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SURGERY BLOCK
2012
Abdominal Wall
Blood Supply
Superior and Inferior Epigastric arteries
located between the rectus abdominis and posterior
rectus sheath
Lower intercostal arteries
Lumbar arteries
Iliac circumflex arteries
Lymphatic Drainage
UPPER HALF of the abdomen
drains into the Axillary Nodes
LOWER HALF of the abdomen
drains into the Iliac Nodes
PERIUMBILICAL area
ascend around the ligamentum teres into the Porta
Hepatis
Nerve Supply
Lower 6 intercostal nerves
Ilioinguinal nerve
Iliohypogastric nerves
CONGENITAL DISORDERS OF THE
Abdominal Wall
Omphalocele
AKA: Exomphalos
COMMONLY associated with
malformations
Cardiac anomalies
NTD
Chromosomal abnormalities
SAC present
formed from an outpouching of peritoneum
protrudes in the midline, through the umbilicus
MANAGMENT
Surgery
Cover w/ allograft to prevent drying
Gastroschisis
Umbilical cord NOT involved in lesions
NO SAC
Parts of organs may be free in the amniotic fluid
SURGERY BLOCK
2012
Differential Diagnosis
Ventral Abdominal Hernia
Midline Aponeurosis is affected
CAUSES
Advancing age
Obesity
Pregnancy
Lifting Heavy weights
DIAGNOSIS
Physical examination
CT scan
TREATMENT:
Plication Of The Broad Midline Aponeurosis
Rectus Sheath Hematoma
Due to rupture of the Epigastric Artery or Vein
EPIDEMIOLOGY
More frequent in female than male
M<F
rare in children
th
peak incidence in the 5 decade of life
Often SELF-LIMITING
May simulate acute abdomen
ETIOLOGY
Direct trauma to the epigastric blood vessels
Inelasticity of the artery or vein
atheromatous vessel
Debilitating illness
Collagen diseases
Blood dyscrasias
Hemophiliac
Leukemia
Anticoagulant therapy
Umbilical Hernia
result when persistence of a patent umbilical ring
may spontaneously close or many require surgical repair
Congenital Diastasis Recti
Separation of Rectus Abdominis at midline d/t more lateral
insertion of the rectus muscle to the ribs and costochondral
junction
ACQUIRED DISORDERS OF THE
Abdominal Wall
CLINICAL MANIFESTATIONS
Sudden onset of low abdominal pain
Hypotension (in severe bleeding)
Tender mass on the lower abdomen
Hematoma location varies in relation to Arcuate line of
Douglas
Bleeding ABOVE the line
dont cross the midline
hematoma limited by the linea alba
bleeding is below the line
Hematoma may cross past midline
(+) Fothergill sign
mass in the abdominal wall DOES NOT cross midline
Mass does not change with flexion of the rectus
muscles
Indicates rectus sheath hematoma
Ecchymosis
(+) Cullens Sign
Periumbilical ecchymosis
DIAGNOSIS:
Medical history
Trauma
Sudden exertion
BENIGN TUMORS OF
SURGERY BLOCK
2012
Usually SOLITARY
no true capsule but has a pseudocapsule with
multiple projections into the surrounding tissue
cause of RECURRENCE after its excision
Well-differentiated fibroblast and fibrocyte
with variable degree of cellularity
from moderate to almost acellular
may present w/ few or no mitoses.
Cells infiltrate the surrounding muscle
LOCAL INVASION is common
DOES NOT metastasize to lymph nodes
There are reported cases of metastasis but
very rare
DOES NOT invade the skin.
