ABDOMINAL WALL, OMENTUM, MESENTERY, & RETROPERITONEUM
ANTERIOR ABDOMINAL WALL 2. Idiopathic Segmental Infarction
1. Rectus Sheath Hematoma
Produces a surgical picture that may simulate the acute surgical
abdomen.
Bleeding is usually the result of rupture of the epigastric artery
or veins secondary to trauma or occur spontaneously in patients
with debilitating diseases or blood dyscrasia and in patients on
anticoagulation therapy.
Bleeding also occurs without obvious trauma or disease after
minor straining.
Clinical Manifestations
Sudden onset of pain is localized to the side of the abdomen
where the bleeding occurred.
A tender mass may be palpable.
Ultrasonography or CT shows complex lesions w/in the rectus sheath.
Treatment
Managed non-operatively with bed rest and analgesics
Surgical intervention for hematoma is evacuation
Bleeding points are then ligated & the wound closed w/o drainage
2. Desmoid Tumor
An aggressive variant w/in a grp of conditions referred to as
Fibromatoses
Desmoids tumor is of aponeurotic origin & is found w/in or deep
to the flat muscles of the anterior abdominal wall
It is seen in women of childbearing age, after a recent gestation,
and it may be the result of hemorrhage.
Tumors are locally invasive benign tumors that rarely undergo
malignant transformation to a low-grade fibrosarcoma.
Metastases have not been reported.
Tends to recur after local excision
Clinical Manifestations
Usually painless, deeply situated mass that is solitary, rarely
crosses the midline, and may be fixed.
It may vary in size from a few cm to a tumor weighing several kg.
Treatment
Diagnosis is established by biopsy
Tx is wide excision with at least a 1-2-cm margin of normal tissue.
Radiation therapy-unresectable or with gross disease left at the
margins, is recommended.
Recurrences can be treated by reexcision.
For abdominal wall desmoids, prognosis is excellent.
Prognosis for extraabdominal desmoids is less favorable
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OMENTUM
1. Torsion
A twist on the long axis of the omentum to an extent causing
vascular compromise
Primary omental torsion is relatively rare
Secondary omental torsion is associated w/ adhesions of the
free end of the omentum to tumors, foci or intraabdominal
inflammation, prostoperative wounds, or internal or eternal hernias.
Secondary tosion is more common than primary.
Clinical Manifestations
Pain begins suddenly and is usually localized to the RLQ.
Tenderness, rebound tenderness, & voluntary spasm are frequent
The finding of free serosan-guineous fluid at the time of
celiotomy in the absence of a pathologic condition in the
appendix, gallbladder, or pelvic organs should alert the surgeon
to the possibility of omental torsion.
Treatment
Resection of the involved omentum with correction of any
underlying etiologic condition.
An acute vascular disturbance of the omentum not accompanied
by omental torsion or an intraabdominal pathologic condition.
It is precipitated by thrombosis of ometnal veins.
Clinical Manifestations and Treatment
Most patients are young or middle-aged adults who present
with right-sided abdominal pain.
Always w/ tenderness & rebound tenderness over the region of the
infarction
Resection of the infracted area is indicated to prevent the
possible complications of gangrene and adhesions
3. Cysts
True omental cysts: have an endothelial lining similar to cystic
lymphangiomas.
Dermoid cysts: are lined with squamous epithelium and may
contain hair, teeth, and sebaceous material.
Pseudocysts of the omentum probably result from trauma with
hematoma formation.
Clinical Manifestations
Large cysts present as a palpable abdominal mass or with
manifestations of torsion, infection, rupture, or intestinal
obstruction.
Ultrasound or CT shows a fluid-filled mass that often contains
internal septations.
Treatment
Consists of local excision
4. Solid Tumors
Most common solid tumor of the omentum is metastatic
carcinoma, w/c involves the omentum by tumor implant
Primary solid tumors of the omentum are rare.
Most are tumors of smooth muscle, & about 1/3 are malignant.
Excision is indicated.
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MESENTERY
1. Acute Occlusion of the Superior mesenteric Artery
Often due to an embolus than to thrombosis
Most emboli come from the heart and more often lodge at the
egress of the middle colic artery.
Sudden occlusion of the superior mesenteric artery produces
ischemia of the entire small intestine distal to the ligament of
Treitz and also ischemia of the proimal half of the colon.
The extent o intestinal ischemia or infarction depends on the
site of the thrombosis and the status of collateral channels..
Clinical Manifestations:
Clinical features are the same whether occlusion is the result of
embolism or thrombosis.
Males are affected more often than females.
th th
Peak age of incidence is the 5 and 6 decades.
The most striking and constant complaint is sudden extreme
abdominal pain initially out of proportion to the physical findings.
Tenderness and rebound tenderness become severe as
intestinal infraction occurs.
As infarction of the intestine progresses, patient becomes
febrile, pulse rate increases, & the patient becomes hypotensive.
Once bowel necrosis and perforation occur, the findings are
those of generalized peritonitis and sepsis.
Treatment:
Some patients can be treated successfully by arterial infusion of
a vasodilating agent.
