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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_718_Библиотеки_им_академика_М_И_Перельмана
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Indications of surgery:
1.Failure of conservative treatment; avoid excessive physical exertion, eat often in small portions,
and avoid overeating.
2. Progression of the disease
3. Complications; organ rupture, inversion of the stomach, intestines, bleeding.
Methods of surgical Treatment;
1.Incomplete relaxation; phrenoplication; excision of the thinned part of the organ, followed by its
doubling or tripling by its own diaphragmatic tissues.
2.Complete relaxation; plastics with synthetic material (Teflon, polyvinyl alcohol, terylene).
3.In pediatric surgery, stitching of the thoracic barrier.
4.Paraduodneadal hernia: Represents 55% of internal abdominal hernias.
Paraduodenal hernia (Treitz hernia) is an internal hernia of the abdomen, which is formed when
the internal organs (more often the loops of the small intestine) bulge into the duodenal-jejunal
pocket.
Fig.142: Ligament of Treitz. Source [142].
Aetiology:
The main predisposing factors are intrauterine abnormalities of the development of the digestive
organs (connective tissue dysplasia, incomplete bowel rotation and the associated deviation in the
formation of the Treitz pocket).
In adulthood, the cause can be independent and postoperative perivasculitis, adhesive intestinal
disease.
Abdominal operations (liver transplantation, gastric bypass surgery, intestinal resection).
Pathogenesis:
The Treitz pocket is formed on the anterior surface of the posterior abdominal wall, to the left of
the 2nd lumbar vertebra in the area of the transition of the 12th duodenum to the jejunum.
The fossa, bounded by the duodenal-jejunal bend of the small intestine and the peritoneal fold,
forms a hernial gate.
The bottom of the pocket is represented by the parietal peritoneum, forming a hernial sac.
The hernial contents are loops of the small intestine.
Classification:
Paraduodenal hernias can be congenital and acquired, uncomplicated and impaired, have a large
and small size.
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Depending on the location relative to the vertebral column in modern herniology, there are two
types of hernial protrusions:
Left-sided hernia. It occurs in 70-75% of cases, located to the left of the Treitz ligament behind
the stomach.
Right-sided hernia. It is located to the right of the spine, below the transverse colon. The rightsided paraduodenal hernia is characterized by a displacement of the duodenum to the right, the
jejunum to the right and posteriorly.
Symptoms:
Small hernias; Asymptomatic.
As the hernial sac increases; pains occur in the right or left half of the abdomen, radiating into the
spine, lower back or epigastric region. The pain increases in the standing and sitting position and
weakens in a horizontal position on the side opposite to the localization of the hernia.
Belching, flatulence, nausea and vomiting (rarely).
Prolonged constipation: stool delays can be 5-7 days.
Complications:
Intestinal strangulation.
Acute small intestinal obstruction.
Intestinal ischemia and necrosis.
Peritonitis and sepsis.
Diagnostics:
Examination: During visual examination, there is no hernial bulge of the anterior abdominal wall,
with palpation of the abdomen, only large paraduodenal hernias can be felt.
X-ray examination. Barium through the small intestine helps to see intestinal obstruction and
enlarged segments of the small intestine located in the Treitz pocket. Shift of the duodenum 12 to
the right, the jejunum – laterally and posteriorly.
CT abdomen; Allows better visualize the gastrointestinal tract, the hernial sac with its contents.
Differential diagnosis:
Peptic ulcer, benign or malignant neoplasms of the duodenum.
Exacerbation of pancreatitis, cholecystitis.
Treatment:
An upper median laparotomy is performed. The hernial gates are dissected, the organs are released
from the hernial sac. Then the slit-like defect is sutured and the abdominal cavity is revised.
With a strangulated hernia, the hernial sac is removed with a part of the necrotic intestine, after
which the hernial gate is sutured.
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5.Pericecal hernia: Represents (10%-15%) of internal abdominal hernias.
A portion of ileum passes through defects in the mesentery of the cecum to occupy the right
paracolic gutter.
Fig.143: Barium enema; a Pericecal hernia. Source [143].
6.Transmesenteric hernia: Represents (8%-10%) of internal abdominal hernias.
Is a protrusion of viscera through a defect in mesentery of small bowel, transverse colon or
sigmoid colon.
