This study investigated the retroperitoneal oblique corridor and trajectory of L1−L5 as the lateral surgical access to the intervertebral disks in the Chinese population and detected the potential ...relationship between the corridor or trajectory and vertebral parameters, including disk axis, psoas muscle, and retroperitoneal vessel.
Seventy magnetic resonance imaging studies performed from January 2017 to January 2019 were investigated. The oblique corridor was defined as the distance between the left lateral border of the retroperitoneal vessel and the anterior border of psoas. The trajectory was defined as the distance between the retroperitoneal vessel and lumbar plexus.
The oblique corridor analysis to L1−L5 disks have the following mean distances: L1−2 13.36 mm, L2−3 13.36 mm, L3−4 12.37 mm, and L4−5 10.36 mm. There was no difference in the L1−L5 corridor between genders. And the position of retroperitoneal vessel was negatively correlated with the corridor width. The trajectory measurements to L1−L5 disks have the following mean distances: L1−2 27.44 mm, L2−3 30.86 mm, L3−4 30.73 mm, and L4−5 24.36 mm. Moreover, the vertebral parameters, including the disk axis and psoas muscle, were positively correlated with the trajectory width. Otherwise, the position of retroperitoneal vessel was negatively correlated with the trajectory width.
Compared with previous studies, the safe surgical area of the Chinese is generally smaller than that of Caucasian. The position of the retroperitoneal vessel is the vital potential to limit the corridor and trajectory. Preoperative assessment of vertebral parameters, especially vascular structure, is essential for planning surgical process.
Extrauterine leiomyoma occasionally occurs in rare locations with unusual growth patterns, especially pelvic retroperitoneal leiomyoma, which brings great challenges for surgeons to make a diagnosis. ...It is essential to distinguish benign from malignant retroperitoneal neoplasms according to the imaging manifestations. Laparotomy and laparoscopy are the common options for pelvic retroperitoneal neoplasms, while they may cause side effects during operation such as secondary damage. Appropriate surgical techniques should be adopted to ensure the complete excision of neoplasms meanwhile preserve the urination, defecation, and sexual function.
A 30-year-old woman was referred to our hospital because of dull pain in the perianal region for 1 month. Laboratory results including tumor markers were all within normal limits. The digital rectal examination revealed a huge and tough mass with smooth mucosa protruding into the rectal cavity from the rear area of rectum.
Imaging examinations were performed. Contrasted computed tomography (CT) of pelvis showed an enhanced retroperitoneal solid mass in the space between sacrum and rectum, and very close to the levator ani muscle. The mass was about 11.0*8.0 cm in size. Computerized tomography angiography (CTA) showed the distal branches of bilateral internal iliac artery went into the mass. Endoscopic ultrasonography (US) showed the mass compressed the rectum, as well as a clear boundary to the rectal wall. A histopathologic examination confirmed the mass was a pelvic retroperitoneal leiomyoma.
The patient underwent an operative resection with da Vinci Si surgical system after routine preoperative preparation. Anorectal motility was weekly monitored postoperation. No additional adjuvant therapy was performed.
The patient could walk after 1 day and defecate normally on the third day after operation. She was discharged on the seventh postoperative day. No adverse events including pelvic floor hernia or defecation dysfunction occurred in the follow-up period. At 4 weeks follow-up, the patient was pain-free and recovered well.
Although imaging examinations were crucial for retroperitoneal neoplasms, histopathological examination remains the "gold standard" for making a definite diagnosis. This case highlights the possibility of retroperitoneal leiomyoma occurring in a woman of reproductive age and the advantages of robotic surgical system in pelvic retroperitoneal surgeries.
Laparoscopic adrenalectomy is a standard surgical procedure for benign adrenal diseases. Laparoscopic posterior retroperitoneal adrenalectomy (LPRA) has many benefits. However, it is associated with ...factors such as prolong operation time. The aim of the study was to determine the predictive factors associated with prolonged operation time in LPRA.
This study retrospectively analyzed data from 284 patients who underwent LPRA between 2014 and 2019 at Asan Medical Center. Then, we analyzed the predictive factors prolonging operation time using multivariate logistic regression analysis and classified the differences according to the learning curve using cumulative sum analysis.
In multivariate logistic regression analysis, the following were determined as factors associated with prolonged operation time: male sex (OR, 2.540; 95% CI, 1.225–5.266), pheochromocytoma (OR, 3.669; 95% CI, 1.548–8.694), right site (OR, 2.499; 95% CI, 1.086–5.748), surgeon A (OR, 3.293; 95% CI, 1.522–7.122), depth of descended adrenal tumor location to kidney (OR, 3.793; 95% CI, 1.660–8.667), large periadrenal fat volume (OR, 2.366; 95% CI, 1.120–4.996), and posterior adiposity index (PAI) (OR, 2.171; 95% CI, 1.090–4.324) (all p < 0.05). However, in the period after the learning curve, periadrenal fat volume was not a significant predictor of surgery time prolongation.
