Download The peritoneum

The peritoneum
General features
• The peritoneum is a thin serous
membrane that line the walls of the
abdominal and pelvic cavities and
cover the organs within these cavities
• Parietal peritoneum －lines the walls
of the abdominal and pelvic cavities
• Visceral peritoneum －covers the
organs
• Peritoneal cavity －the potential
space between the parietal and
visceral layer of peritoneum, in the
male, is a closed sac, but in the
female, there is a communication with
the exterior through the uterine tubes,
the uterus, and the vagina
Function
• Secretes a lubricating
serous fluid that
continuously moistens
the associated organs
• Absorb
• Support viscera
The relationship between viscera and peritoneum
•
•
•
Intraperitoneal viscera －viscera completely surrounded by peritoneum,
example, stomach, superior part of duodenum, jejunum, ileum, cecum,
vermiform appendix, transverse and sigmoid colons, spleen and ovary
Interperitoneal viscera －most part of viscera surrounded by peritoneum,
example, liver, gallbladder, ascending and descending colon, upper part of
rectum, urinary bladder and uterus
Retroperitoneal viscera －some organs lie on the posterior abdominal wall
and are covered by peritoneum on their anterior surfaces only, example, kidney,
suprarenal gland, pancreas, descending and horizontal parts of duodenum,
middle and lower parts of rectum, and ureter
Intraperitoneal viscera
Interperitoneal viscera
Retroperitoneal viscera
Interperitoneal viscera
Structures which are formed by
peritoneum
Omentum
－
two-layered fold of
peritoneum that
extends from stomach
to adjacent organs
Lessor omentum
－two-layered fold of
peritoneum which extends
from porta hepatis to
lesser curvature of stomach
and superior part of
duodenum
•
Hepatogastric ligament
－extends from porta
hepatis to lesser curvature
of stomach
•
Hepatoduodenal ligament
Extends from porta hepatis
to superior part of
duodenum
–
Contains common bile duct,
proper hepatic a. and hepatic
portal v.
Omental foramen
• Behind the right border
of hepatoduodenal
ligament
• Superior－caudate
lobe of liver
• Inferior－superior part
of duodenum
• Anterior－
hepatodudenal
ligament
• Posterior－peritoneum
covering the inferior
vena cava
Greater omentum
－four-layered fold of
peritoneum, the anterior two
layers descend from the
greater curvature of stomach
and superior part of
duodenum and hangs down
like an apron in front of coils
of small intestine, and then
turns upward and attaches to
the transverse colon. If an
infection occurs in the
intestine, plasma cells formed
in the lymph nodes combat
the infection and help prevent
it from spreading to the
peritoneum.
Lessor omentum
Greater omentum
Omental bursa
Position－situated behind the lesser
omentum and stomach
Walls
•
Superior－peritoneum which covers
the caudate lobe of liver and
diaphragm
•
Anterior－formed by lesser
omentum, peritoneum of posterior
wall of stomach, and anterior two
layers of greater omentum
•
Inferior－conjunctive area of anterior
and posterior two layers of greater
omentum
•
Posterior－formed by posterior two
layers of greater omentum,
transverse colon and transverse
mesocolon, peritoneum covering
pancreas, left kidney and suprarenal
gland
•
•
Left－formed by the
spleen,
gastrosplenic
ligament and
splenorenal ligament
Right－formed by
omental foramen
The Omental bursa (lesser
sac) communicates with
the greater sac through
the omental foramen.
