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Abstract Recently, the concept of interfascial planes has become the prevalent theory among radiologists for understanding the retroperitoneal anatomy, having replaced the classic tricompartmental theory. However, it is a little known fact that the concept remains incomplete and includes embryological errors, which have been revised on the basis of our microscopic study. We believe that the concept not only provides a much clearer understanding of the retroperitoneal anatomy, but it also allows further development for diagnosis and treatment of retroperitoneal injuries and diseases, should it become an accomplished theory.
We explain the history and outline of the concept of interfascial planes, correct common misunderstandings about the concept, explain the unconsciously applied therapeutic procedures based on the concept, and present future perspectives of the concept using our published and unpublished data. This knowledge could be essential to acute care physicians and surgeons sometime soon. I seem to have been only like a boy playing on the seashore, and diverting myself in now and then finding a smother pebble or a prettier shell than ordinary, whilst the great ocean of truth lay all undiscovered before me.
Sir Isaac Newton Introduction Surprisingly, the structure of the retroperitoneum has not been entirely clarified. Even the famous tricompartmental theory for retroperitoneal structures advocated by Meyers et al.
Request PDF on ResearchGate On Sep 1, 2015, Agnes B Fogo and others published AJKD Atlas of Renal Pathology: Fabry Nephropathy. Fellype de Carvalho Barreto Fabry disease is an X-linked lysosomal storage disease due to alpha-galactosidase A (α-Gal A) deficient activity which leads to the accumulation of glucoesphingolipids.
has failed to explain the dynamic changes of retroperitoneal pathologies. Diagrams of retroperitoneal anatomy. A, Cross-sectional diagram of the median and left parts of the retroperitoneum according to the tricompartmental theory. The retroperitoneum is divided into the anterior pararenal space (green area), perirenal space (yellow area), and posterior pararenal space (gray area) by the anterior renal fascia (red line), posterior renal fascia (purple line), and lateroconal fascia (blue line). Ao, aorta; IVC, inferior vena cava; K, kidney, PM, psoas muscle. B, Cross-sectional diagram of the same area in panel A, according to the concept of interfascial planes. This diagram depicts the interfascial planes as potential spaces among the three compartments: the retromesenteric plane (red area) corresponds to the anterior renal fascia; the retrorenal plane (purple area) corresponds to the posterior renal fascia; and the lateroconal plane (sky-blue area) corresponds to the lateroconal fascia.
Note that the perirenal space is closed medially. C, Longitudinal diagram of the retroperitoneum according to the tricompartmental theory.
As shown within the dotted circle, the bottom of the perirenal space is patent, and the retroperitoneum below the discontinued renal fasciae (olive area) is ambiguous. D, Longitudinal diagram of the retroperitoneum according to the concept of interfascial planes. The perirenal space is closed inferiorly (open arrow). The combined interfascial plane (pink area) is formed by the inferior blending of the retromesenteric and retrorenal planes and continues into the pelvis. Renal lesions can reach interfascial planes through the perinephric bridging septa (described below) and spread within the combined interfascial plane into the pelvis. E, Aizenstein's advanced diagram of the planes. A renal lesion (red area) spreads within the perinephric bridging septa (dotted arrows) and intrudes into the interfascial planes.
Histology
The lesion can extend contralaterally (red dashed arrow) by way of the retromesenteric plane. Traumatic retroperitoneal hematoma. A, A 74-year-old man with left renal injury. Computed tomography (CT) image on admission shows hematoma sequentially spreading from perinephric bridging septa (thin dotted white arrows) in the perirenal space (Type II) to the retromesenteric (white thick arrows), retrorenal (black triangles), and lateroconal (white arrowhead) planes. Note that the psoas muscle and quadratus lumborum muscle are located close to the hematoma within the medial part of the retrorenal plane (purple arrows) as well as in panels B and C. B, A 62-year-old man with lumbar spine injury.
