberculosis, or actino-
mycosis. It also is associated with a variety of malignancies,
including prostate, pancreas, and gastric cancer, as well as non-
Hodgkin’s lymphoma, stromal tumors, and carcinoid tumors.
Retroperitoneal fibrosis has been described in association with
Figure 35-17. Computed tomography scan of retroperitoneal autoimmune disorders including ankylosing spondylitis, sys-
abscess complicating complex, surgically treated retroperitoneal temic lupus erythematosus, Wegener’s granulomatosis, and
infection that had resulted from ampullary perforation at the time polyarteritis nodosa.
of endoscopic retrograde cholangiopancreatography. This pattern There is strong evidence that methysergide, a semisyn-
of infection may be difficult to treat and result in multiple interven- thetic ergot alkaloid used in the treatment of migraine head-
tions such as percutaneous drainage before resolution. aches, plays a causal role in some cases of retroperitoneal
1462 fibrosis. Other medications that have been linked to retroperi- based on patient symptoms and interval imaging studies. Cyclo-
toneal fibrosis include β-blockers, hydralazine, α-methyldopa, sporin, tamoxifen, and azathioprine have also been used to treat
and entacapone, which inhibits catechol-O-methyltransferase patients who respond poorly to corticosteroids.
and is used as an adjunct with levodopa in the treatment of Par- The overall prognosis in idiopathic retroperitoneal fibrosis
kinson’s disease. The retroperitoneal fibrosis regresses upon is good, with 5-year survival rates of 90% to 100%. Because
discontinuation of these medications. long-term recurrences have been described, lifelong follow-up
Presenting symptoms depend on the structure or structures is warranted.
affected by the fibrotic process. Initially, patients complain of
the insidious onset of dull, poorly localized abdominal pain. BIBLIOGRAPHY
Sudden-onset or severe abdominal pain may signify acute mes-
Entries highlighted in bright blue are key references.
enteric ischemia. Other symptoms of retroperitoneal fibrosis
may include unilateral leg swelling, intermittent claudication, General References
PART
UNIT II

oliguria, hematuria, or dysuria. Burt BM, Tavakkolizaden A, Ferzoco SJ. Incisions, closures, and
management of the abdominal wound. In: Zinner MJ, Ashley
As with the patient’s symptomatology, findings on physi-
SW, eds. Maingot’s Abdominal Operations. 11th ed. New York:
cal examination vary with the retroperitoneal structure involved. McGraw Hill; 2007:71-102.
Consequently, findings may include hypertension, the palpation Flament JB, Avisse C, Delattre JF. Anatomy of the abdominal wall.
of an abdominal or flank mass, lower-extremity edema (uni-
SPECIFIC CONSIDERATIONS

