Retroperitoneal fasciae as barriers for nerve and arterial passages connecting the retroperitoneal region to the peritoneal organs.

The fascia of the pancreatic head is referred to as the retropancreatic fascia of Treitz, and that of the body and tail of the pancreas is named the retropancreatic fascia of Toldt. However, the spatial relationship between the nerves, fascia, and the distribution of the fascia on the dorsal side of the pancreas remains unclear. Therefore, this study aimed to explore the distribution of these fasciae and elucidate the spatial relationship between the nerves and arteries connecting the retroperitoneal space and the peritoneal organs by studying eight cadavers using macroscopic anatomical examination, wide-range serial sectioning, and three-dimensional reconstruction. The fasciae of Treitz and Toldt converge caudally to the root of the superior mesenteric artery (SMA), forming a narrower gap around the roots of the celiac trunk and SMA than in the celiac plexus. The fasciae eventually get closer to each other, and the boundary between them becomes obscured, providing coverage to the anterior surface of the aorta between the SMA and the inferior mesenteric artery. The celiac plexus does not penetrate the fascia but converges before spreading into the pancreas. Similarly, the arteries pass through this gap in the fasciae. Our findings suggest that the retroperitoneal space and peritoneal organs are connected through a narrow no-fascia area, with the distribution of the fascia relating to nervous and vascular pathways. Our findings reveal that the distribution of the avascular plane may provide a crucial anatomical foundation for abdominal digestive organ surgery by reducing bleeding volume and determining the dissection region.

Retroperitoneum revisited: a review of radiological literature and updated concept of retroperitoneal fascial anatomy with imaging features and correlating anatomy.

PURPOSE: Spread of disease in the retroperitoneum is dictated by the complex anatomy of retroperitoneal fasciae and is still incompletely understood. Conflicting reports have led to insufficient and incorrect anatomical concepts in radiological literature. METHODS: This review will discuss previous concepts prevalent in radiological literature and their shortcomings will be highlighted. New insights from recent anatomical and embryological research, together with imaging examples, will be used to clarify patterns of disease spread in the retroperitoneum that remain unexplained by these concepts. RESULTS: The fusion fascia and the renal fascia in particular give rise to planes and spaces that act as vectors for spread of disease in the retroperitoneum. Some of these planes and structures, such as the caudal extension of the renal fascia, have previously not been described in radiological literature. CONCLUSION: New insights, including the various fasciae, potential spaces and planes, are incorporated into an updated combined retroperitoneal fascial concept.

Ligament of Treitz: Anatomy, Relevance of Radiologic Findings, and Radiologic-Pathologic Correlation.

OBJECTIVE. The objective of this article is to discuss the anatomy, embryonic origin, normal variants, and various attachments of the ligament of Treitz. We also describe the pathologic processes that develop along the ligament of Treitz and the role of cross-sectional imaging in identifying these conditions. CONCLUSION. The ligament of Treitz, also known as the suspensory ligament of the duodenum, is an important anatomic landmark in the abdomen. It is essential that radiologists understand the anatomic attachments, normal variants, and various pathologic conditions involving the ligament of Treitz as well as the role of cross-sectional imaging in the assessment of these conditions.

Useful Pelvic Retroperitoneal Neuroanatomy for Benign Gynecologic Surgery: A Cadaveric Dissection.

