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13 Abdomen: Surgical Anatomy andGeneral Consideration inEmergency Settings
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if the pain persists beyond 8–12h. Such instructions are targeted at ensuring the
return of a patient who has progressed from an early appendicitis or small bowel
obstruction, the two most common surgical entities erroneously discharged
from an ED.
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13.3 Some Useful Considerations inEmergency Setting
13.3.1 Timing ofSurgery
Emergency surgery is required for many patients suffering from trauma, acute (surgical) disease process, or surgical complications. However, not all emergencies are
equal. Some need surgery as soon as possible, for example, patients with major
intra-abdominal hemorrhage or vascular compromise associated with bowel ischemia. Patients with generalized peritonitis might benet from a short period for
stabilizing the physiology as long as antimicrobial treatment is promptly started,
and the delay does not exceed a couple of hours. The acceptable delay for patients
where prolonged delay might lead to generalized peritonitis and poorer outcome
(acute appendicitis) or more invasive surgical treatment and prolonged hospital stay
(acute cholecystitis), respectively, is more controversial, and the trends seem to go
in opposing directions. Nonoperative management with antibiotic treatment for
acute uncomplicated appendicitis is gaining more favor, whereas early (laparoscopic) cholecystectomy for acute cholecystitis or even symptomatic cholelithiasis
is supported by several recent studies. Most surgeons would agree that patients with
non-strangulated small bowel obstructions or infected pancreatic necrosis (unless in
septic shock) do not need to be operated on in the middle of the night, and the same
is true for many other abdominal emergencies. Finally, there are many nonelective
procedures that are performed by emergency surgery teams that are not true emergencies such as changing dressings in open abdomen patients or performing tracheostomies for patients from intensive care or acute neurology units. Prioritizing
emergency operations by urgency and using some form of categorization into different groups is becoming more common. The so-called trafc light color coding system has been used at the Helsinki University hospital for a decade. It consists of
three categories coded red (surgery as soon as possible), orange (surgery within
24h), and yellow (surgery within 48h). Only patients with red code are operated on
at nighttime. The majority of emergency surgery is performed during the daytime
(three designated operation tables for emergency surgery) or during the evening
shift ending at 22.00h. Several studies show that in most patients with a surgical
emergency, an operation performed as soon as possible is benecial from a medical
point of view, as it reduces complications and length of hospital stay. It saves hospital resources (every day spent waiting in a surgical ward for an emergency operation
is a wasted day), and patients appreciate not having to wait for surgery longer than
necessary. However, nighttime surgery is expensive and might not be as safe as
surgery performed during regular hours. The solution to the dilemma could include
the following components at least. Emergency surgery should be seen as an equal to
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S. Molno et al.
elective surgery, thereby guaranteeing sufcient daytime operating room capacity,
and should probably be separated to an independent “production line” not affected
by unexpected delays in elective procedures requiring substitute personnel from the
emergency surgery teams. Accumulation of patients waiting for emergency surgery
should be minimized by a exible system that permits adjustments to the inevitable
day-to-day variation in patient numbers [4].
13.3.2 Role ofLaparoscopy inEmergency Setting
Abdominal emergencies can also be operated on through the laparoscopic approach:
the approach can be diagnostic laparoscopy, surgery assisted by laparoscopy or
laparotomy directed according to the ndings of the laparoscopy. The general contraindications refer above all to the state of haemodynamic instability of the patient
and to seriously ill patients (ASA IV). In the absence of any specic counterindications for the specic laparoscopic procedure to be carried out, many abdominal diseases requiring emergency surgery can be performed with the laparoscopic
approach. The most frequent indications are appendicitis, acute cholecystitis, gastroduodenal perforation, occlusion of the small intestine, and some abdominal traumas. With a correct selection of patients and the appropriate experience of the
surgeon, the results are excellent and better than open surgery (less infection of the
wound, complications, hospital stay, and postoperative pain). A detailed explanation is given of the basic aspects of the surgical technique in the most frequent
procedures of emergency laparoscopy [5].
13.3.3 Final Consideration
Patients undergoing emergency abdominal surgery managed by high volume surgeons have better survival outcomes. These ndings contribute to the ongoing discussion regarding conguration of emergency surgery services and emphasize the
need for effective clinical governance regarding observed variation in outcomes
within and between institutions [6].
