RETROPERITONEAL SPACE [spatium retroperitoneale (PNA, BNA); synonym retroperitoneal space] — back department of an abdominal cavity.
In front 3. the item it is limited to a back (dorsal) part of a parietal peritoneum (peritoneum parietale), behind — a back wall of an abdominal cavity (see. Lumbar area ), the intra belly fascia (fascia endoabdominalis) covered from within, from above — a diaphragm and a phrenic fascia; down 3. the item stretches to the cape of a sacrum (promontorium) and an ambit of a basin (linea terminalis) where passes into subperitoneal space of a small pelvis. 3. the item it is executed fatty and friable not properly executed connecting by fabrics in which retroperitoneal bodies with their vessels, nerves and neuroplexes, limf, the device are located (tsvetn. fig. 1 and 2).
In 3. items distinguish three departments: median (across Pirogov «a mediastinum of a stomach») and two lateral, lying on the parties from a backbone and limited from sides to the line of transition of a parietal peritoneum with side on a back abdominal wall. Median department 3. the item corresponds to bodies of lumbar vertebrae and stretches from legs of a diaphragm, through openings the cut occurs connection of a mediastinum of a breast with «a mediastinum of a stomach», to the cape of a sacrum. The friable not properly executed connecting fabric filling this department 3. the item, passes into similar fabric between leaves of mesenteries thin and cross colonic guts. In median department 3. items are located a ventral aorta with its branches, the lower vena cava, the beginning of a portal vein, a part of a head and a body of a pancreas, a horizontal part of a duodenum, prevertebral vegetative neuroplexes, lumbar department of a sympathetic trunk, numerous limf, nodes and the tank chest limf, a channel with its roots. Lateral departments 3. items are also executed fatty and friable connecting by fabrics in which there are adrenal glands, kidneys, ureters, a part of a head of a pancreas, the descending part of a duodenum ascending (on the right) and descending (at the left) colons, branches of lumbar neuroplex. Friable connecting and fatty fabrics in lateral departments 3. items are divided into several layers by a retroperitoneal (subperitoneal) fascia (fascia retroperitonealis, s. subperitonealis), edges originates from a parietal peritoneum in the place of its transition from a sidewall of a stomach to back.
Within lateral departments 3. the item is distinguished on 4 kletchatochny spaces. 1. The retroperitoneal kletchatochny layer, or actually retroperitoneal cellulose (textus cellulosus retroperitonealis), is located between intra belly and a retroperitoneal fastsiyama. In outside departments actually retroperitoneal cellulose is more plentiful and directly passes kpered into preperitoneal cellulose, knutr — into cellulose of median department 3. the item, below — in cellulose of a basin, above — reaches a diaphragm. 2. The pararenal kletchatochny space (paranephron, s. capsula adiposa renis) is limited to leaves of a retroperitoneal fascia. Knutri passes the specified space into the cellulose surrounding an aorta and the lower vena cava, outside and from above it is closed, and below passes into the cellulose surrounding an ureter. 3. The periureteral kletchatochny space (paraureteron) is around an ureter between before - and a pozadimochetochnikovy fastsiyama, from top to bottom it connects to the cellulose lying behind a bladder. 4. The Okoloobodochny kletchatochny space (paracolon) lies kpered and lateralno from pararenal space. Above paracolon reaches the right or left bends of a colon, below — the blind person (on the right) or initial department of a sigmoid colon (at the left).
Degree of isolation of the listed spaces at different people is not identical that it is connected with various expressiveness of a retroperitoneal fascia. Possibility of the message of kletchatochny layers 3. the item is used during the carrying out diagnostic and to lay down. actions (retropneumoperitoneum, lumbar and perinephric blockade, etc.).
