Chapter 11 Petroperitoneum

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HISTORY

The anatomic and surgical history of the retroperitoneum is shown in Table 11-1.

Table 11-1. Anatomic and Surgical History of the Retroperitoneum

Morgagni 1761 Described retroperitoneal lipoma found at autopsy

Cloquet 1817 Studied perirenal fascia

Bogros 1823 Studied surgical anatomy of the iliac area

Lobstein 1829 First use of term "retroperitoneal tumor"

Broca 1850 Discovered retroperitoneal tumors at autopsy

Moynier 1850

Treitz 1853 Stated theory of "absorption." Described retroduodenopancreatic fascia.

Dickinson 1871 Described a teratomatous tumor s imilar to the dermoid teratomas commonly found in the ovary

Toldt 1879, 1893 Theory of conjoined visceral fasciae

Zuckerkandl 1883 Described posterior renal fascia

Bass in i 1889 Described a re troperitoneal cys tadenoma that resembled a pseudomucinous cys tadenoma of ovary

Rogie 1894 Described retroperitoneal anatomy

Gerota 1895 Described anterior renal fascia

Poire r e t a l. 1923 Studied lobula tion o f adipose tissue in the pararena l and perirena l a reas

Drouet 1941 Studied subperitoneal area

Baumann 1945 Described embryology of renal area

Altmeir & Alexander 1961 Described extraperitoneal compartments above pelvic brim

Stevenson & Ozeran 1969 Subdivided anatomy of extraperitoneal pelvis into posterior, anterior, inferior, and superior spaces

Meyers et a l. 1972 Descriptions of anterior and posterior pararenal and perirenal spaces

Wickham 1979 Operated in a pneumore troperitoneum to endoscopica lly remove a ure te ric s tone

Hureau et al. 1990, 1991 CT study of extraperitoneal spacesKorobkin et a l. 1992 Used CT to study anatomy and fluid collections in retroperitoneal space

Gaur 1992 Performed retroperitoneal videoscopic renal surgery

McDougall et al. 1994

History table compiled by David A. McClusky III and John E. Skandalakis.

References:

Crepps JT, Welch JP, Orlando R III. Management and outcome o f retroperitoneal abs cesses. Ann Surg 1987;205:276-281.

Hureau J, Agossou-Voyeme AK, Germain M, Pradel J. [The poste rior interparietoperitoneal spaces or retroperitoneal spaces. 1: Normal topographic

anatomy]. J Radiol 1991;72:101-116.

Hureau J, Pradel J, Agossou-Voyeme AK, Germain M. [The posterior interparieto-peritoneal or retroperitoneal spaces. 2: Pathological x-ray computed

tomographic image]. J Radiol 1991;72:205-227.

Korobkin M, Silverman PM, Quint LE, Francis IR. CT of the extraperitoneal space: normal anatomy and fluid collections. AJR 1992;159:933-941.

McDougall EM, Clayman RV, Fadden PT. Retroperitoneoscopy: the Washington University Medical School experience. Urology 1994;43:446-452.

Pack GT, Tabah EJ. Primary retroperitoneal tumors. Int Abstr Surg 1954;99(3):209-231, 99(4):313-341.

EMBRYOGENESIS

Normal Development

The peritoneum develops around the third week of embryonic life. Differentiation to mesothelial cells by the primitive mesodermal lining of the early

fetal coelomic cavity produces the parietal and visceral layers.

The development of the retroperitoneal fasciae is enigmatic and obscure. The dorsal myotomes are responsible for the development of the psoas

major and the quadratus lumborum muscles. The ventral myotomes are responsible for the genesis of the transversus abdominis muscle. Perhaps

both myotomes are responsible for the genesis of these peripatetic fasc iae, which are united at the lateral border of the psoas major muscle.


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dorsal myotomes of truncal somites and characteristically maintain their innervation from the segmental spinal nerves at the levels of the origin of

the muscles.

Congenital Anomalies

The retroperitoneum is an uncharted sea. The anomalies of this area are the anomalies of the organs involved and perhaps the several

compartments that form this embryologically and anatomically enigmatic space.

SURGICAL ANATOMY

The retroperitoneal spaces are vast territories lacking an accurate and accepted map; Figure 11-1 offers a highly diagrammatic representation.

More work must be done to know and understand the surgical anatomy of this hidden area.

Fig. 11-1.

Retroperitoneal spaces (highly diagrammatic). PR, perirenal space; RF, renal fascia (Gerota's); P, peritoneum; APRS, anterior pararenal space; PPRS,

posterior pararenal space; TLF, thoracolumbar fascia; TF, transversalis fascia; M, muscles.

Topographic Relations

The retroperitoneal space is the area of the posterior abdominal wall that is located between the parietal peritoneum and the deep or internal


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sur ace o e ransversa s asc a. n s space are em ryoogca y re a e organs w c are re erre o as e re roper onea v scera. ese

include the adrenals, kidneys, and ureters. There are also numerous vascular and neural structures, including the aorta and its branches, the

inferior vena cava and its tributaries, the lymphatics and the lymph nodes, the lumbar plexus with its branches, and the sympathetic t runks.

In addition to the organs and tissues that develop in the retroperitoneum, several other organs at tain a sec ondarily retroperitoneal position in later

embryologic development. These include most of the duodenum, the pancreas, and major portions of the ascending and desc ending colon.

Within the greater retroperitoneal space, there are also several small spaces, or subcompartments. Loose connective tissue and fat surround the

anatomic entities, and, to a variable degree, occupy the smaller spaces. The parietal peritoneum is in continuity with the visceral peritoneum, and

vice versa.

Compartments of the Retroperitoneal Space

Three compartments of the retroperitoneal space are related to the kidney:

Anterior pararenal compartment

Posterior pararenal compartment

Perirenal compartment

The renal fascia, a c ollagenous connective tissue of mesodermal origin enveloping the kidney, is responsible for this compartmentalization.

The fascial layers and the spaces related to the kidney are as follows, from anterior to posterior:

Peritoneum

Anterior pararenal space (with a variable quantity of loose connective tissue and fat)

Anterior lamina of Gerota's fascia

Perirenal space (the kidney and the ureter; the adrenal in a separate subcompartment; fat)

Posterior lamina of Gerota's fascia

Pos terior pararenal space (usually with a large content of more compact fat)

Thoracolumbar (lumbodorsal) fascia and the fascia of the psoas muscle

To generalize, the muscle fascia lining the abdomen is referred to as the transversalis fascia (Fig. 11-2). More specifically, however, the

transversalis fasc ia, which is the fasc ial lining of t he transversus abdominis muscle, is continuous with the subdiaphragmatic fasc ia above. Medially

it is continuous with the psoas fascia and the thoracolumbar (or lumbodorsal) fascial investment (anterior lamina) of the quadratus lumborummuscle. Below, it is continuous with the fascia of the iliacus muscle and the parietal muscular fascia of the true pelvis.

Fig. 11-2.


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Diagrammatic cross section through posterior body wall in lumbar region. (Modified from Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr,

Colborn GL, Skandalakis JE. Modern Hernia Repair. Pearl River NY: Parthenon, 1996; with permission.)

Nobel et al.3found that in most dissect ions four extraperitoneal layers of fasc ia lie superficial to and parallel with the sheath of the iliacus muscle.

Three potential spaces, or pouches, form between these layers of fascia.