Symptoms due to compression or invasion of
adjacent muscle, tendon, nerves, periosteum,
bones, lymph nodes and ureters
DIAGNOSIS
Clinical History & Physical Examination
gives some clue as it often interrupts
intramuscular and soft tissue planes
Plain Abdominal Xray
Show visceral displacement or obstruction
Contrast enhanced studies;
Show thinning and even occasional
extravasation of intraluminal material into
the desmoid
Excretory urography
displacement of ureter and compression
Ultrasound
CT scan/MRI
MOST USEFUL diagnostic examination
shows homogenous soft tissue mass that
displaced adjacent viscera
T2 weighted MRI
illustrates relationship of desmoid
tumor to rectus abdominis muscle
T2 Weighted MRI
MANAGEMENT
Surgery
Complete Surgical Extirpation
only form of therapy that can give a
long-term remission.
PRINCIPLE
complete excision with 1-2 cm of
normal margin
RADICAL Excision
Musculocutaneous flap is needed
to close the defect
Exenteration and/or Hemipelvectomy
BEST MANAGEMENT for desmoid that
is located in the pelvis and involves
adjacent organs
Radiation Therapy
INDICATIONS:
UNRESECTABLE Desmoid tumor
Gross disease left at the margin
4.8 to 61.2 Gy dose
given in doses of 1.6 to 1.8 Gy per
fraction
5 fractions per week
Port should be designed to cover the tumor
bed w/ generous overlap margin
Chemotherapy
VAC Chemotherapy
Vincristine
Actinomycin D
Cyclophosphamide
Success rate
not good
takes up to 27 months for desmoid
tumor to respond
Pharmacology
Indomethacin
Given with high dose of ascorbic acid
effect on cyclic AMP
inhibit of Ornithine decarboxylase
Sulindac and other non-steroidal antiinflammatory drugs
Tamoxifen
because estrogen is thought to be
involved
Dicarbazine and Doxorubicin/Iridium
192 implantation
PROGNOSIS
Intra-abdominal desmoid tumor are difficult to
treat because it is usually located along the
superior mesenteric artery and its branches
Surgery will lead to SHORT BOWEL
SYNDROME
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Omentm
RECURRENCE
If excision is not complete RECURRENCE
FACTORS contributing to local recurrence
AGE
Late teens & 30s
Recurrent disease at presentation
Inadequate incision at the time of 1st
operation
Radiation therapy not administered for
gross residual disease
Omental Torsion
The omentum twist on its long axis, causing vascular
compromise which varies from mild vascular constriction
(edema) to complete strangulation (infarction and gangrene)
Two situations that must exist to cause torsion
Redundant and mobile segment
Fixed point around which the segment can twist
2 TYPES
PRIMARY (IDIOPATHIC) OMENTAL TORSION
PREDISPOSING factors:
Anatomic variation
tonguelike projections from
the free
edge of the omentum
bifid omentum
accessory omentum
Large and bulky omentum with a narrow pedicle
Obesity
Venous redundancy relative to the omental
arterial blood supply
OMENTUM
Omentum w/ TONGUE-like
projection
Omentm
Omentum
Consist of a DOUBLE SHEET of flattened endothelium
AKA
Police Officer of the Abdomen.
Has no spontaneous or ameboid activity
Displacement occur as a result of
intestinal peristalsis
diaphragmatic excursion
postural change of the individual.
Rich in macrophages
PRECIPITATING factors
Factos that cause omental displacement
Heavy exertion
Sudden change in body position
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CLINICAL MANIFESTATIONS:
Right abdominal pain
Steady pain
direct and rebound tenderness
Fever
leukocytosis
TREATMENT:
Resection of the infarcted area
to prevent the possible complication of
gangrene
adhesion formation
TUMORS OF THE
Omentum
Cystic Tumors of the Omentum
TRUE CYST
Are BENIGN
Lymphatic Cyst
caused by
obstruction of lymphatic channels
growth of congenitally misplaced lymphatic
Dermoid Cyst
Rare
lined by squamous epithelium
contains hair, teeth and sebaceous material
X-ray
Mass w/ smooth rim of calcification
CT Scan
Multiloculated cyst
PSEUDOCYST
Results from
fat necrosis
trauma with hematoma
foreign body reaction.
