1、The peritoneumGeneral featuresnThe peritoneum is a thin serous membrane that line the walls of the abdominal and pelvic cavities and cover the organs within these cavitiesnParietal peritoneum lines the walls of the abdominal and pelvic cavitiesnVisceral peritoneum covers the organsnPeritoneal cavity

2、 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 vaginaFunctionnSecretes a lubricating serous fluid that continuously moistens the ass

3、ociated organsnAbsorbnSupport visceraThe relationship between viscera and peritoneum nIntraperitoneal viscera viscera completely surrounded by peritoneum, example, stomach, superior part of duodenum, jejunum, ileum, cecum, vermiform appendix, transverse and sigmoid colons, spleen and ovarynInterperi

4、toneal viscera most part of viscera surrounded by peritoneum, example, liver, gallbladder, ascending and descending colon, upper part of rectum, urinary bladder and uterusnRetroperitoneal viscera some organs lie on the posterior abdominal wall and are covered by peritoneum on their anterior surfaces

5、 only, example, kidney, suprarenal gland, pancreas, descending and horizontal parts of duodenum, middle and lower parts of rectum, and ureterIntraperitoneal visceraInterperitoneal visceraRetroperitoneal visceraInterperitoneal visceraStructures which are formed by peritoneum Omentum two-layered fold

6、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 duodenumn Hepatogastric ligament extends from porta hepatis to lesser curvature of stomach nHepatoduodenal lig

7、ament Extends from porta hepatis to superior part of duodenumqContains common bile duct, proper hepatic a. and hepatic portal v.Omental foramen nBehind the right border of hepatoduodenal ligamentnSuperiorcaudate lobe of liver nInferiorsuperior part of duodenumnAnteriorhepatodudenal ligamentnPosterio

8、rperitoneum 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 th

9、e 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 omentumGreater omentumOmental bursaPositionsituated behind the lesser omentum and stomachWallsnSuperiorperitoneum which

10、 covers the caudate lobe of liver and diaphragmnAnteriorformed by lesser omentum, peritoneum of posterior wall of stomach, and anterior two layers of greater omentumnInferiorconjunctive area of anterior and posterior two layers of greater omentumnPosteriorformed by posterior two layers of greater om

11、entum, transverse colon and transverse mesocolon, peritoneum covering pancreas, left kidney and suprarenal glandnLeftformed by the spleen, gastrosplenic ligament and splenorenal ligament nRightformed by omental foramen The Omental bursa (lesser sac) communicates with the greater sac through the omen

12、tal foramen.Mesenteries or mesocolonstwo-layered fold of peritoneum that attach part of the intestines to the posterior abdominal wall Mesentery suspends the small intestine from the posterior abdominal wallnBroad and a fan-shaped nConsists of two peritoneal layers nIntestinal borderfolded, 7 m long

13、nRadix of mesenteryq15 cm longqDirected obliquely from left side of L2 to in front of right sacroiliac jointMesoappendix nTriangular mesenteryextends from terminal part of ileum to appendixnAppendicular artery runs in free margin of the mesoappendix Transverse mesocolon a double fold of peritoneum w

14、hich connects the transverse colon to the posterior abdominal wallSigmoid mesocolon inverted V-shaped, with apex located in front of left ureter and division of common iliac arteryLigaments two-layered folds of peritoneum that attached the lesser mobile solid visera to the abdominal wall Ligaments o

15、f liver nFalciform ligament of liver qConsists of double peritoneal layer qExtends from anterior abdominal wall (umbilicus) to liveqFree border of ligament site of ligamentum teres nCoronary ligament the area between upper and lower parts of the coronary ligament is the bare area of live, this area

16、is devoid of peritoneum and lies in contract with the diaphragmnLeft and right triangular ligaments formed by right extremity of coronary ligament and left leaf of falciform ligament, respectivelynHepatogastric ligamentnHepatoduodenal ligamentnLigamentum teres hepatisLigaments of spleennGastrospleni

17、c 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 vesselsnSplenorenal ligament extends between the hilum of spleen and anterior aspect of left kidney. The splenic vessels li

18、es within this ligament, as well as the tail of pancreasnPhrenicosplenic ligamentnSplenocolic ligament Ligaments of stomach nHepatogastric ligament nGastrosplenic ligament nGastrophrenic ligament nGastrocolic ligament nGastropancrestic ligament Folds and recesses of posterior abdominal wallnSuperior

19、 duodenal fold and recess nInferior duodenal fold and recess nIntersigmoid recess formed by the inverted V attachment of sigmoid mesocolon nRetrocecal recess in which the appendix frequenty liesnHepatorenal recess lies between the right lobe of liver, right kidney, and right colic flexure, and is th

20、e lowest parts of the peritoneal cavity when the subject is supineFolds and fossas of anterior abdominal wallnMedial umbilical fold contain the remnant of urachus (median umbilical ligaments)nMedial umbilical fold contains remnants of the umbilical arteries (medial umbilical ligaments)nLateral umbil

21、ical fold contains the inferior epigastric vesselsnSupravesical fossanMedial inguinal fossa nLateral inguinal fossaPouches nIn malerectovesical pouch nIn female qRectouterine pouch between rectum and uterus qVesicouterine pouch between bladder and uterus Peritoneal subdivisionsThe transverse colon a