References
1. Henry Gray’s Anatomy of the Human Body. ISBN:8821431320.
2. Abbott J.Pelvic pain: lessons from anatomy and physiology. J Emerg Med. 1990;8:441–7.
3. Silen W.Cope’s early diagnosis of the acute abdomen. In: Principles of diagnosis in acute
abdominal disease. NewYork: Oxford; 2010. p.3–17.
4. Leppäniemi A.What is acceptable delay in emergency abdominal surgery? Scand J Surg.
2013;102:54.
5. The role of laparoscopy in emergency abdominal surgery. ISBN 978-88-470-2326-0 e-ISBN
978-88-470-2327-7. https://doi.org/10.1007/978- 88- 470- 2327- 7. NewYork: Springer.
6. Nally DM, Sørensen J, Valentelyte G, etal. Volume and in-hospital mortality after emergency
abdominal surgery: a national populationbased study. BMJ Open. 2019;9:e032183. https://doi.
org/10.1136/bmjopen- 2019- 032183.
Acute Abdominal Aorta andVisceral
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Vessel Disease
DavideEsposito andElenaGiacomelli
14.1 Introduction
Data from the National Hospital Ambulatory Medical Care Survey of 2006
(NHAMCS) reports that abdominal pain is the most common specic principal reason given by adult patients for visiting the Emergency Department after chest
pain [1].
The evaluation of a patient presenting at the emergency department with acute
abdominal aorta or visceral vessel disease is very often difcult since the clinical
diagnosis is made elusive by the non-specicity of the symptoms, such as abdominal pain, back pain, or hypo/hypertension.
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14.2 Acute Abdominal Aorta
Acute disorders of the abdominal aorta include a range of conditions which could
be potentially lethal and require prompt recognition and management. In this scenario, imaging plays a crucial role in rendering it possible to make a precise diagnosis. Computed tomography (CT) represents the rst-line imaging approach, with
magnetic resonance imaging (MRI) as an alternative method for stable patients who
have a contraindication to iodinated contrast [2].
Acute abdominal aortic syndrome comprises unstable or ruptured aneurysm,
penetrating atherosclerotic ulcer, intramural hematoma (IMH) and dissection, but
also more unusual conditions such as inammation, infection, traumatic injury,
D. Esposito · E. Giacomelli (*)
Department of Vascular and Endovascular Surgery, Careggi University Hospital of Florence,
Florence, Italy
e-mail: davide.esposito@uni.it
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
D. Bissacco et al. (eds.), Primary Management in General, Vascular and
Thoracic Surgery, https://doi.org/10.1007/978-3-031-12563-8_14
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D. Esposito and E. Giacomelli
stulization, and occlusion of the abdominal aorta, all of which could likely be catastrophic if misdiagnosed.
14.2.1 Abdominal Aortic Aneurysm
An aneurysm is dened as a dilation, more or less circumscribed, of the caliber of
an artery [3]. The current denition of abdominal aortic aneurysm (AAA) is based
on the measurement of the diameter of the abdominal aorta: an aneurysm is considered a diameter greater than or equal to 3cm [4]. The prevalence of AAA increases
with age and is most common in men [5]. The segment of aorta most commonly
involved is the infrarenal.
The most threatening complication of an AAA is rupture, with mortality rates
ranging from 70% to 94% [6]. The risk of aneurysm rupture increases with AAA
diameter, aneurysm expansion rate, smoking, and uncontrolled hypertension [7].
Rupture usually presents with a classic clinical manifestation consisting of pain
(abdominal, back or ank), hypotension, and a pulsatile mass.
The suspicion of an aneurysm rupture must be investigated using CT imaging.
The primary imaging ndings of AAA rupture include a retroperitoneal hematoma
extending directly from the aneurysm and active extravasation of contrast material
(Fig.14.1a). In case of impending or contained rupture, the ndings may be much
more subtle, including perianeurysmal soft tissue stranding.
ab
cd
Fig. 14.1 CT images of ruptured abdominal aortic aneurysm (a), penetrating atherosclerotic ulcer
(b), intramural hematoma (c), aortic dissection (d)
14 Acute Abdominal Aorta andVisceral Vessel Disease
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Treatment of an acute or impending rupture can be both endovascular aneurysm
repair (EVAR) and open surgery.
BOX Signs of acute or impending rupture of aneurysms of the abdominal aorta:
Clinical: pain (abdominal, back or ank), hypotension, pulsatile mass.
Diagnostic: retroperitoneal hematoma, active contrast extravasation, perianeu-
rysmal stranding.
