Retroperitoneal Anatomy

CHAPTER 3 Retroperitoneal Anatomy

Graham F. Greene, MD, FACS

What forms the lateral boundaries used to take down the bladder during an anterior approach to a robotic-assisted laparoscopic prostatectomy?

The obliterated umbilical arteries, which form the medial umbilical folds.

Retractor compression on the psoas muscle during surgery can affect which nerve?

The femoral branch of the genitofemoral nerve.

It is necessary to take care in placing the stitch in the psoas muscle during a bladder hitch procedure, so that what nerve is not injured?

The femoral nerve.

When performing a transverse colon conduit what cavity is exposed?

The lesser sac.

When exposing the infrahepatic inferior vena cava (IVC) what critical structure anteromedially that is associated with the liver can be injured?

The common bile duct.

What ligamentous attachments of the liver to the diaphragm need to be divided in order to rotate (flip) the liver and gain access to the suprahepatic and transhepatic IVC?

The gastrophrenic ligament, the falciform ligament, and the coronary ligament.

When closing a flank incision, which muscle layer has an obvious free border?

The external oblique muscle has a free border laterally that extends from the lower border of the 12th rib to its aponeurotic insertion along the iliac crest.

Between which 2 muscle layers do the intercostal nerves and vessels course?

They course between the transversus abdominis and the internal oblique muscles. This is important when closing incisions to avoid entrapment of these structures.

What is another name for Gerota fascia?

Perirenal fascia. It is a specialized condensation within the intermediate stratum of the retroperitoneal connective tissue. It forms a barrier to benign and malignant processes.

Does Gerota fascia form a tight seal around each kidney?

No. Gerota fascia is weakest at its caudal aspect along the course of the gonadal vessels and ureter.

When resecting a large left upper pole renal mass from an anterior approach, what medial attachments need to be divided to allow reflection of the spleen, pancreas, and stomach?

Division of the phrenicocolic, splenorenal, gastrosplenic, and gastrophrenic ligaments will allow reflection of the spleen, pancreas, and stomach from the craniolateral aspect of the retroperitoneum exposing the upper pole of the left kidney and adrenal gland.

What surgical maneuver will allow access to the intra- and suprahepatic vena cava?

Division of the right and left triangular ligaments and continuing the incision along the cranial and caudal coronary ligaments will allow reflection of the right lobe of the liver, providing dramatic exposure to the inferior vena cava as it receives the hepatic veins and perforates the diaphragm.

What nerve is commonly seen coursing anterolaterally in the inguinal canal?

The ilioinguinal nerve (L1) courses through the inguinal canal on the cord to exit the external ring and provide sensation to the pubic area.

What other nerve besides the ilioinguinal nerve follows the cord through the inguinal canal?

The genital branch of the genitofemoral nerve (L1, L2). It is less conspicuous than the ilioinguinal nerve and has a dual function supplying motor innervation to the cremasteric muscle and sensation to the anterior scrotum or labia majora.

What nerve is clearly visualized coursing along the ventrum of the psoas muscle and proves useful in defining the lateral border for a complete pelvic lymph node dissection?

The genitofemoral nerve (L1, L2) serves a dual purpose in supplying motor function to the cremasteric muscle and sensation to the perineum and anterior thigh.

Define the arterial blood supply of the right adrenal gland.

The right adrenal receives its blood supply from 3 main sources. The 2 obvious ones include branches from the inferior phrenic artery as well as branches from the right renal artery. A branch that is often forgotten that passes behind the inferior vena cava is the middle adrenal artery. This can lead to significant bleeding if unrecognized and cut during a right adrenalectomy.

Into what structures do the gonadal vessels on either side drain?

The right gonadal vein enters the inferior vena cava on its ventral lateral aspect at an oblique angle. The left gonadal vein empties into the left renal vein.

What is the significance of a varicocele that does not diminish when examined in the supine position?

Suspect a retroperitoneal mass or process that is impairing venous drainage such as lymphoma, testicular cancer, renal cell carcinoma, or retroperitoneal fibrosis.

What are the primary sites of lymphatic drainage from the left testis?

The most common site on the left side is the left para-aortic lymph nodes followed by the preaortic, interaortocaval, left common iliac, and left suprarenal lymph nodes in decreasing order. Left-to-right lymphatic drainage tends not to occur unless there is lymphatic obstruction.

What are the primary sites of lymphatic drainage from the right testis?

The most common site on the right side is the interaortocaval lymph nodes followed by precaval, preaortic, right paracaval, right common iliac, and left para-aortic lymph nodes in decreasing order. Lymphatic drainage proceeds from the right to left side of the retroperitoneum. Alternative routes can occur when there is lymphatic obstruction.

Which division of the renal artery supplies the majority of the kidney?

The anterior division supplies more than 75% of the kidney, including apical, upper, middle, and lower vascular segments of the kidney. The posterior renal artery supplies the majority of the dorsal aspect of the kidney.

How often can a surgeon anticipate accessory renal arteries?

In 25% to 40% of cases, there is more than one renal artery arising from the lateral aorta at the level of the second lumbar vertebra. Accessory renal arteries to the right lower pole will often cross anterior to the vena cava. It becomes important to recognize such branches so that they are not divided when exposing the right renal hilum.

Where do the renal pelvis and the upper ureter receive their arterial blood supply?

There are 3 anastomosing arteries providing the upper ureter and renal pelvis with blood supply. They include the renal artery, aorta, and gonadal artery.

Which adrenal gland is more intimate with the cranial aspect of the kidney?

The left adrenal gland is most intimate with the cranial aspect of the left kidney. It often will drape over the ventral aspect of the upper pole. The right adrenal gland is decidedly cranial to the right kidney, and care must be given when removing it because of its short adrenal vein entering dorsolaterally into the inferior vena cava.

What is an alternate route for venous drainage of the left adrenal gland?

The left inferior phrenic vein. The adrenal gland vein drains into the left renal vein. Close to where it enters, it is joined by the inferior phrenic vein that cranially also empties into the inferior vena cava above the level of the hepatic veins. This means that you can divide the adrenal vein at the level of the renal vein without compromising its venous drainage.

Does ligation of the gonadal arteries at the level of the aorta compromise the gonads?

No. The rich collateral circulation provided by the artery to the vas deferens and external spermatic artery in the male and the uterine artery in the female provide collateral blood supply to the gonad.

What are the first branches of the intra-abdominal aorta?