Thoracolumbar Fascia

Behind the fasc iae that invest the kidney and the pararenal fat is the muscle fascia of the posterior abdominal wall, including the thoracolumbar

fasc ia (formerly called the lumbodorsal fascia). There are different points of view regarding the terminology and topography of the thoracolumbar

fascia, and whether it consists of 2 or 3 layers.

From our point of view, the thoracolumbar fascia includes 3 layers of connective tissue which cover or enclose the musculature of the back,

including the quadratus lumborum. In the lumbar region, the thoracolumbar fascia is composed of anterior, middle, and posterior laminae, or layers.

In fact, the term thoracolumbar fascia describes a continuous system of fascia that begins at the occipital area and terminates at the sacrum

(Figs. 11-3, 11-4, 11-5).

Fig. 11-3.

Thoracolumbar fascia. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)

Fig. 11-4.


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Three compartments formed by thoracolumbar fascia. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)

Fig. 11-5.


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Osteofibrous compartment for erector spinae muscle; fascial compartment for quadratus lumborum muscle. (Modified from Brantigan OC. Clinical Anatomy.

New York: McGraw-Hill, 1963; with permission.)

The posterior lamina of the thoracolumbar fascia arises from the vertebral spinous processes. It incorporates, and is continuous with, the

aponeurosis of the latissimus dorsi (Fig 11-6).

Fig. 11-6.

Schema of thoracolumbar fascia. Cross section of pos terior abdominal wall. (Modified from Hollinshead WH. Anatomy for Surgeons. New York: Hoeber-

Harper, 1956; with permission.)

The middle lamina arises from the posterior surfaces and tips of the t ransverse processes of the lumbar vertebrae. In the view of some anatomists,

this is the anterior lamina of the thoracolumbar fascia. The middle layer is thickened superiorly by a stout band, the lumbocostal ligament, which is

attached to the transverse processes of the first two lumbar vertebrae and the inferior surface of the 12th rib. The sharp edge of the lumbocostal

ligament is an extremely important landmark for the inferior line of pleural reflection and should be avoided while operating.4The middle and

posterior laminae envelop the erector spinae.

The anterior lamina of the thoracolumbar fascia is the thinnest of the three layers. It arises from the bases and ventral surfaces of the transverse

processes deep to the psoas muscle (Fig 11-6). It is strengthened superiorly by the lateral arcuate ligament, which serves as part of the origin of

the diaphragm. The anterior lamina of the thoracolumbar fascia covers the ventral surface of the quadratus lumborum, and is continuous medially

with the fascial investment of the psoas muscle.

The middle and anterior laminae enclose the quadratus lumborum muscle and separate it from the deeper erector spinae musculature. All three

laminae unite laterally and are continuous with the aponeurotic origins of the internal oblique and the transversus abdominis (Fig 11-6).

Topographically, it can be useful to remember that the external oblique muscle does not extend all the way posteriorly to t he vertebral column; its

posterior border descends almost vertically from the t ip of the 12th rib to the summit of the iliac c rest, and thereby provides a ready landmark for

the position of that rib.

The origin of the internal oblique from the aponeurotic lamina provides a guide for posterior incisions at the level of the kidney. The position of the

subcostal nerve (spinal nerve T12) inferior to the 12th rib should be remembered in this regard. Likewise, the iliohypogastric and ilioinguinal nerves

(or the ventral primary ramus of L1 from which they may arise) lie just deep to the aponeurosis and the internal oblique muscle. Obviously, they are

at risk in posterior incisions.

Retroperitoneal (Extraperitoneal) Connective Tissue

Hinman5subdivided the retroperitoneal connect ive tissue into three layers (strata): outer stratum, intermediate st ratum, and inner stratum (Fig.

11-7). The outer stratum forms the abdominopelvic fasc ia, which is the transversalis fascia. The intermediate stratum forms the renal fascia (the

fascia of Gerota). The inner stratum is merely the peritoneum and the so-called fusion-fascia (Fig. 11-8) present at the junction of "an

intraperitoneal organ (the pancreas, the duodenum, or the ascending or descending colon) with the undersurface of the primitive celomic

epithelium."

Fig. 11-7.


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Retroperitoneal fascial development at 5 weeks.

Fig. 11-8.


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Distribution of retroperitoneal fasciae at 7 months. (Modified from Hinman F. Atlas of Urosurgical Anatomy. Philadelphia: Saunders, 1993.)

Hinman5further stated that the inner stratum covers the gastrointestinal viscera and its blood supply. The intermediate stratum envelops the

adrenals, kidneys, ureters, and the vessels and nerves. The outer stratum forms the internal fascia lining the body wall. We would add the thought

that the intermediate stratum represents the extraperitoneal connective tissues that are associated with the anterior, lateral, and posterior wallsof the abdominopelvic cavity. These tissues are locally condensed, or otherwise specialized in form, in association with distinct organs such as the

kidneys.

Davies6observed that the extraperitoneal connective tissue, like the subcutaneous tissue beneath the skin, consists of two layers. The layer

closest to the peritoneum is fatty (like Camper's fasc ia). The second layer, c loser to the muscle fascia, is more membranous in character (like

Scarpa's fascia). According to this thesis, the glands of the skin invade the subcutaneous tissue beneath; similarly, the abdominal and pelvic

viscera develop into the fibroareolar layer of extraperitoneal connective t issue, acquiring their mesenteries and connective tissue capsules. Some

organs also receive an additional covering of peritoneum. The perirenal connect ive tissues consist, therefore, of an inner fatty-areolar matrix and

the membranous outer layer of perirenal tissue.

Boundaries of the Retroperitoneal Region

The boundaries of the retroperitoneal region are, perhaps, as follows.

Above:T12 and 12th rib

Below:Base of the sacrum, the iliac crest, the uppe r rami of the pubic bones, and the pelvic diaphragm

Lateral:The vertical line be tween the erector spinae muscle (sacrospinalis) and the three flat abdominal muscles, or to the lateral border of the quadratu

lumborum muscle. Pack and Tabah7extend the space as follows: "In a practical sense , we would extend this space more laterally to the tip of the twelfth

rib and a line dropped perpendicularly downw ard to a point on the iliac crest situated approximately at the junction of the anterior half with the posterior

half of the iliac crest. This line corresponds w ith the point at which the transversus abdominis muscle becomes aponeurotic, by which aponeurosis it arises

from the tips and borders of the transverse processes of the lumbar vertebrae."

Medial:The lumbar and sacral vertebrae with the abdominal aorta, the inferior vena cava and their branches; the sympathetic chains and nerve plexuses

and the lymphatic elements.

Anterior:The anatomic entities related to the anterior wall and parietal peritoneum of the retroperitoneal space a re: part of the liver and its bare area,

part of the duodenum, part of the ascending colon, part of the descending colon, and much of the pancreas within the lesse r sac. The colon, duodenum,

and pancreas are intraperitoneal organs during much of their embryologic development, but become fixed in their definitive retroperitoneal positions byfusion of their peritoneal investment with the posterior parietal peritoneum.

Posterior:The posterior wa ll of the space is related to several muscles. From lateral to medial, they are: the aponeurosis of the transversalis abdominis;

the quadratus lumborum muscle; and, most medial, the psoas muscle. These three muscles a re covered by a relatively tough layer of fas cia, which is

common for the iliopsoas muscles. However, the anterior layer of the thoracodorsal fascia covers the quadratus lumborum. These boundaries form the

lumbar area o f the retroperitoneal space, which is the home of the right adrenal gland, the right kidney, the ascending colon, the duodenum, the left

adrenal gland, the left kidney, and the des cending colon.

