Surgery of the Abdominal Wall

294 Pages·1987·13.96 MB·English

by  J. P. H. Neidhardt (auth.)

Surgery of the
Abdominal Wall
Edited by J. P. Chevrel
With the Collaboration of
M.Caix G.Champault 1.Hureau
S.luskiewenski D. Marchac 1. P. H. Neidhardt
1. Rives R. Stoppa
Foreword by Lloyd M. Nyhus
With 203 Figures in 425 Separate Illustrations,
Some in Color
Springer-Verlag
Berlin Heidelberg GmbH
Professeur Jean Paul Chevrel
Service de Chirurgie Generale et Digestive, H6pital Avicenne,
Universite Paris 13, 125 Route de Stalingrad, F-93009 Bobigny
Translator: Dr. Elliot Goldstein
Bachlettenstrasse 82, CH-4054 Basel
Title of the original French edition: Chirurgie des parois de I'abdomen
©Springer-Vedag Berlin Heidelberg New York Tokyo 1985
ISBN 978-3-662-10166-7
ISBN 978-3-662-10166-7 ISBN 978-3-662-10164-3 (eBook)
DOI 10.1007/978-3-662-10164-3
Library of Congress Cataloging-in-Publication Data. Chirurgie des parois de
l'abdomen. English. Surgery of the abdominal wall. Translation of: Chirurgie des parois
de l'abdomen. Includes bibliographies and index. 1. Abdominal wall-Surgery.
I. Chevrel, J. P. (Jean Paul) II. Caix, M. (Michel) III. Title. [DNLM: 1. Abdominal
Wall-surgery. WI 900 C5415] RD540.2.C4813 1986 617'.553 86-6535
This work is subject to copyright. All rights are reserved, whether the whole or part of the
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© Springer-Verlag Berlin Heidelberg 1987
Originally published by Springer-Verlag Berlin Heidelberg New York in 1987
Foreword
The abdominal wall has always been of interest to surgeon-anato
mists. It was recognized as a barrier, and volumes have been written
demonstrating how to breach this wall. Similarly, great importance
has been placed on the methods of repairing the abdominal wall,
whether that repair is necessitated by a primary operative wound, a
congenital failure, an acquired defect, or the ubiquitous iatrogenic
problem, the postoperative abdominal wall hernia.
French surgeons have a long tradition of excellence in the field of
human anatomy: the names of Pare, Bichat, Cloquet, and Fru
chaud readily come to mind. It is not surprising then, that this com
prehensive text on the subject of the abdominal wall and its defects
emanates from France.
Although there are many interesting aspects to this presentation of
abdominal wall problems, I find the review of prosthetic material
and its use to be most unique. The synthetic meshes available today
may well revolutionize our various approaches for repair of hernial
defects. Considerable experience has evolved in the use of these
prosthetic materials, particularly in the United Kingdom and Eu
rope. I have been a proponent of prosthetic mesh for the cure of
recurrent groin hernia during the past decade. According to the re
sults reported in this book, the use of a prosthetic material in select
ed patients needing primary hernia repair seems indicated.
I would be remiss if the organization GREPA were not highlighted.
It is common today to form clubs dedicated to the study of single
organ systems, such as the pancreas or the esophagus. GREPA is a
group dedicated to the study of problems relating to the abdominal
wall and is another example of how concentrated attention given to
a single subject can significantly advance our knowledge. Editor
Chevrel and his colleagues can be proud of what has been accom
plished by GREPA and of the superb documentation of its efforts
in this monograph.
Lloyd M. Nyhus
M. D., Dr. h. c., Warren H. Cole Professor
and Head, Department of Surgery
University of Illinois
College of Medicine at Chicago, USA
Introduction
It has now been 8 years since the working group known as GREPA
was formed (Groupe de Recherche et d'Etude de la Paroi Abdomi
nale - Group for Research and Study of the Abdominal Wall).
