and Edgar D. Guzman-Arrieta3
(1)
Department of Surgery Advocate Illinois Masonic Medical Center, University of Illinois Metropolitan Group Hospitals Residency in General Surgery, Chicago, IL, USA
(2)
University of Illinois at Chicago, Chicago, IL, USA
(3)
Vascular Specialists – Hattiesburg Clinic, Hattiesburg, MS, USA
Keywords
RetroperitoneumAortaInferior vena cavaMesenteric vesselsRetroperitoneal exposures1.
All of the following are correct except:
(a)
The retroperitoneum is bound by the peritoneum and the posterior body wall.
(b)
The retroperitoneum is continuous with the preperitoneal space.
(c)
Retroperitoneal pathology may extend into the thigh and inguinal area.
(d)
The retroperitoneal space extends anteriorly between the leaves of the mesentery.
(e)
The retroperitoneal space does not extend above the diaphragm.
Comments
The retroperitoneum is a space containing the kidneys, adrenals, great and gonadal vessels, lymphatics, pancreas, duodenum, ascending and descending colon, and varying amounts of areolar and fatty tissue. While its boundaries are didactically demarcated, this space is in reality continuous with the preperitoneal space. This determines that abscesses, hematomas, and tumors originating in the retroperitoneum may extend away from it along the body wall. Conversely, the retroperitoneal space may be entered through a flank approach to expose the anterior aspect of the vertebra, kidneys, and great vessels. The major advantage of this surgical exposure is that one stays extraperitoneal, decreasing the incidence of postoperative ileus.
The psoas muscle (filet mignon) traverses the entire retroperitoneum from T12 to L5, inserting below the inguinal ligament into the lesser trochanter of the femur, thus creating a route for the spread of infection. Abscesses of the psoas muscle can then present in the medial thigh as well as in the inguinal area [1–3]. Lastly, there is a communication towards the posterior mediastinum, which may become apparent in the case of pancreatic pseudocysts [4]. It is interesting to note that all the mesenteric vessels extend from the aorta towards the bowel between the leaves of the mesentery, which anatomically demarcate an extension of the retroperitoneum.
Answer
e
2.
Mark the correct answer.
(a)
The SMA leaves the retroperitoneum at the lower edge of the pancreas.
(b)
The left spermatic artery arises from the left renal artery.
(c)
The right spermatic vein drains into the right renal vein.
(d)
The renal pelvis lies anterior to the renal vasculature.
(e)
The renal artery is anterior to the renal vein.
Comments
The disposition of the spermatic vessels, renal vessels, and collecting system is often a source of confusion. Their position can be easily remembered when one considers the location of the vena cava and aorta in relation to the posterior midline. Since the vena cava lies slightly anterior and to the right of the midline, this will determine that the right renal vein will follow a short course to the kidney, while the left renal vein will cross the midline and continue anterior to the aorta to reach the left kidney. The reverse holds true for the aorta and renal arteries (i.e., long right renal artery and short left renal artery). As the left renal vein crosses in front of the aorta, it comes in relation to the superior mesenteric artery, which courses along its superior and anterior aspects.
Since the spermatic veins do not cross the midline, the right spermatic vein drains into the vena cava, whereas the left spermatic vein drains into the left renal vein. Both spermatic arteries arise directly from the aorta [5].
Finally, the collecting structures of the kidney as well as the ureters take a dorsal position in relation to the above-described vascular structures.
Answer
a
3.
All of the following are correct except:
(a)
Meralgia paresthetica may be a key clinical manifestation of a retroperitoneal tumor.
(b)
The femoral nerve can be injured in the wide excision of locally advanced colon cancer.
(c)
The psoas muscle is unique in that it is enclosed in a stocking-like fascial sheath.
(d)
The ureter, gonadal vessels, and genitofemoral nerve overlie the psoas in the medial to lateral direction.
(e)
The lumbar plexus lies in the substance of the quadratus lumborum.
Comments
The lumbar plexus (T12–L4) and the associated sympathetic ganglia are in close relation to the psoas muscle, with fibers passing within its substance or closely behind it. The lumbar plexus innervates the infraumbilical body wall as well as the upper thigh. In the retroperitoneum, four branches of the lumbar plexus are particularly vulnerable to retroperitoneal tumors as well as to surgical injury: the lateral femoral cutaneous nerve, the genitofemoral nerve, the femoral nerve, and the obturator nerve. Retroperitoneal tumors may grow to large sizes as they displace the peritoneal contents anteriorly and laterally.