Mesenteries or mesocolons
－two-layered fold of
peritoneum that attach part
of the intestines to the
posterior abdominal wall
Mesentery
－suspends the small
intestine from the
posterior abdominal wall
• Broad and a fan-shaped
• Consists of two peritoneal
layers
• Intestinal border－folded,
7 m long
• Radix of mesentery
– 15 cm long
– Directed obliquely from
left side of L2 to in front
of right sacroiliac joint
Mesoappendix
• Triangular mesentery－
extends from terminal
part of ileum to
appendix
• Appendicular artery
runs in free margin of
the mesoappendix
Transverse mesocolon
－a double fold of
peritoneum which
connects the transverse
colon to the posterior
abdominal wall
Sigmoid mesocolon
－inverted V-shaped, with
apex located in front of left
ureter and division of
common iliac artery
Ligaments
－two-layered folds of
peritoneum that attached
the lesser mobile solid
visera to the abdominal wall
Ligaments of liver
• Falciform ligament of liver
– Consists of double
peritoneal layer
– Extends from anterior
abdominal wall (umbilicus)
to live
– Free border of ligament site
of ligamentum teres
• Coronary ligament
－the area between
upper and lower parts of
the coronary ligament is
the bare area of live, this
area is devoid of
peritoneum and lies in
contract with the
diaphragm
• Left and right triangular
ligaments
－formed by right extremity
of coronary ligament and
left leaf of falciform
ligament, respectively
• Hepatogastric ligament
• Hepatoduodenal
ligament
• Ligamentum teres
hepatis
Ligaments of spleen
• Gastrosplenic ligament －a double layer of peritoneum that
connects the fundus of stomach to hilum of spleen. In this
double layer of peritoneum are the short gastric and left
gastroepiploic vessels
• Splenorenal ligament －extends between the hilum of spleen
and anterior aspect of left kidney. The splenic vessels lies
within this ligament, as well as the tail of pancreas
• Phrenicosplenic ligament
• Splenocolic ligament
Ligaments of stomach
•
•
•
•
Hepatogastric ligament
Gastrosplenic ligament
Gastrophrenic ligament
Gastrocolic ligament
•
Gastropancrestic ligament
Folds and recesses of posterior
abdominal wall
• Superior duodenal
fold and recess
• Inferior duodenal
fold and recess
• Intersigmoid recess
－formed by the
inverted V attachment
of sigmoid mesocolon
• Retrocecal recess
－in which the
appendix frequenty
lies
• Hepatorenal recess
－lies between the
right lobe of liver, right
kidney, and right colic
flexure, and is the
lowest parts of the
peritoneal cavity
when the subject is
supine
Folds and fossas of anterior
abdominal wall
• Medial umbilical fold －
contain the remnant of
urachus (median umbilical
ligaments)
• Medial umbilical fold －
contains remnants of the
umbilical arteries (medial
umbilical ligaments)
• Lateral umbilical fold －
contains the inferior
epigastric vessels
• Supravesical fossa
• Medial inguinal fossa
• Lateral inguinal fossa
Pouches
• In male－
rectovesical pouch
• In female
– Rectouterine pouch
－between rectum and
uterus
– Vesicouterine pouch
－between bladder
and uterus
Peritoneal subdivisions
The transverse colon and
transverse mesocolon divides
the greater sac into supracolic
and infracolic compartments.
Supracolic compartments
(subphrenic space)－lies
between diaphragm and
transverse colon and transverse
mesocolon
Suprahepatic recess lies
between the diaphragm and live
－the falciform ligament divides
it into right and left suprahepatic
recesses
• Left suprahepatic
recesses
– left anterior
suprahepatic spaces
– left posterior
suprahepatic spaces
• Right suprahepatic
recesses
– right anterior
suprahepatic spaces
– right posterior
suprahepatic spaces
– bare area of live
(extraperitoneal space)
Infrahepatic recess
lies between the live and
transverse colon and
transverse mesocolon－the
ligamentum teres hepatic
divides it into right and left
infrahepatic recesses
• Right infrahepatic recesses
(hepatorenal recess)
• Left infrahepatic recesses
– left anterior infrahepatic
space
– left posterior infrahepatic
space
Infracolic
compartments －lies
•
•
•
•
below the transverse colon and
transverse mesocolon
Right paracolic sulcus (gutter)
－lies lateral to the ascending
colon. It communicates with the
hepatorenal recess and the
pelvic cavity. It provides a route
for the spread of infection
between the pelvic and the
upper abdominal region.
Left paracolic sulcus (gutter)
－lies lateral to the descending
colon. It is separated from the
area around the spleen by the
phrenicocolic ligament, a fold of
peritoneum that passes from the
colic flexure to the diaphragm.