OBJECTIVE: Knowledge of the retroperitoneal anatomy is particularly important to facilitate surgical procedure and reduce the number of complications. The objective of this video is to demonstrate pelvic neuroanatomic structures and their relationships in the pelvic sidewall and the presacral space in a laparoscopic cadaveric dissection. DESIGN: Case report (anatomic study). SETTING: Medical training center (AdventHealth Nicholson Center, Orlando, FL). INTERVENTIONS: The dissection started with the mobilization of the iliac vessels from the pelvic sidewall to identify the obturator nerve. The peritoneum of the ovarian fossa was opened, and the ureter was dissected up to the level of the uterine artery. The hypogastric nerve was identified. The close relationship between the ovarian fossa and the obturator nerve could be demonstrated. The deep dissection of the obturator fossa allowed for the identification of the lumbosacral trunk, S1, the sciatic nerve, S2, S3, S4, and the splanchnic nerves. Then, the ischial spine and the sacrospinous ligament were identified. The pudendal nerve and vessels could be observed passing below the sacrospinous ligament, entering the pudendal canal (Alcock's canal). The presacral space was dissected, and the hypogastric fascia was opened. S1 to S4 were identified coming from the sacral foramens. The laparoscopic dissection, using the cadaveric model, allowed for the development of the entire retroperitoneal anatomy, focusing on the dissection of the pelvic innervation. Anatomic relationships among the ureter, the hypogastric nerve, the uterosacral ligament, the splanchnic nerves, the inferior hypogastric plexus, and the organs (bowel, vagina, uterus, and bladder) could be demonstrated. CONCLUSION: A laparoscopic cadaveric dissection can be used as a resource to demonstrate and educate surgeons about the neurologic retroperitoneal structures and their relationships.

Anatomic evaluation of retroperitoneal organs for lateral approach surgery: a prospective imaging study using computed tomography in the lateral decubitus position.

PURPOSE: The aim of this study is to investigate retroperitoneal organ distribution with the retroperitoneal approach in the lateral decubitus position. METHODS: We enrolled 100 patients scheduled for lateral approach surgery, including LIF and lateral corpectomy. We performed computed tomography with lateral decubitus positioning (L-CT) to assess the position of the organs, including abdominal aorta, kidney, descending colon, ureter, and gonadal artery. Anteroposterior organ positions were divided into four zones: A, anterior to the anterior margin of the vertebral body; AL, anterior margin to the middle line of the vertebral body; PL, middle line to the posterior margin of the vertebral body; and P, posterior to the posterior margin of the vertebral body. We defined zone PL-P as the "approach zone." Measurements obtained using L-CT were compared with those obtained in the conventional supine position (S-CT). RESULTS: Retroperitoneal organs in the approach zone significantly decreased in lateral positioning. Eighty-three percent of kidney and 20% of descending colon remain in the approach zone in L-CT. Sixty-six percent of disk levels recorded for the descending colon in zone P in S-CT remained in the approach zone even in L-CT. CONCLUSIONS: We observed anterior migration in L-CT in all retroperitoneal organs. However, a considerable percentage of kidney and that of descending colon remain obstruent while performing LIF. We discuss that the preoperative imaging evaluation is beneficial, and gentle and meticulous surgical detachment is essential for safe and reliable lateral approach surgery, especially in the case that the descending colon extends outside zone P in S-CT. These slides can be retrieved under electronic supplementary material.

The anatomy of the infrarenal lumbar splanchnic nerves in human cadavers: implications for retroperitoneal nerve-sparing surgery.

Injury to the nerves of the aortic- and superior hypogastric plexuses during retroperitoneal surgery often results in significant post-operative complications, including retrograde ejaculation and/or loss of seminal emission in males. Although previous characterizations of these plexuses have done well to provide a basis for understanding the typical anatomy, additional research into the common variations of these plexuses could further optimize nerve-sparing techniques for retroperitoneal surgery. To achieve this, the present study aimed to document the prevalence and positional variability of the infrarenal lumbar splanchnic nerves (LSNs) through gross dissection of 26 human cadavers. In almost all cases, two LSNs were observed joining each side of the aortic plexus, with 48% (left) and 33% (right) of specimens also exhibiting a third joining inferior to the left renal vein. As expected, the position of the LSNs varied greatly between specimens. That said, the vast majority (98%) of LSNs joining the aortic plexus were found to originate from the lumbar sympathetic trunk above the level of the inferior mesenteric artery. It was also found that, within specimens, adjacent LSNs often coursed in parallel. In addition to these nerves, 85% of specimens also demonstrated retroaortic LSN(s) that were angled more inferior compared with the other LSNs (P < 0.05), and exhibited a unique course between the aorta/common iliac arteries and the left common iliac vein before joining the superior hypogastric plexus below the aortic bifurcation. These findings may have significant implications for surgeons attempting nerve-sparing procedures of the sympathetic nerves in the infrarenal retroperitoneum such as retroperitoneal lymphadenectomies. We anticipate that the collective findings of the current study will help improve such retroperitoneal nerve-sparing surgical procedures, which may assist in preserving male ejaculatory function post-operatively.