Has fibrous and inflammatory lining
contain cloudy, blood tinged or pus in fluid
walls are thin & translucent w/ septations
CLINICAL MANIFESTATIONS
Small cyst
asymptomatic
Large cyst
palpable abdominal mass
symptoms
heaviness
pain
manifestations of possible complications
torsion
infection
rupture
intestinal obstruction
Complicated cyst may present as an acute abdomen
DIAGNOSIS
Ultrasonography
CT scan
Exploratory Laparotomy
Makes Absolute diagnosis
TREATMENT:
Local excision
Solid Tumors of the Omentum
METASTATIC TUMOR
MC SOLID tumor of the omentum
Primary source:
Colon
Stomach
Pancreas
Ovary
MANIFESTATION
Epigastric pain
CT scan:
omental cake separating the colon and the small
bowel from the anterior abdominal wall
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2012
Mesentery
Mesentery
Reflection of anterior peritoneum to the surface of the
intestine
Connects the intestine to the posterior abdominal wall
Transmits vessels and nerves
Congenital defects
usually found in
Lower ileum
Sigmoid mesocolon
Transverse mesocolon
space of Riolan
can cause INTERNAL Abdominal Hernias
LOCATION
A: paraduodenal
B: foramen of Winslow
C: intersigmoid
D: pericecal
E: transmesenteric
F: retroanastomotic
Can lead to
Small Intestine Infarction
INTERNAL Abdominal
Hernias
FUNCTION of Mesentery
bactericidal and absorptive properties
Like the omentum
ability to form adhesions
Mesenteric Circulation
Contains 1/3 of the total blood volume
Receives 25-30% of cardiac output
Helps maintain body homeostasis by serving as reservoir in
periods of hypovolemia by autotransfusion
MAIN ARTERIES
CELIAC ARTERY
Stomach
Duodenum
SUPERIOR MESENTERIC ARTERY
rd
3 portion of duodenum to mid transverse colon
BRANCHES
Middle colic artery
Right colic artery
Ileocolic arteries
Jejunal arteries
Ileal arteries
Inferior Pancreaticoduodenal
INFERIOR MESENTERIC ARTERY
Left transverse colon to proximal rectum
BRANCHES
Left Colic Artery
Superior Hemorrhoidal Artery
COLLATERAL CIRCULATION
Between Celiac and Superior mesentery Artery
Superior Pancreaticoduodenal art (from Celiac)
Inferior Pancreaticoduodenal ( frm Sup mesentery)
Between Superior and Inferior mesentery Artery
Middle Colic and left colic (ascending branch)
Between Inferior mesentery and Internal iliac Artery
Superior hemorrhoidal (frm. Inf mesentery)
Inferior hemorrhoidal ( frm Int. Iliac)
Mesentery Response to Pharmacologic Agents
Vasodilatation
Nitroglycerine
Tolazoline
Papaverine
Vasoconstriction
Digitalis
Norepinephrine (alpha adrenergic)
Epinephrine-dose dependent
High dose (alpha adrenergic)
vasoconstrction
Low dose (beta adrenergic)
Vasodilatation
Mesentery
Occlusive Diseases
Acute mesenteric ischemia
Emboli
thrombosis
Chronic mesenteric ischemia
Long standing atherosclerosis
Involves at least 2 of the three mesenteric arteries
Non-occlusive mesenteric ischemia
Acute Mesenteric Ischemia
SMA most common involved vessel.
Based on ETIOLOGY
Acute Thrombotic Mesenteric Ischemia
With underlying atherosclerosis
Typically involves the origin of SMA.
Spares the collateral branches
Acute Embolic Ischemia
Emboli usually is of cardiac in origin.