CT image on admission shows massive retroperitoneal hematoma spreading from the medial part of retrorenal plane (purple arrows) (Type IV), resulting from lumbar fracture and lumbar arteries, into the retromesenteric (white thick arrows), lateroconal (white arrowhead), and lateral part of the retrorenal (black triangles) planes and into the subfascial plane, showing the checkmark sign (gold curved arrow). He died from uncontrollable hemorrhage. Note that the hematoma in the retromesenteric plane is closely located to and elevates the duodenum (shown with orange arrow), and that many strands are detected within the posterior pararenal space (thin white arrows) as well as thickened perinephric bridging septa (thin dotted white arrows). C, A 44-year-old man with left renal injury. CT image 3 days after injury shows massive retroperitoneal hematoma travelling into the undamaged right retroperitoneum (red dotted arrow) through the retromesenteric plane (white thick arrows) from the perinephric bridging septa (thin dotted white arrows) in the perirenal space (Type II). Hematoma also extends to the retrorenal (black triangles and purple arrow) and lateroconal (white arrowheads) planes. Note bilateral checkmark signs (gold curved arrows) and strands (thin white arrows) in the posterior pararenal space.
Acute pancreatitis. A, B, Transverse computed tomography images of a 76-year-old man with severe acute pancreatitis. The pancreas head and the duodenum are swollen and fluid collection spreads within the retromesenteric (white thick arrows), lateroconal (white arrowheads), and retrorenal (black triangles) planes and forms checkmark signs (gold curved arrows) (grade IV).
Fluid collection in the retromesenteric plane elevates the duodenum (orange arrows). C, Reconstructed sagittal computed tomography image in the same patient. Note that the retromesenteric (white thick arrows) and retrorenal (black arrows) planes unite to form the combined interfascial plane (pink rhombus). He recovered 15 days after admission with intensive care. The concept was further applied to the clinical stratification of the retroperitoneal diseases after we revised the relationship between the posterior pararenal space and the retrorenal plane around the psoas muscle and found another retroperitoneal potential space named the “subfascial plane” (Fig. F).
Results from a search on Google Scholar show a dramatic increase in published works written in English on the interfascial planes after 2008. Clinical Application Traumatic retroperitoneal hematoma Morbidity and mortality rates associated with traumatic retroperitoneal hematoma (TRH) remain high despite improvements in prehospital care.
D Margot
Additionally, decision-making in the treatment of TRH is often controversial even after CT scanning. In the early 1980s, Kudsk and Sheldon introduced a famous treatment principle founded on a location-based classification of TRH as central-medial (Zone I) TRH, flank or perirenal (Zone II) TRH, and pelvic (Zone III) TRH. This principle has been used as a bible for the treatment of TRH; nevertheless, the strategy remains controversial.
Table 1. Classification of traumatic retroperitoneal hematoma according to the concept of interfascial planes (partially revised from the classification in our previous paper) Type Origin of the hematoma Injured organ or vessel Therapeutic strategy. Checkmark sign, representing hematoma intruding into the subfascial plane, predicts a poor outcome in every type. IVR, interventional radiology.
I Anterior pararenal space Pancreas, duodenum, colon, etc. Emergent retroperitoneal exploration, surgical hemostasis Retromesenteric plane Subsequent control of contamination II Perirenal space Kidney, adrenals, etc.
Conservative therapy, IVR Posterior pararenal space Surgical hemostasis if renal pedicle injury is complicated Lateroconal plane Lateral part of the retrorenal plane III Pelvic retroperitoneum Pelvic fracture IVR, C-clamp, or external fixation No laparotomy IV Combined interfascial plane Great vessels, psoas muscle, lumbar artery, lumbar vertebral fracture, etc. IVR, emergent exploration of the retroperitoneum Medial part of the retrorenal plane (Strategy is not fully established. Offhand laparotomy sometimes induces poor outcome.) Our previous study recognized the subfascial plane as a part of the posterior pararenal space.
