Detailed anatomy of peritoneum.

1. The Peritoneum

2. • Introduction
• Parts
• Parietal peritoneum
• Visceral peritoneum
• Folds of peritoneum
• Peritoneal cavity
• Functions
• Vertical disposition
• Falciform ligament
• Lesser omentum
Objectives

3. Peritoneum - Introduction
Definition:
• Large, thin serous membrane that lines the walls of
the abdominal and pelvic cavities and cover the
organs within these cavities.
• Also called Serosa
• Consists of 2 layers
– Outer fibrous - Strength
– Inner flattened mesothelial cells - lubrication

4. Formation
Intra-parietal
Closed Sac
Invagination
Outer Parietal
Inner Visceral
Folfd Of
Peritoneum
Folds Of
Peritoneum

5. LAYERS:
• Parietal layer:
• lines the abdominal wall & pelvic cavities &
under surface of diaphragm
• Loosely attached – easily stripped
• Somato-pleural layer of lateral plate mesoderm
• Blood supply & nerve supply – same as overlyng
wall
• Sensitive to pain & temperature

6. LAYERS:
• Visceral layer:
• Lines outer surface of organs
• Firmly adhere to it – can not be stripped
• Splanchno-pleural layer of lateral plate
mesoderm
• Blood supply & nerve supply – same as
underlying viscera = Autonomic
• Sensitive to pain due to stretching, distension or
ischemia of viscera

7. Visceral Parietal

9. Peritoneal cavity:
• Potential space between the
two layers of peritoneum.
• Filled with very thin film of
serous fluid secreted by?
• In the male – closed sac, but
• In the female – open due to
uterine tubes,
the uterus, and
the vagina

10. Peritoneal cavity:
Divided in to:
• Larger part – Greater Sac
• Smaller part – Lesser Sac
Communication
• Epiploic Foramen / Foramen of
Winslow
• Small pockets or recesses – site
for internal hernia

11. Intraperitoneal viscera:
Eg: Stomach, superior part of duodenum, jejunum, ileum,
cecum, vermiform appendix, transverse and sigmoid
colons, spleen , ovary and uterine tube
The relationship between viscera and
peritoneum
Intraperitoneal viscera
completely surrounded by
peritoneum

12. • Retroperitoneal viscera －
Covered by peritoneum on their anterior surfaces only
Eg: Kidney, suprarenal gland, pancreas, 2nd & 3rd parts
of duodenum, ascending & descending colon middle and
lower parts of rectum and ureter
Retroperitoneal viscera

13. Relationship
between
viscera and
peritoneum

14. Folds of Peritoneum
• Mobile organs:
• Suspended by folds
• Fixed:
• Directly rest on Post
wall
• Retroperitoneal
Provide passage for Vessels,
Nerves & Lymphatics

15. Folds of Peritoneum

16. Names of Folds
Mes / Meso Name of organ
Small Intestine /
Enteron:
Mesentery
Large Intestine /
Colon:
Mesocolon
Stomach Omentum / Omenta
Organs – organ /
Abdominal wall
Ligaments

17. Mesentery Small Intestine /
Enteron:

18. Mesocolon Large Intestine /
Colon:

19. Transverse mesocolon
Sigmoid mesocolon
Mesocolon

20. Mesoappendix

21. Omenta
Fold of peritoneum that
connect the stomach with
another viscera
Lessor omentum
Greater omentum

22. Ligaments
Gastro-splenic Lig.
Lieno-renal Lig.
Hepato-duodenal Lig.

23. Functions of Peritoneum
• Movement of Viscera:
– Provide slippery surface – permit
free movements like?
– Peristalsis, movements during
respiration & Filling & evacuation
of hollow viscera
• Protection of Viscera:
– Phagocytic cells & lymphocytes
– Greater omentum – move towards
infection site & seal it
– Policeman of Abdomen

24. Functions of Peritoneum
• Absorption and Dialysis:
– Mesothelium – semipermeable
membrane
– Both secretive & absorptive
– Fluid injection
– Peritoneal dialysis
• Healing power and
Adhesions:
– Mesothelial cells – Fibroblast
– Abnormal adhesion - obstruction
• Storage of Fat:

25. Development of peritoneum

26. Development of peritoneum
Dorsal Mesogastrium
Ventral Mesogastrium

27. Development of the peritoneum

28. Development of peritoneum

29. Development of peritoneum

30. stomach
Lienorenal
Ligament
R
Gastrosplenic
Ligament
R
R
L
lesser sac
Lesser OmentumFalciform ligament
Spleen

