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Highlights • Herniation of the ureter into the inguinal canal is a rare occurrence. • There have been reports of inadvertent injury to the ureter during routine inguinal hernia repair. • After an extensive search of the literature, we believe this is the 1stcase to be managed by Laparoscopic TAPP Repair. • Presence of ureter buried in a large amount of fat can be mistaken for lipoma of the cord and injured with blind clamping. • Presence of unilateral hydroureteronephrosis in a patient with inguinal hernia should prompt a surgeon to proceed with CT., Introduction Herniation of the ureter into the inguinal canal is a rare occurrence. There have been reports of inadvertent injury to the ureter during routine inguinal hernia repair. After an extensive search of the literature, we believe that this is the first case to be managed via laparoscopic Trans Abdominal Pre-Peritoneal Repair and would like to highlight the technical details of the laparoscopic procedure and is presented in line with SCARE 2018 Guidelines [1]. Presentation of case A 60-year-old male presented with left inguinal hernia. He also complained of an increase in frequency of micturition, with an occasional radiating pain from loin to the groin. Imaging revealed the left ureter coursing into the left inguinal canal, descending into the scrotum, and looping back to enter the bladder with mild hydroureteronephrosis. Patient underwent a laparoscopic repair of the inguinal hernia with reduction of ureter under ureteroscope guidance and stent placement. Discussion The presence of ureter buried in a large amount of fat can be mistaken for a lipoma of the cord or extraperitoneal fat and injured with blind clamping and division. Presence of fat without an obvious sac should alert the surgeon to the possibility of ureter being a content. Conclusion Laparoscopy is safe, technically feasible, offers good visualization of all hernial orifices, demonstrates complete reduction of ureter from inguinal canal under vision, allows manipulation of ureter under the vision for ureteroscopy and stenting, making sure there are no loops or kinking and allows placement of mesh in the preperitoneal space.

Objective: The aim of this study is to describe the technique and to evaluate the outcome of single-incision laparoscopic (SILC) approach for linea alba hernia in children. Materials and Methods: A 2 cm vertical umbilical incision was made and stretched horizontally. A 5-mm trocar was inserted through middle port for the telescope. Another extra-long 5-mm 30° trocar was inserted through the lateral port, 5 mm beside the middle port. The extraperitoneal fat was removed, and the defect of linea alba was repaired after hernial sac was excised. The peritoneum was reconstructed with interrupted suture. Results: From May 2014 to May 2015, eight children with linea alba hernia underwent SILC. Pre-operative abdominal ultrasound showed the average diameter of hernia ring was 3.2 ± 0.7 cm. Mean operation time was 32.5 min (range = 30–45 min). Oral intake was resumed during anaesthesia recovery period. All could endure pain and discharge on the post-operative 12 h. There was no post-operative wound infection. The follow-up period was 1–12 months, no recurrence and other complications occurred. Conclusions: SILC approach for linea alba hernia is a safe and effective, minimally invasive new technology. The linea alba hernia could be repaired with a cosmetic outcome.

Diagnosis of steatitis can be challenging due to nonspecific clinical signs and ultrasonography might be a useful aid for making a diagnosis. The objective of this retrospective clinical case study was to describe history, clinical signs, ultrasonographic findings, treatment and outcome in equids with steatitis. The medical records of all equids presented to the Department of Large Animal Internal Medicine, Ghent University between January 2008 and December 2015 were reviewed retrospectively to identify horses suffering from steatitis. A total of 20 cases with steatitis were reviewed. History included dullness, recumbency, decreased appetite and weight loss. Fever, ventral oedema, stiff/painful gait and a painful neck were found. Low haematocrit, low vitamin E and selenium and increased levels of creatinine kinase and particularly lactate dehydrogenase were almost consistent findings. On ultrasound, ventral oedema was found. Ventral extraperitoneal, perirenal, mesenteric, coronary and caudal mediastinal fat showed homogenously increased echogenicity. The ventral extraperitoneal fat in particular was surrounded by oedema or free fluid. Increased amounts of abdominal, thoracic and pericardial fluid were often found. Fat biopsies were taken in the neck, or from the ventral extraperitoneal fat in the ventral flank. Steatitis was confirmed in all horses where a fat biopsy was taken (n = 13). Treatment consisted of selenium and vitamin E (intramuscular injection followed by oral treatment) supplementation and anti-inflammatory treatment (dexamethasone or prednisolone parenteral or oral) for at least 1-4 weeks. A total of 15 animals (75%) survived. Full recovery took about 2-6 months. In conclusion, steatitis is an uncommon disease in young horses usually seen during winter. It may be underdiagnosed because of nonspecific clinical signs. Ultrasonography is a useful aid for the diagnosis of yellow fat disease based upon the increased echogenicity of ventral extraperitoneal, perirenal, mesenteric, coronary and caudal mediastinal fat and increased amount of surrounding fluid.