Blood supply bodies and cellulose 3. the item is carried out by branches of a ventral aorta: the celiac trunk, top and bottom mesenteric, pair renal, lower phrenic, by average adrenal and yaichkovy (ovarian), lumbar arteries, between to-rymi forms the numerous collateral anastomosis playing a significant role at naru/sheniye of blood circulation in an abdominal cavity. They not only connect all branches of a ventral aorta, but also connect them with above - and underlying arteries (intercostal, an upper epigastriß artery — above, the lower epigastriß, iliolumbar, deep artery which is bending around an ileal bone, an artery of a deferent duct, etc. — below).
More plentiful collateral network in 3. the item is formed by veins which belong to three systems: to the lower and upper venas cava and portal vein. Therefore among anastomotic venous networks in 3. items are available a kavo-caval, porto-portal and porto-caval anastomosis. All listed groups of an anastomosis have important functional value at disturbances of a blood-groove in the lower hollow and portal veins. Lymph drainage. Distinguish parietal y visceral limf, nodes 3. item. Nodes (nodi lymphatici lumbales), and also general ileal (nodi lymphatici iliaci communes) belong to parietal lumbar limf. Visceral limf, nodes are very numerous and lie at a celiac trunk, on the course of splenic and gastroduodenal arteries, between a head of a pancreas and a duodenum etc.
From the left part of actually retroperitoneal cellulose limf, vessels go to the lumbar nodes located at a ventral aorta, and from the right part of the same layer — to the same nodes at the lower vena cava. Limf, vessels of okoloobodochny kletchatochny spaces pass respectively to right and left colonic limf, to nodes, limf, vessels of pararenal space reach renal limf, nodes, and periureteral — renal, lumbar and internal ileal limf, nodes.
Innervation. Afferent innervation of friable connecting and fatty tissue 3. the item, the bodies which are in it, retroperitoneal and intra belly fastion is carried out by the sensitive spinal fibers going as a part of prevertebral vegetative textures (celiac, top and bottom mesenteric, renal, aortal, ureteric, yaichkovy, etc.), and also as a part of lumbar nerves.
Methods of a research
the Usual wedge, methods (survey, a palpation, percussion) allow to establish discoloration of integuments, asymmetry, a swelling, infiltrate. These changes can arise at inflammatory and purulent processes of retroperitoneal cellulose, tumors 3. the item, and also at diseases of the bodies located in 3. item. Methods of a research of these bodies — see separate articles, e.g. Aorta , Duodenum , Ureters , Adrenal glands , Pancreas .
Rentgenol, a research includes non-contrast methods — a survey X-ray analysis and roentgenoscopy of belly and chest cavities; contrasting of abdominal organs — a contrast research of a stomach and intestines, holegrafiya (see), pneumoperitoneum (see), splenoportografiya (see); and also excretory or retrograde urography (see), Pneumoretroperitoneum (see), etc. In the presence of special indications (suspicion on damage of a pancreas, circulatory or limf, vessels, etc.) resort to pankreatografiya (see), aortografiya (see), the selection angiography of branches of a ventral aorta, kavografiya (see), limfografiya (see). For studying of bodies of a small pelvis the Pneumoretroperitoneum is combined sometimes with metrosalpingografiya (see), tsistografiya (see) and other special researches. Such double or triple contrast study in combination with a tomography in direct and side projections (see. Tomography ) allows to define exact localization, and in some cases and character patol, process or anomaly of development, a form, the sizes and contours of kidneys and adrenal glands, a condition of pararenal cellulose that is of great value for differential diagnosis patol, processes in 3. the item and in an abdominal cavity.
Retroperitoneal hematomas arise at changes of pelvic bones and a backbone more often, besides, can be a consequence of damage of the body located in 3. the item or in an abdominal cavity (kidneys, a pancreas, a duodenum, a stomach, etc.). In more exceptional cases large vessels (an aorta, the lower vena cava, renal vessels) can be a source of retroperitoneal hematomas. Retroperitoneal hematomas can arise also at hemophilia.
Usually retroperitoneal hematomas are formed as a result of a direct injury without or with injury of bones or internals. They can be also result of blow to a front abdominal wall, at the same time wound of internals not only considerably worsens a condition of patients, but also complicates diagnosis of hematomas.
