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Adult Autopsy
Published in Cristoforo Pomara, Vittorio Fineschi, Forensic and Clinical Forensic Autopsy, 2020
Cristoforo Pomara, Monica Salerno, Vittorio Fineschi
After removing the liver along with the right side of the lesser omentum, including the hepatic–duodenal ligament, incise the parietal peritoneum along the C-shaped duodenal convexity, then completely remove the tissue block. Starting at the pylorus, detach the duodenum and pancreas from the structures behind them, following the cleavage plane of the retropancreatic sphincter of Oddi (this structure is also called the hepatopancreatic sphincter, or Glisson’s sphincter). This structure controls the flow of secretions passing from the liver, pancreas, and gallbladder into the duodenum of the small intestine. It is actually composed of muscle located at the surface of the duodenum. It is located slightly distal to the point where the common bile duct and pancreatic duct join as they enter the descending duodenum to form the ampulla of Vater. The opening is on the inside of the descending duodenum, the sphincter of Oddi, is a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the duodenum.
Peritoneal metastases
Published in Anju Sahdev, Sarah J. Vinnicombe, Husband & Reznek's Imaging in Oncology, 2020
The peritoneal cavity is a serous sac (or coelom) lying between the parietal and visceral peritoneum (Figure 33.1). It consists of a series of communicating potential spaces not normally seen on imaging unless distended by fluid or air. The visceral peritoneum covers the abdominal organs, and the parietal peritoneum lies against the abdominal wall and retroperitoneum, resulting in an extensive surface area as a potential site of tumour deposition. The greater omentum consists of four layers of peritoneum, two from the greater curve of the stomach and two from the transverse mesocolon, which fuse and pass anterior to the small bowel—this is often involved by metastases. The lesser omentum (or gastrohepatic ligament) joins the lesser curve of the stomach to the liver. Ligaments are peritoneal folds connecting abdominal organs. A mesentery is a peritoneal fold joining the small bowel or parts of the colon to the posterior abdominal wall and containing blood vessels, lymphatics, and nerves (3). Ligaments and mesenteries are suspended by the visceral peritoneum and so are not truly intraperitoneal (4).
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy
Published in Tom Cecil, John Bunni, Akash Mehta, A Practical Guide to Peritoneal Malignancy, 2019
The lesser omentum is a frequent site of disease in PMP and is in fact a continuation of the peritoneum covering the porta hepatis. A radical lesser omentectomy aims at removing all the peritoneum between stomach and inferior liver edge down to the aorto-caval groove [5]. In cases where the lesser omentum is not macroscopically involved (e.g. in patients with CPM), it is recommended to open and fenestrate it, to allow circulation of chemotherapy down to the aorto-caval groove during the HIPEC phase. It is often feasible to clear the gastric vessels of all disease, without sacrificing them due to the ‘surface’ nature of the disease, and preservation of the left gastric vessels is key to avoid the need for a total gastrectomy (Figure 9.12). A recent report has demonstrated that a partial or rarely total gastrectomy is necessary to achieve a complete cytoreduction in 12% of cases, either due to gastric vessel involvement or complete encasement of the stomach (Figure 9.11).
Surgical treatment of therapy-resistant reflux after Roux-en-Y gastric bypass. A case series of the modified Nissen fundoplication
Published in Acta Chirurgica Belgica, 2020
Jan Colpaert, Julie Horevoets, Leander Maes, Gilles Uijtterhaegen, Bruno Dillemans
In essence, a laparoscopic 360° fundoplication was performed to reinforce the LES by wrapping the excluded stomach around the distal esophagus. The patient was put in beach chair position and a pneumoperitoneum of 15 mmHg was established. One scope trocar and four utility trocars were placed, using the same position as the initial gastric bypass surgery (Figure 1) [13]. After initial adhesiolysis from the previous surgery the excluded stomach is carefully isolated by dividing the short gastric vessels with harmonic scissors. Subsequently the lesser omentum (or hepatogastric ligament) is opened at the pars flaccida and dissection continues toward the diaphragm to expose the right crus. Further blunt dissection is used to separate the right crus from the esophagus. The dissection is then continued to free the esophagus circumferentially.
The mesentery: an ADME perspective on a ‘new’ organ
Published in Drug Metabolism Reviews, 2018
Aneesh A. Argikar, Upendra A. Argikar
The development of mesentery during and after the embryonic stage has been covered in great detail elsewhere (Martini and Tallitsch 2014). To summarize the embryonic development, the endoderm forms the hindgut and the foregut. During the initial months of the embryo, the gut is just a simple tube. This simple digestive tube is suspended by the mesentery. After gradually disappearing, the ventral mesentery remains in two places, on the ventral surface of the stomach known as lesser omentum and between the liver and anterior abdominal wall known as falciform ligament. The lesser omentum provides stability to the stomach and also provides a way for the blood vessels and other structures to enter and leave the liver. As the embryo grows, the dorsal mesentery enlarges and forms a pouch called the greater omentum. The literature on the expression of enzymes and transporters in the embryonic and fetal mesentery was not available.
Pancreaticopleural fistula: a rare cause of pleural empyema
Published in Acta Chirurgica Belgica, 2019
Wies Vanderbruggen, Vicky Dhooghe, Bart Bracke, Vera Hartman, Geert Roeyen, Dirk Ysebaert, Paul Van Schil, Thiery Chapelle
At the current admission on our ER further investigation through blood analysis showed a normal C-reactive protein, but elevated white blood cell count (23 × 109/L) and high lipase serum levels (8900 IU/L). Hence the past history of pancreatitis with PPF, a CT scan was carried out. This showed an acute on chronic exudative pancreatitis with evidence of fluid effusion into the retroperitoneum, extending through the esophageal hiatus into the mediastinum and right pleural space (see Figure 4). Despite initial conservative therapy with total parenteral nutrition, broad-spectrum antimicrobial treatment and somatostatin rapid respiratory deterioration was seen and patient was referred to the intensive care unit. A diagnostic thoracocentesis showed an empyema with growth of Escherichia coli and Streptococcus anginosus. Initial chest tube placement appeared to be insufficient and surgical intervention was required. Right-sided video-assisted thoracoscopic surgery (VATS) was performed for thorough pleural debridement, proper decortication and drainage of the empyema and placement of chest tubes. Inflammatory parameters remained elevated and an additional abdominal laparotomy with opening of the lesser omentum and drainage of necrotic fluid was mandatory. In attempt to resolve the PPF an omentoplasty was positioned through the diaphragmatic hiatus (see Figure 5). An abdominal drain was placed for external drainage of the collection. Despite thrombolysis of the pleural cavity and multiple antimicrobial therapy, persistent inflammation with elevated white blood cell count and C-reactive protein was seen. Finally the plastic pancreatic stent was removed endoscopically. After the removal and further extensive antimicrobial treatment a good clinical evolution was seen. Oral nutrition could be initiated without major events. Control MRCP confirmed radiographic decrease of the PPF and patient could be discharged after five weeks.