Surgical Exposure/Anatomy of the Lateral Lumbar Spine and Plexus

Seth B. Hayes , Allan D. Levi , in Nerves and Nerve Injuries, 2015

Retroperitoneum

The retroperitoneum is part of the extraperitoneal compartment between the diaphragm and subperitoneal pelvic space. Information technology is located between the parietal peritoneum and muscular fascia. This extraperitoneal space really surrounds the abdominal crenel circumferentially. Along the posterior abdominal wall, the retroperitoneal infinite is bordered by the fascia of the diaphragm (superiorly), psoas, quadratus lumborum (posteriorly), and transversalis fascia (laterally). The extraperitoneal space extends anteriorly as the preperitoneal space, which is located between the partietal peritoneum and transversalis fascia. The retroperitoneal tin can be compartmentalized into three zones. The borders, vascular, and visceral contents of these zones can be plant in Table 12.i (Mirilas & Skandalakis, 2010a).

Table 12.1. Retroperitoneal Zones

Zone I (Central) II (Lateral: Right/Left Flank) 3 (Pelvic)
Borders Upper: diaphragm, aortic, esophageal entry
Lower: sacral promontory
Lateral: psoas		 Upper: diaphragm
Lower: iliac crest
Lateral: lateral abdominal wall
Medial: psoas		 Anterior: retropubic space
Posterior: sacrum
Lateral: bony pelvis
Contents Intestinal aorta, junior vena cava, iliac vessels, pancreas, partial duodenum Kidney (vascular structures, ureters), hepatic and splenic flexure of ascending and descending colon, respectively; lumbar plexus and nerves Pelvic wall, illiac vessels, retrosigmoid colon, part of urogenital organs

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Penetrating Abdominal Trauma

Aidan D. Hamm MD , ... Ernest East. Moore MD, FACS , in Abernathy'southward Surgical Secrets (Seventh Edition), 2018

16 How is the retroperitoneum anatomically divided?

The retroperitoneum is divided into iii zones that correlate with the underlying structures and likelihood of injury to those structures. Management of trauma to the retroperitoneum differs based upon mechanism of injury and zone of injury.

•

Zone I: Midline retroperitoneal hematoma from diaphragmatic hiatus to distal to the aortic and IVC bifurcation. Business organization for major vascular injury to the great vessels. These are e'er explored in penetrating trauma, usually via a left or right medial visceral rotation for supracolic injuries, and isolation of pelvic vasculature for distal IVC, aorta, or proximal iliac injuries.

•

Zone 2: Lateral retroperitoneal hematoma. Concern for injury to the renal hilum and vessels or renal pelvis. In penetrating trauma, these are mostly explored unless very small, nonpulsatile, and non expanding.

•

Zone III: Pelvic retroperitoneal hematoma. In penetrating injuries, this should be explored to dominion out injury to major pelvic vessels.

Key Points: Penetrating Abdominal Trauma

1.

GSWs to the abdomen generally require operative exploration; an exception is the right upper quadrant wounds with isolated hepatic injury.

2.

Following a SW, patients with hypotension, peritonitis, or evisceration should undergo operative exploration.

iii.

Anterior intestinal SWs in stable patients are initially evaluated with local wound exploration; penetration of the peritoneum requires further evaluation with serial examinations and labs.

4.

Flank and dorsum SWs in stable patients are evaluated with contrast CT scan.

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Kidneys, Adrenals, and Retroperitoneum

Ruth L. Katz , Savitri Krishnamurthy , in Comprehensive Cytopathology (3rd Edition), 2008

Liposarcoma

The retroperitoneum is the second most common location for liposarcoma, which may reach very big proportions. Because of the difficulty in completely excising these tumors, the rate of local recurrence is loftier. Attributable to local compression effects, massive recurrence may be fatal. The Armed forces Institute of Pathology nomenclature divides liposarcoma into four categories: (1) myxoid liposarcoma, (2) round cell liposarcoma, (iii) well-differentiated liposarcoma, and (four) pleomorphic liposarcoma (come across Fig. 27.62A–D).