The clinical picture of retroperitoneal hematomas depends first of all on the nature of injuries of bones, bodies 3. the item, a stomach, and also from the size of hemorrhage. As showed P. P. Kiselyov, V. G. Tsuman and Yu. A. Muromsky's researches, in 3. the item can accumulate to 2 l of blood and more. Small hematomas can proceed asymptomatically. The symptomatology of extensive retroperitoneal hematomas is similar to clinic of an internal injury, especially soon after an injury, and is followed shock (see), blood loss (see) and picture acute abdomen (see). Shock in a varying degree almost always accompanies the retroperitoneal hematoma connected with injury of bones or internals. At most of patients morbidity of a stomach is noted, is more often on the party of damage. At massive hematomas Shchetkin's symptom — Blyumberg, a meteorism is observed.
The hemorrhagic syndrome at small hematomas is not expressed. However at considerable hemorrhages the anemization with falling of the ABP is noted up to collapse (see).
Diagnosis of retroperitoneal hematomas is based first of all on the anamnesis (the nature of an injury, a hemorrhage in the past at hemophilia) and local manifestations — a swelling, morbidity in lumbar area or in these or those departments of an abdominal cavity, quickly developing meteorism. Symptoms of dysfunction of an urinary system are of great importance. A characteristic symptom — forced position of the patient with the hip given to a stomach on the party of a hematoma. At massive bleedings the progressing decrease in hemoglobin and number of erythrocytes in peripheral blood, and also the ABP is noted.
Differential diagnosis shall be carried out first of all with injury of abdominal organs and an urinary system.
The retroperitoneal hematoma on roentgenograms is shown by an illegibility of contours and a displacement of the kidney, a lumbar muscle, a bladder or retroperitoneal departments of intestines.
Treatment of the isolated retroperitoneal hematomas shall be conservative. Measures for fight against shock, blood loss, paresis of intestines enter a complex of actions. At suspicion of wound of bodies 3. the item audit by their retroperitoneal access on the relevant party shall be made.
In some cases make a laparocentesis and as a last resort at impossibility to exclude an internal injury a laparotomy. And the retroperitoneal hematoma cannot be emptied in an abdominal cavity because of danger of infection. At the isolated retroperitoneal hematomas the forecast, as a rule, favorable. Infection of a hematoma leads to development of inflammatory and purulent process in 3. the item
Inflammatory and purulent processes in 3. items arise at direct wound (primary infection), metastatichesk and per continuitatem. The contagium can get in the hematogenous way from peripheral suppurative focuses and in a lymphogenous way at the inflammatory processes located in a basin on the lower extremities, in a thorax, intestines etc. The most frequent activators of an inflammation of cellulose 3. items are staphylococcus, a streptococcus and colibacillus. Approximately at a quarter of patients the mixed flora is observed.
Distinguish serous (catarral), purulent and putrefactive inflammatory and purulent processes in retroperitoneal cellulose.
According to an anatomo-topographical structure vospalitelnognoyny processes subdivide on paranephrites (see), paracolites (see) and inflammation of actually retroperitoneal cellulose. At the beginning of development inflammatory process is localized in any one department 3. item. In process of disturbance of an integrity of fascial leaves process extends to the neighboring sites 3. the item and out of its limits, forming extensive purulent flow.
A wedge, a picture of vospalitelnognoyny processes in 3. the item is characterized by temperature increase, changes from peripheral blood. In hard cases considerable frustration of cardiovascular system, breath, urination, etc. are observed.
The onset of the illness can be gradual, with slow development of symptoms or sudden, with rise in temperature and the expressed intoxication. During the progressing of a disease nausea, vomiting, a meteorism, symptoms of irritation of a peritoneum are observed. Quite often inflammatory and purulent processes in 3. items are followed by development of exudative pleurisy, is more often on the party of the defeat accepting sometimes character of purulent. In blood the expressed leukocytosis, band shift of a blood count, ROE later accelerated is noted. Changes in urine are possible.