31. Development of peritoneum

32. Development of peritoneum.

35. Greater Sac
Vertical Disposition

37. • Sickle shape
• Extends from antero-
superior surface of liver to
anterior abdominal wall &
undersurface of
diaphragm
• Free border of the
ligament contains
Ligamentum teres hepetis
(obliterated umbilical vein)
Falciform ligament of liver

39. • From under surface of
diaphragm is reflected
on to superior surface
of right lobe of liver
forming the upper
layer of coronary
ligament

40. • Then, it descends from sup
surface of liver to ant
surface then inferior
surface of liver.
• From post part of inferior
surface peritoneum
reflected on to front of
right kidney & rt suprarenal
gland forming the lower
layer of coronary ligament.

41. Right triangular ligament.
• Short v shaped fold.
• Formed by approximation of two layers of coronary
ligament on right lateral end.

42. Left triangular ligament
Double layer.
On upper border of left lobe.
Anterior layer extends from left layer of falciform ligament.
Posterior layer continuous with left layer of lesser omentum.

43. • The upper & lower layers of coronary ligament &
right triangular ligament bound a large area on
the post surface of the liver which has no
peritoneal covering
bare area

44. Hepato-renal pouch
of Morison
Right para-colic gutter
Pelvic cavity

45. Hepato-renal pouch of Morison

46. Hepato-renal pouch of Morison
Right Para-colic
gutter
Left Para-colic gutter

47. Lesser
Omentum

48. Inferior surface
Ant layer of
Lesser Omentum

49. Right free margin
Epiploic Foramen
Porta Hepatis

50. Lesser omentum
• Double layered fold of
peritoneum which
extends from lesser
curvature of stomach
&1st 2cm of duodenum
to liver

51. Lessor omentum
– Extends from porta
hepatis to 1st part of
duodenum,
– It contains
• Common bile duct,
• Proper hepatic a.
• Hepatic portal v.
Hepato-gastric ligament
– From porta hepatis to
lesser curvature of
stomach
Hepato-duodenal ligament
Two Parts

52. Lessor omentum
Right free margin
Epiploic Foramen

53. Lesser omentum - Contents
Bile Duct
Proper Hepatic a.
Portal Vein
Lymph Nodes &
Lymphatics &
Nerves & Plexus
Left & Right Gastric V.

54. Ant layer of
Lessor omentum
Antero-superior surface
Greater Omentum
4 layers & 3 margins

55. 1st Layer
4th Layer
2nd Layer
3rd Layer

56. Greater omentum
• A four-layered fold of
peritoneum connecting
the greater curvature of
stomach & 1st part of
duodenum to transverse
colon
• Hangs down like an apron
in front of coils of small
intestine

57. Greater omentum - Contents
Left Gastroepiploic
vessels
RightGastroepiploic
vessels

58. Greater omentum - Functions
• Storage of fat
• Protect against infections
– Macrophage – small dens
white patches
– Milky spot
• Limits spread of infection
– Sealing
–Policeman of Abdomen

59. Adult
Transverse
Colon
Fetus & Neonates
Primitive
Transverse
Mesocolon
Zygosis

60. Definitive Transverse
Meso-colon

61. Body of Pancreas
Post Abdominal wall
Small Intestine
Mesentery

62. Mesentery
Broad fan shaped fold that
suspends coils of Jejunum &
Ilium from the posterior
abdominal wall
Breadth:
Maximum – 20cm in center
Decrease towards ends

63. Mesentery - Borders
Attached border =
Root of Mesentery
Free border =
Intestinal Border
15 cm 6 meters
Visceral
Peritoneum

64. Root of Mesentery
Attached border –
downward & right
From Duodeno-jejunal
flexure(Left side of L2)
-
Ilio-cecal junction
(Upper end of Right
Sacro-iliac joint)

65. Root of Mesentery
3rd part of Duodenum
Abdominal Aorta
Right Ureter
Right Psoas Major
Right Sacro-iliac joint
Duodeno-jejunal Flexure
Inferior Vena Cava

66. Most in lower part
From root to intestinal border
Near Intestinal border – oval/circular fat free
translucent area
Distribution of fat in Mesentery
Windows
Jejunum Ileum