Myxoid liposarcoma is the most mutual type of liposarcoma and is characterized histologically by proliferating lipoblasts in diverse stages of differentiation, a delicate plexiform capillary pattern, and a myxoid matrix. On cytology, the tumor cells announced minor and uniform with indistinct cytoplasmic borders. The myxoid background, which stains metachromatically blue-ruddy with Unequal-Quik stain, contains numerous delicate plexiform capillaries composed of modest branching aggregates of endothelial cells. A few modest, multivacuolated lipoblasts may be establish and are characterized past an eccentric scalloped hyperchromatic nucleus with surrounding fat vacuoles (Fig. 27.62D). 158

Circular cell liposarcomas are closely related to myxoid liposarcomas and tend to be more aggressive. 159 Cytologic study reveals excessive numbers of compatible small round cells with vesicular nuclei. These may be confused with other pocket-size round cell neoplasms. The presence of an occasional vacuolated lipoblast too as ultrastructural examination for lipid confirms the diagnosis.

Well-differentiated liposarcomas closely simulate lipomas histologically except for the presence of a few lipoblasts, or cells with hyperchromatic nuclei, or lipocytes showing greater variability in size compared with normal. These well-differentiated liposarcomas are so cytologically bland that they were previously called singular lipomatous tumors past Evans, 159 simply because of the inexorable fatal outcome in the retroperitoneum, they are now designated besides-differentiated liposarcomas. Dedifferentiated liposarcomas are recognized past the coexistence of a well-differentiated liposarcomatous component with a dedifferentiated cellular component that resembles pleomorphic MFH (Fig. 27.62C). 159

Past histology, well-differentiated liposarcoma may have a fibrosclerotic and spindle prison cell component together with focal singular pleomorphic nuclei.

Pleomorphic liposarcoma resembles MFH cytologically but can be diagnosed on the basis of the demonstration of lipoblasts in smears. Lipoblasts may resemble signet ring cells or may be large vacuolated cells with hyperchromatic scalloped nuclei. 160

The differential diagnosis of liposarcoma, depending on the subtype, includes myxoid fibrosarcoma, MFH of myxoid blazon and high-grade MFH, extraskeletal myxoid chondrosarcoma, and chordoma. 166

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Polish Muscle Tumors

Andrea T. Deyrup , in Bone and Soft Tissue Pathology, 2010

RETROPERITONEAL LEIOMYOSARCOMA

Clinical Features

The retroperitoneum and pelvis are the well-nigh common sites for leiomyosarcomas. They occur predominantly in women in the fifth to 7th decades of life. Pain may be the presenting symptom. Because of their location, retroperitoneal leiomyosarcomas can achieve a significant size before diagnosis, and complete surgical resection can be hard.

Pathologic Features

Mross Findings

Retroperitoneal leiomyosarcomas range in appearance from leiomyomatous (firm, white-to-tan, whorled cutting surface) to a fleshy mass that displays areas of hemorrhage, cystic change, or necrosis. Large tumors may involve side by side organs.

Microscopic Findings

The histologic appearance of vascular leiomyosarcoma is like to other leiomyosarcomas: eosinophilic spindled cells arranged in intersecting fascicles and displaying a variable degree of cytologic atypia, mitotic activity, and necrosis (Figure 5-12). Cytoplasmic vacuolation is common, and areas of hyalinization or hypocellularity may be present. Epithelioid morphology and frank anaplasia may be seen (Figure 5-xiii).

Immunohistochemistry

Retroperitoneal leiomyosarcomas express actin, desmin, and h-caldesmon to a varying degree. Rarely, focal expression of cytokeratin, epithelial membrane antigen, Southward-100 protein, or CD34 exists.

Differential Diagnosis

Cellular schwannoma and eGIST should both exist considered in the differential diagnosis of retroperitoneal leiomyosarcoma. Immunohistochemistry is helpful in distinguishing these entities, specially on needle biopsy. eGIST is usually CD117 positive, often CD34 positive, focally SMA positive, and rarely desmin positive. In contrast, cellular schwannoma is strongly and diffusely positive for S-100 protein.

Dedifferentiated liposarcoma, which tin can have a fascicular appearance and immunohistochemical evidence of myoid differentiation, should besides exist considered. An associated well-differentiated liposarcomatous component facilitates diagnosis.

Prognosis and Treatment

Retroperitoneal leiomyosarcomas have an extremely high bloodshed rate, related, at least in office, to the difficulty in achieving articulate surgical margins and the large size attained past these tumors. The lungs and liver are the chief sites for metastasis.

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SURGICAL Anatomy OF THE ABDOMEN AND RETROPERITONEUM

Grant Bochicchio , Thomas M. Scalea , in Electric current Therapy of Trauma and Surgical Critical Care, 2008

EXPLORING THE RETROPERITONEUM

The retroperitoneum is generally divided into three zones ( Figure 4). Zone one is the central portion of the retroperitoneum containing the aorta, vena cava, and the major branch vessels, likewise as the superior mesenteric vein and splenic vein. Whatsoever retroperitoneal hematoma in zone one is generally explored.