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14.2.2 Penetrating Atherosclerotic Ulcer
The term penetrating atherosclerotic ulcer (PAU) describes an ulcerating atherosclerotic lesion that penetrates the intima and progresses through the internal elastic
lamina into the media [8]. It is most common in older patients and results from
preexisting atherosclerotic disease most frequently in the middle and distal thirds of
the thoracic aorta. Typically, patients present with acute intense chest pain, often
described as tearing, ripping, migrating, or pulsating [9].
PAU may resolve spontaneously, but can progress to an enlarging IMH, dissection, subadventitial pseudoaneurysm, or rupture.
On imaging, PAU presents as a focal outpouching of the aortic lumen with associated hematoma in the aortic media (Fig.14.1b).
If the pathology involves the ascending aorta, early/urgent or emergent surgical
intervention is recommended [10]; when it involves the descending aorta, if asymptomatic, aggressive (antihypertensive) medical therapy in combination with close
clinical and radiographic follow-up is recommended [11], if symptomatic or with
signs of progression, endovascular stent-grafting (TEVAR) should be the treatment
of choice [10].
BOX Signs of penetrating atherosclerotic ulcer:
Clinical: acute intense chest pain, described as tearing, ripping, migrating, or
pulsating.
Diagnostic: focal outpouching of the aortic lumen with associated hematoma in
the aortic media.
14.2.3 Intramural Hematoma
IMH is caused by spontaneous rupture of the vasa vasorum into the aortic media
with resultant weakening of the aortic wall. Other theories describing the pathogenesis include thrombosis of a dissection lumen, microscopic intimal tears, progression from a PAU, and traumatic medial injury [8]. Clinical features of IMH are chest
pain radiating to the back and hypertension.
On CT and MR imaging, IMH appears as an eccentric, crescent-shaped collection of blood in the aortic wall (Fig.14.1c).
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If an IMH involves the ascending aorta, surgical treatment is offered to prevent
rupture and progression to classic aortic dissection. Conservative management is
indicated for an IMH of the descending aorta.
BOX Signs of intramural hematoma:
Clinical: chest pain radiating to the back and hypertension.
Diagnostic: eccentric, crescent-shaped collection of blood in the aortic wall.
D. Esposito and E. Giacomelli
14.2.4 Aortic Dissection
Aortic dissection occurs when blood enters the medial layer of the aortic wall
through a tear or penetrating ulcer in the intima and tracks longitudinally along with
the media, forming a second blood-lled channel (false lumen) within the vessel wall.
The most common risk factor for aortic dissection is uncontrolled hypertension,
even if there are other characteristic conditions associated with its development
such as Marfan syndrome, bicuspid aortopathy, vasculitis, cocaine use, and pregnancy [12].
Clinical manifestations depend on the location of the dissection: when occurring
proximally in the abdominal aorta, it may involve the mesenteric and/or renal arteries, leading in some cases to end-organ ischemia and causing affected patients to
present with abdominal and/or ank pain; when distally, it may occlude the iliac
and/or femoral arteries, leading to lower extremity ischemia; patients could also
present with paraplegia if the artery of Adamkiewicz is involved.
Abdominal aortic dissection appears on imaging studies as an intimal ap dividing the aorta into true and false lumens. The true lumen typically is smaller than the
false lumen, is surrounded by calcications when present, and enhances more rapidly than the false lumen (Fig.14.1d).
Treatment options include aggressive blood pressure control with beta-blockers
as they reduce both blood pressure and also heart rate, or immediate surgical repair
depending on the extension of the pathology.
BOX Signs of aortic dissection:
Clinical: if mesenteric and/or renal arteries involved, patients could present with
abdominal and/or ank pain; if iliac and/or femoral arteries involved, lower
extremity ischemia.
Diagnostic: intimal ap dividing the aorta into true and false lumens.
14.3 Abdominal Visceral Vessel Disease
Abdominal visceral vessel diseases are time-sensitive conditions which put perfusion of critical organs at risk, leading to the potential for ischemia, infarction, and
translocation of enteric microbes, bacteremia, and sepsis.
14 Acute Abdominal Aorta andVisceral Vessel Disease
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In visceral artery conditions, blood ow through these arteries becomes reduced
or blocked. Most often, the narrowing or blockage is caused by thrombosis; more
rarely, visceral artery disease involves aneurysms formation or is secondary to
abdominal traumas.
