Transcript 23 - peritoneum

PARTS
The peritoneum is the most 
complex serous membrane
of the body.
It consists of : 
(1) Parietal peritoneum : 
It lines the abdominal and 
pelvic walls (parietes).
It is separated from the 
body wall by areolar
connective tissue
(extraperitoneal tissue).
PARIETAL PERITONEUM
It varies in 
different regions.
It contains a large 
amount of fat in
the area of the
kidney.
(2) VISCERAL PERITONEUM
It is the reflection of 
the parietal
peritoneum on the
organs.
It is firmly united to 
the viscera which it
covers.
PERITONEAL CAVITY
It is the potential space 
between the parietal and
visceral layers.
It consists of : 
A. Greater sac : 
It is the main region. 
B. Lesser sac (omental 
bursa) :
It is a diverticulum behind 
the stomach.
PERITONEAL CAVITY
The lesser omentum 
separates the greater and
lesser sacs.
The two sacs communicate 
through the opening of the
lesser sac (Epiploic
foramen).
PERITONEAL CAVITY
In male, the cavity is 
a closed sac.
PERITONEAL CAVITY
In female, it 
communicates with the
exterior through the
uterine tubes, uterus
and vagina.
PERITONEAL FLUID
It is secreted by the 
peritoneum.
It contains leukocytes. 
It ensures that the 
mobile viscera glide
easily on each other.
It is not static. 
Its accumulation causes 
ascites.
INTRA PERITONEAL ORGANS
They are organs which 
are totally covered
with visceral
peritoneum.
They are not actually 
within the peritoneal
cavity.
Stomach. 
Spleen. 
Jujenum and Ileum. 
RETROPERITONEAL ORGANS
They are organs which 
are partially covered
with visceral
peritoneum.
Ascending and 
Descending colon.
Kidneys. 
Pancreas. 
PERITONEAL LIGAMENTS
They are two- layered 
folds of peritoneum.
They connect the solid 
viscera to the abdominal
wall.
In the LIVER, it is 
connected to the
diaphragm by:
Falciform ligament. 
Coronary ligament. 
Right and Left triangular 
ligaments.
OMENTA
They are two layered 
folds of peritoneum.
They connect the 
stomach to another
viscus.
1. Greater omentum. 
(2) Lesser omentum. 
GREATER OMENTUM
It connects the greater 
curvature of the stomach to
the transverse colon.
It hangs down like an 
apron to cover the coils of
small intestine.
It folded back on itself to 
be attached to the
transverse colon.
LESSER OMENTUM
It extends between the 
lesser curvature of the
stomach and the under
surface of the liver
(porta hepatis and
fissure for ligamentum
venosum) .
GASTROSPLENIC LIGAMENT
(OMENTUM)
It connects the 
stomach to the hilum
of the spleen.
SPLENICORENAL LIGAMENT
It connects the hilum –
of the spleen to the left
kidney.
MESENTERIES
They are two layered 
folds of peritoneum.
They connect parts of the 
intestine to the posterior
abdominal wall.
Mesentery of small 
intestine.
Transverse mesocolon. 
CONTENTS
Blood vessels. 
Lymph vessels. 
Nerves. 
Fat. 
SAGITTAL SECTION OF
PERITONEUM
0. Parietal 
peritoneum lining
the anterior
abdominal wall
ascends upwards
to the
undersurface of the
diaphragm.
SAGITTAL SECTION OF
PERITONEUM
0. It is reflected 
onto the upper
surface of the liver
to the left of the
falciform ligament.
It forms the 
anterior layer of
the left triangular
ligament.
PERITONEUM (SAGITTAL
SECTION)
0. It covers the anterior 
and inferior surfaces of
the liver until it reaches
the porta hepatis.
0. It passes to the lesser 
curvature of the stomach
as the anterior layer of
the lesser omentum.
PERITONEUM (SAGITTAL
SECTION)
0. It covers the 
anterior surface of
the stomach.
0. It leaves the 
greater curvature
to form the
anterior layer of
the greater
omentum.