Zone two is the lateral perinephric area to a higher place the pelvis. Zone two houses the kidney, ureters, and renal artery and vein. In general, zone 2 hematomas are explored after all penetrating injuries. Zone ii hematomas in blunt trauma can be managed expectantly unless in that location is a known injury requiring operation such as a ruptured ureter or if the hematomas are expanding or pulsatile.

Zone 3 houses all pelvic organs. This includes the common and external iliac artery also as the hypogastric avenue. The lower portion of the sigmoid colon is in zone three as well equally the distal ureters. Zone 3 hematomas are explored in penetrating injury merely. In general, surgical exploration of a pelvic retroperitoneal hematoma after blunt trauma is discouraged. The hypogastric artery is curt and branches into a big number of small vessels. Unroofing the pelvic hematoma risks loss of tamponade. Other techniques such every bit external compression or angiographic embolization generally are a wiser course to care for haemorrhage in zone three post-obit blunt trauma.

There are several surgical maneuvers to permit admission to the retroperitoneum. These involve medial visceral rotation on either the left or right side. The viscera can be rotated medially by incising the white line of Toldt. A small incision can be made in the white line and then the white line may be divided using the cautery or a pair of scissors over a finger inserted into the retroperitoneum to protect the deeper structures. The incision should be brought around the hepatic or splenic flexure of the colon. We generally hold the colon up with a mitt then sweep the retroperitoneal contents downward either with a laparotomy sponge, sponge stick, or hand. This protects the mesentery of the colon and allows for raid access to the retroperitoneum.

The original left medial visceral rotation maneuver was described by Creech and DeBakey in 1956. Information technology involves taking downwards the white line of Toldt of the left colon all the way to the splenic flexure and sweeping the spleen, tail of the pancreas, and stomach medially to the hip or the aorta, celiac axis, and superior mesenteric artery.

The so-called "Mattox maneuver" involves medial visceral rotation on the left side (Figure five). The left colon is mobilized equally described previously. This brings the surgeon down into the retroperitoneum. At the base of the mesentery, the surgeon volition then encounter the aorta. The aorta tin be followed up on its lateral margin at 3:00 chop-chop as at that place are no branches until one encounters the left renal artery and vein.

The Mattox maneuver involves mobilizing the kidney with the remainder of the viscera (see Effigy v). We generally prefer to leave the kidney in situ and mobilize it afterwards if necessary. The splenic flexure must be completely mobilized into the bottom sac. The spleen and tail of pancreas can exist mobilized which exposes the aorta up to the level of the hiatus. This is our preferred method of achieving aortic control at the level of the diaphragm. Often, the diaphragmatic crura come down lower than the surgeon expects. Information technology may be necessary to divide the diaphragmatic fibers to command the supraceliac aorta.

Nosotros strongly believe that supraceliac aorta control must exist accomplished past completely encircling the aorta. Blindly placing a clench either from the inductive or lateral aspect of the aorta about certainly results in the clench slipping off. We mobilize the esophagus off the aorta anteriorly and insert a finger from the left side around to the right. It is then possible to bluntly dissect the fibers holding the aorta down to the spine. With a finger completely encircling the aorta, it is and then possible to gently place the cross-clench around the aorta and clamp the aorta. The left-sided medial rotation also provides practiced admission to the left renal artery and vein. If exploring a patient for a penetrating injury to the pelvis, left-sided medial visceral rotation allows aortic control in a higher place the bifurcation. This is also a reasonable exposure to control the superior mesenteric artery at its origin. If ane must expose a longer length of the supermesenteric avenue, we more often than not combine a lesser sac exposure with the left-sided medial rotation.

Supraceliac aortic control tin can also be obtained via a bottom sac approach (Figure 6). The bottom sac is opened widely by dividing the gastrohepatic ligament or lesser omentum, and then dissects down onto the superior attribute of the pancreas. The pancreas is mobilized and the esophagus and stomach frankly dissected. This volition bring the surgeon down onto the aorta. Over again the diaphragmatic crura may have to be divided in order to gain good access to the aorta. With the aorta exposed, a cross-clamp tin be applied.

