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The mesentery and its folds tether the small bowel loops to the posterior abdominal wall. It transmits nerves, vessels, and lymph ensconced in a fatty sponge layer wrapped in a thin glistening peritoneum, from and to the small bowel. Not only does this flexible dynamic fatty apron house various localized primary benign and malignant lesions, it is often involved in and gives an indication of generalized or systemic diseases in the body. An understanding of the anatomy, components, and function of the mesentery helps to classify mesenteric abnormalities. This further allows for characterizing radiological patterns and appearances specific to certain disease entities. Recent reviews of mesenteric anatomy have kindled new interest in its function and clinical applications, heralding the possibility of revision of its role in diseases of the abdomen.

Lumbar hernia is a protrusion of intraperitoneal or extraperitoneal tissues through posterior abdominal wall defect and is considered to be a rare condition. We present a case of 65-year-old lady with primary spontaneous superior lumbar hernia treated laparoscopically, with the detailed operative steps and post-operative follow-up. With the growing experience in laparoscopic inguinal hernia repair, same technique, instruments and device used in transabdominal preperitoneal (TAPP) repair can be applied to treat selected cases of lumbar hernia with good outcome.

The sympathetic chain serves to distribute visceral efferents and afferents over the entire body. The sympathetic chain courses from the base of the skull to the coccyx and sends branches to distribute along spinal nerves and a number of visceral nerves that distribute to cardiac muscle, smooth muscle and glands. During dissection of the posterior abdominal wall, we identified a rare variation of the sympathetic chain. In this subject, the sympathetic chain failed to send gray rami to the L2-4 spinal nerves and terminated by joining the S1 anterior ramus. Such a variation has only been reported once in the literature in 1895. We provide both schematic and photographic documentation of this variation and propose a number of possible circuits whereby visceral axons can reach their target despite these anatomical barriers.

Paraduodenal hernias (PDHs) are rare entities that may present with acute or subacute symptoms, and which pose challenges to prompt diagnosis and treatment. The minimally invasive management of these hernias is emerging as a new compelling approach to optimize surgical recovery. We present the case of a 42-year-old female patient who presented with acute abdominal pain and symptoms of bowel obstruction. Abdominal imaging suggested the presence of a left PDH. Laparoscopic exploration was performed. Intestinal malrotation was noted with incarceration of a small bowel loop in the Landzert fossa. The incarcerated bowel loop was freed and primary repair of the hernial defect was performed. PDHs are usually congenital and involve a herniation of abdominal content into the left mesocolon, between the mesocolon and the posterior abdominal wall. Minimally invasive treatment, consisting of adhesiolysis and repair of the hernial defect, seems to be a valid and safe option.

The aim of this study is to assess the clinical effectiveness of posterior abdominal wall components separation with transversus abdominis muscle release (PCS-TAR) in the management of ventral abdominal hernias. Ventral abdominal hernias complicate up to 11% of laparotomy wounds. Surgical management includes primary repair, hernioplasty, flaps, and components separation. A technique has been described to close large abdominal defects by releasing bilateral myofascial flaps of rectus abdominis from external oblique and advancing these flaps to the midline. Minimally invasive and endoscopic techniques were subsequently developed to reduce complications. A recently described method is PCS-TAR. The hypothesis is that PCS-TAR for abdominal wall reconstruction is associated with lower rates of wound complications and hernia recurrence than other components separation techniques. A comprehensive search of databases including Medline, Embase, Cochrane Central Register of Controlled Trials, and Scopus was conducted in accordance with PRISMA guidelines, looking for the primary outcomes of hernia recurrence and wound complications following different techniques of components separation. Inclusion and exclusion criteria were defined. The quality of studies was examined independently by 2 assessors. A total of 363 studies were identified. Three retrospective comparative studies met the inclusion criteria. No randomized control trial comparing different techniques of abdominal wall components separation was identified. No technique could be identified as superior to others, due to a paucity of the literature. However, based on a few retrospective cohort studies, PCS-TAR emerges as a well-tolerated new technique, with a low incidence of wound complications and hernia recurrence.

The femoral nerve is the largest branch of the lumbar plexus. It is normally composed of the ventral rami of spinal nerves L2 to L4. The psoas major has proximal attachments onto the T12 to L5 vertebrae and related intervertebral discs, fuses with the iliacus deep to the inguinal ligament and then attaches onto the lesser trochanter of the femur. Normally, the anatomical relationship is that the femoral nerve is located between the iliacus and psoas major. Herein, we report a case of the psoas quartus muscle related to several splits of the femoral nerve within the pelvis. Although the embryology for this is unclear, surgeons and physicians should be aware of such anatomical variants in order to better understand pain and entrapment syndromes and during surgical maneuvers in this region such as lateral transpsoas approaches to the lumbar spine.