Since the retroperitoneal space terminates in the pelvic diaphragm and extends laterally to the posterior half of the iliac crest, two areas must be

considered from a surgical standpoint: the iliac fossa and t he pelvic brim of the true pelvis. Also, we need to include (or extend the retroperitonea

space anteriorly to include) the multiple regions between the mesenteric leaflets such as the transverse mesocolon, the mesentery of the small

bowel, and the pelvic mesocolon.

Nunn et al.8proposed a realistic anatomic division of the retroperitoneal space into three zones (F ig. 11-9) for desc ription and decision making in


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the treatment of retroperitoneal injury. These zones, their boundaries, and their contents are as follows:

Zone I (centromedial)

Upper:Diaphragmatic, esophageal, and aortic openings

Lower:Sacral promontories

Lateral:Psoas muscles

Contents:Abdominal aorta, inferior vena cava, pancreas, duodenum (partial)

Zone II (lateral)

Upper:Diaphragm

Lower:Iliac crests

Lateral:Psoas muscles

Contents:Kidneys and their vesse ls, ureters and their abdominal parts, ascending and de scending colon, hepatic and splenic flexure

Zone III (pelvic)

Anterior:Space of Retzius

Posterior:Sacrum

Lateral:Bony pelvis

Contents:Pelvis in toto, pelvic wall, rectosigmoid colon, iliac vessels, urogenital organs (partial)

Fig. 11-9.


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Three anatomic zones of retroperitoneum. (Modified from Nunn CR, Cullinane DC, Morris JA Jr. Retroperitoneal injury. In: Cameron JL (ed). Current Surgical

Therapy (6th ed). St Louis: Mosby, 1998; with permission.)

Falcone et al.9reported that a moderate to severe Zone I hematoma after blunt injury identified by computed tomography coupled with either

multiple intraabdominal injuries or a solid viscus score (SVS) greater than 4 indicated a need for urgent exploration.

Radiologic evaluation of the retroperitoneum was investigated by Chaffanjon et al.10They studied the anatomy of cadavers and healthy subjects

using MRI and CT. They postulated that the orientation of the retroperitoneal viscera (the pancreas, the adrenal glands and the kidneys) depends

both on individual morphology and the size of the liver. There are two hepatic landmarks for radiologic imaging: the middle hepatic vein and the

portal bifurcation. They recommend oblique sec tional planes be used for retroperitoneal studies.

In this chapter, we will briefly present pertinent features of the iliac fossa. We describe the pelvic wall in the chapter on the pelvis and perineum,

and descriptions of the mesenteries are included in the chapters of the associated viscera.

Iliac Fossa

The iliac fossa is lined with peritoneum, which c overs the extraperitoneal fat . It continues medially to the retroperitoneal space (lumbar area), then

downward to the pelvic wall, as well as forward to t he anterior abdominal wall. Just behind the fat is the multilaminar iliacus fasc ia.

The f loor of the iliac fossa is the iliacus muscle. The iliohypogastric nerve usually crosses the iliacus fasc ia from medial to lateral behind the lower

portion of the kidney. Other branches of the lumbar plexus pass through the psoas major and lie deep to the iliac fascia as they cross the iliac

fossa. The femoral nerve descends in the lateral part of the interval between the psoas and iliacus muscles.

The common and external iliac arteries and veins, running inferiorly around the brim of the true pelvis on the medial surface of the psoas, are

covered with a medial extension of the iliacus fascia. Inferiorly, the fascia iliaca contributes to the formation of the iliopubic tract, together with

the transversalis fascia and the transversus abdominis muscle.

Perirenal Space

The perirenal space is the home of the kidneys. Therefore, each organ lies between the posterior lamina and the anterior lamina of the fasc ia of

Gerota. Because of the compartmentalization of the retroperitoneal space by the various retroperitoneal connective tissues and fasciae, the kidney

is enveloped by the anterior and posterior laminae of the renal fascia (fascia of Gerota, or perinephric or perirenal fascia) and by the fatty tissue

inside and outside the fascia.

The anterior lamina is also known as the fascia of Toldt, and the posterior fascia is known as the fascia of Zuckerkandl.

Last11called the renal fascia a "vague condensation of the areolar tissue between the parietal peritoneum and the posterior abdominal wall."

However, he added that "certain of its attachments are worthy of note, since they serve to restrain the extenuation of a perinephric abscess" (Fig

11-10).

Fig. 11-10.


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Horizontal section through left kidney, spleen, and stomach. (Modified from Last RJ. Anatomy: Regional and Applied (5th ed). Baltimore: Williams & Wilkins,

1972; with permission.)

The renal fascia has a peculiar pathway. It covers the fat of the anterior and posterior surface of the kidney. There is some medial fixation with the

adventitial coverings of the renal vessels, with extension to the aorta on the left and the inferior vena cava (IVC) on the right. Above and toward

the adrenal gland and the diaphragm, the anterior and posterior laminae unite, or perhaps fuse, and finally, join the subdiaphragmatic fascia.

However, at the upper pole of the kidney, there is a fasc ial septum separating the adrenal gland from the kidney.

After an anatomic examination of 10 cadavers, Reich et al.12reported a vascularized, wide-based borderline lamella (corresponding to the anterior

lamina of Gerota's fascia) remaining in the area of the 2nd and 3rd parts of the duodenum. It covered the inferior vena cava, but was fixed with th


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.

The lower extent of both the anterior and posterior laminae of the renal fascia is enigmatic. Some anatomists and surgeons believe that the two

laminae fuse. However, others believe that they do not fuse, existing in a state of nonunion which thereby permits the kidney alone and not t he

adrenal gland to travel downward (ptot ic kidney, nephroptosis, or floating kidney). Others support the idea of a weak union which can be ruptured

from above by the collection of fluid in the perirenal space downward to the pelvic wall. Raptopoulos et al.13reported that perirenal disease does

not extend into the pelvis because of the fusion of renal fasciae and the formation of a cone which acts as a barrier to disease extension.

The supporters of nonunion theorize that the inferior extensions of the anterior and posterior laminae form the so-c alled periureteral sheath. One o

the authors of t his chapter (JES) remembers vividly the era of retroperitoneal air insufflation (presacral pneumography). This procedure, done prior

to CT, MRI, etc, precisely outlined the renal contents within the perirenal space. It also indicated pathologic anomalies (if any), especially those of

the adrenal glands (Fig. 11-1). Another of this chapter's authors (GLC) has observed in many dissections that the ureter is seen descending from

behind the anterior lamina of the sheath, bringing with it a mesenterylike membrane, presumably derived from the perirenal fascia. Downwardextension of Gerota's fascia merges with the pararenal fatty tissue in the infrarenal space.

Some investigators t rying to explain nephroptosis refer to weight loss and, therefore, loss of t he perinephric fat, which they think keeps the kidney

in its normal position.

Read an Editorial Comment

The posterior renal lamina unites with the anterior renal fascia close to the posterolateral surface of the ascending or descending colon to form the

so-called lateroconal fascia. This fascia continues to blend with the parietal peritoneum somewhere at the right or left gutter area anterolaterally.

However, it is often seen to be reduced to a thinner mantle of connective tissue intervening between the peritoneum and the transversalis fascia.