Non-traumatic causes of fluid in the retropharyngeal space.

There are multiple reasons for imaging the soft tissues of the neck in the emergency setting, in particular when symptoms are vague or if there is worry for complications from a certain clinical diagnosis. When fluid is seen in the retropharyngeal space, it is important to pay attention to history and look at key structures in the neck. This article will discuss anatomy of the retropharyngeal space, followed by four causes of fluid within the space that the radiologist is likely to encounter in the emergency setting: tonsillitis/pharyngitis, acute calcific tendinitis of the longus colli muscles, internal jugular vein thrombosis, and post-radiation changes. It is important to recognize these entities because each has different clinical implications and management.

Retroperitoneal Laparoscopy in Dogs: Access Technique, Working Space, and Surgical Anatomy.

OBJECTIVE: To develop and describe a laparoscopic retroperitoneal access technique, investigate working space establishment, and describe the surgical anatomy in the retroperitoneal space as an initial step for clinical application of retroperitoneal laparoscopy in dogs. STUDY DESIGN: Cadaveric and experimental study. ANIMALS: Cadaveric (n=8) and healthy (n=6) adult dogs. METHODS: The retroperitoneal access technique was developed in 3 cadavers based on the human technique and transperitoneal observation. Its application and working space establishment with carbon dioxide (CO2 ) insufflation alone was evaluated in 5 cadavers by observing with a transperitoneal telescope and in 6 live dogs by repeated computed tomography (CT) scans at pressure of 0, 5, 10, and 15 mmHg. Recordings of retroperitoneoscopy as well as working space volume and linear dimensions measured on CT images were analyzed. RESULTS: Retroperitoneal access and working space establishment with CO2 insufflation alone were successfully performed in all 6 live dogs. The only complication observed was in 1 dog that developed subclinical pneumomediastinum. As pressure increased, working space was established from the ipsilateral to the contralateral side, and peritoneal tearing eventually developed. Working space volume increased significantly from 5 mmHg and linear dimensions increased significantly from 0 to 10 mmHg. With pneumo-retroperitoneum above 5 mmHg, retroperitoneal organs, including kidneys and adrenal glands, were easily visualized. CONCLUSION: The retroperitoneal access technique and working space establishment with CO2 insufflation starting with 5 mmHg and increasing to 10 mmHg provided adequate working space and visualization of retroperitoneal organs, which may allow direct access for retroperitoneal laparoscopy in dogs.

Supraumbilical primary trocar insertion for laparoscopic access: the relationship between points of entry and retroperitoneal vital vasculature by imaging.