67. Mesentery - Contents
Jejunal and Ileal a. & v.
Superior Mesenteric v.
Superior mesenteric a.

68. Mesentery - Contents
Autonomic Nerve plexus
Lymphatics & Lymph
nodes
Fat

69. Mesentery – Left layer
Left Para-colic gutter

70. Phrenico-colic Lig
Spleen
Sustentaculum Lienis
Triangular fold

71. Spleen
Pancreas
Left Kidney
Lesser Sac
Anterior
Posterior

72. Hilum Of Spleen
Post Layer
Lieno-renal Lig
Left Kidney
Ant Layer
Gastro-splenic
Lig
Post Layer
Gastro-splenic
Lig
Ant Layer
Lieno-renal Lig

73. Anterior
Posterior
Ant Layer
Gastro-splenic
Lig
Post Layer
Lieno-renal Lig
Post Layer
Gastro-splenic
Lig
Ant Layer
Lieno-renal Lig

74. Post Abdominal wall
Sigmoid Colon
Sigmoid Meso-colon

75. Sigmoid Meso-colon
Root – Inverted V

76. Rectum
Differ in Male & Female

77. Recto-vesical pouch
In Males
7.5 cm above anus

78. On each Side
Para-rectal
Fossa
Para-vesical
Fossa

79. In Females
Recto-uterine pouch
of Douglas
Utero-vesical pouch
5.5 cm above anus

80. On each Side
Broad
Ligament
Uterine
tube
Ovary

81. Rectovesical pouchRectouterine pouch
Vesicouterine pouch

82. Apex of Urinary bladder
Posterior surface of
Anterior abdominal wall

83. Median Umbilical fold
Medial Umbilical fold
Lateral Umbilical fold
Median Umbilical Lig
Obliterated Umbilical a.
Inferior Epigastric Vessels

84. Supra-vesical fossa
Medial Inguinal fossa
Lateral Inguinal fossa

85. Greater sac Horizontal Tracing

86. Below Transverse Colon

87. Opposite Epiploic Foramen

88. Above Epiploic Foramen

89. Lesser sac
Omental Bursa

90. Lesser sac-Omental Bursa
• Diverticulum of Greater sac
• Behind & beyond stomach,
lesser omentum & caudate
lobe of liver
• Act as bursa – allow expansion
of stomach = Omental Bursa
• Closed on all side except –
epiploic foramen
• Shape:
– Hot water bag

92. Caudate lobe of liver
Posterior layer of Lesser Omentum
Lesser sac - Boundaries
Postero-inferior surface of stomach
2nd layer of Greater Omentum
Anterior Wall

93. Ant surface of body of pancreas
Upper layer of transverse
meso-colon
Lesser sac - Boundaries
Antero-superior surface of
transverse colon
3rd layer of Greater Omentum
Posterior Wall
Left sura-renal gland, kidney
Diaphragm

94. Lesser sac - Boundaries
Upper Margin
Diaphragm
Caudate lobe of liver

95. After Puberty
Transverse
Colon
Before Puberty
Lower Margin

96. Right Margin
Below Transverse Colon
Right free margin of
Greater omentum

97. Epiploic Foramen
Right Margin
Above Transverse Colon
Deficient

98. Epiploic Foramen
Foramen of Winslow Aditus or Opening of Lesser Sac
• Vertical slit – 3cm long
• Communicate?
• Situation:
–B/H Rt free margin of
lesser omentum
–At T12

99. Epiploic Foramen Boundaries
Right free margin of
lesser omentum
• Common bile duct
• Proper hepatic a.
• Hepatic portal v.
• Hepatic plexus of n.
• Lymphatics
Anteriorly:

100. Epiploic Foramen Boundaries
Inferior Vena Cava
Posteriorly: Right kidney T12

101. Epiploic Foramen Boundaries
Caudate Process of Liver
Superiorly:

102. Epiploic Foramen
Inferiorly:
Boundaries
1st part of duodenum
Hepatic artery

103. Divided by 2 peritoneal folds
Left Gastric artery
Common Hepatic
artery
Subdivision of Lesser Sac
Right Gastro-
pancreatic fold
Left Gastro-
pancreatic fold

104. Subdivision of Lesser Sac
Right Gastro-
pancreatic fold
Left Gastro-
pancreatic fold
Superior Recess
Inferior Recess
Vestiblue
Splenic Recess
Omental Bursa Proper