In process of development of purulent process in cellulose local symptoms are shown more clearly: pain, muscular tension in lumbar area, formation of infiltrate, change of contours of lumbar area. For each anatomic localization of inflammatory and purulent process in 3. the item the form and the place of infiltrate is characteristic. At an arrangement infiltrate is in actually retroperitoneal cellulose in the field of an outside part of an ileal pole in the form of slantwise going from top to down and knutr of consolidation. At lumbar localization infiltrate has no sharply outlined borders, consolidation of an elastic consistence is defined over a wing of an ileal bone. For retroperitoneal localization of an abscess a characteristic symptom — a flexion contracture of a hip on the party of defeat.
At distribution of inflammatory process on surrounding kletchatochny spaces also local symptoms respectively change, along with it the general reactions amplify. At break of an abscess in an abdominal cavity symptoms local or the general join peritonitis (see). Retroperitoneal phlegmons can extend in a mediastinum, to bodies of a chest and abdominal cavity, lead to formation of secondary osteomyelitis, outside intestinal fistulas, an inflammation of a pararectal fat. Cases of distribution of zatek on a rump and even on a hip are observed.
Difficulties of diagnosis decide as the erased beginning of a disease, a big variety a wedge, manifestations, and a community of symptoms on other diseases.
The great value for diagnosis along with a wedge, assessment of the general and local manifestations has rentgenol. research. In the presence of symptoms of a purulent inflammation the diagnostic puncture 3 is sometimes necessary. item.
Differential diagnosis of inflammatory and purulent process in 3. the item it is quite often difficult. At dominance of the general reactions it is necessary to exclude infectious diseases. At more expressed local reactions pyoinflammatory process in 3. the item should be differentiated with diseases zabryushinno of the located bodies, and also abdominal organs (cholecystitis, appendicitis).
Treatment of inflammatory and purulent processes in 3. the item depends on a stage of process. In the absence of symptoms of suppuration antiinflammatory therapy (antibiotics of a broad spectrum of activity, streptocides), fortifying treatment is shown. Phlegmons and abscesses are subject to opening and drainage. For this purpose the best is the section across Pirogov over a wing of an ileal bone. Available flow open through additional cuts and counteropenings. Untimely and inadequate treatment can lead to heavy septic and tromboembolic episodes.
Retroperitoneal fibrosis can be an outcome most often of acute inflammatory diseases or damages. The wedge, his picture is shown by pains and disorders of functions of an urinary system. Rentgenol, a research reveals narrowing of an ureter (usually at the level of an average third), a pyelectasia and cups, and also the slowed-down release of contrast medium during excretory Urografinum. Retroperitoneal fibrosis is differentiated with sarcoma 3. the item, teratoid tumors, neurinoma, lymphoblastomas, malignant tumors of an ureter and pancreas, and also with metastasises.
Primary not organ tumors 3. items develop from entering it fatty, friable not properly executed connecting tissue, fastion, limf, nodes, vessels, nerves, nodes of a sympathetic trunk. Meet identical frequency at patients of both sexes and at any age, making 0,03 — 0,3% of all onkol, diseases. At children they make from 10 to 18% of all tumoral diseases, a half of them — extrarenal retroperitoneal tumors. From the point of view of an embryogenesis of a tumor 3. it is reasonable to item to divide into four groups: mesenchymal, neurogenic origin, teratoma and cyst. Mesenchymomas, lipomas, liposarcomas, lymphoma, lymphosarcomas and lymphogranulomas, fibromas, fibrosarcomas, leiomyomas, leiomyosarcomas, rhabdomyosarcomas, angiomas, myxomas, synovial sarcomas concern to group of mesenchymal tumors. Neurogenic tumors can proceed from nervous elements of adrenal glands, from covers of peripheral nerves — neurilemomas, neurofibromas or from a sympathetic nervous system — a paraganglioma, a neuroblastoma, a ganglioneuroma. Teratomas contain fabrics of three germinal leaves. Chordomas arise from the remains of a back string and are derivatives of a mesoderm. From the embryonal remains horionepitelioma, seminomas, germinomas, extrarenal hypernephromas can develop. From additional adrenal glands — hormonal active true hypernephromas. From all specified forms of tumors lipomatous are observed more often.
