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OMENTUM MESENTRY RETROPERITONEAL SPACE

OMENTUM MESENTRY RETROPERITONEAL SPACE. BY PROF. MOHAMED A. EL GHARBAWI Web Site: www.dr-elgharbawi.com E-mail: elgharma2@yahoo.com. OBJECTIVES:. To know some diseases of Omentum and Mesentery To know about Retro peritoneal Tumors. ANATOMY OF PERITONEUM. Largest Cavity

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OMENTUM MESENTRY RETROPERITONEAL SPACE

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  1. OMENTUMMESENTRYRETROPERITONEAL SPACE BY PROF. MOHAMED A. EL GHARBAWI Web Site: www.dr-elgharbawi.com E-mail: elgharma2@yahoo.com

  2. OBJECTIVES: To know some diseases of Omentum and Mesentery To know about Retro peritoneal Tumors

  3. ANATOMY OF PERITONEUM • Largest Cavity • Histology: Flattened polyhedral cells on a thin fibro-elastic tissue • Formed of 2 layers 1.Visceral layer: Covering the abdominal viscera and mesntery. Poor nerve supply, relativelyinsensitive. So, its pain is vague and not localized 2. Parietal layer: Lining abdominal cavity.Surfacing inner abdominal wall and pelvis.Rich nerve supply (Somatic +Visceral) So, irritation leads to severe pain which can belocalized accurately.

  4. ANATOMY: SUBPHRENIC SPACES • Subphrenic Region:Diaphragm above Transverse colon & transverse mesocolon below • Suphrenic Region includes: A. Intra-Peritoneal Spaces (5) B. Extra-peritoneal Spaces (2)

  5. ANATOMY: SUBPHRENIC SPACES A. INTRA-PERITONEAL SPACES • Liver divides the suphrenic region into: SubphrenicCompartmentSubhepatic Compartment

  6. ANATOMY: SUBPHRENIC SPACES • Falciform Ligament divides the compartments into: Right Spaces:Rt. Subphrenic Space: Diaphragm (Above), Rt. lobe of liver (Below), Falciform Ligament (Medially)Rt. Subhepatic ( Hepato -Renal Pouch): Rt. Lobe of liver (above) and Rt. Kidney (Below), To RT. Of Falciform Ligament It is Deepest Space. It is the Commonest site of a subphrenic abscess which arises fromAppendicitis, Cholecystitis, Perforated D U, Post Abdominal Surgery.

  7. ANATOMY: SUBPHRENIC SPACES Left Spaces:Lt. Subphrenic Space:Diaphragm (Above), Lt. Lobe of Liver (Below), Falciform Ligament (Medially)Lt. Subhepatic Space:Lt. Lobe of Liver (Above) and To Lt. ofFalciform Ligament. Lesser Omentum divides the Left Subhepatic Space into:Lt Posterior Subhepatic space (Lesser Sac)behind Stomach. Lt Anterior Subhepatic space: Stomach& Lesser Omentum (Posterior) Lt. lobe of liver (Below) .

  8. ANATOMY: SUBPHRENIC SPACES B. EXTRA-PERITONEAL SPACES 1. Rt. Extra-peritoneal Space (Bare Area of Liver) Bare area of liver comes into direct contact with the diaphragm, no peritoneum in between. 2. Lt. Extra-peritoneal Space around Lt. supra- renal gland and upper pole of Lt. Kidney

  9. PHYSIOLOGY OF PERITONEUM • Contains a little fluid to facilitate sliding of viscera. • Lymphocytes + Leucocytes found in this fluid • Exudation & absorption occurs through a large lymphatic and blood vessel network. • Healing of peritoneum doesn’t happens from the edges. It heals by metamorphosis of in-situ mesenchymal cells. So, healing of large peritoneal defects heal as rapidly as small defects.

  10. FUNCTIONS OF PERITONEUM • Inflammatory & Immune response • Visceral Lubrication • Pain perception by parietal peritoneum • Absorption of fluid & particulate • Fibrinolytic activity

  11. PERITONITIS TO BE DISCUSSED IN A SEPARATE LECTURE

  12. جنيه مصرى إصدار سنة 1928 يحمل صورة الخادم إدريس

  13. الوجه الآخر للجنيه السابق

  14. EMBRYOLOGY OF OMENTUM

  15. ANATOMY OF OMENTUM

  16. OMENTUM TORSION OF OMENTUM • Rare • Present as Acute Abdomen • PATHOLOGY: Twist of omentum around an axis due to: Adhesion (previous infection or operation) or Involvement of omentum ina hernial orifice. Rarely:Cyst, Fatty or Malignant infiltration