105. Peritoneal subdivisions
• Greater sac divided by
transverse colon and transverse
mesocolon into
– Supracolic and
– Infracolic compartments.
Supra-colic compartments
(subphrenic space)－lies between
diaphragm and transverse colon
and transverse mesocolon
Supra-hepatic recess
between the diaphragm & liver:-
the falciform ligament divides it
into right and left suprahepatic
recesses 107

107. The supra-colic compartment

108. • Left supra-hepatic recesses
– left anterior suprahepatic
spaces
– left posterior suprahepatic
spaces
• Right supra-hepatic recesses
– right anterior suprahepatic
spaces
– right posterior suprahepatic
spaces
– bare area of live
(extraperitoneal space)
110
Supra-hepatic recess

109. Rt. anterior subphrenic space Lt. anterior subphrenic space
Rt. posterior subphrenic
(Rt. Subhepatic)

110. Infrahepatic recess
lies between the liver and
transverse colon and transverse
mesocolon－the ligamentum
teres hepatic divides it into right
and left infrahepatic recesses
• Right infrahepatic recesses
(hepatorenal pouch of morrison)
• Left infrahepatic recesses
– left anterior infrahepatic space
– left posterior infrahepatic space =
Lesser Sac
112

111. Morison’s pouch
left subhepatic
Space
(Lt. posterior subphrenic)

112. Infracolic compartments: lies below
the transverse colon and transverse
mesocolon
• Right paracolic gutter :
– Lateral to the ascending colon
– Communicates with the hepatorenal
recess and the pelvic cavity
– Provides a route for the spread of
infection
• Left paracolic gutter:
– Lateral to the descending colon
– Separated from spleen by the
phrenicocolic ligament
114

113. • 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
115

114. Inferior mesenteric vein in the peritoneal fold,
forming the paraduodenal recess.
Duodenal Recesses
Close to the duodeno-jejunal junction,
four small pocket like pouches of peritoneum

115. Cecal Recesses
Folds of peritoneum close to the cecum produce three
peritoneal recesses called the superior ileocecal, the inferior
ileocecal, and the retrocecal recesses

116. Nerve supply to the peritoneum
The parietal peritoneum
Phrenic nerve
Intercostal
First lumbar nerves
Obturator nerve – Pelvic Cavity
The visceral peritoneum
Autonomic

117. Applied Anatomy
• Ascites:
• Paracentesis
• Internal abdominal hernia
• Perforation of gastric ulcer
• Peritoneal abscess
–Hepato-renal space
–Recto-uterine pouch or recto-vesical pouch
• Peritonitis
• Peritoneal Pain

118. Applied Anatomy
• Pneumoperitoneum
• Laparoscopy & Laparotomy
• Greater omentum – policeman of abdomen
• Referred pain from gut
• Peritoneal Dialysis
• Sub-phrenic abscess

119. Ascites
Excessive accumulation of the peritoneal fluid
within the peritoneal cavity
• Peritoneal fluid
excess, hydroperitoneum
• Most commonly due
to cirrhosis
• TB
• Malignancy

120. Abdominal paracentesis

122. Internal abdominal hernia
Occasionally a loop of
intestine may enter
into the peritoneal
pouch or recesses and
gets strangulated

123. Perforation of gastric ulcer
• Posterior wall
perforation
• Lesser sac
• If closed by
adhesions at epiploic
foramen
– Drained by tube
passed through
lesser omentum

124. Peritoneal abscess
• Hepato-renal space
– m.c. site for
subphrenic abscess
• In supine position
• Recto-uterine pouch
or recto-vesical
pouch
• In Fowler’s position
(45° angle)

125. Peritoneal abscess - drainage

126. Peritonitis
• Inflammation
• Localized
– Pain around site of
infection
– Tenderness
– Rigidity
• Generalized
– Card-board rigidity
– Absent intestinal
sounds

127. Rebound Tenderness
Pressure is applied to the abdominal wall with a
single finger over the site of the inflammation.
The pressure is then removed by suddenly
withdrawing the finger. The abdominal wall
rebounds, resulting in extreme local pain, which
is known as rebound tenderness

128. Pneumoperitoneum
• Air
• Perforations of
stomach or
intestine
• Air under right
dome of diaphragm

129. Laparoscopy

130. Laparotomy

131. Greater omentum – policeman of
abdomen
• Limits spread of infection
– Rupture appendix
– Ruptured gastric ulcer

132. Referred pain from gut

133. Peritoneal Dialysis

134. Sub-phrenic abscess