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1. Musculoaponeurotic anatomic features of the abdominal wall layers differ superior to and inferior to the arcuate line on the posterior aspect of the rectus sheath.

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2. Defects of the complex process of abdominal wall development in the fetus can occur in several ways resulting in persistent midgut herniation (omphalocele and gastroschisis) or vitelline duct remnant abnormalities (Meckel’s diverticulum, or vitelline duct fistula or cyst).

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3. The management of rectus sheath hematomas consists of reversal of any anticoagulation or coagulopathy and observation, unless either hemodynamic instability or enlargement necessitates surgical evacuation.

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4. Incisional hernias of the anterior abdominal wall may occur in up to 10–20% of prior abdominal operations of all types.

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5. Primary suture repair of abdominal wall incisional hernias is associated with an unacceptably high incidence of hernia recurrence, and has prompted the wide use of prosthetic mesh materials for hernia repair.

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6. Laparoscopic incisional hernia repair offers important advantages over open repairs including reduced pain medication use, earlier return to normal function, and possibly superior protection from hernia recurrence.

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7. Sclerosing mesenteritis is a poorly understood mesenteric process characterized by variable degrees of inflammation and fibrosis within mesenteric tissues of the small and large bowel, which frequently requires surgical biopsy to rule out neoplasm and to establish the correct diagnosis.

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8. Retroperitoneal fibrosis is a primary or secondary fibroproliferative process in the retroperitoenum characterized by distortion of retroperitoneal structures, including the ureters and inferior vena cava.

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9. Treatment of retroperitoneal fibrosis may include ureterolysis or ureteral stenting, and medical therapies such as corticosteroids or tamoxifen.

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General Considerations

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The abdominal wall is defined superiorly by the costal margins, inferiorly by the symphysis pubis and pelvic bones, and posteriorly by the vertebral column. It serves to support and protect abdominal and retroperitoneal structures, and its complex muscular functions enable twisting and flexing motions of the trunk. Surgical implications of abdominal wall structure become apparent during the course of managing primary abdominal wall diseases or gaining access to the peritoneal cavity. A surgeon must have a thorough understanding of the arrangement of abdominal wall muscles and aponeuroses.

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Surgical Anatomy

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The abdominal wall is an anatomically complex, layered structure with segmentally derived blood supply and innervation (Fig. 35-1). It is mesodermal in origin and develops as bilateral migrating sheets that originate in the paravertebral region and envelop the future abdominal area. The leading edges of these structures develop into the rectus abdominis muscles, which eventually meet in the midline of the anterior abdominal wall. The muscle fibers of the rectus abdominis are arranged vertically and are encased within an aponeurotic sheath, the anterior and posterior layers of which are fused in the midline at the linea alba. The rectus abdominis has insertions on the symphysis pubis and pubic ...

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