abdominal cavity subdivided into peritoneal cavity and retroperitoneal space. peritoneal cavity limits the parietal peritoneum. Retroperitoneal space - part of the abdominal cavity, lying between the parietal fascia of the abdomen at its posterior wall and the parietal peritoneum.
Bursa pregastrica
bursa omentalis
BURSA OMENTALIS
Has 6 walls:
6. Front wall
WINSLOW HOLE WALLS
ATursa hepatica
Contains the right lobe of the liver.
It communicates with the stuffing bag and with the right lateral canal (located on the middle floor of the abdominal cavity)
Bursapregatrica
Covers the left lobe of the liver.
MIDDLE FLOOR the abdominal cavity is limited
above mesocolon transversum
On the middle floor, between the mesentery and the intestine itself, there are two mesenteric sinuses: right and left.
Two bags of the upper floor communicate with the right lateral canal: b.omentalis, b. hepatica; and ends in the right iliac fossa.
LOWER FLOOR.
In women, the excavation of the rectouterina is of practical importance; from the side of the vagina, it corresponds to its posterior fornix. When performing a puncture of the posterior fornix of the vagina, they fall into the excavatio rectouterina - during pathological processes in the abdominal cavity (for example, an ectopic pregnancy), blood accumulates there.
MINISTRY OF HEALTH OF THE REPUBLIC OF BELARUS
EDUCATIONAL INSTITUTION
"GOMEL STATE MEDICAL UNIVERSITY"
Department of Human Anatomy
With a course of operative surgery and topographic anatomy
E. Yu. Doroshkevich, S. V. Doroshkevich,
I. I. LEMESHEVA
SELECTED QUESTIONS
TOPOGRAPHICAL ANATOMY
AND OPERATIONAL SURGERY
Teaching aid
To practical exercises in topographic anatomy
And operative surgery for students of the 4th course of medical,
Medical-diagnostic faculties and faculty for training
Specialists for foreign countries studying in the specialty
"Medical business" and "Medical-diagnostic business"
Gomel
GomGMU
CHAPTER 1
SURGICAL ANATOMY OF THE ABDOMINAL CAVITY
TOPOGRAPHY OF THE TOP FLOOR AUTHORITIES
ABDOMINAL CAVITY
1.1 Abdomen (cavitas abdominis) and its floors (borders, content)
Borders of the abdominal cavity.
The upper wall of the abdominal cavity is formed by the diaphragm, the posterior - by the lumbar vertebrae and muscles of the lumbar region, the anterolateral - by the abdominal muscles, the lower boundary is the terminal line. All these muscles are covered with a circular fascia - the fascia of the abdomen, which is called the intra-abdominal fascia. (fascia endoabdominalis); it directly limits the space that is called the abdominal cavity (or abdominal cavity).
The abdominal cavity is divided into 2 sections:
─ peritoneal cavity (cavitas peritonei)- slit-like space located between the sheets of the parietal and visceral peritoneum and containing intraperitoneal and mesoperitoneal organs;
─ retroperitoneal space (spatium retroperitoneale)- located between the parietal peritoneum covering the posterior abdominal wall and the intra-abdominal fascia; it contains extra-peritoneal organs.
The transverse colon and its mesentery form a septum that divides the abdominal cavity into 2 floors - upper and lower.
In the upper floor of the abdominal cavity are: liver, stomach, spleen, pancreas, upper half of the duodenum. The sub-gastric gland is located behind the peritoneum; nevertheless, it is considered as an organ of the abdominal cavity, since operative access to it is usually carried out by transection. On the lower floor are located: loops of the small intestine (with the lower half of the duodenum 12) and the large intestine.
Topography of the peritoneum: course, channels, sinuses, bags, ligaments, folds, pockets
Peritoneum (peritoneum)- a thin serous membrane with a smooth, shiny, homogeneous surface. Consists of the parietal peritoneum (peritoneum parietale) lining the abdominal wall and visceral peritoneum (peritoneum viscerale) covering the organs of the abdominal cavity. Between the leaves there is a slit-like space called the peritoneal cavity and containing a small amount of serous fluid, which moisturizes the surface of the organs and facilitates peristalsis. The parietal peritoneum lines the anterior and lateral walls of the abdomen from the inside, at the top it passes to the diaphragm, at the bottom - to the region of the large and small pelvis, behind it does not reach the spine somewhat, limiting the retroperitoneal space.