• Right mesenteric sinus
－triangular space, lies between
root of mesentery, ascending
colon, right 2/3 of transverse
colon and transverse mesocolon
• Left mesenteric sinus
－lies between root of mesentery,
descending colon, right 1/3 of
transverse colon and transverse
mesocolon, its widens below
where it is continuous with the
cavity of the pelvis
Supracolic region
•
•
•
•
•
•
•
abdominal part of esophagus
stomach
duodenum
liver
Extrahepatic Biliary Apparatus
spleen
pancreas
Abdominal aorta
•
•
Continuation of
thoracic aorta at
aortic hiatus of
diaphragm in front of
T12
Terminates at lower
border of L4
vertebra by dividing
into right and left
common iliac
arteries
Parietal branches
•
•
•
Inferior phrenic a.
(one pair)
Lumbar a. (four
pairs of arteries that
supply the posterior
abdominal wall)
Median sacral a.
Visceral
branches
•
Paired branches
–
–
–
Middle suprarenal
artery
Renal artery
Testicular (ovarian)
artery
• Unpaired branches
– Celiac trunk
– －a short thick vessel
that arises from the
front of aorta, at the
level of T12
– Superior mesenteric
a. －arises from the
front of aorta, at the
level of L2
– Inferior mesenteric a.
－arises from the front
of aorta, at level of L3
Celiac trunk
Left gastric a.
Left branch
Right branch
Cystic a.
Short gastric a.
Common
hepatic a.
Splenic a.
Right gastric a.
Proper hepatic a.
Gastroduodenal a.
Splemic branches
Left gastrioeploic a.
Right gastroepiploic a.
Superior pancreaticoduodenal a.
Celiac trunk
Middle colic a.
Inf. pancresticodudenal a.
Right colic a.
Ileocolic a.
Appendicular a.
Superior
Mesenteric v.
Superior
mesenteric a.
Jejunal and ileal a.
Inferior mesenteric v.
Inferior mesenteric a.
Left colic a.
Sigmoid a.
Superior rectal a.
Colic marginal artery
Relations of abdominal
aorta
• Anteriorly (from above
downward)
– Pancreas
– Ascending part of
duodenum
– Radix of mesentery
• Posteriorly
– Upper four lumber
vertebrae
• On its right
– Inferior vena cava
• On its left
– Left sympathetic trunk
Veins of abdomen and pelvis
Internal iliac vein
• Parietal tributaries: accompany with arteries
• Visceral tributaries
→superior rectal vein→inferior mesenteric v.
→inferior rectal vein→internal iliac v.
→anal vein→internal pudendal v.
②Vesical venous plexus →vesical v.
③Uterine venous plexus →uterine v.
①Rectal venous plexus
• External iliac vein–
accompany the artery
• Common iliac vein–
formed by union of
internal and external
iliac veins in front of
sacroiliac joint, end
upon L4~L5 by
uniting each other to
form inferior vena
cava
Inferior vena cava
• Formed by union of two
common iliac veins
anterior to and just to the
right of L4~L5
• Ascends on the right side
of aorta, pierces vena
cava foramen of
diaphragm opposite the
T8 and drains into the
right atrium
• Conveys blood from the
whole body below the
diaphragm to the right
atrium
Chief tributaries
• Parietal
– Paired inferior phrenic v.
– paired lumbar v. (four)
• Visceral
– Right and left renal
veins
– Right suprarenal vein
(left drain into left renal
vein)
– Right testicular or
ovarian v. (left drain into
left renal vein)
– Hepatic veins : right, left
and intermediate
Relations of inferior vena
cava
• Anteriorly (cranially to caudally)
–
–
–
–
–
Liver
Head of pancreas
Horizontal part of duodenum
Right testicular (or ovarian) a.