This study demonstrates that depth of descended adrenal tumor location to kidney is a new and important independent predictive factor for prolonged operation time in LPRA. In addition, periadrenal fat volume is a predictor of surgery time prolongation for beginner surgeons before the learning curve.
•The depth of descended adrenal tumor location to kidney is an important predictor that prolongs the operation time in LPRA.
Purpose
There are reports that performing lateral lumbar interbody fusion (LLIF) in a prone, single position (single-prone LLIF) can be done safely in the prone position because the retroperitoneal ...organs reflect anteriorly with gravity. However, only a few study has investigated the safety of single-prone LLIF and retroperitoneal organ positioning in the prone position. We aimed to investigate the positioning of retroperitoneal organs in the prone position and evaluate the safety of single-prone LLIF surgery.
Methods
A total of 94 patients were retrospectively reviewed. The anatomical positioning of the retroperitoneal organs was evaluated by CT in the preoperative supine and intraoperative prone position. The distances from the centre line of the intervertebral body to the organs including aorta, inferior vena cava, ascending and descending colons, and bilateral kidneys were measured for the lumbar spine. An “at risk” zone was defined as distance less than 10 mm anterior from the centre line of the intervertebral body.
Results
Compared to supine preoperative CTs, bilateral kidneys at the L2/3 level as well as the bilateral colons at the L3/4 level had statistically significant ventral shift with prone positioning. The proportion of retroperitoneal organs within the at-risk zone ranged from 29.6 to 88.6% in the prone position.
Conclusions
The retroperitoneal organs shifted ventrally with prone positioning. However, the amount of shift was not large enough to avoid risk for organ injuries and substantial proportion of patients had organs within the cage insertion corridor. Careful preoperative planning is warranted when considering single-prone LLIF.
There is a broad spectrum of neurogenic tumors that involve the abdomen. These tumors can be classified as those of (a) ganglion cell origin (ganglioneuromas, ganglioneuroblastomas, neuroblastomas), ...(b) paraganglionic system origin (pheochromocytomas, paragangliomas), and (c) nerve sheath origin (neurilemmomas, neurofibromas, neurofibromatosis, malignant nerve sheath tumors). Abdominal neurogenic tumors are most commonly located in the retroperitoneum, especially in the paraspinal areas and adrenal glands. All of these tumors except neuroblastomas and ganglioneuroblastomas are seen in adult patients. Abdominal neurogenic tumor commonly manifests radiologically as a well-defined, smooth or lobulated mass. Calcification may be seen in all types of neurogenic tumors. The diagnosis of abdominal neurogenic tumor is suggested by the imaging appearance of the lesion, including its location, shape, and internal architecture. Benign and malignant neurogenic tumors are difficult to differentiate unless distant metastatic foci are seen. For malignant tumors, imaging modalities other than computed tomography (CT) and magnetic resonance (MR) imaging may be necessary for staging. However, because most neurogenic tumors in adults are benign, CT and MR imaging can be used to develop a differential diagnosis and help determine the immediate local extent of tumor.
Acquired hemophilia-A (AHA) is a rare but potentially life-threatening impaired coagulation disorder characterized by the development of autoantibodies against clotting factor VIII. Only a few case ...reports have been experienced with influenza vaccine-triggered AHA. Here, we report a case of severe hemorrhagic disorder due to AHA following influenza vaccine, which was successfully treated.
The patient presented to the emergency department because of several severe, progressively worsening bruises after receiving the influenza vaccination. Consequently, the patient required intubation due to nasal-oral bleeding, which compromised the airway, and retroperitoneal hemorrhage with shock also developed.
AHA was confirmed through a coagulation factor assay, including coagulation activity and antibody testing, which is possibly triggered by influenza vaccination.
Low-dose cyclophosphamide and hydrocortisone were prescribed until activated partial thromboplastin time showed normal levels. Coagulation factor VIIa was administered, and aggressive blood transfusion was carried out concurrently to address the blood loss.
The upper airway bleeding subsided and bleeding tendencies had been corrected to normal. The patient was smoothly weaned from the ventilator and recovered from critical illness. She was then discharged on the 19th day.
The activated partial thromboplastin time mixing test can be performed immediately to establish the initial differential diagnosis and treatment plan for severe coagulopathy. AHA may be triggered by vaccination, with the hypothesis of activation of autoantibodies and molecular mimicry; this mechanism should be further studied.
Objectives
To develop a routinely applicable severity index for the management of acute appendicitis in adults using combined clinical and radiological parameters and retroperitoneal space planes ...(RSP).
Methods
Two hundred consecutive patients with histologically proven acute appendicitis and available presurgical CT scans were analysed retrospectively. Two radiologists assessed all CT scans for morphologic sings of appendicitis and six RSP. Clinical parameters were age, body temperature, C-reactive protein (CRP), white blood cell count, and duration of symptoms. Radiological parameters were appendix diameter and wall thickness, periappendiceal fat stranding and fluid, intraluminal and extraluminal air, thinning of appendiceal wall, caecal wall thickening, appendicolith and abscess formation.
