Surgical, Radiographic, and Endoscopic Anatomy of the Retroperitoneum

Question 1

The upper pole of the left kidney is typically located at the level of the ___

Answer 1

The upper pole of the left kidney is typically located at the level of the 11th rib

Question 2

The lower poles of the kidneys are between the __ and __ vertebrae

Answer 2

The lower poles of the kidneys are between the L3 and L4 vertebrae

Question 3

he renal hila are approximately at the level of __

Answer 3

he renal hila are approximately at the level of L1.

Question 4

The inferior border of the aponeurosis of the external oblique forms the __

Answer 4

The inferior border of the aponeurosis of the external oblique forms the inguinal ligament

Question 5

Deep to the external oblique lies the internal oblique, which originates from the __ fascia and ___

Answer 5

Deep to the external oblique lies the internal oblique, which originates from the lumbodorsal fascia and the iliac crest.

Question 6

from medial to lateral, list all posterior wall muscle layers

OUTER Layer:

INNER LAYER:

Answer 6

outer: Sacrospinalis –> latissimus dorsi-> external oblique

Inner layer: Psoas muscle- >Quadratus lumborum–> IO –> TA

Question 7

The intercostal vessels and nerves travel between the internal intercostal and innermost intercostal muscles within the ___ on the caudal margin of the superior rib

Answer 7

The intercostal vessels and nerves travel between the internal intercostal and innermost intercostal muscles within the costal groove on the caudal margin of the superior rib

Question 8

The lumbodorsal (thoracolumbar) fascia These three layers merge into one as they travel __. A common access point to the retroperitoneum is ___, where all layers have merged into one. This single layer of lumbodorsal fascia merges with the aponeurosis of the ___ muscle anterolaterally. The posterior lamella originates medially from the spinous process of the lumbar vertebrae and covers the ___. The middle lamella separates these ___ muscles from __. The anterior lamella covers the ___. Extending medially, the anterior lamella attaches to the ___ and is continuous with the fascia that invests the ___.

Answer 8

The lumbodorsal (thoracolumbar) fascia is composed of three distinct layers that invest the posterior abdominal wall musculature. These three layers merge into one as they travel laterally. A common access point to the retroperitoneum is near the tip of the 12th rib, where all layers have merged into one. This single layer of lumbodorsal fascia merges with the aponeurosis of the transversus abdominis muscle anterolaterally. The posterior lamella originates medially from the spinous process of the lumbar vertebrae and covers the erector spinae muscles. The middle lamella separates these erector spinae muscles from quadratus lumborum. The anterior lamella covers the ventral surface of quadratus lumborum. Extending medially, the anterior lamella attaches to the vertebral transverse process and is continuous with the fascia that invests the psoas muscle.

Question 9

dorsal lumbotomy incision, what landmarks and layers

Answer 9

in between latissimus dorsi and external oblique

RETROPERITONEAL FAT, FASCIA LUMBORIS, RENAL FASCIA,RETRORENAL FAT

Question 10

2 fascias must be incised to allow access to the renal hilum

Answer 10

transversalis fascia and gerotas

Question 11

difference of perirenal fat and pararenal fat

Answer 11

The perirenal fat is finer and lighter yellow than the coarser yellow-orange pararenal fat

Question 12

The anterior lamina (__) and the posterior lamina (__) of the renal fascia are derived from the __ which embeds the genitourinary organs.

T

Answer 12

The anterior lamina (fascia of Toldt or prerenal fascia) and the posterior lamina (fascia of Zuckerkandl or retrorenal fascia) of the renal fascia are derived from the intermediate stratum, which embeds the genitourinary organs.

Question 13

Lateroconal fascia

Answer 13

peritoneal thickening which extends anterolaterally from the adjoining merging lateral borders of the anterior and posterior perirenal fasciae.

Question 14

___ this space is significant because it can be developed to gain access to the kidney anteriorly when followed medially from the ___

Answer 14

Anterior pararenal space

white line of TOLDT

Question 15

The anterior pararenal space contains the secondarily retroperitoneal organs

why are they called secondarily retroperitoneal organs

Answer 15

the ascending and descending colon, pancreas, and second and third portions of the duodenum.

These organs are intraperitoneal at one point during embryogenesis; however, they become retroperitoneal secondarily as they attach to the posterior abdominal wall when the inner stratum fuses with the primary dorsal peritoneum.

Question 16

The second, descending portion of the duodenum is critical to the urologist because of its proximity to the ___. The duodenum may be mobilized medially using a ___ to expose these right-sided retroperitoneal structures

Answer 16

The second, descending portion of the duodenum is critical to the urologist because of its proximity to the right renal hilum. The duodenum may be mobilized medially using a Kocher maneuver to expose these right-sided retroperitoneal structures

Question 17

The adventitia is the connective tissue sheath surrounding the vessel. It contains the __ and the __

Answer 17

The adventitia is the connective tissue sheath surrounding the vessel. It contains the nerves that control vasomotor tone and the vasa vasorum
, which are smaller vessels that supply the walls of larger vessels.

