局部解剖学结肠上区.ppt

局部解剖学TopographicalAnatomy,DepartmentofAnatomy,JilinUniversity石岫昆XiukunShi2019.02.08,Section4PeritoneumandPeritonealCavity,I.Introduction1.Peritoneumisaserousmembranewhichlinesabdominopelviccavity,andcanbelikenedtoaslackballoonintowhichorgansareinvaginated.Parietalperitoneumlinesabdominalandpartofpelvicwalls,whileVisceralperitoneumcoversviscera.,Peritonealcavityispotentialspacebetweenparietalandviscerallayerofperitoneum.Inmale,isaclosedsac;butinfemale,thereisacommunicationwithoutsidethroughuterinetubes,uterus,andvagina.Afilmoffluidlubricatessurfacesofperitoneumandfacilitatesfreemovementofviscera,oneagainstanotheroragainstabdominalorpelvicwalls.,2.ThemostimportantfunctionsofperitoneumareAbsorption,SecretionandSupportingviscera.Peritoneumhascapacityofabsorption.Solublesubstancesandwaterareprobablyabsorbeddirectlyintoblood.Peritoneuminsubphrenicregionhasagreaterabsorptivecapacitythanotherregions.,Afterabdominalorpelvicoperations,ithasbeencustomarytoputpatientinFowlersposition,sothatanyinflammatoryintraperitonealeffusionwillgravitateintopelvis.,Fowlersposition,Peritoneummaysecretealubricatingserousfluidthatcontinuouslymoistensassociatedorganstominimizefrictionandtoresistinfection.Undercertainpathologicalconditions,potentialspaceofperitonealcavitymayformanactualspacecontainingseverallitersoffluid.Ascitesisanaccumulationofserousfluidinperitonealcavity(hydroperitoneum).,Theperitoneumsurroundsandsupportsviscerainanumberofdifferentways,whichmaybecharacterisedasfollows:mesentery,ligament,omentum,andsoon.,TreatmentofRenalFailureContinuousAmbulatoryPeritonealDialysis,3.Basedoncoveringofperitoneum,viscerainabdominalandpelviccavitiescanbedividedintothreekinds:Intraperitonealvisceravisceraarealmostcompletelyinvestedbyperitoneumandmoremobilethan,otherviscera,suchasspleen,stomach,smallintestine,transversecolonandsigmoidcolon,etc.,Intraperitonealviscera,Interperitonealvisceravisceraarecoveredbyperitoneumontheirthreeaspects,suchasgall-bladder,liver,ascendingcolon,uterusandurinarybladder.,Retroperitonealvisceravisceraarecoveredbyperitoneumonlyontheironeaspect,suchaspancreas,ureter,kidneyandsuprarenalgland.,Interperitonealviscera,Retroperitonealviscera,II.MainContentsI)Structureswhichareformedbyperitoneum1.Omentaarefoldsofperitoneumbetweenstomachandotherabdominalviscera.Therearetwoomenta,lesserandgreater.,(1)Lessoromentumtwo-layeredfoldofperitoneumwhichextendsfromportahepatistolessercurvatureofstomachandsuperiorpartofduodenum.TheportionoflesseromentumextendingbetweentheliverandstomachisnamedHepatogastricligament.,Hepatoduodenalligamentextendsfromportahepatistosuperiorpartofduodenum.Closetoitsrightfreemarginthetwolayersoflesseromentumencloseproperhepaticartery(leftanterior),hepaticportal,vein(posterior)andcommonbileduct(rightanterior).,(2)Greateromentumconsistsofadoublesheet,foldedonitselfsothatitismadeupoffourlayers.Anteriortwolayersdescendfromgreatercurvatureofstomachandsuperiorpartof,duodenumandpassdownwardslikeanaproninfrontofcoilsofsmallintestine,foravariabledistance,andthenturnsupwardthemselvesasfarastoattachanterosuperioraspectoftransversecolon.,Thepartbetweengreatercurvatureofstomachandtransversecolonisreferredtoasgastrocolicligament.Ifaninfectionoccursinintestine,plasmacellsingreateromentumcombatinfectionandhelppreventitfromspreadingtoperitoneum.,(3)Omentalbursa(lessersac)liesbehindstomachandlesseromentum.Itssuperiorwallisperitoneumwhichcoversthecaudatelobeofliveranddiaphragm;Inferiorwallistransversecolonanditsmesocolon;Anteriorwallisformedbylesseromentum,posteriorwallofstomachandgastrocolicligament;,Posteriorwallisformedbyperitoneumcoveringdiaphragm,pancreas,leftkidneyandsuprarenalgland;Leftwallisboundedbyspleen,gastrosplenicligamentandsplenorenalligament;Ontheright,omentalbursacommunicateswithgreatersacthroughomentalforamen.,(4)Omentalforamen(Winslowsforamen)liesbehindfreeedgeofhepatoduodenallig.anditcanadmittwofingers.Itisachannelbetweenomentalbursaandgreatersac.Itsanteriorwallisformedbyhepatodudenallig.;Peritoneumcoveringinferiorvenacavaliesitsbehind;Caudatelobeofliverformsitsroof;Superiorpartofduodenumisitsinferiorwall.,2.Mesenteriesormesocolonsaretwo-layeredfoldofperitoneumthatattachpartofintestinestoposteriorabdominalwall.,(1)mesentery(ofsmallintestine)isabroad,fan-shapedfoldofperitoneumconnectingcoilsofjejunumandileumtoposteriorabdominalwall.Rootofmesentery(attachedborder)isabout15cmlongandisdirected,obliquelyfromleftsideofL2toinfrontofrightsacroiliacjoint.Intestinalborderofmesenteryisfoldedabout7mlongandcontainssuperiormesenteryvessels,lymphnodes,nerveandacertainamountoffat.,(2)Transversemesocolonisadoublefoldofperitoneumwhichconnectstransversecolontoposteriorabdominalwall.Betweentwolayersarebloodvessels,nervesandlymphaticsoftransversecolon.,(3)Sigmoidmesocolonisafoldofperitoneumwhichattachessigmoidcolontothepelvicwall.,ItslineofattachmenthastheformofaninvertedV-shaped,withapexlocatedinfrontofleftureteranddivisionofcommoniliaca.(4)Mesoappendixisatriangularfoldofperitoneumandextendsfromterminalpartof,ileumtoappendix.Appendiculara.runsinfree,marginofmesoappendix.,3.Ligamentsaretwo-layeredfoldsofperitoneumthatattachedthelessermobilesolidviseratoabdominalwall.(1)Falciformlig.ofliverisasickle-shapedfold,extendsfromanteriorabdominalwall(umbilicus)tolive.Freeborderofligamentsiteofligamentumteres.,(2)Coronarylig.formedbythereflexionofperitoneumfromdiaphragmtoupperandposteriorpartsofrightandlobesofliver.Itsanteriorlayeriscontinuouswithfalciformlig.whichdividesitintoleftandrightcoronaryligaments.Itsposteriorlayercanbefollowedtoinferiorsurfaceofdiaphragm.,Theareabetweenupperandlowerpartsofcoronarylig.isbareareaoflive,thisareaisdevoidofperitoneumandliesincontractwithdiaphragm.(3)Ligamentumteres(acord-likestructure)sitefreemarginoffalciformlig.andisremnantofembryonicumbilicalvein.Paraumbilicalveinsrunalongeithersideofthislig.andemptyintoportalvein.,(4)Gastrospleniclig.isadoublelayerofperitoneumthatconnectsfundusofstomachtohilumofspleen.Itcontainsshortgastricandleftgastroepiploicvessels.(5)Splenorenallig.extendsbetweenhilumofspleenandanterioraspectofleftkidney.Thesplenicvesselslieswithinthisligament,aswellastailofpancreas.,(6)Suspensorylig.ofduodenum(Treitzslig.)consistsofsuspensorymuscleofduodenumandfoldofperitoneum,whichinvestsit.Itliesonleftsideof2ndlumbarvertebra,ascendingfromposterioraspectofduodenumtorightcrusofdiaphragm.Thisligamentisusedtoidentifyduodenojejunalflexure.,4.RecessesIncertainpartofabdomen,peritonealfoldmaysometimesbefoundwhichboundfossaeorrecessesofperitonealcavity.Theserecessesareofsurgicalimportancesincetheymaybecomesiteof“internal”hernia.,(1)SuperiorandInferiorduodenalrecessesTheyoccurmostcommonlyandareformedbyfoldsofperitoneumstretchingfromascendingpartofduodenumtoposteriorabdominalwall,lefttoduodenojejunaljunction.,(2)IntersigmoidrecessliesbehindapexofinvertedV-shapedattachmentofsigmoidmesocolonandformsafunnel-shapedrecess;itsorificeopensdownwards.Leftureterpassesbehindthisrecess.,(3)Hepatorenalrecessliesbetweenrightlobeofliver,rightkidney,andrightcolicflexureandislowestpartsoftheperitonealcavitywhensubjectissupine,5.PouchesInthelesserpelvis,peritoneumdipsdownwardsformingalargefossa,namedpouch.Inmale,rectovesicalpouchliesbetweenrectumandurinarybladder.Inthefemale,rectouterinepouch(Douglaspouch)liesbetweenrectumanduterus,andvesicouterinepouchisformedbetweenuterusandurinarybladder.,Rectouterinepouchinfemaleislowestpartofperitonealcavityinanatomicalposition,andrectovesicalpouchinmale.,Whenpatientisoperatedonorgansinperitonealcavity,patientmaybeproppedinsemi-sittingposition.Fluidinperitonealcavitymaydescendeithertorelativelyaccessiblerectovesicalpouchorrectouterinepouchsothatfluidinpouchmaybeapproachedsurgicallythroughrectumorvagina.,)DivisionsofperitonealcavityPeritonealcavityisdividedintosupracolicandinfracoliccompartmentsbytransversecolonanditsmesocolon.,1.Supracoliccompartments(subphrenicspace)liesbetweendiaphragmandtransversecolonanditsmesocolon.Itincludessomespaces,forexample,SuprahepaticandInfrahepaticrecess.,2.Infracoliccompartmentsliesbelowtransversecolonanditsmesocolon.Ithasfourspaces:rightandleftparacolicsulci(gutters),rightandleftmesenterialsinuses(infracolicspaces).,(1)Rightparacolicsulcus(gutter)lieslateraltoascendingcolon.Itcommunicateswithhepatorenalrecessandpelviccavity.Itprovidesarouteforspreadofinfectionbetweenpelvicandupperabdominalregion.,(2)Leftparacolicsulcus(gutter)liesalonglateralsideofdescendingcolonandopensfreelyintothepelvisatitslowerend.Itisseparatedabovefromsupracoliccompartmentbyphrenicocolicligament.,(3)Rightmesentericsinus(rightinfracolicspacetriangulars