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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 Dissection and Observation superficial structures Three flat muscles , vessels and nerves rectus abdominis rectus sheath inguinal region inguinal canal inguinal triangle Relationships of abdominal viscera First layer－live, gallbladder, stomach Second layer－duodenum, pancreas, spleen Third layer－suprarenal gland, kidney, ureter, inferior vena cava, abdominal aorta, nerves and lymphatics Relationships of the stomach Anterior: Live (right part) Diaphragm (left upper part) Anterior abdominal wall (left lower part) Posterior－separated by peritonum of lesser sac from the following (“stumach-bed”) Pancreas Left suprarenal gland Left kidney Spleen Transverse colon and transvers mesoclon Arteries of stomach Left and right gastric arteries arise from celiac trunk and proper hepatic artery, repectively. These two vessels run in lesser omentum along lesser curvature , and anastomose end-toend. Right and left gastroepiploic arteries arise from the gastroduodenal and splenic artery, repectively. These two vessels pass into the greater omentum, run parallel to the greater curvature, and anastomose end-to-end. Short gastric arteries, branches of splenic artery, course through the gastrosplenic ligament and supply the fundus of stomach. Posterior gastric artery (72%) arise from the splenic artery, course through the gastrophrenic ligament and supply the posterior wall of fundus of stomach. Venous drainage Right and left gastric veins empty directly into hepatic portal vein. Left gastroepiploic and short gastric veins drain into hepatic portal vein via the splenic vein. Right gastroepiploic vein join either superior mesenteric vein. Lymphatics of stomach Right and left gastric ln. lie along the same vessels and finally to the celiac ln. Right and left gastroomental ln. lie along the same vessels, the former drain into subpyloric ln., the latter drain into splinic ln. Supra- and subpyloric ln. receive lymphatics from pyloric part and finally to the celiac ln. Splenic ln. receive lymphatics from fundus and left third of stomach, and finally to the celiac ln. Nerve supply Parasympathetic innervation by anterior (left) and posterior (right) vagal trunks The anterior trunk divides into anterior gastric and hepatic branches The posterior trunk divides into posterior gastric and celiac branches The anterior and posterior gastric branches descend on the anterior and posterior surfaces of the stomach as a rule about 1 to 2 cm from the lesser curvature and parallel to it in the lesser omentum as far as the pyloric antrum to fan out into branches called “crow’s foot” to supply the pyloric part Sympathetic innervation Mainly from celiac ganglia Affent and effent fibers derives from thoracic segments (T5 －L1 The duodenum Relationships of superior part Anteriorly Posteriorly Commom bile duct Gastroduodenal a. Hepatic portal v. Inferior vena cava Superioely Quadrate lobe of live Gallbladder Omental foramen Inferiorly Head of pancreas Relationships of descending part Anteriorly Posteriorly Right renal hilum and ureter Right renal vessels Medially Live Transverse colon and mesocolon Loops of small intestine Head of pancreas Common bile duct and pancreatic duct Laterally Right colic flexure Relationships of horizontal part Superiorly Head of pancreas Inferiorly Anteriorly Loops of small intestine Radix of mesentery Superior mesenteric a. and v. Posteriorly Right ureter Inferior vena cava Abdominal aorta Relationships of ascending part Right Head of pancreas and abdominal aorta Left Left kidney and ureter Relationships of liver Diaphragmatic surface－ separated by diaphragm from the following Right costodiaphramatic recess and lung Cardiac base Visceral surface Left lobe is related to the stomach and abdominal part of esophagus Right lobe is related to the right colic flexure anteroly, gallbladder and superior duodenal flexure medially, right kidney, superarenal gland posteriorly Divisions and relations of common bile duct Supraduodenal segment Descends along the right margin of hepatoduodenal lig. To the right of proper hepatic a. Anterior to hepatic portal v. Retroduodenal segment Behind the superior part of duodenum Anterior to the vena cava To the right of the hepatic portal v. Pancreatic segment Lies in a groove between posterior surface of head of pancreas and duodenum Intraduodenal segment Enters the wall of descending part of duodenum obliquely where jions the pancreatic duct to form the hepatopancreatic ampulla opens at the major duodenal papilla 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 Divisions and relations of pancreas Head of pancreas Located in C-shapes curvature of doudenum Anteriorly Transverse mesocolon Posteriorly Inferior vena cava Right renal vessels Common bile duct Neck of pancreas Anteriorly－pylorus Posteriorly－commencement pf hepatic portal v. (formed by union of splenic and superior mesenteric veins Body of pancreas Anteriorly Posteriorly Separated from stomach by omental bursa Abdominal aorta Left suprarenal gland Left kidney Left renal vessels Spleen vein Superiorly Celiac trunk Celiac plexus Splenic a. Tail of pancreeas Runs in spleicorenal ligament to reach hilum of spleen Accompanies with splenic vessels Blood supply Arteries Superior pancreaticoduodenal a. Inferior pancreaticoduodenal a. Veins－follow arteries, draining directly into superior mesenteric and hepatic portal veins 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. 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.