We prefer the left-sided visceral rotation for several reasons. There are a number of esophageal branches coming off of the inductive aorta. The lesser sac approach risks injuring these as the dissection is somewhat blind. In addition, we accept establish information technology more hard to completely encircle the aorta through the bottom sac. Using this approach, the clench is generally applied somewhat blindly downwards onto the aorta and risks slipping off.

A correct-sided medial visceral rotation, the so called Cattel-Braasch maneuver, exposes the right-sided retroperitoneal structures (Figure seven). The correct colon is mobilized in a technique exactly similar to what was described on the left side. Similarly, the autopsy should be brought effectually the hepatic flexure and into the bottom sac. The duodenum and caput of pancreas should exist completely mobilized via a Kocher maneuver. This brings the surgeon downwardly onto the inferior vena cava (IVC). The IVC can be controlled and traced up to the confluence of the left and correct renal vein. There is a brusk suprarenal segment of the cava so the vena cava becomes retrohepatic in location.

The Cattel-Braasch maneuver is platonic exposure for the vena cava and the correct kidney with its vasculature. When combined with the Kocher maneuver, the duodenum and head of the pancreas tin be completely explored. In addition, the correct-sided pelvic vasculature can exist exposed via this maneuver. The Cattel-Braasch maneuver gives improve access to the pelvic vasculature than does a left-sided approach. The mesentery of the left colon can limit exposure with the Mattox maneuver. As at that place is no mesentery to obscure the view, the Cattel-Braasch maneuver gives wider exposure.

The mesentery of the pocket-sized bowel tin can likewise be incised and lifted upward off the aorta and vena cava in a maneuver like to that used by vascular surgeons during aortic surgery. When combined with the Cattel-Braasch maneuver, it gives the widest exposure of the retroperitoneal vasculature from the aorta and cava down into the pelvis.

Retroperitoneal arterial injuries are handled using the standard technique. Proximal and distal command must exist obtained, and a decision fabricated about directly repair, bypass grafting, or shunting. Injuries to the external iliac avenue at the junction with the mutual iliac and hypogastric arteries can sometimes be managed by using the proximal hypogastric artery equally a conduit. The hypogastric avenue is mobilized out of the pelvis and ligated. An end-to-end anastomosis then can be performed betwixt the hypogastric and the external iliac artery.

Retroperitoneal venous injuries can be amongst the most difficult to treat, particularly if located at the confluence of the vena cava and external iliac vein or in the juxtarenal IVC. Many techniques have been described for temporary vascular control including the use of sponge sticks, vascular clamps, and direct finger pressure to control bleeding. We accept preferred the use of intestinal Allis clamps (Figures 8, 9, and 10). The vascular injury is commencement controlled with digital force per unit area and an Allis clamp is practical at the apex of the injury vessel. The clamps are then sequentially stacked for the length of the injury. The clamps can then be lifted. This allows for restoration of venous render to the heart. A determination tin can be fabricated virtually ligation or repair. Vascular ligation tin exist accomplished past running a suture onto the clamp.

Exposure of the superior mesenteric vein (SMV) within the lesser sac can be extraordinarily problematic. The SMV courses behind the pancreas and joins the splenic vein to go the short portal vein. SMV injuries often nowadays with torrential blood loss.

Occasionally, the pancreas can be mobilized upwards off the SMV and the injury isolated. There are many small branches off the SMV that must be individually ligated. If these are torn, the haemorrhage but becomes more hard to command. Occasionally, identification of the location of an SMV injury is incommunicable, particularly if it is straight behind the pancreas or adjacent to the confluence of the splenic vein. In those cases, we by and large split up the pancreas at the level of the SMV. This is done by gently inserting a finger behind the pancreas and mobilizing the pancreas off the SMV. A GIA stapler can be guided using a Penrose drain and the pancreas divided. This gives excellent exposure to the SMV proper and its junction with the splenic and portal veins. Virtually any injury tin can be identified and repaired. The distal pancreatic remnant can exist resected later or inserted into a loop of jejunum depending on the surgeon'due south preference.

Exposing the pelvic vasculature is a particular claiming (Figure 11). It is essential to identify the aorta proximally and exist certain of its identification. Immature patients in profound hemorrhagic shock can become intensely vasospastic. The common iliac artery may exist mistaken for the external iliac avenue or fifty-fifty the aorta. With the aorta and cava clearly identified and controlled, the surgeon must sequentially expose the common, external and hypogastric arteries. All of these should be individually controlled. The ureter runs through the retroperitoneum and into the pelvis at the confluence of the iliac arteries. This is a constant anatomic human relationship. The ureter should exist identified and protected during whatsoever pelvic exposure.