Early surgical intervention before gangrene and perforation of
the intestine have occurred is optimal
The relatively short segments of affected intestine are best
handled by resection with a primary anastomosis.
 As much as 70% of the small intestine can be removed without
creating serious digestive disturbances.
Embolus usually can be extracted using a Fogarty catheter.
Thrombus w/in a sclerotic vessel will require a
thromboendartererctomy.
2. Nonocclusive Mesenteric Infarction
Pathology: outer surface of the bowel is initially mottled, with
segmental areas of cyanosis distributed throughout the length
of the intestine. Later, gangrenous changes become advanced
and lead to perforation.
Clinical Manifestations
The clinical picture may be identical to that of patients with
acute arterial or venous mesenteric occlusions.
Treatment
An attempt should be made to improve mesen-teric artery flow.
Direct infusion of a vasodilating drug, such as papaverine
hydrochloride, into a catheter positioned in the superior
mesenteric artery is used to improve mesenteric arterial flow.
Antibiotics should be administered.
If abdominal signs & symptoms persist, operation is mandatory.
Primary resection with anastomosis should be attempted.
3. Chronic Occlusion of the Superior Mesenteric Artery (Intestinal Angina)
Intestinal ischemia, intestinal angina, without infarction is due
to collateral blood supply sufficient for life but not for function
of the affected bowel. This is analogous to angina pectoris and
intermittent claudication.
Clinical Manifestations
The dominant feature of intestinal angina is generalized
cramping abdominal pain that comes on soon after eating.
The food-pain relationship soon leads to a reluctance on the part
of the patient to eat.
Treatment
Most surgeons prefer improving the circulation w/ a bypass graft
4. Colonic Ischemia
Etiology: occurs in elderly patients w/ underlying atherosclerotic
stenoses or inflammatory arteriopathies.
The ischemia most often involves the descending & sigmoid colon.
Clinical Manifestations
Sudden cramping lower abdominal pain & the urge to defecate
followed in 1224 h by passage of melena or bloody stool.
Treatment
The condition is reversible in 4050 percent of patients requiring
only supportive measures, with results ranging from complete
healing to stricture formation.
When frank transmural necrosis is seen on initial sigmoidoscopy
(serially), or when symptoms and endoscopic findings are
progressive, early operation is indicated.
Resection of all ischemic colon with end-colostomy and mucous
fistula or Hartmans procedure.
5. Mesenteric Venous Occlusion
Etiology & Pathology: visceral venous occlusion producing
symptoms is almost always due to acute thrombosis.
About 50 percent of patients give a history of prior episodes of
peripheral deep venous thrombosis.
Clinical Manifestation
patient complains of vague abdominal discomfort, anorexia, & a
change in bowel habits a few days or even weeks before the
onset of severe symptoms followed by sudden severe abdominal
pain, vomiting, and circulatory collapse.
Bloody diarrhea is more frequent than with arterial occlusion.
Treatment
w/o operation, the mortality approaches 100%.
Once diagnosed, heparin anticoagulation should be started
immediately.
Patients with peritoneal sign should undergo early operation
soon after receiving supportive fluids and antibiotics.
The prognosis is somewhat better than in mesenteric infarction
due to arterial occlusion.
6. Aneurysms of the Splanchnic Arteries
Aneurysms of the splanchnic arteries are rare.
Etiology: Arteriosclerosis is the usual etiology in older patients;
congenital or acquired defects in the medial wall of
the artery are more often incriminated in the young.
Splenic artery aneurysms compromise about 60%.
Most occur in women, and in about 40% of patients the
aneurysms are multiple.
Hepatic artery aneurysms make up 1620%.
Aneurysms of the celiac artery and the superior mesenteric
artery and its branches each account for about 3%.
Clinical Manifestations
Before rupture, most splanchnic artery aneurysms are asymptomatic.
When rupture occurs, the major symptom is acute abdominal
pain and signs of acute blood loss.
Treatment
A conservative approach is justified for the asymptomatic
patient with a small splenic artery aneurysm.
There is a hazard of rupture during pregnancy, notably during
the third trimester.
Operation is indicated for women of childbearing age.
The preferred treatment is proximal and distal ligation of the
aneurysm with obliteration of all feeding vessels in order to
avoid splenectomy.
If this is not feasible, resection of the aneurysm & splenectomy
will be necessary.
7. Nonspecific Mesenteric Lymphadenitis
Is one of the common causes of acute abdominal pain in young children.
The lymph nodes primarily involved are those which drain the
ileocecal region.
Clinical Manifestations
Most commonly occurs in patients under age 18, w/o sex predilection.
Initial pain is usually in the upper abdomen. Eventually the pain
localizes to the right side; however, an important point in
differentiating the disease from acute appendicitis is that the patient
is unable to indicate the exact site of the most intense pain.
The usual finding on examination of the abdomen is tenderness
in the lower aspect of the right side, w/c is somewhat higher &
more medial & considerably less severe than in acute appendicitis.
8. Mesenteric Panniculitis
process of extensive thickening of the mesentery by a
nonspecific inflammatory process.
Many consider it a variant of retroperitoneal fibrosis.