In: Bendavid R, Abrahamson J, Arregui ME, et al, eds. Abdomi-

lateral or bilateral), or diminished lower-extremity pulses (uni- nal Wall Hernias: Principles and Management. 1st ed. New
lateral or bilateral). Laboratory evaluation may reveal elevated York: Springer-Verlag; 2001:39-63.
blood urea nitrogen and/or creatinine levels. As with many auto- Sauerland S, Walgenbach M, Habermalz B, et al. Laparoscopic
immune inflammatory processes, the erythrocyte sedimentation versus open surgical techniques for ventral or incisional her-
rate almost always is elevated in patients with retroperitoneal nia repair. Cochrane Database Syst Rev 16 (3): 2011.
fibrosis.
Many imaging modalities have been used with various Abdominal Wall
sensitivities to diagnose retroperitoneal fibrosis. Abdominal/ Albright E, Diaz D, Davenport D, Roth JS. The component sepa-
ration technique for hernia repair: a comparison of open and
lower-extremity ultrasonography is the least invasive imag-
endoscopic techniques. Am Surg. 2011;77:839-843.
ing procedure but is technician dependent. It may be useful Anthony T, Bergen PC, Kim LT, et al. Factors affecting recurrence fol-
if iliocaval compressive or renal symptoms predominate. A lowing incisional herniorrhaphy. World J Surg. 2000;24:95-100.
lower-extremity ultrasound may show deep venous thrombosis, Bertani E, Chiappa A, Testori A, et al. Desmoid tumors of the
whereas abdominal ultrasonography may identify a mass lesion anterior abdominal wall: results from a monocentric surgi-
or hydronephrosis. Once the diagnostic procedure of choice, cal experience and review of the literature. Ann Surg Oncol.
intravenous pyelography (IVP) is less commonly used today. If 2009;16:1642-1649.
the ureters are involved, IVP findings include ureteral compres- Blatnik J, Jin J, Rosen M. Abdominal hernia repair with bridging
sion, ureteral deviation toward the midline, and hydronephrosis. acellular dermal matrix: an expensive hernia sac. Am J Surg.
Abdominopelvic CT with oral and intravenous contrast 2008;196:47-50.
is the imaging procedure of choice and will generally allow de Vries Reilingh TS, Bodegom ME, van Goor H, et al. Autolo-
gous tissue repair of large abdominal wall defects. Br J Surg.
the extent of the fibrotic process to be determined. If there is
2007;94:791-803.
diminished renal function, avoidance of the use of intravenous Edlow JA, Juang P, Marglies S, et al. Rectus sheath hematoma. Ann
contrast will reduce the ability to characterize retroperitoneal Emerg Med. 1999;34:671-675.
tissue planes. In this case, MRI may be used, since the signal Halm JA, de Wall LL, Steyerberg EW, et al. Intraperitoneal poly-
intensity of the fibrotic process is discrete from muscle or fat. propylene mesh hernia repair complicates subsequent abdomi-
Additionally, magnetic resonance angiography will generally nal surgery. World J Surg. 2007;31:423-429.
provide a good assessment of the degree of iliocaval involve- Harth KC, Rose J, Delaney CP, et al. Open versus endoscopic
ment. Once a mass lesion is identified, the mass should be biop- component separation: a cost comparison. Surg Endosc.
sied to rule out a retroperitoneal malignancy. The specimen may 2011;25:2865-2870.
be retrieved using image-guided techniques or surgical retro- Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic ventral
and incisional hernia repair in 407 patients. J Am Coll Surg.
peritoneal biopsy, which may be performed laparoscopically or
2000;190:645-650.
during open laparotomy. Hesselink VJ, Luijendijk R, de Wilt JH, et al. An evaluation of risk
Once malignancy, drug-induced, and infectious etiologies factors in incisional hernia recurrence. Surg Gynecol Obstet.
are ruled out, treatment of the retroperitoneal fibrotic process 1993;176:228-234.
is instituted. Corticosteroids, with or without surgery, are the Jin J, Rosen MJ, Blatnik J, et al. Use of acellular dermal matrix for
mainstay of medical therapy. Surgical treatment consists primar- complicated hernia repair: does technique affect outcome? J Am
ily of ureterolysis or ureteral stenting and is required in patients Coll Surg. 2007;205:654-660.
who present with significant hydronephrosis. Laparoscopic ure- Klingler PJ, Wetscher G, Glaser K, et al. The use of ultrasound to
terolysis has been shown to be as efficacious as open the open differentiate rectus sheath hematoma from other acute abdomi-
procedure. Patients with iliocaval thrombosis require anticoag- nal disorders. Surg Endosc. 1999;13:1129-1134.
Knechtel G, Stoeger H, Szkandera J, Dorr K, Beham A, Samonigg
ulation, although appropriate duration of therapy is uncertain.
H. Desmoid tumor treated with polychemotherapy followed by
Endovascular interventions for iliocaval occlusion have also
imatinib: a case report and review of the literature. Case Rep
been shown to be effective in small numbers of patients.
8 Prednisone is initially administered at a relatively high
Oncol. 2010;3:287-293.
Korenkov M, Sauerland S, Arndt M, et al. Randomized clinical
dose (60 mg every other day for 2 months), and then gradually trial of suture repair, polypropylene mesh, or autodermal her-
tapered over the next 2 months. Therapeutic efficacy is assessed nioplasty for incisional hernia. Br J Surg. 2002;89:50-56.