局部解剖学结肠上区课件

局局 部部 解解 剖剖 学学 Topographical AnatomyTopographical Anatomy Department of Anatomy , Department of Anatomy , JilinJilin University University 石岫昆石岫昆 XiukunXiukun Shi 2007.02.08 Shi 2007.02.08 Section 4 Peritoneum and Section 4 Peritoneum and Peritoneal CavityPeritoneal Cavity I. IntroductionI. Introduction 1. 1. Peritoneum is a serous membrane Peritoneum is a serous membrane which lines which lines abdominopelvicabdominopelvic cavity, and cavity, and can be likened to a slack balloon into can be likened to a slack balloon into which organs are which organs are invaginatedinvaginated. . Parietal peritoneumParietal peritoneum lines abdominal lines abdominal and part of pelvic walls, while and part of pelvic walls, while Visceral Visceral peritoneumperitoneum covers viscera. covers viscera. Peritoneal cavityPeritoneal cavity is potential is potential space between parietal and visceral space between parietal and visceral layer of peritoneum. In male, is a layer of peritoneum. In male, is a closed sac; but in female, there is a closed sac; but in female, there is a communication with communication with outsideoutside through uterine tubes, uterus, and through uterine tubes, uterus, and vagina.vagina. A film of fluid lubricates A film of fluid lubricates surfaces of peritoneum and surfaces of peritoneum and facilitates free movement of viscera, facilitates free movement of viscera, one against another or against one against another or against abdominal or pelvic walls.abdominal or pelvic walls. 2. 2.The most importantThe most important functions functions of peritoneumof peritoneum are are Absorption Absorption , , SecretionSecretion and and Supporting viscera. Supporting viscera. Peritoneum has capacity of absorption. Soluble Peritoneum has capacity of absorption. Soluble substances and water are probably absorbed directly into substances and water are probably absorbed directly into blood. Peritoneum in blood. Peritoneum in subphrenicsubphrenic region has a greater region has a greater absorptive capacity than other regions. absorptive capacity than other regions. After abdominal orAfter abdominal or pelvic pelvic operations, it has been customary operations, it has been customary to put patient in Fowlers position, to put patient in Fowlers position, so that any inflammatory so that any inflammatory intraperitonealintraperitoneal effusion will effusion will gravitate into pelvis.gravitate into pelvis. Fowlers Fowlers positionposition PeritoneumPeritoneum may secrete a lubricating serous fluid may secrete a lubricating serous fluid that continuously moistens associated organs to minimize that continuously moistens associated organs to minimize friction and friction and to resist infection.to resist infection. Under certain pathological conditions, potential space Under certain pathological conditions, potential space of peritoneal cavity may form an actual space containing of peritoneal cavity may form an actual space containing several liters of fluid. several liters of fluid. AscitesAscites is an accumulation of serous fluid in peritoneal is an accumulation of serous fluid in peritoneal cavity ( cavity ( hydroperitoneumhydroperitoneum ). ). The peritoneum surrounds and supports viscera in a number of different ways, which may be characterised as follows: mesentery, ligament, omentum, and so on. Treatment of Renal Failure Continuous Ambulatory Peritoneal Dialysis 3. Based on covering of peritoneum, viscera in Based on covering of peritoneum, viscera in abdominal and pelvic cavities can be divided into three abdominal and pelvic cavities can be divided into three kinds:kinds: Intraperitoneal viscera viscera are almost viscera are almost completely invested by peritoneum and more mobile thancompletely invested by peritoneum and more mobile than other viscera, such as spleen, stomach, other viscera, such as spleen, stomach, small intestine, transverse colon and small intestine, transverse colon and sigmoid colon,etc.sigmoid colon,etc. IntraperitonealIntraperitoneal visceraviscera Interperitoneal viscera viscera are covered by viscera are covered by peritoneum on their three aspects, such as gall-bladder, peritoneum on their three aspects, such as gall-bladder, liver, ascending colon, uterus and urinary bladder. liver, ascending colon, uterus and urinary bladder. Retroperitoneal viscera Retroperitoneal viscera viscera viscera are covered by peritoneum only on their are covered by peritoneum only on their one aspect, such as pancreas, one aspect, such as pancreas, ureterureter, , kidney and suprarenal gland.kidney and suprarenal gland. InterperitonealInterperitoneal visceraviscera Retroperitoneal Retroperitoneal visceraviscera II. Main ContentsII. Main Contents I) Structures which are formed by peritoneumI) Structures which are formed by peritoneum 1. 