Retroperitoneal tumors can be high-quality and malignant, however this division is conditional as about a wedge., and with morfol, the points of view. Retroperitoneal lipomas are considered high-quality, however often recur. The tendency to recuring is observed also at other tumors which were considered high-quality — fibromas, leiomyomas. Color of tumors is characteristic: fibroma — white, a lipoma — yellow, sarcoma — from pink to red. Tumors can be single or multiple, their weight fluctuates from several tens grams to several tens kilograms. They grow towards the smallest resistance, i.e. towards an abdominal cavity, and push aside kpered or in the parties bodies of a stomach and retroperitoneal bodies (a stomach, a large intestine, ureters).
At tumors patients show complaints on went. - kish. discomfort, pains and feeling of weight in a stomach, the progressing lose of weight and weakness. These symptoms are a consequence of pressure of a tumor upon abdominal organs. Sometimes accidental detection in a stomach of a tumor is the first sign drawing attention of the patient to the appeared disturbances of digestion. Often tumors reach the considerable sizes before they are found. Also the acute phenomena from bodies of a stomach are possible — impassability of intestines, a renal failure in connection with a prelum of both ureters. Temperature increase of skin on the sick party on 0,4 — 0,8 ° as manifestation of pressure put by a tumor upon a sympathetic trunk of this area (Hesse's symptom) is described.
The diagnosis of primary retroperitoneal tumor can be made by an exception and demands comprehensive inspection of the patient.
X-ray analysis of an abdominal cavity and 3. the item can reveal a number of signs, the general for all volume patol. formations of this localization — an additional shadow according to the palpated tumor (usually low-movable), the shift of a stomach and loops of intestines without disturbance or with disturbance of functions, deformation or lack of a contour of a lumbar muscle on the party of defeat, change of a form, the sizes and position of kidneys, liver or spleen.
The contrast urography allows to reveal change of cavities, the sizes and position of kidneys, shift of ureters (fig. 1), kidneys, etc. If the new growth is localized in an abdominal cavity, then the shift and a prelum of kidneys and ureters usually is not observed. At a contrast research went. - kish. a path pay special attention to character and extent of deformation and shift of a stomach or intestines, and also to existence of signs of primary or secondary defeat of their wall. For specification topics and the character revealed volume patol, educations and clarifications of its communication with other bodies 3. items excretory (or retrograde) prepost urography in the conditions of the imposed pneumoretroperitoneum (fig. 2 and 3).
In some cases also 3 resort to the combined administration of gas in an abdominal cavity, a stomach, intestines. the item (the combined pneumography).
Usually it is possible to come to certain conclusion about existence of a retroperitoneal tumor, but to establish the true nature of a tumor possibly only during operation, sometimes after gistol, researches.
Treatment of retroperitoneal tumors can be surgical, beam, chemotherapeutic or combined. Timely surgical treatment yields the best results. Involvement in tumoral process of the next bodies sometimes makes impossible an oncotomy. Sometimes it is necessary to delete together with it a part of a small, large intestine, a kidney.
Megavoltny radiation therapy is applied as an independent method and in quality of training to surgical intervention. Preirradiation allows to suppress growth of tumor cells that promotes carrying out the subsequent surgical intervention in more favorable conditions; it is shown to patients with fibroblastichesky tumors, liposarcomas, myxosarcomas, and also fusocellular sarcomas. Operational treatment is performed in 7 — 14 days after the end of radiation therapy.
Postoperative radiation therapy is reasonable at rhabdomyosarcomas (an embryonal origin), neuroblastomas and other sarcomas of an undifferentiated and anaplastic row, and also at not radical surgical intervention or recurrent tumors. Radiation therapy is applied as the main method of treatment of hl. obr. at malignant lymphoma (reticulosarcomas, a lymphogranulomatosis).
