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The retroperitoneum is an anatomical room located behind the abdominal muscle or peritoneal cavity. Abdominal organs that are not rely by the mesentery and lie between the abdominal wall and parietal peritoneum are stated to lie within the retroperitoneum. Several individual spaces consist of the retroperitoneum. These spaces room the anterior pararenal space, posterior pararenal space, and also the perirenal space. Every of this spaces has parts of assorted organs and structures. These structures encompass organs that add to numerous systems in the body, including the urinary, adrenal, circulatory, gastrointestinal, and endocrine systems.<1> This short article will talk about the structure, function, embryology, and also anatomy that the retroperitoneum, and will additionally include discussion of that clinical meaning and details surgical considerations.
Structure and also Function
The retroperitoneum divides into three key anatomical spaces: the anterior pararenal space, perirenal space, and posterior pararenal space. The anterior pararenal room contains the head, neck, and also body the the kidnize (the tail the the kidnize is in ~ the splenorenal ligament), ascending and descending colon, and the duodenum (except for the proximal first segment). Structures contained within the perirenal space include the adrenal gland, kidney, ureters, and also renal vessels. The posterior pararenal space, i m sorry is surrounded by the posterior sheet of the renal fascia and muscles that the posterior abdominal muscle wall, includes no major organs and is composed mostly of fat, blood vessels, and lymphatics.<2> There is likewise a fourth, much less well-defined an are known as the good vessel space. The lies anterior come the vertebral bodies and also psoas muscles and also contains the aorta, worse vena cava, and surrounding fat.<3>
The embryologic breakthrough of structures located within the retroperitoneum is categorized based on the location they source from in ~ the abdomen. Retroperitoneal structures deserve to be generally or secondarily retroperitoneal. Primarily retroperitoneal structures are those that were retroperitoneal during the totality of development. These structures incorporate the adrenal glands, kidneys, ureters, ab aorta, worse vena cava, and anal canal. Structures thought about to be secondarily retroperitoneal were initially suspended in the mesentery, and then later on migrated behind the peritoneum during development. This structures encompass the duodenum (except for the first segment), ascending and descending sections of the colon, and the kidneys (except because that the tail).<4>
Blood Supply and Lymphatics
The retroperitoneum contains the large vessels of the abdomen and also pelvis. Arterial blood it is provided is indigenous the ab aorta and all of its branches. The inferior vena cava and also its tributaries administer for venous drainage the the retroperitoneum and also its structures.<5> The lymphatic chain that the retroperitoneum is rich and also extensive. The lymphatics usually follow arteries, with called lymph nodes commonly found close to the root of the arteries. Lymph nodes lie in the retroperitoneal room of the abdomen space the inferior diaphragmatic nodes, and also the lumbar nodes. Lumbar nodes surround the worse vena cava and aorta and further classify together left lumbar, intermediate, and right lumbar. surrounding the an excellent vessels lie, three groups of lymph nodes, with their names equivalent to each vessel. Approximately the aorta room the pre-aortic, para-aortic, and also retro-aortic nodes. Similarly, roughly the worse vena cava exist the pre-caval, para-caval, and retro-caval nodes. The retroperitoneal lymphatic chain of the pelvis is made up of the typical iliac, external and internal iliac, obturator, and sacral lymph nodes.<6>
There is comprehensive network that nerves that both happen through and supply the retroperitoneum and also its linked structures. Six called pairs of parietal nerves branch native the lumbar plexus bilaterally. They are the iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, obturator, and also femoral nerves. The lumbosacral trunk and also ventral rami of S1-S3 and part of S4 come with each other to form the sacral plexus, which offers rise to plenty of of the nerves found within the retroperitoneum. The superior and also inferior gluteal nerves kind from the sacral plexus bilaterally. Likewise arising indigenous the sacral plexus space right and also left lumbar forgiveness trunks, as well as the greater, lesser, and least thoracic splanchnic nerves and four lumbar splanchnic nerves. Every one of these administer sympathetic innervation to abdominal muscle and pelvic viscera. The pelvic splanchnic nerves carry out parasympathetic innervation to structures of the peritoneal cavity. The vagus and also splanchnic nerves, along with celiac, superior mesenteric, and aorticorenal ganglia type the autonomic plexuses. These bring sympathetic, parasympathetic, and sensory (predominantly pain) fibers.<7>
Muscles in ~ the retroperitoneum can be organized based on their location. Muscle contributing come the posterior margin the the retroperitoneal room consist mainly of the transverse abdominal, psoas, quadratus lumborum, and iliacus. The paraspinous muscles add to the medial border on either next of the spine, and also the abdominal musculature creates the lateral margin. The remarkable border is developed in component by the diaphragm, if the iliopsoas muscle is the main muscle contributing to the inferior border.<8>
The treatment of most conditions involving the retroperitoneum requires surgical intervention. As such, a thorough expertise of retroperitoneal anatomy is an important for surgery including this area. Complications might arise native inadvertent damage to structures situated within the retroperitoneum during surgical manipulation or instrumentation.<9> vital consideration in any surgical procedure is gaining accessibility to and also achieving proper exposure that the frameworks in the area the the operation. The Kocher maneuver is a technique that enables accessibility to the retroperitoneum and also visualization of frameworks such together the aorta, worse vena cava, duodenum, and also pancreas. The is perform by very first identifying the duodenum, and then make an scratch in the peritoneum along its instant lateral (right) aspect, permitting the duodenum and also head the the kidnize to it is in separated from their peritoneal attachments and also reflected 180 levels medially (to the patient"s left) to gain access to retroperitoneal structures.<10> If higher exposure is required, the incision have the right to then be extended caudally along the white line of Toldt, enabling the ascending colon come be reflect medially and much more access come the more inferiorly lie retroperitoneal structures. This approach is well-known as an extended Kocher maneuver and is part of another much more extensive method called the Cattell-Braasch maneuver. It is performed v the procedures outlined over with the enhancement of dissecting the little bowel mesentery cephalad come the Ligament of Treitz in an avascular aircraft along the inferior mesenteric vein which enables the entire right colon and tiny bowel to it is in swung medially the end of the abdomen and complete exposure of the retroperitoneal structures.<11><12>
Retroperitoneal fibrosis is an uncommon collagen vascular disorder. That is the an outcome of a fibrotic reaction within the retroperitoneum, and its cause is no well understood. It has correlations through both benign and also malignant conditions, specific medications, and also idiopathic cases, i beg your pardon have likewise been described. Patients will often present initially through symptoms the ureteric obstruction. Apparently CT or MRI are of equal worth in diagnosis. Imaging commonly shows contrast-enhancing fibrosis encasing the frameworks of the retroperitoneum bring about obstruction and also displacement the the ureters or vascular structures. One underlying reason remains unfound in end 70% of cases. Treatment and outcomes vary and are dependent upon etiology and the level of obstruction.
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The retroperitoneum deserve to occasionally it is in a website of far-reaching bleeding, generally after trauma, surgical intervention, or also spontaneously in patients through vascular lesions (e.g., abdominal aortic aneurysm) or those treated with anticoagulation therapy. Presentation varies based upon etiology. Symptoms can incorporate hypotension, tachycardia, ecchymoses in the influenced areas, fatigue, hematuria, and flank or earlier pain. Computed tomography that the abdomen is the diagnostic imaging that choice. management of retroperitoneal hematoma is practically always MEDICAL, through resuscitation, blood transfusions, and also reversal of anticoagulation as necessary.<14>