OBJECTIVES: Advances in laparoscopy have demonstrated that supraumbilical primary ports can be desirable in complex cases with large masses. This study evaluated distances to vital retroperitoneal vasculature that were encountered with 45- and 90-degree angle entry from the umbilicus and 2 commonly described supraumbilical entry points at 3 and 5 cm cephalad from the umbilicus. STUDY DESIGN: Retrospective analysis of computed tomography scans of the abdomen and pelvis from 100 randomly selected women who were 18-50 years old with normal anatomy was performed. Three-dimensional models of sagittal sections were generated using IMPAX software. Measurements from the abdominal wall at the umbilicus and 3 and 5 cm cephalad with 45- and 90-degree angles to retroperitoneal structures were performed. RESULTS: With 90-degree angle entry, the abdominal wall thickness (AWT) was thinnest at the umbilicus; however, the thickness at 3 and 5 cm was similar. AWT increased at all sites with 45-degree angle entry, and the same pattern was observed. AWT and intraperitoneal distance positively correlated with body mass index and supraumbilical entry points. With 90-degree angle entry, the aorta was 1.9 cm (95% confidence interval [CI], 1.4-2.4) and 2.5 cm (95% CI, 2.0-2.9) farther away at 3 and 5 cm cephalad compared with umbilical entry. In one-third of the cases, regardless of port placement, a vascular structure other than the aorta was the most anterior vessel. With 45-degree angle entry at the umbilicus, no vessels were encountered. With 45-degree angle entry at 3 and 5 cm cephalad, the aorta was the most anterior vessel in 1% and 2% of cases, respectively, and was noted to be 1.0 cm (95% CI, 1.0-1.0) and 2.3 cm (95% CI, 1.2-3.3) farther away than with 90-degree angle entry. A vessel other than the aorta was encountered in 4% and 7% of cases at 3 and 5 cm, respectively. CONCLUSION: According to theoretic modeling, supraumbilical primary port placement can be implemented safely in laparoscopy. With supraumbilical entry, the distance to retroperitoneal vessels was greater than at the umbilicus. Compared with a 90-degree angle, with a 45-degree angle entry, it was uncommon to encounter vasculature, and all measured distances were greater.

Primary retroperitoneal masses: what is the differential diagnosis?

Primary retroperitoneal masses include a diverse, and often rare, group of neoplastic and non-neoplastic entities that arise within the retroperitoneum but do not originate from any retroperitoneal organ. Their overlapping appearances on cross-sectional imaging may pose a diagnostic challenge to the radiologist; familiarity with characteristic imaging features, together with relevant clinical information, helps to narrow the differential diagnosis. In this article, a systematic approach to identifying and classifying primary retroperitoneal masses is described. The normal anatomy of the retroperitoneum is reviewed with an emphasis on fascial planes, retroperitoneal compartments, and their contents using cross-sectional imaging. Specific radiologic signs to accurately identify an intra-abdominal mass as primary retroperitoneal are presented, first by confirming the location as retroperitoneal and secondly by excluding an organ of origin. A differential diagnosis based on a predominantly solid or cystic appearance, including neoplastic and non-neoplastic entities, is elaborated. Finally, key diagnostic clues based on characteristic imaging findings are described, which help to narrow the differential diagnosis. This article provides a comprehensive overview of the cross-sectional imaging features of primary retroperitoneal masses, including normal retroperitoneal anatomy, radiologic signs of retroperitoneal masses and the differential diagnosis of solid and cystic, neoplastic and non-neoplastic retroperitoneal masses, with a view to assist the radiologist in narrowing the differential diagnosis.

Retroperitoneal course of iliohypogastric, ilioinguinal, and genitofemoral nerves: A study to improve identification and excision during triple neurectomy.

Triple neurectomy of the iliohypogastric (IHN), ilioinguinal (IIN), and genitofemoral (GFN) nerves is an available treatment option for chronic groin pain when conservative measures are ineffective. This research study attempted to define the variability of IHN, IIN, and GFN by categorizing variation and establishing a relationship to clinically significant landmarks. 22 cadavers (43 specimens) were dissected. Age, gender, ethnicity, BMI, and pertinent medical history were recorded for each specimen. Nerve emergence, insertion, and split points were measured in relation to clinically significant landmarks. Retroperitoneal trajectories of IHN, IIN, and GFN were analyzed and categorized based on nerve branching patterns. IIN and IHN had three branching patterns - type A (47%) in which the IIH and IIN exit as separate branches; type B (26%) in which the IIH and IIN exit as a single bundle and split; and type C (28%) in which the IIH and IIN exit and do not split. The GFN had three branching patterns--type 1 (50%) in which the GFN exited from the psoas major and then split into the genital and femoral branches; type 2 (30%) in which the GFN exited and did not split; and type 3 (20%) in which the GFN exited the psoas major already split into the genital and femoral branches. Variations in the IHN, IIN, and GFN nerves outlined in this study will provide surgeons with clinically useful information aiding in successful and efficient localization of these nerves during retroperitoneal procedures, including laparoscopic triple neurectomy.