Commonly seen in patients with atrial fibrillation or
after MI
Typically lodge the origin of the middle colic artery
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PROGNOSIS
Mortality rate
85%- due to delay with diagnosis
Thrombosis
higher mortality rate than emboli
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Infarction
preceded by sudden and severe abdominal pain and
vomiting
Hypotension
rapid pulse
Watery diarrhea
grossly bloody stools
Diagnostic aid:
Angiography
segmental mesenteric vasospasm w/ normal SMA
Treatment:
Correct the underlying disorder producing the low flow
state
Infusion of vasodilator (Papaverine) thru the catheter
Improvement OBSERVE
No improvement SURGERY
segmental resection with end to end anastomosis
Mortality = 80 %
Colonic Ischemia
Etiology:
chronic obstruction of the inferior mesenteric artery
Causes of obstruction
Atherosclerosis
Cholesterol emboli
Inflammatory arteriopathies
Iatrogenic
Produces symptoms only if collaterals are compromised
Middle colic (from SMA) and ascending limb of left
colic
Superior
hemorrhoidal
and
middle/inferior
hemorrhoidal (branch of internal iliac)
Distribution of blood flow to the colon
originating from the inferior mesenteric artery
branches
left colic
marginal
sigmoid arteries
superior hemorrhoidal
supply the
left colon
superior portion of the rectum
Clinical manifestations:
Descending and sigmoid colon
most commonly affected
Non-specific crampy left lower quadrant mild abdominal
pain
Urge to defecate followed in 24 hours by melena or
hematochezia
Maybe reversible
outcome ranging from complete healing to stricture
formation with obstruction, infarction and perforation
Diagnosis:
Bi-Planar mesenteric angiogram
TREATMENT:
50%- responds to supportive measures
Resection of ischemic segment and temporary colostomy
(Hartmanns )
Mesenteric Venous Occlusion
Etiology:
Thrombosis of the mesenteric venous circulation
Idiopathic-25%
Secondary-75%
80%-jejenum and ileum are involved
Predisposing conditions:
Previous deep vein thrombosis
Intrabdominal infections
Oral contraceptive
Post-operative state
Hypercoagulable disorders
Polycytemia vera
thrombocytosis
Clinical manifestations:
Acute form
TUMORS OF
Mesentery
Tumors of Mesentery
Most are benign
Most are cystic
Benign tumors
more common in female patients
Malignant tumors
more common in males
2/3 are located in the mesentery of the small bowel
mostly in the ileum
Cystic Lesions
Benign Cystic lesions
Chylous or lymphatic cyst:
developmental defects in mesenteric lymphatics
unilocular or multilocular
Traumatic cysts
lined by fibrous tissue
contains body fluid
Enteric cyst:
lined by intestinal mucosa
duplication of the intestinal tract that do not
communicate with the bowel lumen
Dermoid cyst:
cystic lesion of embryonal tissue
Malignant cystic tumors
Lymphangiosarcoma
Malignant teratom
Solid Tumors
Benign
more common
Develop in the periphery near the intestine
Can recur if incompletely excised
Can degenerate to malignant variety
Common Benign tumors
Lipoma
Fibroma
leiomyoma
Malignant solid tumors
Arise near the root of the mesentery
Spread by
local extension
peritoneal implants
COMMON malignant tumors
Liposarcoma
leiomyosarcoma
Clinical manifestations:
Most are asymptomatic
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Mesentery
Nonspecific Mesenteric Lympadenitis
Self-limiting disease
diagnosed only at laparotomy
Most common inflammatory enlargement of the abdominal LN
surpassing T.B.