Spigelian hernias are said to be a rare condition of the elderly population, usually arising below the arcuate line. Local experience has led us to challenge these commonly held beliefs. Operations for Spigelian hernia from 2006–2016 were identified from the Edinburgh Lothian Surgical Audit computerised database and case notes were reviewed. One hundred and one patients underwent surgery for 107 Spigelian hernias in the 10-year period. The female-to-male ratio was 2:1. Ages ranged from 32 to 88 with a median of 64 years. Sixty-five operations were done open and 42 were laparoscopic. Twelve of the 27 for which the precise anatomic location was recorded were situated above the arcuate line. Twenty-nine hernias had small defects and comprised interstitial fat only with no peritoneal sac. Ages in this group ranged from 32 to 80 (median = 48 years). All presented with intermittent local pain and/or swelling, although in three patients the hernias were impalpable. Those three also underwent ultrasound, CT and/or laparoscopy, but the hernias were only identified after open surgical exploration. The remaining 78 cases had peritoneal sacs of varying size with defects up to 9 cm across, and all were identified on imaging and/or laparoscopy. Ages ranged from 38 to 88 (median = 67 years; p

Case History Herniation of the urinary bladder into the inguinal canal is rare and constitutes 1–3% of all inguinal hernias. Bladder herniation is usually asymptomatic and is determined incidentally; however, it may rarely present with urinary obstruction symptoms. Here, we described an incidental bladder hernia in a 76-year-old man who is evaluated in radiology department for fever and left-sided flank pain for three days duration. He had no previous history of trauma, medication abuse, surgery or familial bladder disorders. His additional co morbidities included hypertension and diabetes mellitus. There were no remarkable findings on abdominal examination except left side loin tenderness. On evaluation Computed tomography (CT) revealed that a left inguinal hernia with fluid density lesion continuous with left lateral bladder wall. No bowel was contained in the hernia (Figure 1, 2). The inguinal hernia was confirmed as bladder hernia by CT cystogram (Figure 3). Inguinal hernia usually contains the peritoneum that surrounds the abdominal organs. Bowel loops, omentum, or extraperitoneal fat can be detected within the hernia sac in the inguinal canal. However, as in this case, the bladder can also be present within the hernia sac. Early diagnosis with radiological imaging is important to prevent complications during surgery.

The retroperitoneal space (retroperitoneum) is a potential space in the posterior peritoneal cavity that lies between the parietal peritoneum internally and the fascia of posterior abdominal wall externally. The space extends from the diaphragm superiorly to the sacral promontory and to the arcuate line inferiorly, which communicates with the pelvic extraperitoneal space inferiorly, with mediastinal connective tissue superiorly through the lumbocostal triangles, as well as with extraperitoneal fat bilaterally. Therefore, a primary tumor located in the retroperitoneal space may spread or invade to the posterior mediastinum, lateral abdominal wall, or pelvic extraperitoneal space. The retroperitoneal space can be divided into left lumbar region (left flank), right lumbar region (right flank), prevertebral region, left iliac fossa (RIF), and right iliac fossa (LIF) areas.