The ratio of the visceral peritoneum to the organs is not the same in all cases. Some organs are covered with it from all sides and are located intraperitoneally: the stomach, spleen, small, blind, transverse and sigmoid colons, sometimes the gallbladder. They are completely covered by the peritoneum. Some organs are covered with visceral peritoneum from 3 sides, i.e. they are located mesoperitoneally: liver, gallbladder, ascending and descending colons, initial and final sections of the duodenum.
Some organs are covered with peritoneum only on one side - extraperitoneally: duodenum, pancreas, kidneys, adrenal glands, bladder.
Course of the peritoneum
Visceral peritoneum, covering the diaphragmatic surface of the liver, passes to its lower surface. The sheets of the peritoneum, one from the front of the lower surface of the liver, the other from the back, meet at the gate and go down towards the lesser curvature of the stomach and the initial part of the duodenum 12, participating in the formation of ligaments of the lesser omentum. Leaves of the lesser omentum at the lesser curvature of the stomach diverge, cover the stomach in front and behind, and, reconnecting at the greater curvature of the stomach, descend downward, forming the anterior plate of the greater omentum (omentum majus). Going down, sometimes to the pubic symphysis, the leaves are wrapped and directed upward, forming the posterior plate of the greater omentum. Having reached the transverse colon, the sheets of the peritoneum go around its anterior superior surface and go to the posterior wall of the abdominal cavity. In this place they diverge, and one of them rises, covering the pancreas, the posterior wall of the abdominal cavity, partially the diaphragm, and, having reached the posterior inferior edge of the liver, passes to its lower surface. Another leaf of the peritoneum wraps up and goes in the opposite direction, i.e. from the posterior wall of the abdomen to the transverse colon, which it covers, and again returns to the posterior wall of the abdomen. This is how the mesentery of the transverse colon is formed (mesocolon transversum), consisting of 4 sheets of peritoneum. From the root of the mesentery of the transverse colon, the peritoneal sheet descends and, already as a parietal peritoneum, lines the posterior wall of the abdomen, then covers the ascending (right) and descending (left) colons from 3 sides. Inwards from the ascending and descending colons, the parietal sheet of the peritoneum covers the organs of the retroperitoneal space and, approaching the small intestine, forms its mesentery, enveloping the intestine from all sides.
From the back wall of the abdomen, the parietal sheet of the peritoneum descends into the pelvic cavity, where it covers the initial sections of the rectum, then lines the walls of the small pelvis and passes to the bladder (in women, it first covers the uterus), covering it from behind, from the sides and from above. From the top of the bladder, the peritoneum passes to the anterior wall of the abdomen, closing the peritoneal cavity. For a more detailed course of the peritoneum in the pelvic cavity, see the topic "Topographic anatomy of the pelvis and perineum."
Channels
On the sides of the ascending and descending colons are the right and left channels of the abdominal cavity (canalis lateralis dexter et sinis-ter), formed as a result of the transition of the peritoneum from the lateral wall of the abdomen to the colon. The right channel has a message between the upper floor and the lower one. On the left channel, there is no connection between the upper floor and the lower floor due to the presence of the diaphragmatic-colic ligament (lig. phrenicocolicum).
Sinusesabdominal(sinus mesentericus dexter et sinus mesentericus sinister)
The right sinus is limited: on the right - by the ascending colon; from above - the transverse colon, on the left - the mesentery of the small intestine. Left sinus: on the left - the descending colon, below - the entrance to the cavity of the small pelvis, on the right - the mesentery of the small intestine.
bags
Stuffing bag(bursa omentalis) limited: in front - by the lesser omentum, the posterior wall of the stomach and the gastrocolic ligament; behind - parietal peritoneum covering the pancreas, part of the abdominal aorta and inferior vena cava; top - liver and diaphragm; below - the transverse colon and its mesentery; on the left - the gastro-splenic and diaphragmatic-splenic ligaments, the gate of the spleen. Communicates with the peritoneal cavity through gland hole(foramen epiploicum, Winslow's hole), bounded in front by the hepatoduodenal ligament, from below - by the duodenal-renal ligament and the upper horizontal part of the duodenum, from behind - by the hepatic-renal ligament and the parietal peritoneum covering the inferior vena cava, from above - by the caudate lobe of the liver.