22、nd 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 livethe falciform ligament divides it into ri

23、ght and left suprahepatic recessesnLeft suprahepatic recesses qleft anterior suprahepatic spacesqleft posterior suprahepatic spacesnRight suprahepatic recesses qright anterior suprahepatic spacesqright posterior suprahepatic spacesq bare area of live (extraperitoneal space) Infrahepatic recess lies

24、between the live and transverse colon and transverse mesocolonthe ligamentum teres hepatic divides it into right and left infrahepatic recessesnRight infrahepatic recesses (hepatorenal recess)nLeft infrahepatic recessesqleft anterior infrahepatic spaceqleft posterior infrahepatic spaceInfracolic com

25、partments lies below the transverse colon and transverse mesocolon nRight paracolic sulcus (gutter) nlies 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 regi

26、on.nLeft paracolic sulcus (gutter) nlies 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.nRight mesenteric sinus triangular space, lies between root of mesentery,

27、ascending colon, right 2/3 of transverse colon and transverse mesocolonnLeft 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 pelvisDissection and Observationnsupe

28、rficial structuresnThree flat muscles , vessels and nervesnrectus abdominisqrectus sheathninguinal regionqinguinal canalqinguinal triangle Relationships of abdominal viscera nFirst layerlive, gallbladder, stomach nSecond layerduodenum, pancreas, spleennThird layersuprarenal gland, kidney, ureter, in

29、ferior vena cava, abdominal aorta, nerves and lymphatics Relationships of the stomachnAnterior:qLive (right part) qDiaphragm (left upper part) qAnterior abdominal wall (left lower part) nPosteriorseparated by peritonum of lesser sac from the following (“stumach-bed”) qPancreas qLeft suprarenal gland

30、qLeft kidneyqSpleen qTransverse colon and transvers mesoclonArteries of stomachnLeft 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-to-end.nRight and left gastroepiploic ar

31、teries 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.nShort gastric arteries, branches of splenic artery, course through the gastrosplenic ligament and supply the fundus

32、 of stomach. nPosterior gastric artery (72%) arise from the splenic artery, course through the gastrophrenic ligament and supply the posterior wall of fundus of stomach.Venous drainagenRight and left gastric veins empty directly into hepatic portal vein.nLeft gastroepiploic and short gastric veins d

33、rain into hepatic portal vein via the splenic vein.nRight gastroepiploic vein join either superior mesenteric vein.Lymphatics of stomach nRight and left gastric ln. lie along the same vessels and finally to the celiac ln.nRight and left gastroomental ln. lie along the same vessels, the former drain

34、into subpyloric ln., the latter drain into splinic ln.nSupra- and subpyloric ln. receive lymphatics from pyloric part and finally to the celiac ln.nSplenic ln. receive lymphatics from fundus and left third of stomach, and finally to the celiac ln. Nerve supplyParasympathetic innervation by anterior

35、(left) and posterior (right) vagal trunksnThe anterior trunk divides into anterior gastric and hepatic branchesnThe posterior trunk divides into posterior gastric and celiac branchesnThe anterior and posterior gastric branches descend on the anterior and posterior surfaces of the stomach as a rule a

36、bout 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 “crows foot” to supply the pyloric partSympathetic innervationnMainly from celiac ganglianAffent and effent fibers derives from thoracic segments (T5 L1The d

37、uodenumRelationships of superior part nAnteriorlyqQuadrate lobe of liveqGallbladdernPosteriorlyqCommom bile duct qGastroduodenal a.qHepatic portal v.qInferior vena cavanSuperioely qOmental foramennInferiorly qHead of pancreas Relationships of descending partnAnteriorlyqLive qTransverse colon and mes

38、ocolonqLoops of small intestine nPosteriorly qRight renal hilum and ureterqRight renal vesselsnMediallyqHead of pancreasqCommon bile duct and pancreatic ductnLaterally qRight colic flexureRelationships of horizontal partnSuperiorlynHead of pancreasnInferiorly qLoops of small intestine nAnteriorlyqRa

39、dix of mesenteryqSuperior mesenteric a. and v. nPosteriorlyqRight ureterqInferior vena cavaqAbdominal aorta Relationships of ascending partnRight qHead of pancreas and abdominal aortanLeft qLeft kidney and ureterRelationships of livernDiaphragmatic surfaceseparated by diaphragm from the following qR

40、ight costodiaphramatic recess and lungqCardiac basenVisceral surfaceqLeft lobe is related to the stomach and abdominal part of esophagus qRight lobe is related to the right colic flexure anteroly, gallbladder and superior duodenal flexure medially, right kidney, superarenal gland posteriorlyDivision

41、s and relations of common bile ductSupraduodenal segment nDescends along the right margin of hepatoduodenal lig.nTo the right of proper hepatic a.nAnterior to hepatic portal v.Retroduodenal segment nBehind the superior part of duodenumnAnterior to the vena cavanTo the right of the hepatic portal v.P

42、ancreatic segmentnLies in a groove between posterior surface of head of pancreas and duodenum Intraduodenal segment nEnters the wall of descending part of duodenum obliquely where jions the pancreatic duct to form the hepatopancreatic ampulla nopens at the major duodenal papillaRelationships of spleenDiaphragmatic surfacediaphragmVisceral surfacenAnteriorlyfundus of stomac