The pelvic veins are very large and fragile. They mostly course behind the arteries. Iatrogenic injury to these tin can exist devastating. Even if patients are in deep stupor, the surgeon must be deliberate enough to avoid calculation to the trouble. Temporary venous control can be obtained by packing and the veins individually identified and looped.

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The abdominal wall, peritoneum and retroperitoneum

Michael J. Bradley , David O. Cosgrove , in Clinical Ultrasound (Third Edition), 2011

Anatomy

The retroperitoneum is that part of the abdomen which is divisional anteriorly by the posterior parietal peritoneum, posteriorly by the transversalis fascia and laterally by the latero-conal ligaments ( Fig. 41.53). Information technology is largest posteriorly but continues anteriorly as the properitoneal fatty compartment, and extends from the pelvic brim inferiorly to the diaphragm superiorly. The retroperitoneum contains the adrenals, kidneys and ureters, the duodenal loop and the pancreas, the great vessels with their branches and associated lymph node chains, and the ascending and descending portions of the colon, including the caecum. It tin can be divided into iii singled-out compartments by the fascial planes information technology contains: these constrain the distribution of reteroperitoneal collections such as pseudocysts, haematomas and abscesses, and so an agreement of their organisation has practical diagnostic value.

The anterior pararenal space lies between the posterior parietal peritoneum and the anterior renal fascia; the latero-conal ligament lies laterally, blending with the parietal peritoneum anteriorly. The space is continuous across the midline and contains the pancreas, the duodenum, the ascending and descending colon, the caecum, and too the appendix when it lies in a retrocaecal position.

The perirenal space is confined by the anterior and posterior renal fasciae, which fuse laterally to form the latero-conal ligament. The precise site at which this blends with the renal fascia varies widely. The posterior renal fascia (Gerota's fascia) is generally thicker than the anterior and has at least 2 layers, the anterior of which is continuous with the anterior renal fascia whereas the posterior layer continues into the latero-conal ligament. Superiorly the layers fuse to a higher place the adrenals and adhere to the diaphragm. Inferiorly the renal fasciae extend into the pelvis, where they sparse out and then that the anterior and posterior pararenal spaces communicate in the iliac fossae. The fascial layers consist of dumbo connective tissue which blends with the connective tissue enveloping the aorta, the junior vena cava (IVC) and the roots of the superior mesenteric vessels. The perirenal infinite contains the kidneys, adrenals, fat and blood vessels.

The posterior pararenal space lies between the posterior renal and latero-conal ligaments anteriorly and the transversalis fascia posteriorly. Its medial border is formed past the psoas major and quadratus lumborum muscles. Laterally it communicates with the properitoneal fat compartment (flank stripe). Information technology contains only fat. 85–88

All the compartments of the retroperitoneal infinite contain varying amounts of adipose tissue, depending on body habitus, but the right anterior and both posterior pararenal spaces are unremarkably thin compartments.

The diaphragmatic crura extend inferiorly as tendinous fibres that attach to the vertebrae and their transverse processes down as far as L3 on the right and L1 on the left. The right crus is more prominent and usually more than lobular than the left. It is bounded by the IVC anterolaterally, and past the correct adrenal gland and the correct lobe of the liver posterolaterally. Its fibres diverge as they ascend: the lateral fibres insert on the cardinal tendon of the diaphragm and the medial fibres ascend on the left side of the oesophageal hiatus, decussating with those of the left crus in front end of the abdominal aorta. On parasagittal scans the correct crus can be seen equally a longitudinal echo-poor construction immediately posterior to the IVC or, to the left of the midline, anterior to the aorta. The intra-abdominal portion of the oesophagus begins at the cephalic end of the right crus. The left crus ascends along the anterior lumbar vertebral bodies and inserts into the cardinal tendon of the diaphragm. Information technology is closely related to the adrenal gland, the splenic vessels and the oesophagogastric junction. Occasionally the medial fibres of the left crus cross the aorta and run toward the IVC.

The right crus is more readily seen on ultrasound than the left, though both may be apparent on transverse scans. 89 The prevertebral spaces at the level of the crura contain the aorta, nerves, portions of the azygos venous system, lymph nodes and the cisterna chyli.

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Float Cancer

In Oncologic Imaging, 2007

General Tips

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The retroperitoneum and liver should be scanned for the presence of nodes and metastases and to identify renal obstacle.