The lateral transpsoas approach to the lateral lumbar spine necessitates an in-depth understanding of regional anatomy. Included with this is knowledge of the lymphatics of the posterior abdominal wall. This chapter reviews the lymphatic anatomy of the retroperitoneum.

The posterior abdominal muscles are quadratus lumborum, psoas major, psoas minor, and iliacus. Knowledge of these muscles, especially the pass major, is vital to the lateral transpsoas spine surgeon. This chapter discusses the normal and variant anatomy of these muscles.

Knowledge of the posterior abdominal wall and retroperitoneal space is vital to the lateral transpsoas spine surgeon. This chapter discusses the anatomy of this region including the various fasciae and structures found within its borders.

Objectives: The accessory obturator nerve (AON) is often underrepresented in the literature and unknown to many surgeons. As this variant nerve has been mistaken for other regional nerves e.g., obturator nerve, nerve injury has occurred. Therefore, the current study was undertaken to better understand the surgical anatomy of the AON. Methods: In the supine position, 20 adult fresh frozen cadavers (40 sides) underwent an anterior approach to the retroperitoneal space. When present, the length and diameter of the AON were measured with microcalipers. The position, course and origin of each AON were documented. Results: The AON was identified on 12 sides (30%). The origin was found to be L2–L3 on four sides; L3 on two sides, L3–L4 from three sides, from the obturator nerve on two sides, and from the femoral nerve on three sides. The average length from the origin to the superior pubic ramus was 14.5 cm. The average diameter was found to be 1.2 mm. All AON were found to lie medial to the psoas major muscle. Additionally, on all sides, the AON was medial to the femoral nerve and lateral to the obturator nerve. Two left sides anastomosed with the anterior division of obturator nerve at its exit from the obturator foramen. Eight sides terminated deep (two) or superficial (six) to the origin of pectineus; two of these had demonstrable branches to the hip joint. Conclusion: The AON is a normal anatomical variant and there are many variations in its origin and terminal branches can be “strong” or “weak.” Knowing the normal anatomy and variations of the AON is important for surgeons including neurosurgeons, orthopaedic surgeons, and urologists who deal with the pathologies of this area.

Variations of the muscles of humans are important to remember for those who interpret imaging and for those who operate near these anomalies. Herein, we describe a rare two-headed psoas minor muscle found incidentally during dissection of the posterior abdominal wall. This case is presented with a detailed review of all known variations of the minor psoas and is analyzed through a literature review.

Purpose: In this study, it was aimed to examine the impacts of elastics band trainings, which were applied for 12 weeks on the Olympic-style weightlifters, on their sportive performances and psoas, ilacus, and quadratus lumborum muscle volumes.Materials and Methods: This research study was conducted on 4 groups, comprising of 12 men (elastic band training group (n=6), control group (n=6)), and 12 women (elastic band training group (n=6), control group (n=6)) Olympic-style weightlifters. The athletes in the elastic band training groups were engaged in standing hip flexion exercises, clamshell exercises, lying hip flexion exercises, and side bend exercises. Before and after the elastic band training applied to the Olympic-style weightlifters for 12 weeks, (1.5 Tesla) MRI device was used for the axial images of the regions starting from the 12th thoracic vertebrae to the trochanter minor of femur. The volume calculations of the muscles were conducted via the Cavalieri method.Results: After the elastic band training, it was determined that the total volume of posterior abdominal wall muscles of the men and women weightlifters in the elastic band training groups and the total weights lifted by them were higher compared to those of the control group individuals (p

Background:The minimal repair technique for sports hernias repairs only the weak area of the posterior abdominal wall along with decompressing the genitofemoral nerve. This technique has been shown to return athletes to competition rapidly. This study compares the clinical outcomes of the minimal repair technique with the traditional modified Bassini repair.Hypothesis:Athletes undergoing the minimal repair technique for a sports hernia would return to play more rapidly compared with athletes undergoing the traditional modified Bassini repair.Methods:A retrospective study of 28 patients who underwent sports hernia repair at the authors’ institution was performed. Fourteen patients underwent the modified Bassini repair, and a second group of 14 patients underwent the minimal repair technique. The 2 groups were compared with respect to time to return to sport, return to original level of competition, and clinical outcomes.Results:Patients in the minimal repair group returned to sports at a median of 5.6 weeks (range, 4-8 weeks), which was significantly faster compared with the modified Bassini repair group, with a median return of 25.8 weeks (range, 4-112 weeks; P = 0.002). Thirteen of 14 patients in the minimal repair group returned to sports at their previous level, while 9 of 14 patients in the Bassini group were able to return to their previous level of sport ( P = 0.01). Two patients in each group had recurrent groin pain. One patient in the minimal repair group underwent revision hernia surgery for recurrent pain, while 1 patient in the Bassini group underwent hip arthroscopy for symptomatic hip pain.Conclusion:The minimal repair technique allows athletes with sports hernias to return to play faster than patients treated with the modified Bassini.