Results
One hundred and three patients (51%) had histologically proven complicated appendicitis. Based on three clinical (age ≥52 years, body temperature ≥37.5°C, duration of symptoms ≥48 h) and four computed tomography (CT) findings (appendix diameter ≥14 mm, presence of periappendiceal fluid, extraluminal air, perityphlitic abscess), the APSI was developed using regression coefficients of multivariate logistic regression analyses with a maximum of 10 points. A score of ≥4 points predicted complicated appendicitis with a positive predictive value of 92% and a negative predictive value of 83%. Substantial to excellent interobserver agreement was found for the four radiological parameters of the APSI intraclass correlation coefficient (ICC), 0.78-0.83. The RSP evaluation presented no added value for the diagnosis of complicated appendicitis.
Conclusions
Using APSI, an accurate and simple prediction of complicated appendicitis in adults was possible. The RSP count was not useful for the diagnosis of complicated appendicitis.
Key points
• Appendicitis severity score provides an accurate and simple prediction of complicated appendicitis
• Appendicitis severity score ≥4 accurately predicted complicated appendicitis (PPV 92%;NPV 83%)
• Evaluation of retroperitoneal space planes was not useful in diagnosing complicated appendicitis
Cystic lymphangioma (CL) is a rare benign tumor resulting from a failure of the lymphatic system development. It may occur at any age but it is more frequent during childhood. Its clinical ...presentation and location are various but abdominal CL are uncommon. Among those, mesenteric presentation is the most frequent form whereas CL of the retroperitoneum are particularly rare.
Herein, we report the case of a 17-years-old patient with no medical history who presented with right-upper quadrant (RUQ) pain, but no other symptom. Physical examination showed tenderness of the RUQ without distension. Lab tests were unremarkable.
Abdominal computed tomography (CT) highlighted a retroperitoneal cystic mass potentially infiltrating the mesenterium, raising suspicion of a CL of the retroperitoneum. Diagnosis of CL was confirmed by histological analyses.
Patient underwent an exploratory laparoscopy that infirmed infiltration of the mesenterium and allowed for resection.
Postoperative course was uneventful and there is no evidence of recurrence after 14 months of follow-up.
Although CL essentially occur in children, pediatric retroperitoneal CL is a rare finding, with only 21 cases identified in the literature.In summary, CL are benign tumors rarely located in the retroperitoneum. Despite performant imaging technologies, preoperative diagnosis is challenging. Whenever possible, laparoscopic resection should be the treatment of choice. Herein, we report the largest CL pediatric case laparoscopically resected, and the first review of the literature on the topic.
Retroperitoneal colonic perforation is a rare cause of retroperitoneal abscess. It presents, more frequently in frail elderly patients, with heterogeneous signs and symptoms which hamper the clinical ...diagnosis. Subcutaneous emphysema with pneumomediastinum and iliopsoas muscle abscess are unusual signs. Colonic retroperitoneal perforation may be consequent to diverticulitis or locally advanced colon cancer. Due to the anatomy of the retroperitoneal space and different physiopathology, diverticular perforation may present with air and pus collection; on the other hand perforated colon cancer may cause groin mass and psoas abscess. We reported 2 cases of colonic retroperitoneal perforation from diverticulitis and locally advanced colon cancer, respectively. Aim of this report is to improve differential diagnosis based on clinical signs.
A 71-year-old man presented with pain in his left side, fatigue, fever, nausea, massive subcutaneous emphysema of the neck, and Blumberg sign in the left iliac fossa. A 67-year-old man presented with abdominal pain, sub-occlusion, left groin mass, left groin, and lower limb pain during walking, negative Blumberg sign.
In the first patient the computerized tomography revealed pneumoperitoneum, gas in the mesosigma, pneumomediastinum, wall thickening of the descending colon, and retroperitoneal collection from diverticular perforation. In the second patient abdominal CT scan found thickening of the sigmoid colon adherent to the iliopsoas and fluid collection.
In the first patient, a left hemicolectomy extending to the transverse colon, followed by a toilette and debridement of the retroperitoneum were performed. In the second patient, tumor of descending colon perforated in the retroperitoneum with iliopsoas abscess was treated with left hemicolectomy and a drainage of the abscess.
The first patient underwent right colectomy with ileostomy in the 7 postoperative day for large bowel necrosis. He died of sepsis 2 days after. The second patient had regular postoperative and he is still alive.
The spread of retroperitoneal abscess in complicated colonic diverticulitis is different from that in advanced colonic cancer. The former can present with a subcutaneous emphysema, the latter with a groin mass. Hence a thorough clinical examination and radiological studies are needed to diagnose these conditions.
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