Therefore, the data must be corrected; that is, TRH was identified in the interfascial and subfascial planes in more cases (91.7%, and not 88.8% as originally reported), and the partial volume of TRH within the interfascial planes accounted for 83.2%, and not 78.1%, of the total volume. Traumatic retroperitoneal hematoma encompassing all potential spaces, including the perinephric bridging septa, would result in larger values than those above. Additionally, we noticed that the checkmark sign is only useful when the sign is depicted on CT within several hours after injury because TRH can spread gradually into the subfascial plane (Fig. C). (Presented at the 41st annual meeting of the Japanese Association of Acute Medicine JAAM in 2013.) Acute pancreatitis Early and accurate prediction of the severity of acute pancreatitis is critical to its treatment but is often difficult. Balthazar et al. established the CT severity index, which combines assessment of the degree of pancreatic or extrapancreatic inflammation with the degree of pancreatic necrosis.
However, the CT severity index is not sufficient to accurately represent the location of retroperitoneal lesions because it is based on the tricompartmental theory. Therefore, we clarified the principle of retroperitoneal extension of fluid collection resulting from acute pancreatitis, which had been misunderstood until then, and provided a system to classify the severity of acute pancreatitis, according to the concept of interfascial and subfascial planes. The retroperitoneal extension of acute fluid collection was classified into five grades (Table, Fig. ).
Our classification system has been cited in many published reports because it is in accord with the natural progression of the disease and both identifies and predicts disease severity without the necessity of contrast medium-enhanced CT. Additionally, we found that fluid collection confined to the interfascial planes, corresponding to Grade I, II, or III pancreatitis, resolved spontaneously in all cases, whereas fluid collection in some patients with Grade IV disease and in all patients with Grade V disease did not resolve spontaneously. We suspect that the persistent fluid collection present in Grade V disease can easily progress to infectious abscess requiring drainage. Table 2. Grade of retroperitoneal extension of acute pancreatitis according to the concept of interfascial planes Grade Retroperitoneal extension.
Please refer to our previous paper for detailed information. Other retroperitoneal diseases.
A, B, A 54-year-old man with infectious colitis probably from Aeromonas hydrophila. Note the marked fluid collection in the retromesenteric (white thick arrows), lateroconal (white arrowheads), and retrorenal (black triangles) planes and clear checkmark signs (gold curved arrows). Additionally, note that fluid collection within the medial part of the retrorenal plane is located close to the psoas muscle and quadratus lumborum muscle as well as in panels C and F (purple arrows). He died 10 h after admission despite emergent right colostomy and intensive care. C, A 75-year-old man with obstructive acute pyelonephritis.
Note the fluid collection within the retrorenal plane (black triangles and purple arrows) with the thickened perinephric bridging septa (thin dotted white arrows) and strands (thin white arrows) in the posterior pararenal space. D, A 36-year-old woman with barotraumas due to transtracheal jet ventilation. Massive pneumoretroperitoneum spreads in the retromesenteric plane (white thick arrows) and appears as mobilizing colon and duodenum by Cattell–Braasch maneuver (curved red arrows). E, A 65-year-old man with retroperitoneal abscess accumulated within the retromesenteric (white thick arrows), lateroconal (white arrowhead), retrorenal (black triangle), and subfascial (gold curved arrow) planes, speculated to be a hematogenously disseminated abscess after sepsis. Note the strands (thin white arrow) in the posterior pararenal space.
F, A 69-year-old man with ruptured abdominal aortic aneurysm. Retroperitoneal hematoma in the retromesenteric plane (thick white arrows) spreads beyond the midline (red dotted arrow) and elevates the duodenum (orange arrow). Note the retroperitoneal hematoma within the retrorenal (black triangle and purple arrows), lateroconal (white arrowhead), and subfascial (gold curved arrow) planes and the perinephric bridging septa (thin dotted white arrow). Pneumoretroperitoneum spreads within the interfascial planes (Fig. D) regardless of the etiology, such as colon perforation or extension of pneumomediastinum. Retroperitoneal abscess (Fig. E) or non-traumatic retroperitoneal hematoma (Fig. F) also spreads in the same manner.