Kudos belongs to Meyers and his associates,14-16Oliphant et al.,17-21and Parienty et al.22for their studies of the anatomic and radiologic

anatomy of the renal fascia and the compartments it defines (Figs. 11-11, 11-12). These workers found that both laminae (anterior and posterior)

of Gerota's fasc ia can be seen radiologically in 50% of pat ients. The same authors stated that the posterior lamina is thicker in comparison with th

anterior lamina. The posterior lamina is also more frequently visualized. The anterior fascia is more prominent on the left side.

Fig. 11-11.

A,Axial diagram at level of kidneys. B,Sagittal diagram in plane of right kidney. Three major retroperitoneal compartments shown: anterior pararenal

space (hatched), perirenal space (cross-hatched), posterior pararenal space (stippled). L, liver; P, pancreas; LS, lesse r sac; S, spleen; V, vena cava; A,

aorta; RK, right kidney; LK, left kidney; C, colon; D, duodenum. (Modified from Korobkin M, Silverman PM, Quint LE, Francis IR. CT of the extraperitoneal

space: normal anatomy and fluid collections. AJR 1992;159:933-941; with permission.)

Fig. 11-12.
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A,CT scan at level of left kidney. Anterior renal fascia (long straight arrow). Posterior renal fascia (curved arrow). Lateroconal fascia (short arrows). B,

Diagram of same layers of renal fascia. C, colon; ARF, anterior renal fascia; LCF, lateroconal fascia; PRF, posterior renal fascia. (Modified from Korobkin M,

Silverman PM, Quint LE, Francis IR. CT of the extraperitoneal space: normal anatomy and fluid collections. AJR 1992;159:933-941; with permission.)

The c auses of perirenal fluid collect ion are as follows:

Bleeding due to blunt abdominal trauma, rupture of a vessel or aortic aneurysm, or spontaneous b leeding secondary to benign or malignant neoplasia.

Urinoma secondary to obstructive uropathy, blunt abdominal trauma, or iatrogenic injury (secondary to surgery or d iagnostic instrumentation).

Abscess secondary to either pyelonephritis or an infected urinoma.

Anterior Pararenal Compartment

We agree with Rubenstein et al.23that the anterior pararenal compartment (Figs. 11-13, 11-14) is a distinct retroperitoneal space and not an

intraperitoneal space as Dodds et al.24reported.

Fig. 11-13.

Abscess in anterior pararenal space. CT scan shows fluid and gas bubbles (A) between duodenum, liver, and right kidney. Anterior renal fascia (arrows)

forms posterior border o f abscess. Intraperitoneal ascites surround liver. (From Korobkin M, Silverman PM, Quint LE, Francis IR. CT of the extraperitoneal

space: normal anatomy and fluid collections. AJR 1992;159:933-941; with permission.)

Fig. 11-14.


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Retrorenal extension of pancreatitis fluid. A,CT scan shows fluid (F) in left anterior pararenal space extending posterior to kidney, producing characteristic

wedge-shaped appearance. B,Diagram shows fluid (hatched area) dissecting layers o f posterior renal fascia.Arrowindicates direction of fluid collection in

APS. APS, anterior pararena l space; C, des cending colon; LCF, lateroconal fascia; PRF, two layers of posterior renal fascia. (Modified from Korobkin M,

Silverman PM, Quint LE, Francis IR. CT of the extraperitoneal space: normal anatomy and fluid collections. AJR 1992;159:933-941; with permission.)

According to Korobkin et al.,25fluid collection is more common on the left side than on the right, perhaps due to pancreatitis of the tail (Fig. 11-

15). Fluid collection on the right is secondary to duodenal perforation or pancreat itis.

Fig. 11-15.


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Pathway of extravasations from tail of pancreas. P, pancreas; C, colon; K, kidney. (From Meyers MA. Dynamic Radiology of the Abdomen. New York:

Springer-Verlag, 1976; with permission.)

Posterior Pararenal Compartment

Fluid collect ion in this space is a rare phenomenon. According to Mindell et al.,26it can occur if sufficient fluid is present.

Communication of the Retroperitoneal Spaces

"Ce que l'anatomie suggre, la pathologie peut le dmontrer."27

(What anatomy suggests, pathology can prove.)

The communications of the several retroperitoneal spaces are highly controversial. According to Korobkin et al.,25the anterior and posterior

pararenal spaces merge caudal to the cone of the renal fascia (perhaps conveniently this area is called the infrarenal retroperitoneal space), which

communicates with the prevesical space and other compartments of the pelvic wall.

Raptopoulos et al.28and Feldberg et al.29studied the medial attachment of the posterior renal lamina. They reported that the attachment is not

always the same, inserting near the anterior or the posterior surfaces of the psoas muscle. According to the same authors, the attachment is mostlikely at the posterior aspect of the psoas muscle, or occ asionally, at the quadratus lumborum muscle at the area of the lower renal pole.

The medial extension of the anterior lamina is highly controversial. To what extent does it continue across the midline? If such continuation exists,

do right and left perirenal spaces communicat e? It is our opinion, from an anatomic standpoint, that communication between the right and left

perirenal spaces is still somewhat questionable. However, Kneeland et al.30and Mindell et al.,26using radiologic and cadaveric studies, reported

that the perirenal spaces may communicate ac ross the midline anterior to the aorta and the IVC and posterior to the anterior laminae of the renal

fascia. If this is true, a midline vascular pathology, such as an aortic aneurysm, may travel to the left or even to the right perirenal space. Hopper

et al.31disagreed, advising that the pathway of the blood from such a rupture is to the psoas muscle and then into the posterior pararenal space.

Perhaps Last11was right when he wrote that this "layer" is just areolar tissue. Raptopoulos et al.28agree with Last that the anterior lamina is thin

Since the anterior lamina is thin, perhaps the lateroconal fascia is the product of the posterior lamina only. The water is muddy, the anatomy is

confused; perhaps we cannot interpret the radiologic images of the anatomy 100% correct ly. In the operating room, many times the surgeon is no

sure about the formation of compartments, the pathway of fluids and, finally, the accurate localization of compartmental collection. Maybe Last 11

was right. Or, perhaps, the amount of blood (bleeding from injury of retroperitoneal organs) or inflammatory potentialities (secondary, perhaps, topancreatitis) play a greater or lesser role.

According to Korobkin et al.,25an abscess or infected fluid can be found in any compartment. Pancreatic fluid secondary to pancreatitis is most

likely to collect in the anterior pararenal space, or perhaps, in all retroperitoneal compartments. The senior author of this chapter agrees. As a

matter of fact, he has seen a case of intraperitoneal pancreatic extravasation presenting as hydrocele secondary to collection at the tunica

vaginalis.

Hureau et al.21,32reported the following:

The anterior pararenal space is almost virtual ("quasi virtuel"), demonstrating its existence through pathologic manifestations such as acute pancreatitis

The poste rior pararenal space continues to the space of Bogros (Fig. 11-16), which is a lateral extension of the retropubic space of Retzius. The space of

Bogros is formed laterally by the iliac fascia, anteriorly by the transversalis fascia, and medially by the parietal peritoneum.

The perirenal spaces continue down to the bladder and the prevesical space.

Fig. 11-16.