Injury to the nerves of the lumbar plexus can result in significant disability. Therefore, the clinician should be knowledgeable of both the normal and variant anatomy of these branches. We report what we believe to be the first description of the accessory obturator nerve providing a branch to the psoas major muscle. Such a variant innervation to the psoas major muscle should be kept in mind by those who examine patients or operate near the lumbar plexus.

Introduction. Positional anomalies of the right half of the colon are quite common whereas positional anomalies of the left half of the colon are much less common because of embryological disorders during the period of the embryological development of that part of the bowel. The process of the fixation of the descending colon to the posterior abdominal wall can be absent. In that case, when the descending colon has a free descending mesocolon, it shows some degree of mobility. Case Outline. We are presenting an example of one of the anomalies, which is characterized by the persistent descending mesocolon, which extends from the splenic flexure or just below it to the sigmoid colon. The persistent descending mesocolon in our case contains or surrounds almost complete small bowel in a recess which is located laterally to the left of the midline. The content of this hernial sac simulates the symptoms of an internal hernia followed by clinical symptoms and roendgenographical signs. Conclusion. We are of the opinion that this anomaly is more common than some surveys of literature would suggest.

Introduction The module utilizes the team-based learning (TBL) approach to teach the gross anatomy of the posterior abdominal wall, kidneys, and diaphragm. The application exercises include two different case studies: pyelonephritis and the pain management of cholangiocarcinoma. Methods This TBL module was originally delivered to an interprofessional class of first-year surgical physician assistant (PA) and nurse anesthetist (NA) students at the University of Alabama at Birmingham in the fall of 2014 in the NA/PA Gross Anatomy course, and designed to supplement cadaveric dissection activities following a traditional regional anatomy-based lecture. Following the standard TBL format, each TBL session included a preclass assignment in which students were given learning objectives and assigned readings to prepare for the session. Students were then administered individual readiness assurance tests, group readiness assurance tests, and a series of group application exercises centered on the clinical gross anatomy of the posterior abdominal wall and diaphragm. Results Following completion of the NA/PA Gross Anatomy course, student outcomes data was evaluated to determine the effectiveness of incorporating this TBL. Students of the 2014 course who participated in TBL outscored students of the 2013 course on all written and practical examinations. On average, students who participated in TBL in conjunction with lecture and dissection scored 4.9 percentage points higher on written examinations and 5.0 points higher on practical examinations than those who only participated in lectures and dissections. Discussion This TBL module successfully solidifies students' knowledge of the clinical gross anatomy of the posterior abdominal wall and diaphragm. While the content included in this module was written for first-year NA and PA students, the module is suited for a variety of health science disciplines including medicine, dentistry, optometry, and physical therapy.

Object. Reports describing surgical landmarks with which to identify the branches of the lumbar plexus found on the posterior abdominal wall are lacking in the English-language literature. Methods. The authors examined 22 sides from six female and five male cadavers. Measurements were made between the branches of the lumbar plexus and various bone landmarks such as the midline vertebral bodies, supracristal plane—a horizontal line connecting the superior-most aspect of the left and right iliac crests approximating the L4–5 vertebrae—and anterior superior iliac spine (ASIS). The mean distances from the midline and as they emerged through or lateral to the psoas major muscle to the subcostal, iliohypogastric, ilioinguinal, lateral femoral cutaneous, genitofemoral, and femoral nerves, were 5.5, 6, 6.5, 6, 4.5, and 4.5 cm, respectively. At a vertical line through the midpoint between the ASIS and the midline, the subcostal, iliohypogastric, and ilioinguinal nerves were superior to the supracristal plane at mean distances of 8, 4, and 5 cm, respectively. Inferior to the supracristal plane and in a vertical line through a midpoint between the ASIS and the midline, the lateral femoral and femoral nerves were found to have mean distances of 5 and 5.5 cm, respectively. The obturator nerve had a mean distance of 3 cm lateral to the midline. Additionally, the lateral femoral cutaneous nerve had a mean distance of 1.5 cm inferomedial to the ASIS. Conclusions. A good working knowledge of the locations and anatomy of the nerves of the lumbar plexus on the posterior abdominal wall is necessary for the surgeon who operates in this region. The measurements provided herein will aid the surgeon who wishes to expose or avoid these nerves, thus precluding injury.