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14.3.1 Mesenteric Ischemia
Mesenteric ischemia refers to vascular compromise of the bowel and its mesentery
that in the acute setting has a very high mortality if not treated promptly.
It presents clinically as a severe abdominal pain that is disproportionate to examination ndings and that responds poorly to analgesia.
Mesenteric ischemia can be classied into acute (most common) or chronic
and specically, in the acute setting, it could be determined by either arterial
thrombosis/embolism, venous thrombosis, or non-occlusive mesenteric ischemia (NOMI).
CT is now the investigation of choice for patients with suspected intestinal ischemia, by virtue of its capacity to volumetrically assess the whole abdomen in multiple vascular phases and to diagnose alternative causes of acute abdominal pain.
Common CT imaging features result from the bowel wall necrosis and perforation
and include: pneumatosis intestinalis (gas in intestinal wall), pneumatosis portalis
(gas in the portal vein or in mesenteric vein), pneumoperitoneum (perforation of the
bowel), submucosal hemorrhage and free uid in the abdomen [13].
In general, treatment is surgical and depends on the severity and extension of the
ischemia, with the need of bowel viability assessment and eventual necrotic tissue
resection, along with endovascular thrombolysis/thrombectomy when needed.
BOX Signs of mesenteric ischemia:
Clinical: severe abdominal pain that is disproportionate to examination ndings
and that responds poorly to analgesia.
Diagnostic: pneumatosis intestinalis, pneumatosis portalis, pneumoperitoneum,
submucosal hemorrhage and free uid in the abdomen.
14.3.2 Visceral Artery Aneurysms
Visceral artery aneurysms, which include renal and splanchnic lesions, are quite
rare and usually asymptomatic. According to a large case series, 95% of the
visceral artery aneurysms are detected during routine investigation into unrelated abdominal symptoms, with splenic and hepatic representing the most common types; aneurysms that rupture are typically greater than 2cm, so this is
often considered the threshold for repair in patients with asymptomatic disease [14].
Most of the times these aneurysms go asymptomatic until the time of rupture,
which is a rare occurrence commonly presenting with abdominal pain.
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D. Esposito and E. Giacomelli
SVS Clinical Practice Guidelines on the Management of Visceral Aneurysms
Hepatic Artery
• Symptomatic
• Size >2cm
• Growth >0.5cm/year
Pancreaticoduodenal and
Gastroduodenal Arteries
Repair all aneurysms regardless of size
Superior Mesenteric Artery
Repair all aneurysms regardless
of size
Jejunal and Ileal Arteries
Gastric and Gastroepiploic Arteries
Repair all aneurysms regardless of size
• Symptomatic
• Size >2cm
Colic Artery
Repair all aneurysms
regardless of size
Splenic Artery
• All pseudoaneurysms
• Size >3cm
• All sizes in women of
childbearing age
Celiac Artery
• All pseudoaneurysms
• Size >2cm
Renal Artery
• Symptomatic
• Size >3cm
• All sized
- in women of childbearing age
- in patients with refractory
hypertension and renal artery
stenosis
Fig. 14.2 Schematic representation of SVS Clinical Practice Guidelines on the Management of
Visceral Aneurysms [15]
Focusing on splenic artery aneurysms, there is an increased prevalence of this
disease in women, particularly those who are multiparous, so a high index of suspicion must be taken in such scenarios.
Hepatic artery aneurysms instead are more common in men and are typically
associated to vascular diseases such as bromuscular dysplasia and polyarteritis
nodosa; unruptured hepatic artery aneurysms could cause symptoms secondary to
compression on the biliary tree.
Renal artery aneurysms are not infrequently bilateral and mostly of saccular type
occurring prevalently at the bifurcation of the main renal artery or rst-order branch.
Visceral vessel aneurysms appear on CT imaging as contrast-lled outpouching
in the course of the artery.
Treatment recommendations vary according to the different types of visceral
artery involved and are schematically reassumed in Fig.14.2 [15].
BOX Signs of visceral artery aneurysms:
Clinical: most of the times asymptomatic, unless nearby compression or rupture.
Diagnostic: contrast-lled outpouching in the course of the artery.
References
1. Pitts SR, Niska RW, Xu J, Burt CW.National Hospital Ambulatory Medical Care Survey: 2006
emergency department summary. Natl Health Stat Rep. 2008;7:1–38.