PERITONEUM (SAGITTAL
SECTION)
0. The greater 
omentum forms a fold
in front of the coils of
intestine.
0. On reaching its 
lowest limit, the
peritoneum folds on
itself to form the
posterior layer of the
greater omentum.
PERITONEUM (SAGITTAL
SECTION)
0. The peritoneum 
forms the posterior
layer of the
transverse
mesocolon.
0. It passes to the 
anterior border of
the pancreas and
the 3rd part of the
duodenum.
PERITONEUM (SAGITTAL
SECTION)
0. The peritoneum 
leaves the
posterior
abdominal wall as
the anterior layer
of the mesentery of
the small intestine.
PERITONEUM (S.S) IN FEMALE
It descends down to 
cover the anterior
surface of the rectum.
It is reflected onto the 
posterior surface of the
upper part of the
vagina and forms the
rectouterine pouch
(pouch of Douglas).
PERITONEUM (S.S) IN FEMALE
It passes over the upper 
surface of the uterus and
reflected from its
anterior surface onto the
upper surface of the
bladder.
It forms the shallow 
uterovesical pouch.
It passes from the 
bladder onto the anterior
abdominal wall.
PERITONEUM (S.S) IN MALE
From the anterior surface 
of the rectum, it reflected
onto the upper part of the
posterior surface of the
bladder and the seminal
vesicles.
It forms the rectovesical 
pouch.
It passes from the bladder 
onto the anterior
abdominal wall.
TRANSVERSE SECTION OF
PERITONEUM AT (L4)
The parietal peritoneum 
lining the anterior
abdominal wall is mostly
smooth.
It is raised by two ridges : 
Median umbilical ligament 
(urachus) : remains of fetal
allantois.
Lateral umbilical ligaments : 
obliterated umbilical
arteries.
T. S. OF PERITONEUM AT (L4)
It ascends onto the 
posterior abdominal
wall and becomes
continuous with the
visceral peritoneum
which covers the
front and sides of the
ascending and
descending colon.
T. S. OF PERITONEUM AT (L4)
Para colic gutters: 
(grooves) lie medial and
lateral to the ascending
and descending colons.
T. S. E OF PERITONEUM AT
(L4)
At the level of the 
aorta and inferior
vena cava, it
becomes
continuous with
mesentery of the
small intestine.
T. S. OF PERITONEUM AT (T12)
1. The parietal 
peritoneum above
the umbilicus
forms
The Falciform 
ligament.
FALCIFORM LIGAMENT
It is a sickle – shaped 
fold.
It connects the anterior 
surface of the liver to
the diaphragm and
anterior abdominal wall.
Its free border contains 
ligamentum teres
(obliterated umbilical
vein).
T. S. OF PERITONEUM AT (T12)
2. At the left side of 
the abdomen :
0. The parietal 
peritoneum becomes
continuous with the
visceral peritoneum
covering the lateral
margin and anterior
surface of left
kidney.
T.S. OF PERITONEUM AT (T12)
0. It passes to the hilum 
of the spleen as the
posterior layer of the
splenicorenal ligament.
0. It covers the spleen. 
0. It is reflected at the 
hilum as the anterior
layer of the gastrosplenic
ligament.
T. S. OF PERITONEUM AT (T12)
0. It covers the 
anterior surface of the
stomach .
0. It leaves the lesser 
curvature as the
anterior layer of the
lesser omentum.
0. On the right, the 
lesser omentum has a
free border.
T. S. OF PERITONEUM AT (T12)
0. The peritoneum is 
folded around the bile
duct, hepatic artery
and portal vein.
0. It forms the 
posterior wall of the
lesser omentum
(anterior wall of the
lesser sac).
T. S. OF PERITONEUM AT (T12)
0. It leaves the greater 
curvature of the
stomach.
0. It forms the 
posterior layer of the
gastrosplenic ligament.
0. At the hilum of the 
spleen, it is reflected as
the anterior layer of
the splenicorenal
ligament.
T. S. OF PERITONEUM AT (T12)
0. It covers the 
anterior surface of
Aorta, Inferior vena
cava and Pancreas.