Background. Lumbar hernia is a rare type of hernia. Awareness of the anatomical basis of this hernia is important for proper diagnosis and treatment. Introduction. Lumbar hernia is a protrusion of either extraperitoneal fat or intraperitoneal contents through either of the lumbar triangles. Primary lumbar hernias are extremely rare thereby rendering such a case reportable, to create an awareness about this condition to upcoming surgeons. Case Report. A case of primary lumbar hernia treated successfully by open mesh repair is presented. Discussion. The anatomical aspects underlying this condition along with diagnostic tests, their pitfalls, and surgical approaches are discussed. Conclusion. Awareness of this condition is essential for arriving at a clinical diagnosis. CT scan provides a road map for deciding the approach. Both the traditional open and the newer laparoscopic approaches are described. However open meshplasty is still a very safe and effective method of treatment.

The aim of the research was to determine the incidence, significance, and anatomy of spermatic cord and round ligament lipomas. Between 2000 and 2010 we evaluated 969 consecutive patients with 1,070 indirect inguinal hernias, who underwent open repair. A total of 22 lipomas of the spermatic cord or round ligament were identified and resected in 22 patients. No neoplastic changes confirmed in histopathologic examinations of the specimens were reported. Lipomas of the cord and round ligament occur with a considerable incidence. We believe that even if there is no peritoneal sac, the herniation of extraperitoneal fat through the inguinal canal should be counted as an inguinal hernia, and it requires adequate treatment.

Inguinal canal lipomas are a frequent, often unrecognised finding on abdominopelvic CT. Commonly referred to as spermatic cord or round ligament lipomas, they are not true tumours of fat but are extrusions of extraperitoneal fat into the inguinal canal. Their fat content and shared location in the inguinal canal result in confusion with fat-containing inguinal hernias with which they often coexist. As laparoscopic herniorrhaphies proliferate, greater awareness of the condition by radiologists is needed to provide accurate preoperative information. This pictorial essay highlights the differentiating diagnostic features of inguinal canal lipomas and fat-containing inguinal hernias.

A femoral hernia is a (rare) herniation of extraperitoneal fat or a viscus (bowel or bladder) through the femoral canal in children. The femoral vein, artery and nerve are lateral to the hernia, although the hernia may sometimes protrude and overly these structures. Many approaches have been described. If there is risk of incarceration or strangulation then a suprainguinal, extraperitoneal approach is used. (This is described in the Chap. F2, ‘Inguinal Hernia and Ligation of Patent Processus Vaginalis’). The commonest approach however is directly over the hernia mass using an infrainguinal approach. This approach is now described

We read with interest the article by Dr Sadhu and colleagues [1] that details a technique of open insertion of laparosocpic cannula very much similar to the one we described and published in the Indian Journal of Surgery well over 9 years ago [2]. Both of us have since used it in more than 5000 patients without any instance of bowel or vascular injury. Having also taught the technique to several surgeon and gynecologist colleagues, we can vouch for its safety, simplicity and reproducibility. Over the years we have refined our technique to make it applicable in patients of all body habitus. Some of the technical aspects are highlighted below. 1 In thin patients and in those with a lax abdominal wall (e.g. multi-parous women) it is easy to evert the umbilicus completely by grasping the bottom of the umbilical pit with a towel clip. After a vertical incision on the umbilical cicatrix or the “umbilical tube” a cannula with a blunt inner trocar can then be guided into the peritoneal cavity directly.2 In most patients with a deep umbilicus and particularly in the obese, however, it is not always possible to evert the umbilicus. In these patients we place a towel clip on one lip of the umbilicus that has been everted with a toothed forceps, and apply a strong upward traction. This produces the desired effect of making the umbilical tube prominent allowing its easy identification after the skin has been incised. 3 We have observed that the umbilical tubes vary greatly in their texture, toughness and the amount of extraperitoneal fat they cover. Muscular and obese men often have a fibrous tube. After its incision, it is essential to grasp the cut edges with toothed instruments (our preference is single-toothed, straight Kocher’s forceps) to provide counter traction that allows a blunt-tipped hemostat to gently pierce and stretch the posterior rectus sheath/peritoneum underneath. 4 If the hemostat fails to gain easy entry into the peritoneal cavity, the incision on the umbilical tube needs to be extended onto the area where the umbilical tube merges with the horizontally placed linea alba. During this step, the short curved end of a baby Deaver’s retractor retracts and protects the skin to avoid a “T” extension of the incision. 5 A fair proportion of obese patients (and some not so obese ones) have a thick pad of extraperitoneal fat beneath the umbilical tube. If the tip of the hemostat does not “walk into” the peritoneal cavity after the tube is incised and its edges are lifted upwards, it is unwise to use force for the fear of causing injury to a loop of bowel lying under the incision. In such instances, we advance the blades of Deaver’s retractors to the depth of the extraperitoneal fat so as to identify and pick up the posterior sheath/peritoneum with two Kocher’s forceps. This layer is then incised. Additional manoeuvres such slightly extending the transverse skin incision, insertion of a third retractor