2. Mellnick VM, Heiken JP.The acute abdominal aorta. Radiol Clin N Am. 2015;53(6):1209–24.
3. Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC.Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial
Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and
14 Acute Abdominal Aorta andVisceral Vessel Disease
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North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg.
1991;13(3):452–8.
4. Wanhainen A, Themudo R, Ahlström H, Lind L, Johansson L.Thoracic and abdominal aortic
dimension in 70-year-old men and women- a population-based whole-body magnetic resonance imaging (MRI) study. J Vasc Surg. 2008;47(3):504–12.
5. Bengtsson H, Bergqvist D, Sternby NH.Increasing prevalence of abdominal aortic aneurysms.
A necropsy study. Eur J Surg. 1992;158(1):19–23.
6. Assar AN, Zarins CK.Ruptured abdominal aortic aneurysm: a surgical emergency with many
clinical presentations. Postgrad Med J. 2009;85(1003):268–73.
7. Aggarwal S, Qamar A, Sharma V, Sharma A.Abdominal aortic aneurysm: a comprehensive
review. Exp Clin Cardiol. 2011;16(1):11–5.
8. Ko JP, Goldstein JM, Latson LA, Azour L, Gozansky EK, Moore W, Patel S, Hutchinson
B. Chest CT angiography for acute aortic pathologic conditions: pearls and pitfalls.
Radiographics. 2021;41(2):399–424.
9. Lansman SL, Saunders PC, Malekan R, Spielvogel D. Acute aortic syndrome. J Thorac
Cardiovasc Surg. 2010;140(6 Suppl):S92–7. discussion S142–S146.
10. Baikoussis NG, Apostolakis EE.Penetrating atherosclerotic ulcer of the thoracic aorta: diagnosis and treatment. Hell J Cardiol. 2010;51(2):153–7.
11. Khosa F, Krinsky G, Macari M, Yucel EK, Berland LL. Managing incidental ndings on
abdominal and pelvic CT and MRI, Part 2: white paper of the ACR Incidental Findings
Committee II on vascular ndings. J Am Coll Radiol. 2013;10(10):789–94.
12. Bhalla S, Menias CO, Heiken JP.CT of acute abdominal aortic disorders. Radiol Clin N Am.
2003;41(6):1153–69.
13. Furukawa A, Kanasaki S, Kono N, Wakamiya M, Tanaka T, Takahashi M, Murata K.CT
diagnosis of acute mesenteric ischemia from various causes. AJR Am J Roentgenol.
2009;192(2):408–16.
14. Pulli R, Dorigo W, Troisi N, Pratesi G, Innocenti AA, Pratesi C.Surgical treatment of visceral
artery aneurysms: A 25-year experience. J Vasc Surg. 2008;48(2):334–42.
15. Chaer RA, Abularrage CJ, Coleman DM, Eslami MH, Kashyap VS, Rockman C, Murad
MH.The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms. J Vasc Surg. 2020;72(1S):3S–39S.
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Acute Abdomen andAcute Abdominal
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Conditions
EmanueleBotteri, GianmariaCasoniPattacini,
AlessioGiordano, andFrancescaRatti
15.1 Acute Calculus Cholecystitis
15.1.1 Introduction
The estimated overall prevalence of gallstones is 10–15% in the general population,
with some differences across countries. Between 20 and 40% of patients with gallstones will develop gallstone-related complications, with an incidence of 1–3%
annually; acute calculus cholecystitis (ACC) is the rst clinical presentation in
10–15% of the cases [1, 2]. In 95% of cases ACC is caused by gallstones, while in
the remaining 5% of cases it can be associated with cardiovascular disorders, following trauma or severe burns, following abdominal or cardiac surgery, in prolonged fasting typical of critically ill patients, in severe immunodeciencies, in
elderly and diabetic patients [3].
15
E. Botteri (*)
General Surgery Unit, ASST Spedali Civili di Brescia, Brescia, Italy
G. C. Pattacini
General Surgery, Emergency Surgery and New Technologies, Baggiovara’s Hospital,
Modena, Italy
A. Giordano
General Surgery Unit, Azienda ASL Toscana Centro, Nuovo Ospedale “S.Stefano”,
Prato, Italy
F. Ratti
Hepatobiliary Surgery Unit, Ospedale San Raffaele, Milan, Italy
e-mail: ratti.francesca@hsr.it
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
D. Bissacco et al. (eds.), Primary Management in General, Vascular and
Thoracic Surgery, https://doi.org/10.1007/978-3-031-12563-8_15
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