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Highly diagrammatic representation o f the layers of the abdominal wall and inguinal area. 1, External oblique fascia (fascia of Gallaudet); 2, External

oblique aponeurosis; 3, Internal oblique muscle; 4, Transversus abdominis muscle and its aponeurosis; 5, Transversalis fascia anterior lamina (third layer)

6, External spermatic fascia; 7, Cooper's ligament; 8, Pubic bone; 9, Pectineus muscle; 10, Possible union of transversalis fascia laminae; 11, Transversalis

fascia posterior lamina (second layer); 12, Vessels (second space); 13, Peritoneum (first layer); 14, Space of Bogros (first space); 15, Preperitoneal fat;

16, Transversus abdominis aponeurosis and anterior lamina of transversalis fascia; 17, Femoral artery; 18, Femoral vein. (Modified from Skandalakis JE,

Colborn GL, Androulakis JA, Skandalakis LJ, Pemberton LB. Embryologic and anatomic basis of inguinal herniorrhaphy. Surg Clin North Am 1993;73:799-836. Drawn with R.C. Read; with permission.)

The authors of this chapter emphasize that they do not have all the answers about these spaces, which extend to the diaphragm and to the

pelvis, assuming the guided migration of pathologic processes.

Other Spaces and Anatomic Entities Related to the Retroperitoneal Space

Subperitoneal Pelvic Space (Extraperitoneal)

Fig. 11-17 will aid in understanding the anatomy of the fasciae and the spaces around the urinary bladder, and therefore, the anatomy of the sub-

and extraperitoneal spaces.

Fig. 11-17.


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A,Sagittal section showing pe rivesical space and preves ical (retropubic) space (of Retzius). B,Introducing a finger into the retropubic space will identify

the structures entering the obturator foramen. (Modified from Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skandalakis JE.

Modern Hernia Repair. Pearl River NY: Parthenon, 1996; with permission.)

VESICOUMBILICAL FASCIA AND VESICAL SPACES


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The retroperitoneal space is, of course, the more posterior aspect of the intraabdominal extraperitoneal space; that is, the space circumferentially

surrounding the peritoneal cavity between the peritoneum and the t ransversalis fasc ia. Anteriorly, between the peritoneum and the transversalis

fasc ia, the extraperitoneal connective tissue becomes rather consolidated, taking a bilaminar form medial to the inferior epigastric vessels. We hav

observed that the more anterior layer continues with variable thickness medially on the posterior aspect of the rectus sheath. The posterior lamina

forms the vesicoumbilical fascia, investing the umbilical arteries (both the patent and nonpatent parts), t he midline urachus, and the urinary

bladder. Occupying the interval bounded by the umbilicus, the inferior epigastric vessels, and the upper parts of the pubic bones, the

vesicoumbilical fascia has a roughly triangular form.

The spac e between the anterior lamina of extraperitoneal t issue and the vesicoumbilical fasc iae is, as noted by Korobkin et al.,25continuous with

the prevesical space and the retropubic space of Retzius. The posterior lamina of connective tissue forms a perivesical space containing the

bladder and the urachus. Korobkin et al. compared the perivesical spac e to the perirenal space surrounding the kidney, and the prevesical space to

the anterior pararenal space.

Muntean33has applied the name "urogenital fascia" to an intermediate st ratum of extraperitoneal connect ive tissue which is asssociated with the

kidneys, genital vessels, ureters, and presacral (superior hypogastric) nerves. Within the pelvis, this layer of tissue incorporates the ductus

deferens and ends in front of the presac ral fascia of Waldeyer a couple of centimeters below the pelvic brim, sometimes with a conspicuous border

arching between the bilateral superior hypogastric nerves. We would add to this that in our studies, this fasc ial layer invests the round ligaments i

the female. Muntean c onfirmed the presence of the rectovesical septum in the male and rectovaginal septum in the female, observing in the latter

how readily it could be separated from the vagina and that this fascia incorporated the vaginal venous plexus.

Auh et al.34accumulated information on extraperitoneal pelvic f luid collect ion by reviewing the literature, studying the pathway of cadaveric

inject ion, using sonography and CT sc an and, finally, by c linical observations (Fig. 11-18, Fig. 11-19, Fig. 11-20, Fig. 11-21). Their striking

demonstration presented images that assumed the configuration of a "molar tooth" (Fig. 11-19). They noted that the "crown" portion lies between

the umbilicovesical fascia and the transversalis fasc ia of the anterior abdominal wall, anterior to the urinary bladder. The "root" portion of the mola

tooth has a posterior extension between the fascia and the peritoneum above or between the fascia and the parietal pelvic fascia below.

Fig. 11-18.

Midsagittal view of extraperitoneal spaces of ventral abdominal wa ll. Umbilicovesical fascia surrounds the urinary bladder and urachus, which lie within

perivesical space. Fibrous adventitia of bladder is a derivative of umbilicovesical fascia. Prevesical space represented by blackarea ante rior to

umbilicovesical fascia and pos terior to transversalis fascia. Prevesical space also extends into small potential space (arrows)between umbilicovesical fascia

and peritoneum. Pubovesical ligament forms anteroinferior bounda ry of prevesical and perivesical spaces. Rectovaginal septum is formed by fus ion of

anterior and posterior layers of peritoneum (dashed line)that line cul de sac. cds,cul de sac; fab,fibrous adventitia of bladder;pev(or PEV), perivesical

space;pl,pubovesical ligament;prv(or PRV) prevesical space;pu,pubis; re,rectum; rvs,rectovaginal s eptum; tf,transversa lis fascia; u,umbilicus; ub,

urinary bladder; urc,urachus; ut,uterus; uv(or UV), umbilicovesical fascia. (Modified from Auh YH, Rubenstein WA, Schneider M, Reckler JM, Whalen JP,

Kazam E. Extraperitoneal paravesical spaces: CT delineation with US correlation. Radiology 1986;159:319-328; with permission.)

Fig. 11-19.


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Schematic drawing of prevesical collection at transverse section indicated by line "A" in Fig. 11-18. Collection in prevesical space represented by shaded

area, which has shape of a "molar tooth." Crown po rtion of collection displaces umbilicovesical fascia and urinary bladder posteriorly. Roots extend

posterolaterally, separating peritoneal coverings of medial umbilical ligaments. Collection surrounds inferior epigastric vessels and is contiguous to rectus

abdominis muscles, from which it is separated by only a thin, multiperforated poste rior rectus sheath. Prevesical fluid may also extend into small potential

space (arrows)anterior to peritoneum and posterior to umbilicovesical fascia. cec, cecum; eivs,external iliac vessels; ievs,inferior epigastric vessels; il,

ileum; ilm,iliacus muscle; mlul,medial umbilical fold;p(or P), peritoneum;ppf,parietal pelvic fascia;prv(or PRV), prevesical space;ps,psoas muscle; rab,

rectus abdominis muscle; sgc,sigmoid colon; tf,transversa lis fascia; ub,urinary bladder; ur,ureter; ut,uterus; uv(or UV), umbilicoves ical fascia; vur,

vesicouterine recess. (Modified from Auh YH, Rubenstein WA, Schneider M, Reckler JM, Whalen JP, Kazam E. Extraperitoneal paravesical spaces: CT

delineation with US correlation. Radiology 1986; 159:319-328; with permission.)

Fig. 11-20.

Sagittal diagram of lower abdomen and pelvis shows umbilicovesical fascia, prevesical space, and perivesical space. R, rectum; U, uterus; B, bladder;

Dotted line,peritoneum. (Modified from Korobkin M, Silverman PM, Quint LE, Francis IR. CT of the extraperitoneal space: normal anatomy and fluid

collections. AJR 1992;159:933-941; with permission.)

Fig. 11-21.