Understanding the Anatomy of Retroperitoneal Interfascial Space: Implications for Regional Anesthesia.

BACKGROUND: Fascial plane block techniques have evolved considerably in recent years. Unlike the conventional peripheral nerve block methods, the fascial plane block's effect can be predicted based on fascial anatomy and does not require a clear vision of the target nerves. The anatomy of the retroperitoneal interfascial space is complex, since it comprises multiple compartments, including the transversalis fascia (TF), the retroperitoneal fasciae (RF), and the peritoneum. For this reason, an in-depth, accurate understanding of the retroperitoneal interfascial space's anatomical characteristics is necessary for perceiving the related regional blocks and mechanisms that lie underlie the dissemination of local anesthetics (LAs) outside or within the various retroperitoneal compartments. OBJECTIVES: This review aims to summarize the retroperitoneum's anatomical characteristics and elucidate the various communications among different interfascial spaces as well as their clinical significance in regional blocks, including but not limited to the anterior quadratus lumborum block (QLB), the fascia iliaca compartment block (FICB), the transversalis fascia plane block (TFPB), and the preperitoneal compartment block (PCB). STUDY DESIGN: This is a narrative review of pertinent studies on the use of retroperitoneal spaces in regional anesthesia (RA). METHODS: We conducted searches in multiple databases, including PubMed, MEDLINE, and Embase, using "retroperitoneal space," "transversalis fascia," "renal fascia," "quadratus lumborum block," "nerve block," and "liquid diffusion" as some of the keywords. RESULTS: The anatomy of the retroperitoneal interfascial space has a significant influence on the injectate spread in numerous RA blocking techniques, particularly the QLB, FICB, and TFPB approaches. Furthermore, the TF is closely associated with the QLB, and the extension between the TF and iliac fascia offers a potential pathway for LAs. LIMITATIONS: The generalizability of our findings is limited by the insufficient number of randomized controlled trials (RCTs). CONCLUSIONS: Familiarity with the anatomy of the retroperitoneal fascial space could enhance our understanding of peripheral nerve blocks. By examining the circulation in the fascial space, we may gain a more comprehensive understanding of the direction and degree of injectate diffusion during RA as well as the block's plane and scope, possibly resulting in effective analgesia and fewer harmful clinical consequences.

A Morphometric Study of Cadavers for the Anterior Approach to the Lower Lumbar Spine.

AIM: To explore the relationship between the retroperitoneal vasculature and anterior surface of the lower spine, and to establish values for aiding in prediction of the pertinence of anterior approach at the L4-L5 and L5-S1 intervertebral discs. MATERIAL AND METHODS: The study included 13 fresh human cadavers. After exploration of the abdominal cavity and removal of the visceral organs, the vasculature, and anterior spinal surface were revealed beneath the lower extension of the perirenal fascia. Morphometric measurements of the great vessels and the intervertebral discs were obtained. All measurements were analyzed and presented as mean and standard deviation. Differences in the values between sexes were assessed. RESULTS: The anterior height of the L4-L5 and L5-S1 intervertebral disc was 6.8 ± 0.81 mm and 6.7 ± 0.99 mm, respectively. The widths of the aorta, inferior vena cava, right and left common iliac arteries, and right, and left common iliac veins were 16.4 ± 3.58, 20.6 ± 3.36, 11.5 ± 2.32, 11.5 ± 2.43, 14.7 ± 3.13, and 15.5 ± 3.27 mm, respectively. The mean aortic bifurcation angle was 45.5°. The aortic bifurcation was located above the lower endplate of the L4 vertebrae in 53.8% of the cadavers. The area of the interarterial and interiliac trigones was 14.6 ± 5.33 cm < sup > 2 < /sup > and 7.1 ± 4.35 cm2, respectively. No statistically significant differences were noted between the sexes. CONCLUSION: An elaborate radiological examination of the vasculature should be performed prior to surgery to avoid unwanted vascular complications during the anterior approach. Knowing the area of the interarterial and interiliac triangles and the aortic bifurcation location could be aid in assessing the safe working zone.