  17. OMENTUM • CLINICAL PICTURE:Present with Acute Abdomen Sudden sever abdominal pain May be shock Rigid Tender abdomen Twisted omentum is rarely palpable • Mainly, surgical diagnosis on EXPLORATION • TREATMENT:Exploration and excision of the twisted or strangulated omentum

  18. EXCISION OF STRANGULATED OMENTUM

  19. جنيه مصرى إصدار 1924 يحمل صورة الجمل

  20. الوجه الأخر للجنيه السابق

  21. MESENTERY MESENTRIC LYMPHADENITIS Definition: Inflammation of the mesentric lymph nodes. It may be 1. Non-specific: e.g. Acute non-specific mesentric lymphadenitis 2. Specific: e.g. T.B. mesentric lymphadenitis (Tabes mesenterica)

  22. MESENTERY Acute Non-specific Mesentric Lymphadenitis • Etiology:Unknown etiology Usually Children May be Viral 25% of cases are proceeded by URTI • Pathology: Enlarged inflammed mesenteric lymph nodes.Ileum & Mesentery : Congested + OedematousLittle peritoneal fluid Glands are hyperaemic + cellular hyperplasi Glands & peritoneal fluid are sterile on culture

  23. MESENTERY • CLINICAL PICTURE: 1. Children especially Males 2. Mistaken for Acute Appendicitis 3. Appendicitis : Mesenteric Adenitis is 10 : 1 4. Differences: Preceded with URTI H/O Previous similar attacks Patient moves freely during the attacks severe abdominal colicky pain Point of maximum tenderness is higher & more medial than in A. Appendicitis

  24. MESENTERY Rovsing’s sign is negative Turn the patient to Lt. side, point of maximum tenderness moves to midline or even to Lt. side (Shifting Tenderness) • MANAGEMENT: Careful history & clinical examination can differentiate both diagnoses. US can differentiate A. Appendicitis from A. mesenteric lymphadenitis Treatment is medical If surgery is done by mistake, do appendectomy to reach proper pathologic diagnosis

  25. MESENTERY TUBERCULOUS MESENTERIC ADENITIS ( TABES MESENTERICA) DEFINITION: Tuberculous Inflammation of Mesenteric Lymph Nodes Primary Intestinal T.B. in Children PATHOLOGY: • Ingestion of T.B. Bacilli with contaminated milk • Consists of primary complex (like that of lung) • Primary Complex = Focus in distal ileum (Payer’s Patches) + Huge enlarged mesenteric LNs

  26. MESENTERY FATE OF PRIMARY COMPLEX: This depends on body resistance. A. Resolution and healing by fibrosis &calcification. Adhesions may lead to intestinal obstruction or volvulus B. Activation and caseation to form mesenteric cold abscess. Rupture into peritoneal cavity leading to T.B. peritonitis Spread to thoracic duct leads to Miliary T.B.

  27. MESENTERY CLINICAL PICTURE: Symptoms: (due to T.B. Toxemia) 1. Abdominal pain 2. Low grade fever & Sweating 3. Wasting (Latin TABES means Wasting) Signs: 1. Tenderness below & Rt. To umbilicus 2. Enlarged LNs may be felt as irregular mass 3. May be sever tenderness, rigidity and even rebound tenderness in Rt. Iliac fossa to simulate A. Appendicitis

  28. MESENTERY INVESTIGATIONS: 1. WBCs: Normal but relative lymphocytosis 2.. Tuberculin test: If –ve , excludes T.B 3. Plain X-ray abdomen: May be calcific (Radio opaque) irregular LNs (DD. Urinary stones), Changes of position in repeated X-ray films help to differentiate from urinary stones. TREATMENT: 1. General: Good diet+ Better hygiene 2. Anti T.B. drugs for active lesions, Calcified, uncomplicated cases : No Medication 3. Surgery for adhesive intestinal obstruction (Adhesolysisor Bypass) and for volvulus (Untwist or Resection anastomosis for gangrene)

  29. MESENTERY MESENTERIC CYSTS DEFINITION: It is a fluid filled cyst in between the 2 layers of the small intestine mesentery TYPES: A. True mesenteric cysts With epithelial lined cyst wall B. False mesenteric cysts No cyst wall

  30. MESENTERIC CYSTS

  31. MESENTERY TRUE MSENTERIC CYSTS 1. Chylo lymphatic Cyst: * Commonest * Retention Cyst * Due to obstructed lymphatic * Wall is thin, with epithelial lining * Contents: Lymph (Chyle) * Separate blood supply from that of the related intestinal loop * Treatment by enucleation