Usually affects LN at the ileocecal area
due to decrease intestinal transit at this area
MANIFESTATIONS
similar to acute appendicitis
Mesenteric Panniculitis
AKA: Retractile Mesenteritis
Extensive thickening of the mesentery of the small bowel by a
non-specific inflammatory process
Affects male more
M>F
rare in children
Etiology:
Unknown:
could be due to insult of the fatty tissue of the
mesentery
Treatment:
Laparotomy is done to rule out carcinoma or sarcoma
Steroid
radiotherapy
ANEURYSM OF
Splanchnic Arteries
Visceral Artery Aneurysm
Uncommon
Splenic artery
involved in 60%
Hepatic artery
second most common at 20%
May occur spontaneously w/o known cause
Etiology:
Recognized causes are:
Connective tissue disorder
Mycotic Infection
Pancreatitis
Trauma
multiparity
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Pelvic Diaphragm
LATERAL
Trasversalis Fascia
Inner aspects of lateral abdominal muscles
POSTERIOR
Body Wall
Organs
Secondary Retroperitoneal Structures
Portions of duodenum: segment 2
Pancreas
Ascending & descending colon
Primary Retroperitoneal Structures
Kidneys
Renal pelves
Ureters
Adrenal glands
Large nerves
IVC
Aorta
Diagnostics
Physical Examination
Radiologic procedures
Pyelography
Venography
Arteriography
Ultrasonography
CTscan/MRI
TUMORS OF
Retroperitoneum
Splenic artery aneurysm
More common in female
Most are asymptomatic
Some presents as left upper quadrant pain radiating to the
left clavicle
Diagnosis is usually incidental
X-ray of the abdomen
Left upper quadrant ring like calcification
Rate of rupture
Non-pregnant-2%
Pregnant-90%
Treatment:
Observation
Resection or ligation w/ or w/o splenectomy
Indications for surgical intervention
Presence of symptoms
Pregnancy
Intention to become pregnant
>2cm size of the aneurysm
Other aneurysms
Surgical correction
high incidence of spontaneous rupture
Celiac artery
excision without reconstruction
Hepatic and SMA
excision with reconstruction with autogenous
venous graft
RETROPERITONEUM
ANATOMY & PHYSIOLOGY OF
Retroperitoneum
Retroperitoneum
Anatomy
Boundaries
SUPERIOR
Diaphragm
ANTERIOR
Posterior Parietal Peritoneum
INFERIOR
Treatment:
Surgical
1/3 Inoperable (Distant Metastasis)
Operable Cases (Biopsy Frozen Section)
Malignant
wide excision
transperitoneal approach
Benign
complete resection
recur liposarcomtous change
OUTCOME
< 25 % can be completely resected with
anticipated cure
10 25 % operative mortality
30 50 % recurrence rate
Tumors become more malignant with each
recurrence
re-operation becomes more hazardous
Long term survival reported after multiple
resection
Irradiation
Palliative
rarely curative
affords relief of pain and obstruction
Indications:
Inoperative tumors
Tumor recurrence following previous resection
Radiosensitive tumors
Lymphoma
Adjunct to surgery
Neuroblastoma
Liposarcoma
Rhabdomyosarcoma
Undifferentiated Anaplastic Sacrcoma
Radiotherapy and/or Chemotherapy
treatment of choice for malignant lymphomas
Overall prognosis: POOR
5 Year survival- less than 10%
Chemotherapy (Lymphoma)
FIBROSIS OF
Retroperitoneum
Retroperitoneal Fibrosis
Non-specific non-suppurative inflammation of the fibroadipose
tissue
More common in MALES
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2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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d. None
17. Most common malignant retroperitoneal tumors
a. Sarcoma
b. squamous cell CA
c. Adeno CA
d. Lymphoma
18. Benign retroperitoneal tumors
a. Mesenchal tyhoma
b. Sinouoma
c. Cyst of Urogential origin
d. Lipoma
19. True of omentum
a. double sheet of flattened endothelium
b. police officer of the abdomen
c. both of the above
d. none of the above
20. Predisposing factor of primary or idiopathic omental torsion:
a. heavy exertion
b. anatomic variations
c. hyperperistalsis with overeating
d. coughing and straining
21. Most common tumor of omentum:
a. Leiomyosarcoma
b. metastatic carcinoma
c. hemangiopericytoma
d. None
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