Complications in right-sided paraaortic lymphadenectomy: ventral tributaries of the inferior vena cava.

The purpose of this study was to describe the distribution and structure of ventral tributaries leading into the inferior vena cava where right-sided paraaortic lymphadenectomy is performed. The study examined 21 retroperitoneal specimens by graphic reconstruction, statistical evaluation, and histological examination of ventral tributaries (VTs). Seventy VTs were identified. The average number per specimen was 3.33. There were 20, 40, and 40% of VTs found in Levels I, II, and III, respectively. During the preparation, we observed an unusual arrangement of the IVC wall, into which VTs were led through a preformed sleeve-like channel and anchored near the lumen. This finding is a key mechanism that explains the ease with which VTs are extracted during surgery. Knowledge of the distribution and histological structure of VTs allows proper orientation of the retroperitoneal area of the front wall of inferior vena cava, which is essential for uncomplicated right-sided paraaortic lymphadenectomy. The histological structure of the VT ostium within the wall of the inferior vena cava explains why injury is easy during the procedure.

The prevesical space: anatomical review and pathological conditions.

The prevesical space is the largest potential space within the pelvic extraperitoneal space. Located anterosuperior to the bladder, it has complex communications with the adjacent pelvic extraperitoneal spaces, rectus sheath, and retroperitoneum. The prevesical space is also the site of various pathological processes, and can act as a conduit for the spread of these conditions. Therefore, awareness of the detailed anatomy and potential routes of communication may help radiologists in making accurate diagnoses of pathological conditions involving the prevesical space.

[Regularities of the computer-tomographic and macro-microscopical anatomy and topography of the retroperitoneal space structures].

Variant-, age- and sex-related peculiarities of the intravital anatomy and topography of the retroperitoneal space (RS) fasciae, fatty tissue layers, structures and organs were studied on autopsy material (organ complexes of 50 men and women aged 22-71 years) and on clinical material (computer tomographs of 140 men and women aged 20-75 years). Te quantitative analysis has shown that the height of the RS was equal to 198 +/- 26 mm, its cross sectional area--to 35 +/- 5 mm2, and total RS volume--to 1254+/- 169 cm3. Current classifications of RS regions and parts as well as RS fatty tissue layers, are presented. The latter distinguishes five fatty tissue layers: retroperitoneal, parasuprarenal, pararenal, paraureteral, paracolonic, and retropancreatic.

[Anatomy and physiology of autonomic pelvic innervations].

Autonomic innervation is responsible for the correct function of the organs in the pelvis. Retroperitoneal surgery is associated with trauma of the nerve structures. For this reason a detailed knowledge of topographic anatomy of the pelvis is needed, when surgery for oncological diseases or endometriosis is performed. Faster recovery, decrease of the number of postoperative complications and a better quality of life are the result of the nerve-sparing approach.

Peritoneal and retroperitoneal anatomy and its relevance for cross-sectional imaging.

It is difficult to identify normal peritoneal folds and ligaments at imaging. However, infectious, inflammatory, neoplastic, and traumatic processes frequently involve the peritoneal cavity and its reflections; thus, it is important to identify the affected peritoneal ligaments and spaces. Knowledge of these structures is important for accurate reporting and helps elucidate the sites of involvement to the surgeon. The potential peritoneal spaces; the peritoneal reflections that form the peritoneal ligaments, mesenteries, and omenta; and the natural flow of peritoneal fluid determine the route of spread of intraperitoneal fluid and disease processes within the abdominal cavity. The peritoneal ligaments, mesenteries, and omenta also serve as boundaries for disease processes and as conduits for the spread of disease.