Fig.144: Barium enema; jejunal loop through a defect in the small bowel mesentery. Source
[144].
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7.Hernia of foramen of Winslow (Blandin's hernia): Represents (6%-10%) of internal
abdominal hernias.
The hernia occurs across the omental hiatus, bounded by the inferior vena cava posteriorly and
the portal triad anteriorly.
Fig.145: foramen of Winslow. Source [145].
8.Intersigmoid hernia: Represents (4%-8%) of internal abdominal hernias.
Herniation of bowel loops into the intersigmoid fossa (ISF).
9.Periviscualr hernia (Pericardio-Peritoneo-Diaphragmatic Hernia (PPDH) : Represents
(1%-3%) of internal abdominal hernias.
Is characterized by incomplete formation of the septum transversum during early embryonic
development, meaning that the peritoneal cavity and pericardial sac remain continuous in later life.
The defect may also result from a failure of the septum transversum to fuse with the
pleuroperitoneal folds.
Fig.146: Internal hernias. Source [146].
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CHAPTER FIVE: THE RETROPERITONEAL SPACE. TOPOGRAPHO-SURGICAL
ANATOMY, EXPLANATION.
M.Sh F. Mekhaeel , S.Sameh
Definition:
It is the part of the abdominal cavity which located between the parietal peritoneum and intraabdominal fascia, extending from the diaphragm to the pelvis; filled with fat and loose connective
tissue with organs, vessels, nerves and lymph nodes located in them.
Borders:
1. Superior: Posterior part of the diaphragm at the level of T11.
2. Inferior: Pelvic diaphragm.
3. Laterally: edge of quadratus lumborum and lateral edge of 12
TH
rib.
4. Anterior: Parietal peritoneum.
5. Posterior: Muscles of the posterior abdominal wall.
Fig.147: The retroperitoneal space. Source [147].
The retroperitoneum can be further subdivided into the following:
1.Perirenal (or perinephric) space:
Bounded by the anterior and posterior leafs of the renal fascia.
It contains; Kidney, adrenal gland, renal vessels and perirenal fat "adipose capsule of the kidney"
which may be considered as a part of the renal capsule.
2.Anterior pararenal (or paranephric) space:
Bounded by the posterior layer of peritoneum and the anterior leaf of the renal fascia.
It contains; Pancreas, ascending and descending colon and the duodenum.
3.Posterior pararenal (or paranephric) space:
Bounded by the posterior leaf of the renal fascia and the muscles of the posterior abdominal wall.
It contains only fat (pararenal fat), and is also called the paranephric body, or pararenal fat body.
134
Fig.148: Retroperitoneal spaces. Source [148].
Retroperitoneal structures:
I)Primarily retroperitoneal; structures were retroperitoneal during the entirety of development:
1)Urinary
1. Adrenal glands
2. Kidneys
3. Ureter
2)Vascular;
1. Aorta
2. Inferior vena cava
3)Anal canal.
II)Secondarily retroperitoneal; structures initially were suspended in mesentery and later
migrated behind the peritoneum during development:
1.The duodenum, except for the proximal first segment, which is intraperitoneal.
2.Ascending and descending portions of the colon.
3.Pancreas, except for the tail.
Retroperitoneal organs:
Organs are retroperitoneal if they have peritoneum on their anterior side only.
Structures that are not suspended by mesentery in the abdominal cavity and that lie between the
parietal peritoneum and abdominal wall are classified as retroperitoneal.
1.The kidney:
The renal capsule consists from3 layers:
1.Fibrous layer (capsula fibrosa).
2.Fat layer (capsula adiposa s. paranephron).
3.External layer (capsula externa).
135
kidney possess:
2 surfaces: the front surface is convex and faces laterally; the back surface is flattened.
2 edges: the lateral edge is convex and faces the posterior wall of the abdomen; the medial edge
is concave and faces down, medially and forward.
2 poles: upper and lower.
Blood supply:
Fig.149: Anatomy of the kidneys. Source [149].
From the renal arteries (branches of the abdominal Aorta), extending at the level of L1-L2.
The right renal artery passes behind the IVC and the descending part of the colon, and the left renal
artery behind the tail of the pancreas.