Its founding surgeons were initially united by a common desire
to promote the study of the abdominal wall. Very quickly strong
bonds of friendship developed among the founding members
ofGREPA.
Many talented surgeons were already distinguished for their work
on the abdominal wall. However, it was our belief at that time that
an up-to-date analysis of new techniques, modern prosthetic mate
rials and certain little known surgical approaches would lead to im
proved results in surgery of the abdominal.
A few members of GREPA, who had previously done considerable
work in the field of abdominal wall surgery, agreed to collate the
fruits of their vast experience in this book. I am greatly indebted to
them for their contribution; they have brought a certain distinction
to this sometimes difficult and often underestimated field of sur
gery.
This book is divided into two parts.
The first part begins with the classical surgical anatomy of the ab
dominal wall and its weak points. This section is followed by a
study of the electromyography and histoenzymology of the mus
cles, with special emphasis on recent findings. Part One concludes
with the diagnostic features of ultrasonography and computerized
tomography of the abdominal wall.
The second part of this book is devoted to the study of the abdomi
nal wall according to the following outline:
- Surgical approaches
- Pre- and postoperative care
- Postoperative complications
- Closed trauma of the abdominal wall
- Defects of the abdominal wall: pathological, iatrogenic
- Hernias
- Pathology of the umbilicus
- Plasty of the abdominal wall
- Abdominal wall in infants and children
VIII Introduction
Each of the contributing authors has been asked to give the essen
tial fruits of his experience. No attempt has been made to produce
an encyclopedia of the abdominal wall or treatise of surgical tech
nique. The modest aim of this book is to present a series of tradi
tional and modern, or even stilllitt1e known solutions to the patho
logical conditions involving the abdominal wall. It is hoped that
these solutions will be of benefit to the experienced surgeon as well
as the young surgical resident.
On behalf of the contributing authors, I would like to express our
sincere gratitude to Doctor G6tze who sponsored this book for
publication by Springer-Verlag. We also thank Mrs. A. Travadel
who designed the illustrations.
This book is dedicated to my four daughters.
Paris, October 1986 1. P. Chevrel
List of Co-authors
Professor Michel Caix
with the collaboration of G. Outrequin, B. Descottes, M. Kalfon,
X. Pouget, and G. Catanzano
Service de Chirurgie, CHU Dupuytren, F-S7031 Limoges Cedex
Professor Gerard Champault
Service de Chirurgie Digestive, H6pital Jean Verdier, Avenue du 14 Juillet,
F-93140 Bondy
Professor Jean Paul Chevrel
Service de Chirurgie Generale et Digestive, H6pital Avicenne,
125 Route de Stalingrad, F-93009 Bobigny
Professor Jacques Hureau
with the collaboration of J. Taboury and J. Pradel-Raynal
Service de Chirurgie Viscerale et Digestive, H6pital Corentin Celton,
37 Bd. Gambetta, B. P. 66 Cedex, F-92133 Issy les Moulineaux
Professor Serge Juskiewenski
Service de Chirurgie Infantile et Neo-natale, CHU Toulouse Purpan,
Place du Dr. Baylac, F-31059 Toulouse Cedex
Professor Daniel Marchac
130 Rue de la Pompe, F-75016 Paris
Professor Jean Pierre Hanno Neidhardt
Service des Urgences Chirurgicales, Centre Hospitalier Lyon Sud,
Chemin du Grand Revoyet, F-69310 Pierre Benite