Schematic axial diagram at transverse section indicated by line "B" in Fig. 11-18 shows large fluid collection distending and enlarging prevesical space,

producing characteristic "molar tooth" configuration. R, rectum; U, uterus; B, bladder; C, cecum; S, sigmoid; Dotted line,peritoneum. (Modified from

Korobkin M, Silverman PM, Quint LE, Francis IR. CT of the extraperitoneal space: normal anatomy and fluid collections. AJR 1992;159:933-941; with

permission.)

It is likely, as we envision it, that the lateral borders of the "crown," as seen on CT, represent the site along the inferior epigastric vessels where

the c onsolidated extraperitoneal t issue divides into anterior and posterior laminae, the latter being the vesicoumbilical fasc ia. It c ould also be that

the anterior lamina of extraperitoneal connective t issue is that layer which is believed by some to be a "posterior layer of transversalis fasc ia" (see

Read,35for example).

Korobkin et al.25

further point out that the prevesical extraperitoneal compartment c ontinues upward with the infrarenal retroperitoneal


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compartment below the cone of the renal fascia. Fluid collection accumulates within the infrarenal space, with possible extension into the ipsilatera

prevesical space and vice versa (Fig. 11-22). According to Auh et al.,34the prevesical space is also continuous with the rectus sheath, the

presacral space and the femoral sheath.

Fig. 11-22.


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Extraperitoneal hematoma associated w ith femoral vascular catheterization and anticoagulation. A,CT scan shows hematoma (H) in left side of prevesical

space abutting and obscuring left femoral vessels (v). Fluid (F) present in retrorectal presacral extension of preves ical space also. B,CT scan shows that

hematoma (H) also involves left posterior pararenal space. (Korobkin M, Silverman PM, Quint LE, Francis IR. CT of the extraperitoneal space: normalanatomy and fluid collections. AJR 1992;159:933-941; with permission.)

Trerotola et al.36reports the following locat ions of retroperitoneal hematomas secondary to femoral catheterization in 21 patients (7 pat ients had

hematomas in two locations): retroperitoneum (12), peritoneum (3), groin and thigh (8), and abdominal wall (5).

PSOAS MUSCLE

The relations of the thoracolumbar fascia and the muscles of the posterior abdominal wall have been presented previously. For all practical

purposes, t he psoas muscle extends from the posterior mediastinum to the thigh. On its way downward it is c losely associated with the perirenal

space and, perhaps, with the posterior pararenal space. The senior author of this chapter (JES) witnessed tuberculous psoas abscesses pointing a

the medial upper thigh just below the inguinal ligament (Scarpa's femoral triangle).

Other abscesses of pyogenic organisms may be formed by a retrocecal perforated appendix, colonic diverticulitis, and Crohn's disease. Santaella et

al.37state that an abscess involving the iliopsoas area should be drained surgically and not percutaneously. Tejido Sanchez et al. 38reported

percutaneous drainage of retroperitoneal abscess.

The pathway of renal inflammatory processes is from the perirenal space direct ly to the psoas muscle. Hematomas in the psoas muscle have been

reported. Other pathologic processes involving the muscle are malignant neoplasms of the retroperitoneal space. Such a case was presented by

Nathanson and Sonnino.39They excised the tumor and the entire muscle via the retroperitoneal approach without violation of the peritoneal cavity

Retroperitoneal Lymphatics

Following is a brief presentation of the retroperitoneal lymph nodes (Fig. 11-23). The details of the lymphatic drainage of the individual

retroperitoneal organs are presented in the c hapters on t hose organs. The general surgeon should be familiar with the lymph nodes of the

gastrointestinal tract and the three unpaired glands. The urologist must know the groups of lymph nodes pertaining to the kidney, ureter, bladder,

prostate, penis, and testicles. The gynecologist deals with the lymph nodes of the uterus, fallopian tubes, ovaries, and vulva.

Fig. 11-23.


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Retroperitoneal lymphatics. 1, 2,Retroperitoneal lymph nodes. 3,Union of right and left lumbar trunks plus intestinal trunk forms thoracic duct. (Modified

from Healey JE Jr, Hodge J. Surgical Anatomy. Philadelphia: BC Decker, 1990; with permission.)

From an anatomic standpoint, the retroperitoneal lymph nodes can be rather difficult to c lassify. The retroperitoneal lymphatics form a very rich

and extensive chain from the inguinal ligament and pelvis to the respiratory diaphragm and posterior mediastinal nodes. Usually, these lymph nodes

are located close to the aorta and IVC. The right paraaortic lymph nodes are in very close relationship with the left paracaval lymph nodes. The

number of abdominal and pelvic lymph nodes is approximately 230.40

The following classificat ion is very simple, logical, and anatomic:

Aortic Group

Preaortic nodes

Retroaortic nodes

Paraaortic nodes

Caval Group

Precaval (prevenous) nodes

Retrocaval (retrovenous) nodes

Paracaval (laterovenous) nodes

Pelvic Group

Common iliac nodes


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x erna ac no es

Internal iliac (hypogastric) nodes

Obturator nodes

Sacral nodes

Aortic Group

PREAORTIC NODES

One to three celiac nodes are located around the base of the celiac artery. They are very closely related to the celiac ganglion and the lymphnodes of the superior mesenteric artery. These nodes receive lymph from the st omach, liver, pancreas, and superior mesenteric nodes. Efferents

from the celiac nodes form the intestinal lymph trunk which enters the abdominal lymph complex called the cisterna chyli, between the aorta and

the right c rus of the diaphragm.

Two or three superior mesenteric nodes receive lymph from the small bowel, right colon, part of the transverse colon, and pancreas. They

communicate with inferior mesenteric nodes and drain to the celiac nodes. The two nodes of the inferior mesenteric artery receive lymph from the

left colon.

RETROAORTIC NODES

The retroaortic lymph nodes provide a stat ion of communicat ion between the pre- and paraaortic lymph nodes in front of the third and fourth

lumbar vertebrae. Healey and Hodge41stated that the retroaortic lymph nodes are variable in number and are not true regional lymph nodes.

PARAAORTIC NODES

The right lateral paraaortic nodes, together with the left paracaval nodes, form the right lumbar chain of nodes, which can be found intimately

related to the inferior vena cava. The left paraaortic (left lumbar) lymph nodes form a group of five to ten lymph nodes drained by the left lumbar

trunk posterolateral to the abdominal aorta. The right and left lumbar lymph trunks communicate with the common iliac nodes distally and drain into

the abdominal confluence (cisterna chyli) proximally.

Caval Group

PRECAVAL NODES

Precaval lymph nodes are located at the anterior wall of the IVC. Healey and Hodge41stated that two of these nodes, one at the aortic bifurcatio

and one at the termination of the left renal vein, are constant.

RETROCAVAL NODES

Retrocaval lymph nodes are located on the psoas muscle and the right c rus of the diaphragm.

PARACAVAL NODES

Paracaval nodes are found at the right lateral side of the cava. One node at the entrance of the right renal vein to the IVC is the metastatic sitefor right testicular malignancy. The left paracaval nodes are in close association with the right aortic nodes.

Pelvic Group

COMMON ILIAC NODES

There are four to six common iliac lymph nodes which are located around the artery. The medial nodes of this group lie against the body of the fift

lumbar vertebra and are called the nodes of the promontory. Efferents pass to the lumbar nodes.

EXTERNAL ILIAC NODES

There are eight to ten external iliac lymph nodes, which are located laterally and medially, and oc casionally, anteriorly to the external iliac artery.