A contraindication for beam treatment — the expressed intoxication, a cachexia.
At beam treatment of tumors 3. items apply gamma and therapeutic installations (Rokus, «Agate With»), linear accelerators, betatrons. Irradiate area of primary tumor, its bed and zones of regional innidiation. Single focal doses 200 — 220 I am glad 5 weekly. Total doses at preirradiation 3500 — 4000 I am glad. At the localized forms of malignant lymphoma 3. the item radiation is carried out by a technique of consecutive fields with inclusion of a tumor and all zones of regional innidiation to the level of a diaphragm (fig. 4). Total focal doses on area of a tumor 4500 — 5000 I am glad, on zones of possible innidiation — 3500 — 4000 I am glad. At dissimination of process on 3. it is reasonable to item to apply a technique of the displaced strips. Radiation is carried out on 2 — 3 strips 3 cm wide by counter bunches with single focal doses 240 — 260 is glad. Daily the field of radiation is displaced on 3 cm gradually to irradiate everything 3. the item, then a course repeats to a total focal dose 1800 — 2200 is glad (fig. 5). According to literature, metastasises at primary malignant retroperitoneal tumors arise in 30% of cases. The postoperative lethality reaches 25%.
The cysts which are found in 3. items, can proceed from the remains of primary urinogenital system, develop in a mesentery of intestines. Here lymphatic, mucous cysts or entero-cysts meet. Their symptomatology is similar about a wedge, a picture of tumors. Treatment operational.
Vagenknekht L. V. and Over. Diagnosis and treatment of retroperitoneal fibrosis, in book: 24th congress Mezhdunarodn. islands of surgeons, under the editorship of B. V. Petrovsky, t. 1, page 299, M., 1972; Varnovitsky G. I. Radiodiagnosis of diseases of a pancreas, M., 1966, bibliogr.; Gostev V. S. Retroperitoneal hemorrhages at the closed changes of pelvic bones, Vestn, hir., t. 106, No. 2, page 49, 1971, bibliogr.; D at r N about in L. A., B at x - N y A. F. and L of e e d e in V. I. Tumors of retroperitoneal space and an abdominal cavity at children, M., 1972, bibliogr.; A. V. Klinik's millers and prevention of retroperitoneal and pelvic phlegmons at wounded in a stomach, L., 1956; Mikhaylets P. V. O retroperitoneal abscesses, Klin, hir., No. 5, page 40, 1967, bibliogr.; Pytel A. Ya. and Pytel Yu. A. Radiodiagnosis of urological diseases, M., 1966, bibliogr.; Ratner Yu. A. Retroperitoneal tumors, Kazan, 1965; Surgical anatomy of a stomach, under the editorship of A. N. Maksimenkov, L., 1972; Circassian V. L., Kowalewski E. O. and Solovyov Yu. N. Extra organ retroperitoneal tumors, M., 1976, bibliogr.; Shanin A. P. Retroperitoneal tumors, L., 1962; Shpizel R. S. Acute inflammatory diseases of cellulose of retroperitoneal space, Surgery, No. 11, page 59, 1971, bibliogr.; D e b and at G h. e. a. Diagnostic radiologique des tumeurs retroperiton6-ales, Ann. Radiol., t. 14, p. 721, 1971, bibliogr.; Reschke H. Arteriography of the retroperitoneal space and the adrenals, J. beige Radiol., v. 54, p. 565, 1971; W i r b a t z W. u. M a t e e v B. Diag-nostik der Tumoren des Retroperitoneal-raums, Radiol, diagn. (Berl.), Bd 7, S. 87, 1966.
G. I. Vorobyov; B. A. Ankudinov (I am glad.), L. A. Atanasyan (PMC.), A. N. Kishkovsky (rents.), P. A. Kupriyanov, S. S. Mikhaylov (An.).