Epigastric hernia are usually small, single or multiple and usually contains extraperitoneal fat or omentum. Our case presentation is however that of a giant epigastric hernia which contained the stomach, omentum, 70cm of ileum, caecum, appendix, ascending colon, and most of the transverse colon. The neck measured 14cm in diameter and necessitated the use of mesh to effect repair. Keywords : Epigastric, giant, hernia, mesh repair Ebonyi Medical Journal Vol. 6 (2) 2007: pp. 118-120

Thirty years ago, the imaging investigation of the liver and the biliary tree began with the plain x-ray. Nowadays it is considered less valuable since the ultrasound has become the modality of choice for their initial examination. The liver casts an appreciable shadow on a simple X-ray film. The hepatic shadow appears homogenous and is mostly formed by the right lobe. It is delineated at the right quadrant of the abdomen, though modified by individual variations of shape and orientation. Its outline is deduced due to contrast differences between the right lobe and the right hemidiaphragm and lung above, the preperitoneal fat line laterally, and the extraperitoneal fat and the kidney below. The liver lies approximately at the level of fifth intercostal space at the midclavicular line. The lower border extends to or slightly below the costal margin and should not cross the right psoas margin. The lower anterior edge of the liver that is the one clinically palpated is not directly seen on a plain film, but the gas in the right colon usually indicates its position

PURPOSE: To study the feasibility of three-dimensional (3D) whole-body, head-to-toe, water/fat resolved MRI, using continuously moving table imaging technology. MATERIALS AND METHODS: Experiments were performed on nine healthy volunteers, acquiring 3D whole-body head-to-toe data under continuous motion of the patient table. Two different approaches for water/fat separation have been studied. Results of a three-point chemical shift encoding and a spectral presaturation technique were compared with respect to image quality and performance. Furthermore, fast, low-resolution, whole-body water/fat imaging was performed in two minutes total scan time to derive patient-specific parameters such as the total water/fat ratio, the intraperitoneal/extraperitoneal fat ratio, and the body mass index (BMI). RESULTS: Good water/fat separation with decent image quality was obtained in all cases. The three-point chemical shift encoding approach was found to be more efficient with respect to signal-to-noise ratio (SNR) and acquisition time. CONCLUSION: Whole-body water/fat sensitive MRI using continuous table motion is feasible and could be of interest for clinical practice. Some improvements of the method are desirable.

Whereas interstitial hernias of infancy are a result of congenital abnormalities, those in adults have been blamed on anatomical banding. Many of the latter are associated with systemic, genetic, or acquired connective tissue disease, however. This results in attenuated aponeuroses, ruptured tendons, and atrophied fascia from collagen malformation and destruction. Muscle contractility is compromised by loss of connective tissue septae, reducing capillary density. The result is wasting and disaggregation, which explains interstitial defects filled with herniated extraperitoneal fat, which account for 1% of primary inguinal herniae. These were originally described in the transversus and internal oblique musculature by Hessert (Surg Gyn Obstet 16:566–568, 1913). Similar slits are seen with Spigelian herniae, all of which are interstitial. This hypothesis, if proven, would imply treatment of the pervasive co-morbidity with the protrusions.

Fatty tissue within the internal cremasteric fascia is frequently encountered during hernia surgery, and it is called a cord lipoma in the surgical literature. Between 1997 and 2001, 128 consecutive patients with 139 indirect inguinal hernias, who underwent open repair, were evaluated. A total of 100 lipomas of the spermatic cord or round ligament were identified and resected in 92 patients. There were no reported neoplastic changes noted in histopathologic examinations of the specimens. The incidence of cord lipoma associated with indirect inguinal hernia was 72.5%. Average body mass index (BMI) was 25.7 in patients with lipoma and 24.6 in patients without lipoma ( P=0.048). The incidence of cord lipoma in large hernias (Nyhus Type II and IIIb) was higher in our patients ( P0.005). It can be clearly seen during laparoscopic exploration of the preperitoneal space that cord lipoma is a continuation of extraperitoneal fat tissue. We believe that even if there is no peritoneal sac, the herniation of extraperitoneal fat through the inguinal canal should be counted as an inguinal hernia, and it requires treatment.