The medial group is, essentially, the internal continuation of the deep inguinal lymphatics, receiving lymph from the superficial and deep inguinal

nodes. They receive lymph from the glans, clitoris, anterior abdominal wall, the region of the obturator vessels, the neck of the bladder, the

prostate, and the internal iliac nodes. The posterior (intermediate) group, situated deep to the external iliac artery near the femoral ring, receives

lymph from the bladder, prostate, cervix, and upper part of the vagina.

INTERNAL ILIAC NODES

The internal iliac lymph nodes are located chiefly at the points of origin of the branches of the internal iliac artery. The nodes receive lymph from

the t issues supplied by t he respect ive arterial branches which pass to the perineum, gluteal region, posterior thigh, and pelvic organs.

OBTURATOR NODES

There are one or two obturator lymph nodes. They are located at the obturator foramen close to the obturator neurovascular structures.

SACRAL NODES

The sacral lymph nodes are located in or near the midline, close to the median and lateral sacral vessels. They receive afferents from the prostate

and rectum, and drain to the internal iliac and lumbar nodes.

Retroperitoneal Innervation

Six nerves (Fig. 11-24) and the lumbar sympathetic chains are present in the retroperitoneal space. The six nerves are branches of the lumbar

plexus, which is formed by a branch of T12 as well as by the anterior primary rami of the first four lumbar nerves. Most of the branches of the


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plexus are related to the psoas major muscle, passing through it or behind it or being formed within it.

Fig. 11-24.

Nerves of the retroperitoneum. (From Healey JE Jr, Hodge J. Surgical Anatomy. Philadelphia: BC Decker, 1990; with permission.)

The nerves formed by the plexus are:

Iliohypogastric

Ilioinguinal

Genitofemoral

Lateral femoral cutaneous

Obturator

Femoral

Iliohypogastric Nerve: T12-L1

Arising from T12-L1 or L1 only, the iliohypogastric nerve (Fig. 11-24) is the first nerve of the lumbar plexus. It emerges from the lateral border of

the psoas muscle. After passing between the lower pole of the kidney and the quadratus lumborum muscle, it pierces the transversus abdominis

muscle above the iliac crest and travels downward between the internal oblique muscle and the transversus abdominis muscle, supplying these

muscles. It divides into two branches: the lateral cutaneous branch for the anterolateral skin of the gluteal area, and the anterior cutaneous

branch. The anterior cutaneous branch pierces the internal oblique 2-3 cm medial to the anterior superior iliac spine, and thereafter, penetrates th

aponeurosis of the external oblique above the superficial inguinal ring. The iliohypogastric nerve supplies the skin of the suprapubic region.

Ilioinguinal Nerve: L1

The ilioinguinal nerve (Fig. 11-24) has the same general pathway as the iliohypogastric nerve, piercing the internal oblique just medial to the


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anterior superior iliac spine. The two nerves may be combined prior to their separation in the vicinity of the superficial inguinal ring. Usually, the

ilioinguinal nerve traverses the inguinal canal together with the spermatic cord, emerging through the superficial inguinal ring to supply the skin of

the upper inner thigh, the root of the penis and the scrotal skin or the mons pubis and the labium majus. When the combined ventral ramus divides

very late, the ilioinguinal nerve may appear as a singular entity just above the external inguinal ring, crossing the spermatic cord obliquely to reach

its lateral side and exit the lateral aspect of the ring. All or part of t he ilioinguinal nerve may accompany the lateral femoral cutaneous nerve acros

the iliac fossa, thereafter penetrating the muscular wall to reach the inguinal canal.

Genitofemoral Nerve: L1 and L2

The genitofemoral nerve (Fig. 11-24) pierces the psoas muscle anteriorly. In some cases, t he two roots of the genitofemoral nerve may remain

separate through their passage in the psoas muscle, joining as they emerge from the muscle. It gives origin to two branches: the genital branch

and the femoral branch. The genital branch leaves the ventral surface of the psoas, passes ventral to the external iliac vessels, and crosses

ventral to the iliopubic tract to enter the inguinal canal just lateral to the inferior epigastric artery and the origin of the cremaster branch of the

inferior epigastric artery. Passing through the inguinal canal, it supplies the cremaster muscle and part of the scrotal skin. The femoral branch

passes below the inguinal ligament within the anterior layer of the femoral sheath and participates in the innervation of the skin of the triangle of

Scarpa (femoral triangle).

Lateral Femoral Cutaneous Nerve: L2 and L3

The lateral femoral cutaneous nerve (Fig. 11-24) emerges from the lateral border of the psoas muscle approximately at the level of L4. After

perforating the inguinal ligament, or passing deep to it close to the superior anterior iliac spine, it passes posterolaterally to supply the lateral

aspect of the thigh.

Obturator Nerve: Anterior Divisions of L2, L3, L4

The obturator nerve (Fig. 11-24) rises and courses beneath the medial border of the psoas muscle. Then, entering the true pelvis, it passes on its

lateral wall to reach the obturator foramen. It traverses the obturator canal with the obturator vessels, continuing downward to innervate the

adductor muscles and the skin of the medial part of the thigh.

Femoral Nerve: Posterior Divisions of L2, L3, L4

The femoral nerve (Fig. 11-24) emerges from the lateral border of the psoas muscle. It is more or less concealed beneath the iliopsoas fasc ia

between the lateral edge of the psoas and the iliacus as it passes inferiorly. It passes through the lacuna musculorum under the inguinal ligament,

and is closely assoc iated with t he iliopsoas muscle. It supplies the muscles of the anterior compartment of the thigh and provides sensory fibers to

the anterior and medial thigh and the medial side of the leg.

Lumbar Sympathetic Chains

The right and left lumbar sympathetic chains lie right and left, respect ively, along the medial border of the psoas muscle. Each chain is located

anterior to the lumbar vertebrae, covered by the IVC at the right and the right paraaortic nodes at the left. Each is formed by four ganglia which

vary in size and position. They communicat e with each other, as well as with the thoracic trunk above and the pelvic trunk below. Several lumbar

splanchnic nerves arise from the right chain posterior to the IVC and emerge between the cava and the aorta to join the preaortic nerve plexus.

The splanchnic branches of the left sympathetic chain pass laterally around the aorta to enter the nerve plexus. Lumbar splanchnic branches of the

left c hain pass around the lateral aspect of the aorta t o enter this plexus. Communicat ing rami pass posterolaterally from the sympathetic chains

between the lumbar vertebral discs and the tendinous origin of the psoas muscle to join the ventral primary rami of the lumbar nerve plexus.

RETROPERITONEAL PATHOLOGY AND NEOPLASIA

The literature on pathology of the retroperitoneal region is extensive. Chronic and acute inflammatory processes, benign and malignant neoplasms

(primary or metastatic), and parasites such as filaria may be found in this large, anatomically enigmatic space which extends for all pract ical

purposes from the posterior mediastinum to the pelvis.

Pathology

Khaw et al.42presented 6 cases of male patients with groin masses secondary to ruptured abdominal aortic aneurysms. They reported that the

anatomic pathway from the perirenal space is the transversalis fascia leading to the inguinal area, then to the inguinal sac, and finally to the

scrotum. Thus, if the hematoma travels behind the t ransversalis fasc ia along the iliac vessels, it will reach the femoral ring and then the femoral

triangle (Fig. 11-25).

Fig. 11-25.


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Hematoma from ruptured aortic aneurysm contained in retroperitoneal space by transversalis fascia. Note hematoma at superficial inguinal ring and

femoral sheath. (Modified from Khaw H, Sottiurai VS, Craighead CC, Batson RC. Ruptured abdominal aortic aneurysm presenting as symptomatic inguinal

mass: report of six cases. J Vasc Surg 1986;4:384-389; with permission.)