Question 18

Arterial supply of ADRENALS

. The superior adrenal artery branches from the___ artery and supplies the ipsilateral adrenal gland. The superior arterial blood supply to the adrenal is constant; however, the middle and inferior arteries to the adrenal are variable. These arteries vary in number and location with the most common variant being the middle adrenal artery arising from the __ and the inferior adrenal arising from the __

Answer 18

Arterial supply of ADRENALS

. The superior adrenal artery branches from the inferior phrenic artery and supplies the ipsilateral adrenal gland. The superior arterial blood supply to the adrenal is constant; however, the middle and inferior arteries to the adrenal are variable. These arteries vary in number and location with the most common variant being the middle adrenal artery arising from the aorta and the inferior adrenal arising from the renal artery.

Question 19

The middle colic artery anastomoses with the left colic artery off the inferior mesenteric artery (IMA) via the __

Answer 19

The middle colic artery anastomoses with the left colic artery off the inferior mesenteric artery (IMA) via the marginal artery of Drummond

Question 20

The celiac artery (celiac
trunk or truncus coeliacus), which is a short, unpaired artery that arises anteriorly at the midline at the__

superior mesenteric artery (SMA) branches next off the aorta, arising anteriorly in the midline at approximately the level of the middle adrenal arteries at __

The paired renal arteries are the next branch of the aorta. These classically arise at the __

The inferior mesenteric artery (IMA) arises from the anterior aorta in the midline at the level of __

At the ___, the aorta bifurcates to form the common iliac arteries

Answer 20

The celiac artery (celiac
trunk or truncus coeliacus), which is a short, unpaired artery that arises anteriorly at the midline at the level of T1

superior mesenteric artery (SMA) branches next off the aorta, arising anteriorly in the midline at approximately the level of the middle adrenal arteries at L1-L2

The paired renal arteries are the next branch of the aorta. These classically arise at the L1-L2 vertebral levels

The inferior mesenteric artery (IMA) arises from the anterior aorta in the midline at the level of L3-L4

At the fourth lumbar vertebra, the aorta bifurcates to form the common iliac arteries

Question 21

. In males, the gonadal veins (testicular veins) receive drainage from the __, which is the venous complex that emerges from the testes.

Answer 21

. In males, the gonadal veins (testicular veins) receive drainage from the pampiniform plexus, which is the venous complex that emerges from the testes.

Question 22

The right testicular vein typically enters into the ___ ; however, it may enter into the ____ in up to 10% of cases.

Answer 22

The right testicular vein typically enters into the right anterolateral aspect of the IVC; however, it may enter into the right renal vein in up to 10% of cases

Question 23

These anatomic differences have clinical significance because the increased__ and __ of the left testicular vein into the left renal vein may account for the increased incidence of __

Answer 23

These anatomic differences have clinical significance because the increased length and perpendicular entry of the left testicular vein into the left renal vein may account for the increased incidence of left-sided varicoceles.

Question 24

a sudden-onset ___ should increase suspicion for a renal or retroperitoneal malignancy causing obstruction and poor venous outflow (e.g., right side renal cell cancer with venous thrombus).

Answer 24

a sudden-onset right varicocele should increase suspicion for a renal or retroperitoneal malignancy causing obstruction and poor venous outflow (e.g., right side renal cell cancer with venous thrombus).

Question 25

Lymph generally flows ___ from ___ to ___ until it returns to the venous circulation at the __

Answer 25

Lymph generally flows cephalad from right to left until it returns to the venous circulation at the left innominate (brachiocephalic) vein

Question 26

____ are of considerable interest to the urologist because they provide the primary lymphatic drainage for structures supplied by ___ : the kidneys, adrenals, ureters, and gonads

Answer 26

The lumbar nodes are of considerable interest to the urologist because they provide the primary lymphatic drainage for structures supplied by lateral aortic arterial branches: the kidneys, adrenals, ureters, and gonads

Question 27

three groups of lumbar nodes can be defined:

Answer 27

left lumbar (aortic), interaortocaval (interaorticovenous), and right lumbar (caval) nodal groups.

Question 28

The left testis drains to the __ nodes with some drainage to the __. The right testis drains primarily to the __ with some drainage to the right __.

Answer 28

The left testis drains to the left para-aortic nodes with some drainage to the interaortocaval nodes. The right testis drains primarily to the interaortocaval nodes with some drainage to the right paracaval nodes.

Question 29

a saccular dilated structure known as the cisterna chyli. This marks the beginning of the __, which runs __ posterior to the aorta and empties into the __.

Answer 29

a saccular dilated structure known as the cisterna chyli. This marks the beginning of the thoracic duct, which runs cephalad posterior to the aorta and empties into the left innominate vein.

Question 30

The adrenal gland serves as a special autonomic nervous system because

Question 31

The ___ may be injured during a psoas hitch procedure (suture placement) and laparoscopic varicocelectomy (ligation).

Answer 31

The genitofemoral nerve may be injured during a psoas hitch procedure (suture placement) and laparoscopic varicocelectomy (ligation).

Question 32

Electrocautery employed during a transurethral resection of bladder tumor (TURBT) procedure may result in __ with subsequent rapid, __

Answer 32

Electrocautery employed during a transurethral resection of bladder tumor (TURBT) procedure may result in obturator nerve stimulation with subsequent rapid, forceful hip adduction.

Question 36

The epididymis is tightly coiled and encapsulated within the ____ sheath and would measure ___m in length if stretched out

Answer 36

The epididymis is tightly coiled and encapsulated within the tunica vaginalis sheath and would measure 3 to 4 m in length if stretched out