1. OmentaOmenta are folds of peritoneum between stomach and are folds of peritoneum between stomach and other abdominal viscera. There are two other abdominal viscera. There are two omentaomenta, lesser and , lesser and greater.greater. (1)(1) LessorLessor omentumomentum two-layered two-layered fold of peritoneum which extends from fold of peritoneum which extends from portaporta hepatishepatis to lesser curvature of to lesser curvature of stomach and superior part of duodenum.stomach and superior part of duodenum. The portion of lesser The portion of lesser omentumomentum extending between the liver and stomach extending between the liver and stomach is named is named HepatogastricHepatogastric ligament ligament. . HepatoduodenalHepatoduodenal ligament ligament extends from extends from portaporta hepatishepatis to to superior part of duodenum.superior part of duodenum. Close to its right free margin Close to its right free margin the two layers of lesser the two layers of lesser omentumomentum enclose proper hepatic enclose proper hepatic artery (left anterior), hepatic portal artery (left anterior), hepatic portal vein (posterior) and common bile vein (posterior) and common bile duct (right anterior).duct (right anterior). (2) (2) Greater Greater omentumomentum consists of a double sheet, folded consists of a double sheet, folded on itself so that it is made up of four layers. on itself so that it is made up of four layers. AnteriorAnterior two layers descend from two layers descend from greater curvature of greater curvature of stomach and superior part ofstomach and superior part of duodenum and duodenum and passpass downwardsdownwards like an apron in front of coils of like an apron in front of coils of small intestine,small intestine, for a variable for a variable distance, distance, and then turns upward and then turns upward themselves as far as to themselves as far as to attachattach anterosuperioranterosuperior aspect of aspect of transverse colon. transverse colon. The The partpart between greater curvature of stomach and between greater curvature of stomach and transverse colon is referred to as transverse colon is referred to as gastrocolicgastrocolic ligament. ligament. If an infection occurs in intestine, plasma cells in If an infection occurs in intestine, plasma cells in greater greater omentumomentum combat infection and help prevent it combat infection and help prevent it from spreading to peritoneum.from spreading to peritoneum. (3) Omental bursa (lesser sac) lies behind stomach and lesser omentum. Its superior wall is peritoneum which covers the caudate lobe of liver and diaphragm; Inferior wall is transverse colon and its mesocolon; Anterior wall is formed by lesser omentum, posterior wall of stomach and gastrocolic ligament; Posterior wall is formed by peritoneum covering diaphragm, pancreas, left kidney and suprarenal gland; Left wall is bounded by spleen, gastrosplenic ligament and splenorenal ligament; On the right, omental bursa communicates with greater sac through omental foramen. (4) (4) OmentalOmental foramen foramen (Winslow (Winslow s foramen)s foramen) lies behind lies behind free edge of free edge of hepatoduodenalhepatoduodenal liglig. and it can admit two . and it can admit two fingers. It is a channel between fingers. It is a channel between omentalomental bursa and greater bursa and greater sac. sac. Its anterior wall is formed by Its anterior wall is formed by hepatodudenalhepatodudenal liglig. .; ; Peritoneum covering inferior vena cava Peritoneum covering inferior vena cava lies its behind; lies its behind; Caudate lobe of liver Caudate lobe of liver forms its roof;forms its roof; Superior part of Superior part of duodenum duodenum is its inferior wall. is its inferior wall. 2. Mesenteries or mesocolons are two-layered fold of peritoneum that attach part of intestines to posterior abdominal wall. (1) mesentery (of small intestine) is a broad, fan- shaped fold of peritoneum connecting coils of jejunum and ileum to posterior abdominal wall. Root of mesentery (attached border) is about 15cm long and is directed obliquely from left side of L2 to in front of right sacroiliac joint. Intestinal border of mesentery is folded about 7 m long and contains superior mesentery vessels, lymph nodes, nerve and a certain amount of fat. (2) Transverse mesocolon is a double fold of peritoneum which connects transverse colon to posterior abdominal wall. Between two layers are blood vessels, nerves and lymphatics of transverse colon. (3) Sigmoid mesocolon is a fold of peritoneum which attaches sigmoid colon to the pelvic wall. Its line of attachment has the form of an inverted V- shaped, with apex located in front of left ureter and division of common iliac a (4) Mesoappendix is a triangular fold of peritoneum and extends from terminal part of ileum to appendix. Appendicular a. runs in free margin of mesoappendix. 