Radix of mesentery
• Posteriorly
–
–
–
–
Right crus of diaphragm
Upper four lumber vertebrae
Left sympathetic trunk
Parietal branches of abdominal aorta
• On its right
– Psoas major
– Right kidney
– Right suprarenal gland
• On its left
– Abdominal aorta
Hepatic portal vein
General features
• Formed behind the neck of
pancreas by the union of
superior mesenteric vein and
splenic vein
• Ascends upwards and to the
right, posterior to the first part
of duodenum and then enters
the lesser omentum to the
porta hepatis, where it divides
into right and left branches
• There are no functioning
valves in hepatic portal system
• Drains blood from
gastrointestinal tract from the
lower end of oesophagus to
the upper end of anal canal,
pancreas, gall bladder, bile
ducts and spleen
Variation and anomalies
of hepatic portal vein
Tributaries of
hepatic portal
vein
1. Superior mesenteric v.
2. Inferior mesenteric v.
3. Splenic v.
4. Left gastric v.
5. Right gastric v.
6. Cystic v.
7. Paraumbilical v.
Portal-systemic anastomoses
1. At the lower end of the oesophagus
Hepatic portal vein → left gastric vein → esophageal
venous plexus → esophageal vein → azygos vein
→ superiorvena cava
2. At rectal venous plexus
Hepatic portal vein → splenic vein → inferior mesenteric
vein → superior rectal vein → rectal venous plexus →
inferior rectal and anal veins → internal iliac vein →
inferior vena cava
3. At periumbilical venous plexus
Hepatic portal vein→paraumbilical vein→periumbilical
venous plexus→
–
–
thoracoepigastric and superior epigastric vein →
superiorvena cava
superficial epigastric and inferior epigastric veins →
inferior vena cava
4. Portal-retroperitoneal anastomosis
Between the retroperitoneal branches of the colic
veins and the lumbar veins,
pancreaticoduodenal veins with the renal veins
and the subcapsular veins of the liver with the
phrenic veins twigs of colic veins (portal)
anastomosing with systemic retroperitoneal
veins
The lymphatic drainage of
abdomen
Lymphatic drainage of
abdominal wall
• To axillary lymph node
from region above
umbilicus
• To superficial inguinal
lymph node from region
below umbilicus
• To lumbar lymph node
from post wall of
abdomen
Lymphatic drainage of
abdominal viscera
• Lumbar lymph nodes
– Lie on posterior
abdominal wall, along
the abdominal aorta and
inferior vena cava
– Receive lymph from
kidneys, suprarenal
glands, testes, ovaris,
fundus of uterus, ovary,
and common iliac nodes
– Right and left lumbar
trunks formed by efferent
vessel
– Paired viscera－drain to
the lumbar lymph nodes
• Celiac lymph nodes
－situated around the
celiac trunk
• Superior mesenteric
lymph node －situated
around superior
mesenteric a.
• Inferior mesenteric
lymph node －situated
around inferior
mesenteric a.
• Intestinal trunk －
formed by efferent
vessel of celiac,
superior and inferior
lymph nodes
Thoracic duct
• Begins in front of L1 as a dilated sac,
the cisterna chyli, which formed by
joining of left and right lumbar trunks
and intestinal trunk
• Enter thoracic cavity by passing
through the aortic hiatus of the
diaphragm and ascends along on the
front of the vertebral column, between
thoracic aorta and azygos vein
• Travels upward, veering to the left at
the level of T5
• At the roof of the neck, it turns laterally
and arches forwards and descends to
enter the left venous angle
• Just before termination, it receives the
left jugular, subclavian and
bronchomediastinal trunks
• Drains lymph from lower limbs, pelvic
Spleen
Location: lies in the left
hypochondriac region
(between stomach
and diaphragm) deep
to the 9th to 11th rib,
its long axis
corresponds roughly
to the 10th rib
Shape－reddish in
colour
Two surfaces
• Diaphragmatic: smooth, convex
• Visceral: concave, hilum of spleen
Two extremities
• Anterior－wider
• Posterior－rounder
Two border
• Superior－has 2-3 splenic notch, which
serve as a landmark on palpation when it
is enlarge; normally it is not palpable
• Inferior－rounder
Functions: the spleen is considered to be
important in:
• Formation of lymphocytes and monocyte
• Phagocytosis of bacteria, inert particles
and white blood cells and platelets
• Destroying effete or abnormal red blood
cells
• Making antibodies
Spleen
 Function
Erythrocyte storage
Phagocytosis
Cytopoiesis
Immune responses
Relationships of spleen
Diaphragmatic surface
－diaphragm
Visceral surface
• Anteriorly－fundus of
stomach
• Posteriorly－left
suprarenal gland and
kidney
• Inferiorly－tail of
pancreas and left colic
flexure