0. It forms the 
posterior wall of the
lesser sac.
0. It passes onto the 
anterior surface of the
right kidney.
T. S. OF PERITONEUM AT (T12)
0. It passes onto the 
anterior surface of the
right kidney.
0. It sweeps around the 
lateral abdominal wall to
reach the anterior
abdominal wall.
0. It forms a continuous 
layer around the
abdomen.
LESSER SAC
It is a peritoneal pouch. 
Position : 
Behind the lesser 
omentum and stomach.
In front of the structures 
of the posterior
abdominal wall
(pancreas & duodenum).
LESSER SAC (EXTENSIONS)
Superior recess : 
As far as the diaphragm 
& caudate lobe of the
liver.
Inferior recess : 
Between the layers of 
the greater omentum.
This is often 
obliterated.
LESSER SAC (BOUNDARIES)
1. Left : 
Spleen. 
Gastrosplenic & 
Splenicorenal
ligaments.
2. Right : 
Opening of the lesser 
sac (epiploic foramen).
3. Below: 
Left free border of the 
greater omentum.
EPIPLOIC FORAMEN
Anterior :
Free border of the 
lesser omentum
with its contents
(bile duct, hepatic
artery and portal
vein).
EPIPLOIC FORAMEN
Posterior : 
Inferior vena cava. 
EPIPLOIC FORAMEN
Superior : 
Caudate lobe (caudate 
process) of the liver.
Inferior : 
First part of the 
duodenum.
GREATER SAC
It is divided by the 
transverse mesocolon
into :
(1) Supra colic part. 
(2) Infracolic part. 
SUPRA COLIC PART
It contains : 
1. Anterior subphrenic 
between the liver and
diaphragm.
This is divided by the 
falciform ligament into:
A. Right anterior 
subphrenic.
B. Left anterior 
subphrenic.
SUPRA COLIC PART
2. Right posterior 
subphrenic (hepato renal)
pouch.
It is between the right lobe 
of the liver, right kidney
and right colic flexure.
3. Right extraperitoneal 
space :
Between the layers of the 
coronary ligament (bare
area) of liver.
INFRA COLIC PART
It is divided into : 
1. Right infracolic 
compartement.
2. Left infracolic 
compartement.
3. Paracolic gutters. 
RIGHT PARA COLIC GUTTER
Superiorly : 
It is communicated with the 
right posterior subphrenic
space.
Inferiorly : 
It is closed off from the pelvic 
cavity by the mesentery of the
small intestine.
LEFT PARA COLIC GUTTER
It is only separated 
from the spleen by the
phrenicocolic
ligament.
The subphrenic spaces 
and para colic gutters
may be the sites for
collection and
movement of infected
peritoneal fluid.
DUODENAL RECESSES
They are (4) peritoneal 
pouches at the duodeno
jujenal junction.
They are : 
Superior. 
Inferior . 
Paraduodenal . 
DUODENAL RECESSES
Retroduodenal 
CECAL RECESSES
They are occasionally 
deep peritoneal
pouches close to the
cecum.
1. Superior ileocecal. 
2. Inferior ileocecal. 
3. Retrocecal 
INTER SIGMID RECESS
It is at the apex of 
the inverted Vshaped root of the
sigmoid
mesocolon.
It lies in front of 
the left ureter.
These pouches may 
be sites for internal
abdominal hernias.
NERVE SUPPLY
1. Parietal peritoneum : 
It is sensitive to : 
Pain, touch, temperature 
and pressure.
(A) The peritoneum of 
the anterior abdominal
wall is supplied by the
lower (6) thoracic and
1st lumbar nerves.
NERVE SUPPLY
(B) Diaphragmatic 
peritoneum :
a. Central part : 
Phrenic nerve. 
b. Peripheral part : 
Lower (6) 
intercostal nerves.
NERVE SUPPLY
2. Visceral 
peritoneum :
Sensitive only to 
stretch and
tearing.
It has an 
autonomic supply.
Over distension of 
a viscous leads to
the sensation of
pain.