Материал: Advanced Imaging of the Abdomen - Jovitas Skucas

PERITONEUM, MESENTERY, AND EXTRAPERITONEAL SOFT TISSUES

with peritoneal complications, although such complication as small bowel obstruction do occur. Other complications encountered include hematoma, seroma, protrusion of the prosthetic mesh, infection, and hernia recurrence. Generally, however, no imaging study is necessary in most patients after laparoscopic hernia repair.

Laparoscopic ventral hernia repair using a mesh does not obliterate completely a preoperative hernial sac, and thus postoperative fluid collections here are common (83); CT differentiation of such fluid from an abscess or recurrent hernia is difficult and, in the absence of symptoms, serial follow-up appears reasonable.

thread was no longer present and the sponge was presumably spontaneously expelled.

Biopsy

A pneumothorax is relatively common after a lung biopsy. Occasionally not only a pneumothorax but also a pneumoperitoneum develops after a lung biopsy.

Abdominal biopsies and fluid aspirations are performed under sterile conditions, yet the introduction of bacteria and the resultant peritonitis is a recognized complication of these procedures.

An endoscopic suction biopsy can result in small bowel perforation.

Other Laparoscopic Complications

Incisional hernias through laparoscopic trocar sites are uncommon and develop mostly through trocar sites >10mm in diameter. Even acute appendiceal strangulation has developed within a laparoscopic port hernia (84).

One complication of laparoscopy is injury to extraperitoneal vessels, often due to blind insertion of needles and trocars. These patients manifest with acute hypotension intraoperatively and require conversion to an open laparotomy.

Small bowel necrosis or mesenteric infarction is rare.

Retained Sponges

A gossypiboma, or textiloma, is a tumor within the body composed of a cotton matrix, such as a laparotomy sponge. Conventional radiography identifies most retained sponges by their radiopaque markers. For a number of reasons CT does not identify radiopaque markers in all patients with retained sponges. Gas bubbles can develop within a gossypiboma without an abscess being present. In time, a sponge becomes encased in fibrosis, a phlegmon, or occasionally an abscess.A rare one migrates into the bowel lumen through a fistula and obstructs (85).

Colonoscopy identified the thread of a surgical sponge at the tip of a granuloma in the sigmoid colon of a patient with a prior hysterectomy (86); conventional radiography identified a radiopaque thread, and CT revealed a gossypiboma. Later study showed that the

Tumor Seeding

Tumor seeding is associated with laparoscopic, biopsy, and catheter drainage procedures and is discussed in the appropriate organ-related chapters. Subcutaneous tumor seeding has even developed along a needle track used for alcohol sclerotherapy of a hepatocellular carcinoma. The type of tumor and probably its pathologic grade are relevant factors in tumor spread. These implants tend to be homogeneous on precontrast CT and heterogeneous and enhancing on postcontrast CT.

The risk of abdominal wall tumor seeding during needle biopsies is probably underestimated in the literature. An unfortunate consequence of tumor seeding after a fine-needle biopsy is that it renders any subsequent attempted curative resection into a palliative one.

Numerous reports describe metastases at laparoscopic trocar sites. These have occurred with both extraperitoneal and intraperitoneal laparoscopy. The relative prevalence of these metastases compared to incisional recurrence after a laparotomy is difficult to place in perspective.

Although rare, tumor seeding also occurs along percutaneous drainage tracts in patients undergoing abscess drainage in a setting of an underlying cancer.

Heterotopic Calcifications

Heterotopic calcification in abdominal incisions is a known sequela of abdominal surgery. These

calcifications often are palpable, and some are painful. They are often visible with not only CT but also conventional radiography. Why they form is not known. Some patients appear to be predisposed to heterotopic bone formation because calcifications recur after the primary one is excised.

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Technique

Magnetic Resonance

Magnetic resonance (MR) relaxation characteristics of focal tumors tend to be similar to normal splenic tissue and thus difficult to detect. With the spleen located in the left upper abdomen close to the left hemidiaphragm, magnetic resonance imaging (MRI) of the spleen requires control of motion artifacts. A number of breath-hold techniques have been developed that allow dynamic contrast-enhanced images. Faster MRI techniques allow postcontrast images to be obtained during perfusion, equilibrium, and more delayed phases. Some focal lesions equilibrate with normal splenic parenchyma within several minutes after contrast injection and thus early postcontrast images accentuate tumors compared to normal tissue.

Superparamagnetic iron oxide contrast agents are taken up by the reticuloendothelial cells and shorten T2, making high signal intensity tumors more conspicuous. While these agents are theoretically advantageous in the spleen, research activity in this field peaked about a decade ago, and little current clinical application exists in the spleen.

Scintigraphy

Some of the more common radiopharmaceuticals useful in splenic imaging are technetium-

99m (Tc-99m)–sulfur colloid, indium-111– white blood cells, and Tc-99m–red blood cells.

Biopsy/Drainage

Splenic biopsies are performed in both adults and children with few complications. A variety of needles are used, with 20and 22-gauge needles being the most common (1). Biopsies establish a specific diagnosis in most patients with a focal splenic abnormality.

Congenital Anomalies

Malposition

The spleen is normally located in the left upper quadrant of the abdomen. Malposition is due to either a congenital maldevelopment or an acquired condition, such as a prior surgical procedure. Excessive mobility to the spleen is secondary to laxity of the splenic suspensory ligaments, including the lienorenal ligament. At times the splenic hilum is located along the superior aspect of the spleen, a condition that is probably a normal variant. The spleen can herniate into a prior lumbar incision.

Many patients with a hypermobile spleen are asymptomatic, and these “wandering spleens” are discovered incidentally when an imaging study is performed for other purposes. An asymptomatic wandering spleen can even be located in the right side of the pelvis, mimick-