Laparoscopic repair of ventral abdominal wall hernias involves intraperitoneal placement of a mesh, which may lead to adhesion formation and bowel fistulation. The first series of selected patients with ventral abdominal wall hernias treated laparoscopically by extraperitoneal placement of a polypropylene mesh is presented. Thirty-four patients (24 women and 10 men; median age, 52 years [range, 34-70]) were selected from among 122 patients undergoing laparoscopic ventral hernia repair. Of these patients, 18 had a primary ventral abdominal wall hernia and 16 had an incisional hernia. After reduction of sac contents and adhesiolysis intraperitoneally, a large flap of peritoneum (with extraperitoneal fat, fascia, and posterior rectus sheath where present) was raised to accommodate a suitably sized polypropylene mesh, which was then covered again with the peritoneal flap at the end of the procedure. Intraoperatively, apart from circumcision of the hernial sac at the neck, a total of 24 iatrogenic peritoneal tears occurred in 20 patients, mainly at the site of the previous scar. In two patients, it was observed that greater than 25% of the mesh was exposed after the procedure. The median (+/-SD) duration of hospitalization postoperatively was 1 day (+/-0.56). One patient's hernia recurred 4 months after surgery, and one patient's infected mesh was removed 8 months after surgery. Laparoscopic extraperitoneal placement of a mesh is feasible and appears to be an advance over laparoscopic intraperitoneal mesh placement for ventral abdominal wall hernias in selected patients. However, longer follow-up and controlled clinical trials will be necessary before any firm conclusions can be drawn.

The high incidence of bilateral inguinal hernias in the pediatric population and the fact that most of these children undergo contralateral hernia repair months or years after the first intervention for a clinically unilateral inguinal hernia have resulted in numerous examinations aimed at finding a contralateral hernia. We have found that the presence of protruding extra-peritoneal fat on the operated side could be considered a predictor of bilaterality after observing this finding in a large number of children operated upon months or years before for a unilateral inguinal hernia.

Magnetic resonance (MR) imaging has an increasing role in evaluating soft-tissue masses of the extraperitoneal spaces. Since the MR imaging features of most soft-tissue masses are nonspecific, prediction of a specific histologic diagnosis remains a challenge for the radiologist. However, there are certain specific MR imaging appearances that are helpful for more accurate diagnosis. Some histologic components, such as myxoid stroma, collagen fibers, calcification, and fat, have characteristic MR imaging features. Recognition of these features can assist the radiologist in limiting the differential diagnosis. Dynamic enhancement patterns can reflect the vascularity of masses and may be useful in diagnosis, especially in differentiating benign from malignant soft-tissue masses. Familiarity with specific signs and knowledge of diagnostic pitfalls are also important for shortening the list of differential diagnoses. Specific signs are the target sign, the bowl of fruit sign, a whorled appearance, a flow void, speckled enhancement, associated lymphadenopathy, and extension into the intervertebral foramen. Diagnostic pitfalls are as follows: a myxoid stroma simulating cystic degeneration and necrosis, collagen fibers simulating hemorrhage, a fat component simulating extraperitoneal fat, extensive intratumoral hemorrhage simulating hematoma, benign masses mimicking malignant ones, malignant masses mimicking benign ones, and peritoneal lesions mimicking extraperitoneal masses.