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Nodal metastases often mimic the characteristics of the primary tumor (such every bit the caste of enhancement and/or the presence of calcification).

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Superficial tumors may take been resected prior to staging, and thickening of the bladder wall may represent residual tumor, edema, or inflammatory reaction.

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Tumors arising within a bladder diverticulum are more difficult to assess with CT than with MRI. The walls of diverticula lack a muscle layer; therefore tumors within diverticula are more than likely to extend into the perivesical fat and also to metastasize to lymph nodes.

•

Loftier false-negative rates for nodal involvement are due to tumor replacing the normal node with little, if any, nodal enlargement.

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Laparoscopic Arroyo to Gynecologic Malignancy

Reitan Ribeiro , Audrey T. Tsunoda , in Principles of Gynecologic Oncology Surgery, 2018

Retroperitoneal Exposure

Exposure of the retroperitoneum is very important when ane is attempting to perform a paraaortic lymphadenectomy. Failure to attain adequate exposure is one of the nearly common reasons for surgeons not to perform a total lymphadenectomy to the renal vessels. When the steps as suggested hither are applied, it is certainly feasible to achieve an adequate lymphadenectomy, fifty-fifty in obese patients.

The operation starts with the placement of the modest bowel on the superior abdomen, particularly on the correct side. A small right lateralization of the surgical table tin can be helpful to proceed the bowel on the right side. The retroperitoneum is opened over the right common iliac avenue upward to the duodenum. Autopsy of the avascular plane between the retroperitoneum and the duodenum is then performed. Information technology is crucial to maintain excellent hemostasis in this area to ensure splendid exposure of the anatomic landmarks. On the correct side, the peritoneum is dissected up to the level of the ovarian vessels. On the left side it is dissected up to the level of the ligament of Treitz.

Stay sutures with straight needles or devices specifically designed for this purpose, such as the T'Lift (Vectec, Hauterive, France), are placed through the intestinal wall to suspend the edges of the peritoneum and expose the retroperitoneal area over the infrarenal aorta and vena cava. These sutures are inserted lateral to the trocars to avoid conflict with the instruments. The sutures are fixed with Kelly clamps (come across Fig. 25.31) exterior the abdominal wall, and traction of the sutures can exist adjusted. The number of peritoneal suspension sutures varies from two in thin patients to six or fifty-fifty more in obese patients. Fig. 25.32 shows the retroperitoneal exposure subsequently placement of the transabdominal sutures.

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Deaths: Trauma, Abdominal Cavity – Pathology

J.A. Prahlow , in Encyclopedia of Forensic and Legal Medicine (2d Edition), 2016

Retroperitoneum

Interest of the retroperitoneum by trauma is typically manifest equally retroperitoneal hemorrhage. Significant amounts of retroperitoneal hemorrhage (retroperitoneal hematomas) can upshot in stupor and expiry. Relatively big amounts of retroperitoneal hemorrhage can remain hidden clinically. In addition, such bleeding can occur slowly, over time, before becoming symptomatic. Retroperitoneal hemorrhage frequently occurs with pelvic or spinal fractures, but may also occur with injuries of the pancreas, duodenum, and urinary tract, including the kidneys. External prove of retroperitoneal hemorrhage is occasionally axiomatic as ecchymosis of the flank; this is referred to as the 'Grey-Turner sign' ( Prahlow, 2010; Figure seven).

Figure 7. The so-chosen 'Grey-Turner' sign: hemorrhagic discoloration of the flank region, indicative of retroperitoneal hemorrhage.

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Endoscopic Ultrasound

Peter R. McNally Exercise , in GI/Liver Secrets (Fourth Edition), 2010

8 Describe the normal EUS anatomy of the retroperitoneum. What are its major landmarks?

The pancreas and retroperitoneum are the most challenging and hard areas to examine with intraluminal Usa. Familiarity with the gross and The states beefcake is essential. The examination begins with the echoendoscope at the level of the duodenal ampulla. Antimotility agents, such as glucagon, are frequently necessary. The US examination unremarkably is conducted with a seven.5-MHz scanning frequency. The normal paraduodenal beefcake is shown in Effigy 72-ii. The normal pancreas has a homogeneous echo pattern, normally slightly more hyperechoic than the liver. In that location is considerable interobserver variation in measurement of the caput of the pancreas, probably due to variations in the angle of view. The remainder of the pancreas is examined from a paragastric position. In the stomach, the h2o-filled lumen method is used.

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