Professor Jean Rives
with the collaboration of J. C. Fire, J. B. Flament, and J. P. Palot
Clinique Chirurgicale, CHU Robert Debre, Rue Alexis Carrel,
F-51100 Reims
Professor Rene Stoppa
Service de Clinique Chirurgicale Universitaire, Centre Hospitalier
Regional, 1 Place Victor Pauchet, B. P. 3006, F-S0030 Amiens Cedex
Table of Contents
Part 1. General
Chapter 1. Surgical Anatomy of the Anterolateral and Posterior
Abdominal Walls and Points of Weakness
J. P. H. Neidhardt . . . . . . . . . . . . 3
1. The Anterolateral Abdominal Wall 4
A. Cutaneous and Subcutaneous Layer . 4
B. Vascularization of the Cutaneous Layers of the Abdomen 4
1. Arterial Vascularization 4
2. Venous Drainage . . 5
3. Lymphatic Drainage 5
C. Myofascial Layer . . . 5
1. Rectus Abdominis . 5
2. Abdominal Oblique and Transverse Muscles 6
a) ExternalOblique ........ 6
b) Internal Oblique . . . . . . . . . 6
c) Transversus Abdominis Muscle 7
(1) Transversalis Fascia. . . . . 7
(2) Fascia Propria . . . . . . . . 8
3. Rectus Sheath (Vagina Recti Abdominis) 8
a) Arcuate Line (Semicircular Line of Douglas) 8
b) Adhesion of the Rectus Abdominis to the Laminae of
Its Sheath .......... 9
4. Linea Alba. . . . . . . . :--: . . . . . . . . . . . . . . . 9
5. Semilunar Line (Spigelius Line) . . . . . . . . . . . . . 9
D. Vascularization of the Muscle Layers of the Anterolateral
Abdominal Wall . ; . . . . 10
1. Arterial Vascularization 10
2. Venous Drainage . . . . 11
3. Lymphatic Drainage . . 11
E. Innervation of the Anterolateral Abdominal Wall. 11
1. Superficial Layers. . . . . . . . . . . . . . . . . 11
2. Deep Layers: Motor Innervation of the Parietal Muscles 12
3. Neural Anastomoses and Metamerization .. 14
II. Weak Points of the Anterolateral Abdominal Wall. . . . . . . 14
A. Umbilicus . . . 14
1. Outer Aspect ... 14
2. Structure. . . . . . 14
a) Umbilical Ring 14
b) Round Ligament of the Liver . 14
XII Table of Contents
c) Umbilical Arteries . . . . . . . . . . . . . . . . . . . . 15
d) Urachus . . . . . . .. ..... 15
e) Umbilical Fascia .................... 15
1) Umbilical Peritoneum. . . . . . . . . . . . . . . . . . 16
3. Vascularization and Innervation of the Umbilical Region 16
a) Arteries. . . . . . . . . .. ............. 16
b) Veins. . . . . . . . . . . . . . . . . . . . . . . . . . . 16
c) Lymph Vessels. . . . . . . . . . . . . . . . . . . . . .. 16
d) Nerves . . 17
B. Inguinal Region . . . . . . . . . . . . . . . . . . . . . 17
1. Outer Layer . . " . . . . . . . . . . . . . . . . . . 17
2. Aponeurosis of the External Oblique Muscle of the
Abdomen. . . . . . . . . . . . . . . . . . . . . . . . . 17
3. Deep Myofascial Layer - The Myopectineal Orifice. . 17
a) Components of the Fibromuscular Frame. . . . 17
(1) Medial Margin .. 17
(2) Superior Margin ............... 18
(3) Inferior Margin . . . . . . . . . . . . . . . . 18
b) Umbilicoprevesical Fascia and Inguinal Peritoneum . 21
C. Other Weak Points of the Anterior Abdominal Wall .... 21
1. Linea Alba. . . . . . . . . 21
2. Semilunar Line . . . . . . 21
III.The Posterior Abdominal Wall 22
A. Deep Layer ....... 22
1. Median Spinal Axis. . 22
2. Lateral Spinal Muscles 22
a) Iliopsoas Muscles . 22
b) Quadratus Lumborum 23
3. Vascularization and Innervation of the Deep Muscle Layer
of the Posterior Abdominal Wall. . . . . . . . . . . 24
a) Arterial Vascularization and Venous Drainage . . . .. 24
b) Lymphatic Network. . . . . . . . . . . . . . . . . . .. 24
c) Innervation ........................ 24