The lumbosacral plexus: anatomic considerations for minimally invasive retroperitoneal transpsoas approach.

PURPOSE: The minimally invasive transpsoas approach can be employed to treat various spinal disorders, such as disc degeneration, deformity, and lateral disc herniation. With this technique, visualization is limited in comparison with the open procedure and the proximity of the lumbar plexus to the surgical pathway is one limitation of this technique. Precise knowledge of the regional anatomy of the lumbar plexus is required for safe passage through the psoas muscle. The primary objective of this study was to determine the anatomic position of the lumbar plexus branches and sympathetic chain in relation to the intervertebral disc and to define a safe working zone. The second objective was to compare our observations with previous anatomical studies concerning the transpsoas approach. METHODS: A total of 60 lumbar plexus in 8 fresh cadavers from the Department of Anatomy were analyzed in this study. Coronal and lateral X-Ray images were obtained before dissection in order to eliminate spine deformity or fracture. All cadavers were placed in a lateral decubitus position with a lateral bolster. Dissection of the lumbar plexus was performed. All nerve branches and sympathetic chain were identified. Intervertebral disc space from L1L2 to L4L5 was divided into four zones. Zone 1 being the anterior quarter of the disc, zone 2 being the middle anterior quarter, zone 3 the posterior middle quarter and zone 4 the posterior quarter. Crossing of each nervous branch with the disc was reported and a safe working zone was determined for L1L2 to L4L5 disc levels. A safe working zone was defined by the absence of crossing of a lumbar plexus branch. RESULTS: No anatomical variation was found during blunt dissection. As described previously, the lumbar plexus is composed of the ventral divisions of the first four lumbar nerves and from contributions of the sub costal nerve from T12. The safe working zone includes zones 2 and 3 at level L1L2, zone 3 at level L2L3, zone 3 at level L3L4, and zone 2 at level L4L5. No difference was observed between right and left sides as regards the relationships between the lumbar plexus and the intervertebral disc. CONCLUSION: We observed some differences concerning the safe working zone in comparison with other cadaveric studies. The small number of cadaveric specimens used in anatomical studies probably explains theses differences. The minimally invasive transpsoas lateral approach was initially developed to reduce the complications associated with the traditional procedure. The anatomical relationships between the lumbar plexus and the intervertebral disc make this technique particularly risky a L4L5. Alternative techniques, such as transforaminal interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF) or anterior interbody fusion (ALIF) should be used at this level.

[Superior attachment of renal fascia: a study with multidetector computed tomography and three dimensional reconstruction].

OBJECTIVE: To observe the superior attachment of renal fascia (RF) and the perirenal space (PS) in order to identify the spreading pathway of inflammatory and malignant tumors. METHODS: Multidetector computed tomography (MDCT), with double phase enhancement scanning and three dimensional reconstruction of images were performed on 121 healthy adults. The RF attachments upward were observed and their connections with the PS were evaluated. RESULTS: The left anterior renal fascia (ARF) fusing with peritoneum accounted for 27.3% (33/121) and the left ARF fusing with peritoneum of the spleen laterally and with the subdiaphragmatic fascia interiorly accounted for 19.8% (24/121) of the upper attachments of the RF above the upper renal pole (URP). Under the URP, the left ARF fusing with peritoneum accounted for 52.9% (64/121) of the upper attachments of the RF. The right ARF fusing with peritoneum did not display above the URP. The posterior renal fascia (PRF) of both side fused with subdiaphragmatic fascia under the URP. The ARF and PRF of the left and right kidney showed no upward integration. The right PS communicated with the subdiaphragmatic retroperitoneal space (SDRS) that is a bare area of the liver. The left PS communicating with the SDRS accounted for 80.2% (97/121) and the left PS communicating with the SDRS laterally but separating from the SDRS interiorly accounted for 19.8% (24/121) of the SDRS communication. CONCLUSION: MDCT and three-dimensional reconstruction can remarkably display RF and its superior attachment, as well as the connection between the PS and SDRS.