3. Ligaments are two-layered folds of peritoneum that attached the lesser mobile solid visera to abdominal wall. (1) FalciformFalciform liglig. of liver. of liver is a sickle-shaped fold, is a sickle-shaped fold, extends from anterior abdominal wall (umbilicus) to live.extends from anterior abdominal wall (umbilicus) to live. Free border of ligament site of Free border of ligament site of ligamentumligamentum teresteres. . (2) (2) Coronary Coronary liglig. . formed by the formed by the reflexionreflexion of peritoneum of peritoneum from diaphragm to upper and posterior parts of right and from diaphragm to upper and posterior parts of right and lobes of liver. lobes of liver. Its anterior layer is continuous with Its anterior layer is continuous with falciformfalciform liglig. which . which divides it into left and right coronary ligaments. Its divides it into left and right coronary ligaments. Its posterior layer can be followed to inferior surface of posterior layer can be followed to inferior surface of diaphragm. diaphragm. The area between upper and lower parts of coronary lig. is bare area of live, this area is devoid of peritoneum and lies in contract with diaphragm. (3) Ligamentum teres (a cord-like structure) site free margin of falciform lig. and is remnant of embryonic umbilical vein. Paraumbilical veins run along either side of this lig. and empty into portal vein. (4) (4) GastrosplenicGastrosplenic lig lig. . is a double layer of peritoneum is a double layer of peritoneum that connects that connects fundusfundus of stomach to of stomach to hilumhilum of spleen. It of spleen. It contains short gastric and left contains short gastric and left gastroepiploicgastroepiploic vessels. vessels. (5) (5) SplenorenalSplenorenal liglig. . extends between extends between hilumhilum of spleen of spleen and anterior aspect of left kidney. The and anterior aspect of left kidney. The splenicsplenic vessels lies vessels lies within this ligament, as well as tail of pancreas.within this ligament, as well as tail of pancreas. (6) (6) SuspensorySuspensory liglig. of duodenum (. of duodenum (TreitzsTreitzs liglig.) .) consists consists of of suspensorysuspensory muscle of duodenum and fold of peritoneum muscle of duodenum and fold of peritoneum which invests it. which invests it. It lies on left side of 2nd It lies on left side of 2nd lumbar vertebra, ascending lumbar vertebra, ascending from posterior aspect of from posterior aspect of duodenum to right duodenum to right cruscrus of of diaphragm. diaphragm. This ligament is used to This ligament is used to identify identify duodenojejunalduodenojejunal flexure.flexure. 4. Recesses 4. Recesses In certain part of abdomen, peritoneal fold In certain part of abdomen, peritoneal fold may sometimes be found which bound may sometimes be found which bound fossaefossae or recesses or recesses of peritoneal cavity. These recesses are of surgical of peritoneal cavity. These recesses are of surgical importance since they may become site of “internal” importance since they may become site of “internal” hernia. hernia. (1) Superior and Inferior (1) Superior and Inferior duodenal recessesduodenal recesses They occur most They occur most commonly and are formed by folds commonly and are formed by folds of peritoneum stretching from of peritoneum stretching from ascending part of duodenum to ascending part of duodenum to posterior abdominal wall, left to posterior abdominal wall, left to duodenojejunalduodenojejunal junction. junction. (2) (2) IntersigmoidIntersigmoid recess recess lies behind apex of lies behind apex of invertedinverted V- V- shaped attachment of sigmoid shaped attachment of sigmoid mesocolonmesocolon and forms a and forms a funnel-shaped recess; its orifice opens downwards. Left funnel-shaped recess; its orifice opens downwards. Left ureterureter passes behind this recess. passes behind this recess. (3) (3) HepatorenalHepatorenal recess recess lies lies between right lobe of liver, right between right lobe of liver, right kidney, and right colic flexure and kidney, and right colic flexure and is lowest parts of the peritoneal is lowest parts of the peritoneal cavity when subject is supinecavity when subject is supine 5. 5. PouchesPouches In the lesser pelvis, peritoneum dips In the lesser pelvis, peritoneum dips downwards forming a large downwards forming a large fossafossa, named pouch. , named pouch. In male, In male, rectovesicalrectovesical pouch pouch lies between rectum and lies between rectum and urinary bladder. In the female, urinary bladder. In the female, rectouterinerectouterine pouch pouch ( ( Douglas pouch )Douglas pouch ) lies between rectum and uterus, and lies between rectum and uterus, and vesicouterinevesicouterine pouch is formed between uterus and urinary pouch is formed between uterus and urinary bladder. bladder. RectouterineRectouterine pouch in female is lowest part of peritoneal pouch in female is lowest part of peritoneal cavity in anatomical position, and cavity in anatomical position, and rectovesicalrectovesical pouch in pouch in male. male. When patient is operated on organs When patient is operated on organs in peritoneal cavity, patient may be in peritoneal cavity, patient may be propped propped in semi-sitting positionin semi-sitting position. . Fluid in peritoneal cavity may Fluid in peritoneal cavity may descend either to relatively accessible descend either to relatively accessible rectovesicalrectovesical pouch or pouch or rectouterinerectouterine pouch so that fluid in pouch may be pouch so that fluid in pouch may be approached surgically through rectum approached surgically through rectum or vagina. or vagina. ) ) Divisions of peritoneal cavity Peritoneal cavity is divided into supracolic and infracolic compartments by transverse colon and its mesocolon. 1.Supracolic compartments (subphrenic space )lies between diaphragm and transverse colon and its mesocolon. It includes some spaces, for example, Suprahepatic and Infrahepatic recess. 2. Infracolic compartments lies below transv