Objectives To study the clinical anatomy of the transversalis fascia (TF) and to explore the intertransversalis fascia approach in urologic laparoscopic operations (ULOs). Design Prospective study. Setting Two academic hospitals. Other Participants Data from 1217 urologic laparoscopic or open operations and 10 laparoscopic hernia repairs were analyzed between January 1, 2009, and April 30, 2011. Findings from 3 fresh autopsies were also included. Main Outcome Measures The anatomy of the TF was studied and the intertransversalis fascia approach was explored in ULOs; furthermore, they were proved in the open operations and fresh autopsies. Photographs were taken from the intertransversalis fascia approach in ULOs, micrographs were obtained to examine the microscopic structure of the TF, and the color atlas of TF anatomy (cross and sagittal sections) was drawn. Results The TF is a general plane of connective tissue lying between the inner surface of the transversus abdominis and the extraperitoneal fat. It can be divided into 2 layers (superficial and deep), with an amorphous fibroareolar space between them. The intertransversalis fascia approach in ULOs is the approach between the 2 layers of the TF. Conclusions The intertransversalis fascia approach is described for the first time, to our knowledge. Surgeons can obtain a clean, clear, and bloodless operating space in ULOs using the intertransversalis fascia approach.

A basic knowledge of normal anatomic relationships and variants is essential to understanding the effects of pathologic processes. Fundamental considerations include constant anatomic landmarks, variations in positions of structures, relationships maintained and bounded by peritoneal and fascial attachments, distribution of intra—and extraperitoneal fat providing the contrasting interfaces of organ and viscus contours, and governance of the configuration of the hollow viscera by specific anatomic characteristics and general physical laws.

Eighteen cases of urachal abscess were studied with sonography. Their configurations were cone shaped in 11 cases, tubular in 4, curved club shaped, and oval and irregular in one each. Their complications, such as intraperitoneal spread, chronic cystitis, and adhesion to the omentum or the colon, could also be suggested by ultrasonography. Gas was found in 50% of the lesions, which were all larger than 1 cm in diameter. An abscess smaller than 1.2 cm in diameter (which can be as long as 5 cm) can be treated with antibiotics or incision and drainage without total excision. A lesion within the extraperitoneal fat space of abdominal wall at the midline below umbilicus suggests the diagnosis of urachal abscess in cases of umbilical discharge and/or when the lesion extends to the umbilicus.

A lumbar hernia usually involves protrusion of extraperitoneal fat or bowel through an area of weakness in the posterolateral abdominal wall bounded superiorly by the 12th rib, inferiorly by the iliac crest, posteriorly by the erector spinae muscle, and anteriorly by the posterior border of the external oblique muscle. Most are due to an acquired nontraumatic or congenital cause. Acute blunt abdominal trauma is a rare cause of lumbar hernia; to our knowledge, the CT diagnosis of this variety has not been reported. Since 1985, approximately 850 patients have undergone emergent abdominal CT for evaluation of acute abdominal trauma at our hospital; in seven of these patients, a traumatic lumbar hernia was diagnosed prospectively. In three patients, CT showed a flank hematoma with herniation of bowel through the lumbar triangle. CT showed pelvic fractures in three other patients, accompanied by herniation of bowel in one patient, herniation of extraperitoneal fat in another, and herniation of extraperitoneal fat and blood in the third. One patient had both a flank hematoma and a pelvic fracture with herniation of bowel. Acute traumatic lumbar hernia is a rare but significant abnormality that should be considered in patients with blunt abdominal trauma, especially in those with large flank hematomas and pelvic fractures. The hernia contents, associated injuries, and disrupted muscle layers are all well demonstrated on CT.

Plain abdominal radiographs were studied in 280 children aged between one day and fourteen years to assess the age-related width of the extra-peritoneal fat. At the same time the limitations of assessing the size of the right side of the liver, the lower pole of the spleen and the psoas shadow were investigated. A significant rise in the evaluation of this method was only obtained after the sixth year and this was 86% in relation to the right lobe of the liver and 36% in relation to the lower pole of the spleen. From this age onwards, the preperitoneal fat is demonstrable in 94% of cases. The investigation suggests that from the sixth year onwards, the absence of the extra peritoneal fat line is an indirect indicator that there is intra-peritoneal fluid or a retro-peritoneal tumour. Eck

Medial displacement of the liver was observed in 35 cases of ascites using plain radiographs, total-body opacification, tomography, radionuclide imaging, peritoneography, and∕or ultrasonography. In 16 cases the displaced liver was seen on plain radiographs. Separation of the liver and kidney was seen on ultrasonograms in every case; it was increased by addition of increments of fluid in patients undergoing peritoneal dialysis. Since the liver is surrounded by fluid, an interface between it and the extraperitoneal fat cannot account for the displacement seen on plain radiographs: rather, this is the result of a difference in density between liver and fluid.