4. Site of Emergence of the Terminal Branches of the Lumbar
Plexus in Relation to the Iliopsoas Muscle . . . . . . . .. 24
5. Action of the Deep Muscles ofthe Posterior Abdominal
Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
B. Superficial Layer of the Posterior Abdominal Wall . . . . .. 25
Chapter 2. Functional Anatomy of the Muscles of the Anterolateral
Abdominal Wall: Electromyography and Histoenzymology
Relationship Between Abdominal Wall Activity and Intra-abdominal
Pressure
M. Caix with the collaboration of G. Outrequin, B. Descottes,
M. Kalfon, X. Pouget, and G. Catanzano . . . . . . . . . . . . 27
I. Detailed Study of Structure: Histochemical Analysis of the
Fibers of the Abdominal Wall . . . . . . . . . . . . . . . . . .. 28
A. Material and Methods ..................... 28
B. Results . . . . . . . . . . . . . . . . . . . . . . . . . . 29
C. Functional Deductions . . . . . . . . . . . . . . . . . 30
II. Detailed Study of Function: Quantitative Kinesiological
Electromyography of the Abdominal Wall Musculature. 30
Table of Contents XIII
A. Principles of the Method .................. . 30
1. Automatic Analysis of the Recordings .......... . 30
2. Selection of Muscle Activities Within Narrow Frequency
Spectra ........................... . 30
B. Overall Results and Tentative Interpretation ....... . 31
C. Results of the Method Applied to the Study of the Function
of the Abdominal Wall Muscles ........... . 32
1. Technique . . . . . . . . . . . . . . . . . . . . . . . 32
2. Comparative Performance of the Rectus and Flat
Abdominal Muscles According to Study Subgroup 32
a) Assessment of Performance. . . . . . . . . . . . 32
b) Results According to Subject Category ..... 32
III. Study ofIntra-abdominal Pressure in Operated Patients. 34
A. History ........ . 34
B. Material and Methods 35
C. Results ........ . 36
1. Baseline Pressure . . 36
a) First Postoperative Day . . 36
b) Fourth Postoperative Day 36
2. Respiratory Modifications . . . 36
3. Effort of Defecation with Blocking of Expiration 36
4. Modulation of Abdominal Pressure by Speech . . . . . . . 36
5. Effects of Coughing on Abdominal Pressure ....... . 36
D.Comments .......................... . 36
IV. Correlation of the Activity of the Diaphragm and Abdominal
Wall Muscles with Intra-abdominal Pressure . . . 39
A. Material and Methods ........ . 39
B. Results ............. . 39
1. With Normal Respiration .. ......... ... . 39
2. With Deep Inspiration . . . . .. . . . . . . 39
3. During Effort of Coughing . . . ...... . 39
4. Intra-abdominal Pressure and Circulatory Physiology . 39
V. Conclusions and Surgical Applications . . . . . . . . . . . . . . 39
Chapter 3. Procedures for Investigation of the Abdominal Wall
J. Bureau with the collaboration ofJ . Taboury and J. Pradel-Raynal 41
I. Echography of the Abdominal Wall (J. Taboury) . 42
A. Technique of Echographic Investigation. . . . 42
B. Echographic Anatomy of the Abdominal Wall 42
1. Epidermis and Dermis ........... . 42
2. Hypodermis . . . . . . . . . . . 42
3. Muscles ofthe Abdominal Wall 42
4. Sheaths and Aponeuroses . . . 45
5. Peritoneum . . . . . . . . . . . 45
C. Echography of the Pathological Abdominal Wall . 45
1. Parietal Collection of Fluid .......... . 45
2. Hernia ........ . 46
3. Incisional Hernia . . . . . . . . . . . . . . . . 47
4. Tumor ..................... . 49
5. Spontaneous Hematoma of the Rectus Sheath 50
6. Other Anomalies Seen on Echography . . . . 50