Edwards and Eckhauser43discussed retroperitoneal perforation of the appendix presenting as subcutaneous emphysema. Michel and Pagliano44

reported the second case of retroperitoneal abscess, with rupture to the peritoneal cavity. Crepps et al.45stated that the most common causes o

isolated retroperitoneal abscesses in their series were renal disease and postoperative infect ion. Gallstones retained after laparoscopic

cholecystectomy may cause retroperitoneal abscess. Galizia et al.46advocate removal of missed stones by surgical incision or laparoscopic

procedure.

Retroperitoneal polyarteritis nodosa was reported by Lie.47Roussel et al.48reported retroperitoneal filariasis. Jayatunga et al.49and Mokoena50

reported necrotizing retroperitoneal fascitis with recovery. Paule et al.51described retroperitoneal lymphocele secondary to surgery of the

abdominal aorta.

Retroperitoneal fibrosis (RPF) is a rare idiopathic medical entity of the retroperitoneal layers and spaces. It involves retroperitoneal organs such as

ureters, vessels, parts of the GI tract , et c. Normal tissue of the retroperitoneum is replaced with fibrosis and/or chronic inflammation.52Ureteric

and colonic obstruction have been reported secondary to RPF.50

Nobel et al.3reported femoral nerve palsy secondary to iliacus hematoma.

Dagradi et al.54reported the removal of a cystic mass from the "upper retroperitoneal space" of a 47-year-old pat ient. The mass had been present

since birth, and contained hairs and bony structures.

Neoplasia

Levine et al.55presented the occurrence of bilateral diffuse orbital retrobulbar masses and retroperitoneal fibrosis. Retroperitoneal fibrosis with

scirrhous gastric cancer was reported by Dohmen et al.56Retroperitoneal fibrosis as a host response t o papillary renal cell carcinoma was reported

by Fromowitz and Miller.57

Gheysens et al.58reported a case of retroperitoneal Castelman's disease. Miyashita et al.59reviewed the literature on primary retroperitoneal

synovial sarcoma.

Hida et al.60removed a retroperitoneal schwannoma, a lumbar paraspinal lesion. De Peralta et al.61stated that retroperitoneal cysts of mullerian

type require excision, rather than less radical procedures, because of a possible malignant component. Retroperitoneal ganglioneuroma was reporte

by Lambruschi et al.62Posner et al.63reported diffuse retroperitoneal amyloidosis. Retroperitoneal sarcoidosis was reported by Bach and Vellet,64

and retroperitoneal bronchogenic cyst was reported by Foerster et al.65and Reichelt et al.66

We present information on mesenteric cyst s in the c hapter on the small intest ine.

SURGERY

The retroperitoneum can be approached and explored by several routes, including the transperitoneal route and the extraperitoneal route. The

surgical anatomy of these routes and their modifications will be described with the presentation of the surgical anatomy of the incisions of the

surgery of the upper and lower urinary system, as well as t he surgery of other retroperitoneal anatomic ent ities.

Flummerfelt and Karakousis67advise a c ombination of extraperitoneal and transperitoneal dissect ion for the removal of retroperitoneal tumors.

Incision is made with the patient in a lateral supine position.

Malerba et al.68reported the surgical t reatment of 42 patients with primary retroperitoneal soft tissue sarcomas with radical surgery. The 5-year

survival was 48.1% and 5-year disease-free rate was 38.8%. The authors recommended wide surgical excision as the best chance for long-term

survival. Bautista et al.,69acknowledging the high rate of local recurrence, urge an aggressive surgical approach with reoperation to produce

prolonged survival in patients with low-grade retroperitoneal sarcoma. Since soft tissue sarcomas of the extremities can spread to the

retroperitoneum, Lev-Chelouche et al.70advocate aggressive surgical resection of these retroperitoneal metastases and follow-up including

abdominal imaging studies.

Retroperitoneal hematoma may be produced by blunt or penetrating injuries (Table 11-2).8For all practical purposes, the retroperitoneum is an

areolar space without geographic limitation. Therefore, hematoma may be localized or it may spread rapidly.

Table 11-2. Operative Management of Retroperitoneal Hematomas


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Mechanism of Injury

Blunt Penetrating

Zone I (centromedial) Explore Explore

Zone II (lateral) Observe Explore

Zone III (pelvic) Observe Explore

Source:Nunn CR, Cullinane DC, Morris JA Jr. Retroperitoneal injury. In: Cameron JL (ed). Current Surgical Therapy (6th ed). St. Louis: Mosby, 1998, with

permission.

There are two accepted procedures used for diagnosis of retroperitoneal injuries and for exploration of clinicopathological entities. The Cattell

maneuver exposes right-sided structures. The Mattox maneuver exposes left-sided structures.

Cattell maneuver(Fig. 11-26)

Step 1.Incise the lateral peritoneum along the cecum, ascending colon, and hepatic flexure

Step 2.Divide the white line of Toldt (peritoneal reflection at the area of the lateral wall of the cecum and ascending colon)

Step 3.Perform duodena l mobilization (Kocherization)

Step 4.Mobilize all right-sided anatomic entities anteromedially

Fig. 11-26.

Right-sided approach to exposure of retroperitoneal s tructures using Cattell maneuver. (Modified from Nunn CR, Cullinane DC, Morris JA Jr. Retroperitonea

injury. In: Cameron JL (ed). Current Surgical Therapy (6th ed). St Louis: Mosby, 1998; with permission.)

Mattox maneuver(Fig. 11-27)

Step 1.Incise the lateral peritoneum along the splenic flexure, descending colon, and upper sigmoid

Step 2.Divide the white line of Toldt

Step 3.Carefully mobilize the spleen, including the pancreatic tail, stomach, and left colon


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Step 4.Gently push all left-sided anatomic entities anteromedially

Fig. 11-27.

Mattox maneuver to expose retroperitoneum from left side. (Modified from Nunn CR, Cullinane DC, Morris JA Jr. Retroperitoneal injury. In: Cameron JL (ed).

Current Surgical Therapy (6th ed). St Louis: Mosby, 1998; with permission.)

Capelouto et al.71reported that safe and reliable primary retroperitoneal access can be performed for laparoscopy and laparoscopic surgery.

Hulbert,72Gaur et al.,73and Chiu and Babayan74also reported on the laparoscopic approach to the retroperitoneal space. Janetschek75advocatelaparoscopic retroperitoneal lymph node dissection for both surgical efficiency and oncologic efficacy. Because of the long and steep learning

curve, this is currently a procedure for specialized centers. Rassweiler et al.76reported that laparoscopic retroperitoneal lymphadenectomy

following laparoscopic dissection was a safe and accurate method for low-stage germ cell tumors with minimal invasiveness, but one requiring

technical expertise and experience.

ANATOMIC COMPLICATIONS

Read an Editorial Comment

The anatomic c omplicat ions of retroperitoneal surgery are the c omplicat ions of the organs located in the several compartments of the

retroperitoneal space.

McDougall et al.77reported on retroperitoneal laparoscopic surgery and balloon dilatat ion of the retroperitoneal space through the inferior lumbar

triangle in 12 patients (10 nephrectomies, 1 partial nephrectomy and 1 nephropexy). There was minimal morbidity, no mortality, and only 2

complications (pneumothorax and right hip bruise).

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. , , , , , . . - .

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Chapter 11 Petroperitoneum

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