Plain film identification of intraperitoneal structures is generally limited to those aspects outlined by contrasting extraperitoneal fat or naturally occurring intraluminal gas. The demonstration of abdominal masses by gastrointestinal series and barium enema examination requires mucosal alterations or bowel displacement. These routine contrast studies of the intestinal tract permit visualization of its internal mucosal contour alone. An outstanding limitation is the inability to accurately evaluate the thickness of the bowel wall. Only indirect signs must be relied upon for the radiologic diagnosis of mural or serosal disease. The classic radiologic differential diagnosis between mucosal, submucosal (intramural), and extrinsic lesions is a distinction made on indirect signs only, based upon the contours of a defect. Terminology includes such descriptions as “mural defect”, yet the actual wall of the structure studied is rarely visualized radiologically.

Extraperitoneal perforations of the gastrointestinal tract, although uncommon, may be fatal if not recognized.The clinical and roentgen features of 5 cases of extraperitoneal perforation are described. In all, one or more of the following roentgen signs were seen: extraperitoneal gas, obliteration of normal extraperitoneal fat lines, and abnormal position of nasogastric tube. Usually an alert roentgenologist will be able to provide the diagnosis earlier than can the clinician.

To determine the radiographic signs of ascites, roentgenograms of 200 normal children and 29 children with ascites were studied. Many of the indirect radiographic signs are related to the development of the extraperitoneal fat pads. These include visualization of the hepatic angle and flank stripe widening, and nonvisualization of the psoas and splenic outlines. These signs may not be present due to lack of extraperitoneal fat pad development. However, radiographic diagnosis is usually possible by direct signs of intraperitoneal fluid such as visualization of the lateral liver border, “dog ears” in the pelvis, and measurable widening of the flank stripe to colon distance.

Recognition of the presence or absence of intraperitoneal fluid may be of considerable importance in the evaluation of abdominal disease. The indebtedness of radiologists to the work of Laurell (4, 5) and Frimann-Dahl (3) is difficult to overestimate. There are times, however, when the signs described are hard to apply. Frimann-Dahl was quick to point out the difficulties when the bowel is fluid-filled, when it is distended by a combination of gas and fluid, and even when it is relatively devoid of gas. Because of these problems we have sought a more usable technic of determining the presence or absence of peritoneal fluid. A further consideration of the anatomy of the flank has led us to the lower and lateral margins of the liver, the hepatic angle. Evaluation of the Flank Stripe The roentgen anatomy of the extraperitoneal and muscle plane fat has been described by both Laurell and Frimann-Dahl. These and other authors further state that the intra-abdominal viscera indent and mold the extraperitoneal fat...

HISTORICAL REVIEW Attention was called to the possible value in nutrition of oils and fats given subcutaneously, by von Leube1in 1895. He remarked the rapid disappearance of very large injections of camphorated oil which he was giving for stimulation and sought to find whether oils remained in the tissue spaces or were utilized in nutrition. An emaciated dog, previously brought into nitrogenous equilibrium at a very low level, was given daily subcutaneous injections of butter-fat for over six weeks in an amount which equaled about 1,400 gm. The weight rose from 4.4 kilos to 5.4 kilos. A laparotomy performed at the end of the injection period showed large masses of extraperitoneal fat, two-thirds of which was butter-fat. The omental fat consisted wholly of dog-fat. On a very low ration of fat-free meat at the end of a further three and one-half months, the same dog weighed 4.1 kilos

The anatomy of the extraperitoneal fat has been described in detail previously. Visualization of the cephalic extension of the extraperitoneal fat can localize the diaphragm on its undersurface. The extraperitoneal perivisceralfat pad is limited in its cephalic extent by the insertion of the diaphragm. Laterally, the point of insertion of the lateral aspect of the diaphragm may be ascertained because at this point the so-called flank fat ends. Medially the crus of the diaphragm can be clearly identified as an extension of soft tissue density from the superior portion of the psoas margin.