Near the gate, the renal artery often divides into two branches. In a third of cases, there are
additional renal arteries.
The renal veins flow into the IVC.
Lymph drayage: to the nodes that are located around the IVC and Aorta.
Innervation: Renal plexus (Plexus renalis).
Skeletopy: The kidneys lie on the sides of the spine:
Right – at the level of Th12-L1. 12Th rib divides right kidney into upper 1/3 and lower 2/3.
left - Th11-L2. 12TH rib divides the left kidney into 2 halves.
Holotopy:
Projects on the epigastric and subcostal regions (the right kidney – also in the umbilical and
lateral), on the Retroperitoneal space- in the lumbar region.
Anterior renal point (projection of the gate on the Anterior side wall) – in the corner between the
outer edge of the straight Abdominal Muscles and the costal arch.
The posterior renal point (projection of the gate on the Retroperitoneal space) is in the corner
between the lateral edge of m. erector spinae and the 12th rib.
136
Syntopy:
1)Posteriorly; lumbar part of the diaphragm, square muscle, aponeuroses of musculus
transversus abdominis and psoas muscle.
2) Anteriorly;
The right kidney; the right lobe of the liver, the ascending part of the colon).
The left kidney; the stomach, the tail of the pancreas, the spleen bend and the descending part of
the colon, the small intestine, the spleen.
3) The upper pole of each kidney; is covered by the adrenal gland.
4) Near the gates of the kidneys; Right –IVC, left –Aorta
The locking apparatus of the kidneys (the fixation system):
The kidney is kept fixed to its place because of:
1.Ligaments: lig. hepatorenale, lig. duodenorenale, lig. pancreaticolienale, lig. lienorenale.
2.The capsule of the kidney.
3.Kidney leg. (a set of structures located in the gate of the kidney; the ureter is located behind.
anterior renal arteries and veins)
4.Intra-abdominal pressure.
2.The adrenal glands (glandulae suprarenales):
Fig.150: Renal ligaments. Source [150].
Syntopy:
The left adrenal gland; upper pole of the left kidney, tail of the pancreas (lower edge), spleen,
stomach (front surface)
The right adrenal gland; the upper pole of the right kidney, lumbar part of the diaphragm, posterior
surface of the liver, IVC.
Skeletopy: At the level of T11-T12.
Holotopy: Projects into the right and left hypochondria.
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3.The ureter:
Fig.151: The adrenal glands. Source [151].
Consist of two departments: Abdominal (pars abdominalis) and Pelvic (pars pelvina).
They have three constrictions (isthmus): -
1. place of transition of the pelvis to the ureter.
2. place of transition to the pelvis.
3. just before the bladder.
Holotopy: Projects On the outer edge of the rectus abdominis muscle –on the Anterolateral Wall
Along the line connecting the transverse processes of the vertebrae - Retroperitoneal space.
4.Abdominal aorta:
It is located to the left of the median line beyond the transverse processes.
Bifurcation occurs at the level of L3-L4.
Syntopy:
Right; IVC.
Anterior; Pancreas, mesentery root of the small intestine, left renal vein.
Left; lumbar section of the left sympathetic trunk.
Branches:
A) Visceral branches:
1- Celiac trunk (Truncus coeliacus)
2- Superior mesenteric a. (A. mesentrica superior).
3- Inferior mesenteric a. (A. mesenterica inferior).
4- Renal a. (A. Renales).
5- Suprarenal a. (A. Suprarenales)
6- Testicular a. in males and ovarian a. in females (A. Testiculares (ovaricae)
B) Parietal branches:
1.Inferior phrenic a. (a. phrenicae inferiores)
2. Lumbar a. (a. Lumbales)
3. Media sacral a. (a. sacralis mediana)
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5.Inferior vena cava IVC:
Fig.152: The abdominal aorta. Source [152].
Origin:
It begins at the level of L9-L10, formed by merging vv. Iliacae communes.
It lies on the spine, to the right of the median line.
Syntopy:
Anteriorly – root of the mesentery of the small intestine, head of the pancreas, portal vein,
posterior surface of the liver
On the right – the lumbar muscle, the right ureter, the inner edge of the right kidney and the
right adrenal gland
Left – Aorta
Posteriorly - The right renal artery.
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