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  1. There are important anatomic differences in the rectus sheath structures above and below the arcuate line. The laminae of the internal oblique, which contribute to both the anterior and (along with the transversus abdominis) posterior rectus above the arcuate line, only contribute to the anterior sheath below the arcuate line. There is no aponeurotic posterior covering on the lower portion of the rectus muscles.

  2. Rectus diastasis is associated with abdominal wall bulging consequent to separation of the rectus abdominis muscles in the midline. It does not represent a hernia, and surgical interventions for this condition are of questionable, if any, clinical benefit.

  3. When resection of abdominal wall desmoid tumors is undertaken, it must be recognized that failure to achieve negative margins is associated with an extremely high risk of local recurrence of the tumor.

  4. Primary repair of ventral incisional hernias is associated with unacceptably high failure rates, and repair using other approaches, such as use of prosthetic mesh, is preferred.

  5. The addition of the closed videoscopic technique to components separation procedures has been associated with a significant decrease in the incidence of local wound complications.

  6. Potential benefits of laparoscopic incisional hernia repairs compared to open repairs with mesh include shorter hospitalization, lower risk of wound complications, and better abdominal wall function. A lower recurrence rate benefit remains controversial.

  7. Surgical treatment of sclerosing mesenteritis is most often undertaken to confirm diagnosis and to rule out neoplasm as the cause of a mesenteric mass. Resection possibilities are limited by the extensiveness of the process as well as by the questionable benefit in most cases.

  8. Potential surgical interventions in retroperitoneal fibrosis include operative biopsy to rule out neoplasm, ureteral stent placement, open or laparoscopic ureterolysis, and endovascular interventions for iliocaval occlusion.


General Considerations

The abdominal wall provides structure, protection, and support for abdominal and retroperitoneal structures and is defined superiorly by the costal margins, inferiorly by the pelvic ring, and posteriorly by the vertebral column. Knowledge of its specific anatomic features is required for management of abdominal wall diseases or during entry into the peritoneal cavity.

Surgical Anatomy

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, which 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 anterior midline. The rectus abdominis is longitudinally oriented and encased within an aponeurotic sheath, the layers of which are fused in the midline at the linea alba. The rectus insertions are on the pubic bones inferiorly and on the fifth and sixth ribs, as well as the seventh costal cartilages and the xiphoid process superiorly. The lateral border of the rectus muscles ...

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