Etiology: is unknown. Usually it involves the mesenteric root of
the small bowel.
Clinical Manifestations
Men are affected more often than women.
Rarely described in children.
The clinical features are nonspecific; they include recurrent episodes of
moderate to severe abdominal pain, nausea, vomiting, and malaise.
Treatment
Laparotomy is necessary to establish the diagnosis & to rule out
other tumefactions of the abdomen.
Since neoplasms of the mesenteric lymph nodes may present a
similar gross appearance, several biopsies from different sites
should be obtained.
The inflammatory process is self-limiting and seldom causes any
serious complications.
9. Tumors of the Mesentery
Primary tumors are quite rare.
In contrast, malignant implants from intraabdominal or pelvic tumors or
metastases to mesenteric lymph nodes are relatively common.
Pathology: Primary tumors of the mesentery may be cystic or solid.
A classification of these tumors is shown in the table below.
below
Most cystic mesenteric tumors are benign.
Benign solid tumors of the mesentery are more common than
malignant ones.
Solid malignant tumors arise near the roott of the mesentery;
solid benign tumors have a greater tendency to develop
peripherally near the intestine.
Clinical Manifestations
In most patients, symptoms are few or nonexistent, and the
tumor is detected during routine examination.
Imaging techniques es are the most useful means for diagnosing
both cystic and solid mesenteric tumors.
Treatment
Surgical excision is the only treatment for benign & malignant lesions.
All mesenteric cysts of a size sufficient to be palpated should be
removed if at all possible, since even benign lesions eventually
cause pain and compression of neighboring structures.
Wide excision,, together with resection of adjacent intestine, is
recommended for benign solid tumors, since these have a
tendency toward local recurrence and malignant degeneration.
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RETROPERITONEUM
1. Idiopathic Retroperitoneal Fibrosis
A nonspecific, nonsuppurative inflammation of fibroadipose
tissue that produces symptoms by the gradual compression of
the tubular structures in the retroperitoneal space.
The disease represents one of the manifestations of a
widespread entity termed systemic idiopathic fibrosis. fibrosis
Clinical Manifestations
natural history of the disease has been divided into 3 periods:
(1) the period of incidence and development
(2) the period of activity, i.e., spread of the cellular and
fibrotic process to envelopment of the
retroperitoneal structures
(3)) the period of contraction of the fibrotic mass with
compression of the involved structures.
The disease is apparently self-limiting limiting once the fibrotic stage is
reached, a factor of major importance in considering types of
therapy.
st
1 complaint: invariably ably dull, noncolicky pain; usually originates
in the flank or low back & often radiates to the lower abdomen,
groin, genitalia, or anteromedial aspect of the thigh; thigh unilateral at
st
1 but may become bilateral later, as the fibrotic process spreads.
Moderate fever and leukocytosis are often present early; the
erythrocyte sedimentation rate is elevated.
A triad that is highly suggestive of retroperitone
retroperitoneal fibrosis on the
pyelogram is:
(1) hydronephrosis with a dilated, tortuous upper ureter
(2) medial deviation of the ureter
(3) extrinsic ureteral compression
Treatment
Some patients improve with supportive measures.
With the onset of urinary infection or depression of renal
function, surgical intervention usually becomes necessary.
Steroid-induced regression
ression of the inflammatory edema may
reestablish urinary patency and thus facilitate elective, rather
than emergency, surgery.
Ureterolysis with intraperitoneal transplantation
transplantation: currently the
most effective means of relieving obstruction of the involved u
ureter.
2. Retroperitoneal Tumors
Lymphomas, retroperitoneal
etroperitoneal liposarcomas & leiomyosarcomas
are the most common nonvisceral malignant tumors of the
retroperitoneum.
The majority occur in the fifth or sixth decade, with a peak
incidence at about age 60
The tumors may be solid, cystic, or a combination of both.
Their color varies from white (fibroma), yellow (lipoma), or
pinkish to red (sarcoma) depen
depending on the predominant tissue.
As a rule, the predominantly cystic tumors are benign; solid
tumors are usually
sually malignant.
Clinical Manifestations
The tumor may attain large size before producing symptoms.
As the tumor grows, it compresses, obstructs, or invades
adjacent organs or structures so that the presenting symptoms
are often referable to these organ
organs.
The initial manifestations include an enlarging abdomen,
backache, a sense of fullness or heaviness, and vague, indefinite
pain that later may become more severe and radicular.
Pain radiating into one or both thighs is usually late and due to
involvement of lumbar and sacral nerve routes; it invariably
denotes a malignant tumor.
The predominant physical finding is an abdominal mass.
Treatment
Some retroperitoneal tumors are benign and can be cured by
simple excision; some are histologically b benign but clinically
malignant; others grow slowly and tend to recur and invade
locally; and still others are rapidly malignant from the start.
Treatment of these growths consists of surgical or irradiation
therapy or a combination of the two. With the exc exception of
lymphomas, chemotherapy has only limited therapeutic
application.
Surgical treatment is most effective and offers the greatest
prospect for cure.
Histologic grade is the most important factor in determining
prognosis.
For a malignant tumor, the initial operation offers the best
chance of cure.