Information about abdominal wall can be used for many applications from organ segmentation, registration, and surgical simulation. The challenges exist in abdominal wall extraction due to its varieties in shapes, connection to the internal organs and anterior layer edge formed between the muscle and fascia/fatty layer, which may distract the shape model. In this paper we present an approach to the posterior abdominal wall extraction using the shape model and other abdominal context, particularly with the rib-spine bone information and the wall image features. The shape model is constructed based on the training abdominal walls that are delineated manually. After bone information being extracted, the wall shape deforms from the prior shape model using the snake, which is constrained by the bone context and guided by the processed image energy map with the aim of removing distracted image features of anterior abdominal wall and the outer region from the original map. Meanwhile, an overall convex shape is maintained by limiting the angles of the contour points. The proposed approach is tested on abdominal CT data which provides encouraging results.

The abdominopelvic autonomic nervous system is a complicated network of interdigitated fibers stemming from the sympathetic and parasympathetic systems. Harmony between these two systems is important in the functions of the abdominopelvic viscera. This chapter highlights the specific course and origin of the fibers that come together to innervate the visceral structures of this region.

Vascular malformations (VMs) are congenital abnormalities of aberrant angiogenesis with reported prevalence of 1.2–1.5%. VMs can be either high flow (eg, arteriovenous malformation (AVM) or arteriovenous fistula (AVF)) or low flow (eg, capillary, venous, lymphatic) type.1 Head, neck and extremities are the common sites for VMs.2 Although congenital and often asymptomatic they rarely manifest before adolescence. Pain, bleeding, compressible lump, congestive heart failure and cosmetic appearance are clinical presentations of VMs which …

Wartime injuries from explosive devices have created the need for atypical responses to devastating and unusual injuries. We report a case of an explosive abdominal injury that produced a huge defect in the posterior abdominal wall which was ultimately repaired with a rectus abdominus flap, an usual use of this versatile muscle flap. The rectus abdominus muscle may be another tool available for the repair of wartime injuries.

Because the third portion of the duodenum is located behind the superior mesenteric vessels and transverse mesocolon, a direct approach to it would be hazardous. Liberating the right colon and small bowel mesentery from their attachments to the posterior abdominal wall permits the surgeon to elevate the right colon and entire small bowel to a position over the patient’s thorax. This changes the course of the superior mesenteric and middle colic vessels so that they travel directly cephalad, leaving the transverse portion of the duodenum completely exposed.

The kidneys are placed retroperitoneally on the posterior abdominal wall, the right lower than the left. At the renal hilum are found, from before back, the renal vein, artery, pelvis of the ureter and a small posterior artery branch. There are also lymphatics and sympathetic fibres (T12–L1), which account for referred renal pain to the lower abdominal wall and external genitalia. The pelvis of the ureter divides into two or three major calyces, which divide into minor calyces, each indented by a renal papilla, onto which discharge the renal tubules. The three fascial layers are: the capsule, which is easily stripped from the healthy kidney; the perinephric fat; and the investing renal fascia, which adheres to the structures at the hilum and usually tamponades a closed rupture of the kidney, which can thus be treated conservatively. The ureter is 25 cm long, comprising the pelvis and an abdominal, pelvic and vesical portion; the last acting as a sphincter. The ureter is crossed by the gonadal vessels and may be injured here in gynaecological surgery. The ureter can be identified as it constantly crosses the common iliac artery at its bifurcation and then lies on the anterior aspect of the internal iliac artery.

Laparoscopy has become the forefront of urologic surgery for the management of malignant and nonmalignant diseases. With this, an increasing number of urologists are performing routine and complex laparoscopic procedures with the aim of more minimal invasive approaches, which have the potential for significant reduction in patient morbidity. Understanding the anatomical landmarks and relationships of the urinary tract of these approaches is therefore vital to minimizing complications and maximizing success. Retroperitoneal laparoscopic surgery in urology is becoming relatively common and has led to great familiarity with the retroperitoneal anatomy. Knowledge of the complex anatomy of the entities lying between the posterior abdominal wall and peritoneum and recognition of common variations and their potential implications are crucial for successful surgery of retroperitoneal organs.