Unsolved Problems Embryology The concept of interfascial planes had a serious defect in that there was no embryological evidence to support their existence. The advocators of the concept considered the retromesenteric plane as the potential space within fusion fascia of Toldt and that of Treitz, according to the paper by Dodds et al., but they explained the origin of neither retrorenal nor combined interfascial plane. Their consideration has been accepted and taught worldwide without any verification. If it is valid, however, the interfascial planes must escape from the retroperitoneum into the peritoneal cavity (Fig. S4). Moreover, such consideration is incompatible with the formation process of fusion fascia embryologically explained as follows: after fusion of the opposed peritoneum, mesothelial cells immediately disappear and the two young connective tissues, subserosal layers of the peritoneum, fuse intimately, producing a single inseparable layer. According to the theory, a potential space in the fusion fascia is highly improbable, and, at least, an “interfascial” structure never forms because of the bilaterally vanished peritoneum.
Therefore, we re-examined the embryological development of the retroperitoneal fasciae in light of the interfascial planes. In our observations, just as in the classical anatomical researches, the retroperitoneal organs were embedded in the homogeneous loose mesenchymal tissues in the embryonic stage, and around the 12th week of fetal life, fibrous structures, considered as the primordial renal or transversalis fascia, were identified in the homogeneous connective tissue. Then, around the 25th week, both the renal and transversalis fasciae became clearly identifiable, and primitive adipose tissue developed. Additionally, we noticed that another fascia-like structure, considered as the lateroconal fascia, appeared between the renal fascia and the primitive adipose tissues of the flank pad (Fig. A), and the pre-existing homogeneous loose connective tissue was conversely compressed and narrowed between the opposing fasciae or peritoneum.
Our concept for the development of interfascial planes. A, Our findings. The clear renal and transversalis fasciae and the developing lateroconal fascia are located in the loose connective tissues (flesh-colored area).
Immature adipose tissues can be detected in the connective tissues between the lateroconal fascia and the transversalis fascia and in those within the perirenal space. B, Our concept. The pre-existing loose connective tissues are narrowed by developing fatty tissue and organs and destined to be the interfascial planes: the retromesenteric (red), retrorenal (purple), and lateroconal (sky-blue) planes. Additionally, the loose connective tissues within the perirenal space are also narrowed by adipose tissues and presumed to be the perinephric bridging septa (flesh-colored area). The loose connective tissue lateral to the flank pad is also destined to be the subfascial plane (gold area). Dotted lines are not confirmable in our study but are presumed to be formed as migration fasciae. P, psoas muscle; PBS, perinephric bridging septa; Q, quadratus lumborum muscle.
Figures are reprinted from our previous paper with permission from the copyright owners (Springer Science+Business Media). Filename Description application/mspowerpoint, 2128K Fig. S1. “Interfascial spaces” advocated by Sato. Application/mspowerpoint, 204K Fig. S2. Our previous interpretation of the interfascial planes based on the “interfascial spaces”.
Application/mspowerpoint, 821K Fig. S3-1. Dynamic spread of a traumatic retroperitoneal hematoma of Type II (Fig. A). Application/mspowerpoint, 8123K Fig. S3-2. Dynamic spread of a traumatic retroperitoneal hematoma of Type IV (Fig. B). Application/mspowerpoint, 393K Fig. S4. If the interfascial planes were the potential spaces within the fusion fascia. Application/mspowerpoint, 1412K Fig. S5.
Microscopic observation of the retroperitoneal structure in the early-stage fetus. Application/mspowerpoint, 592K Fig. S6. Our tentative model of the retroperitoneal anatomy. Word document, 25K Please note: Wiley-Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors.
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