  32. MESENTERIC CYSTS

  33. MESENTERY TRUE MSENTERIC CYSTS 2. Enterogenous Cysts: * A sequestrated loop * Arises during embryonic life from a diverticulum at mesenteric border of the intestine (Duplication of Intestine) * Thick cyst wall * Common blood supply with the related loop of intestine * Treatment is excision + resection anastomosis of the related intestinal loop

  34. MESENTERY TRUE MSENTERIC CYSTS 3. Dermoid Cysts 4. Hydatid Cysts

  35. MESENTERY FALSE MESENTERIC CYSTS 1. Blood cyst: * Haematoma of mesentery: * Due to trauma, * Observe for absorption, Evacuate if found on operation + hemostasis 2. T.B. mesenteric Cold Abscess: * It is a caseating T.B. mesenteric LNs. * Treatment: Anti T.B. medications 3. Gas Cyst: * Intestinal gas is forced through a cracked mucosa (e.g. in peptic ulcer). It is very rare

  36. MESENTERY MESENTERIC CYSTS CLINICAL PICTURE: * Painless abdominal swelling It has 3 characters( Tilaux’s Triad) 1. Cystic(Fluctuant) abdominal swelling near the umbilicus 2. Moves freely perpendicular on the of the line of mesenteric attachment (i.e. from upper Lt. to lower Rt. Abdomen) 3. Cyst is dullon percussion, resonance around and a band of resonance around it

  37. MESENTERY * Recurrent abdominal pain +/- Vomiting; Food is impacted in the bowel segment stretched over the cyst. * Patient may present with acute abdomen due to: Torsion Rupture (traumatic) Hemorrhage in the cyst Infection (abscess formation)

  38. MESENTERY INVESTIGATIONS: Barium Meal, Intestine is displaced by the cyst US, CT, MRI Needle Aspiration: for chemistry and cytology

  39. CT MESENTERIC CYST

  40. جنيه مصرى إصدار 1938 يحمل صورة رمسيس

  41. الوجه الأخر للجنيه السابق

  42. RETRO PERITOEAL TUMOURS DEFINITION: A group of primary tumors which arise the tissues occupying the retroperitoneal space It is not including tumors arising from the retroperitoneal organs (pancreas, kidneys adrenal glands) INCIDENCE: Mainly in 5th &6thdecades 15% in children < 10 years old

  43. RETRO PERITOEAL TUMOURS PATHOLOGY: 1. Malignant > Benign 4:1 2. 75% of Malignant tumors are Sarcomas 3. Arise from different tissues: * Lymph nodes Lymphosarcoma (Malignant) * Lymph vessels Lymphangioma (Benign) Lymphangiosarcoma (Malignant) * Fatty (Adipose) tissue Lipoma (Benign) Liposarcoma (Malignant

  44. RETRO PERITOEAL TUMOURS * Fibrous (Connective) tissue Fibroma (Benign) Fibrosarcoma (Malignant) * Striated muscle fibers Rhabdomyoma (Benign) Rhabdomuosarcoma (Malignant) * Nerve tissue Neurofibroma (Benign) Ganglioneuroma (Benign) Neuroblastoma (Malignant)

  45. RETRO PERITOEAL TUMOURS * Vascular tissue Haemangioma (Benign) Haemangioendothelioma ( Malignant) * Embryologic cell rests Dermoid tumor (Benign) Teratoma (Malignant)

  46. RETRO PERITOEAL TUMOURS CLINICAL PICTURE: 1. Abdominal mass: Fixed, usually Hard Commonest presentation 2. Abdominal pain: Vague 3. Present with complications Colonic obstruction ( progressive constipation) Ureteric obstruction ( Renal colic)

  47. RETRO PERITOEAL TUMOURS INVESTIGATIONS: 1. Plain X-ray abdomen * Calcification * Teeth & bony elements with Teratomas 2. Barium studies to exclude GI tumors 3. US, CT and MRI Shows the Site, extension to surrounding structures, depth of the tumor and tissue planes 4. Laparoscopy, Laparotomy and Biopsy To get a tissue diagnosis

  48. CT RETRO PERITOEAL SARCOMA

  49. RETRO PERITOEAL TUMOURS TREATMENT: 1. Surgery: Surgical exploration is indicated in most of cases. Resection if possible Most of cases are non- resectable, only biopsy is taken Debulking of the tumor mass may be helpful for the radiotherapy 2. Radiotherapy may be therapeutic or palliative 3. Combined Radiotherapy & Surgery

  50. RETRO PERITOEAL TUMOURS

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