The lateral femoral cutaneous nerve is responsible for meralgia paresthetica (numbness and paresthesias of the lateral thigh). This nerve is frequently compressed at the level of the superior anterior iliac spine by tight or heavy belts as well as by redundant adipose tissue. In the absence of these sources of compression, retroperitoneal pathology must be suspected [6, 7]. While the genitofemoral nerve is most often injured during inguinal surgery, it is also prone to injury during surgery for retroperitoneal neoplasms, as it follows a long course along the anterior surface of the psoas muscle, laterally to the ureters and in immediate relation to the gonadal vessels (Fig. 10.1).
Fig. 10.1
Meralgia (thigh pain in Greek) paresthetica refers to the pain and paresthesia on the anterolateral aspect of the thigh as shown in the dotted area above. This condition is typically secondary to chronic injury to the lateral cutaneous nerve of the thigh near the anterior superior iliac spine. However, the presence of meralgia paresthetica should always raise suspicion for a retroperitoneal neoplasm as the lateral cutaneous nerve (L2, L3 with often contribution from L1) runs the entire length of the retroperitoneum. T retroperitoneum neoplasm, LC lateral cutaneous nerve of the thigh, S sartorius muscle, ASIS ant. sup. iliac spine
The femoral nerve may be injured as it becomes lateral to the psoas muscle. This may occur in the setting of cecal or sigmoid colon carcinoma, extending into the retroperitoneum, as well as extensive primary retroperitoneal tumors. When damaged, extension of the knee will be compromised.
While the obturator nerve lies in a more protected position along the lateral pelvic wall, it is important to consider that it is responsible for the adduction of the thigh. Compression to it may also manifest as paresthesias to the inner thigh (Howship–Romberg sign).
The psoas muscle arises from the transverse processes and bodies of T12 to L5 and inserts in the lesser trochanter of the femur, acting as a hip flexor and internal rotator. The psoas sheath circumferentially envelops the psoas muscle. When affected by infection, it may harbor abscesses that extend into the thigh, lateral to the femoral vessels. Worldwide, the most common etiology of psoas abscesses continues to be tuberculosis. In the United States, staphylococcal and E. coli infections are the most common causes.
Answer
e
4.
Select the correct statement.
(a)
Retroperitoneal sarcomas are a nonsurgical disease.
(b)
The Mattox maneuver includes the kocherization of the duodenum.
(c)
The Cattell maneuver is carried out from the left of the patient towards the right.
(d)
The spleen and pancreas are mobilized en bloc for retroperitoneal exposure to the suprarenal aorta.
(e)
The retroperitoneum can be fully exposed by a unilateral approach.
Comments
Exposure of retroperitoneal structures is classically obtained by two maneuvers. The Cattell maneuver exposes the right retroperitoneum through a combination of mobilization of the right colon by incising the white line of Toldt and kocherization of the duodenum and pancreas (Fig. 10.2a–c).
Fig. 10.2
(a) The goal of the Cattell–Braasch maneuver is to gain quick access to the right retroperitoneal space, including the inferior vena cava and the aorta. In the first step, an incision is made along the avascular white line (Toldt line), which is the embryological plane of fusion between the right colon and the retroperitoneum in the right paracolic gutter. This incision is extended along the lateral wall of the terminal ileum. The appropriate axis of mobilization is along the superior mesenteric artery, which is supplying the entire midgut with a plan to lift it anteriorly and fold it on itself towards the left upper quadrant of the abdomen (b) As the right colon, hepatic flexure, and small bowel are being mobilized to the left upper quadrant, one must be very cautious in the area of the uncus of the pancreas. Multiple arteries and veins to the rt. hemicolon as well as inferior pancreaticoduodenal vessels connect to the superior mesenteric vessels. Specifically, the superior mesenteric vein (SMV) is vulnerable in this exposure. Avulsion injuries from the superior mesenteric vein can cause brisk bleeding as it is a high-pressure vein. During this step, the duodenum is completely kocherized to gain additional exposure (c) Mobilization of the duodenum and pancreas is carried past the inferior vena cava to the aorta. This is the last step in the Cattell–Braasch maneuver to complete the exposure of the retropancreatic inferior vena cava and aorta from the right side. This exposure is critical in traumatic injuries to this area as well as in the elective exposure of large adrenal, renal, and pancreatic neoplasms. The major limiting factor for adequate supracolic exposure in this area is the presence of the liver, especially when it is enlarged and/or firm and fibrotic. In the latter case, hepatic mobilization or an additional transthoracic exposure may be required
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