Right liver bag(bursa hepatica dextra) from above it is limited by the tendon center of the diaphragm, from below - by the diaphragmatic surface of the right lobe of the liver, from behind - by the right coronary ligament, on the left - by the sickle-shaped ligament. It is the site of subdiaphragmatic abscesses.
Left hepatic sac(bursa hepatica sinistra) it is bounded from above by the diaphragm, behind - by the left coronary ligament of the liver, on the right - by the falciform ligament, on the left - by the left triangular ligament of the liver, below - by the diaphragmatic surface of the left lobe of the liver.
Pregastric bag(bursa pregastrica) from above it is bounded by the left lobe of the liver, in front - by the parietal peritoneum of the anterior abdominal wall, behind - by the lesser omentum and the anterior surface of the stomach, on the right - by the falciform ligament.
Preomental space(spatium preepiploicum)- a long gap located between the anterior surface of the greater omentum and the inner surface of the anterior abdominal wall. Through this gap, the upper and lower floors communicate with each other.
Ligaments of the peritoneum
In places where the peritoneum passes from the abdominal wall to an organ or from an organ to an organ, ligaments are formed (ligg. peritonei).
Hepato-12-duodenal ligament(lig. hepatoduodenale) stretched between the gates of the liver and the upper part of the duodenum 12. On the left, it passes into the hepatogastric ligament, and on the right it ends with a free edge. Between the sheets of the ligament pass: on the right - the common bile duct and the common hepatic and cystic ducts that form it, on the left - the own hepatic artery and its branches, between them and behind - the portal vein ("TWO"- ductus, vein, artery from right to left), as well as lymphatic vessels and nodes, nerve plexuses.
Hepatogastric ligament(lig. hepatogastricum) represents a duplication of the peritoneum, stretched between the gates of the liver and the lesser curvature of the stomach; on the left it passes to the abdominal esophagus, on the right it continues into the hepatoduodenal ligament.
In the upper section of the ligament, the hepatic branches of the anterior vagus trunk pass. At the base of this ligament, in some cases, the left gastric artery is located, accompanied by the vein of the same name, more often these vessels lie on the wall of the stomach along the lesser curvature. In addition, often (in 16.5%), an additional hepatic artery is located in the tense part of the ligament, coming from the left gastric artery. In rare cases, the main trunk of the left gastric vein or its tributaries pass here.
When mobilizing the stomach along the lesser curvature, especially if the ligament is dissected near the hilum of the liver (for gastric cancer), it is necessary to take into account the possibility of passing the left accessory hepatic artery here, since its intersection can lead to necrosis of the left lobe of the liver or part of it.
On the right, at the base of the hepatogastric ligament, the right gastric artery passes, accompanied by the vein of the same name.
hepatorenal ligament(lig. hepatorenale) It is formed at the place of transition of the peritoneum from the lower surface of the right lobe of the liver to the right kidney. In the medial part of this ligament, the inferior vena cava passes.
Gastrophrenic ligament(lig. gastrophrenicum) located to the left of the esophagus, between the fundus of the stomach and the diaphragm. The ligament has the shape of a triangular plate and consists of one sheet of peritoneum, at the base of which is loose connective tissue. On the left, the ligament passes into the superficial sheet of the gastrosplenic ligament, and on the right - into the anterior semicircle of the esophagus.
The transition of the peritoneum from the gastrophrenic ligament to the anterior wall of the esophagus and to the hepatogastric ligament is called diaphragmatic-esophageal ligament(lig. phrenicooesophageum).
Diaphragmatic-esophageal ligament (lig. phrenicoesophageum) represents the transition of the parietal peritoneum from the diaphragm to the esophagus and the cardial part of the stomach. At its base, in loose fiber, along the anterior surface of the esophagus, r. esophageus from a. gastric sinistra and the trunk of the left vagus nerve.
Gastro-splenic ligament (lig. gastrolienale), stretched between the fundus of the stomach and the upper part of the greater curvature and the gates of the spleen, is located below the gastro-phrenic ligament. It consists of 2 sheets of peritoneum, between which short gastric arteries pass, accompanied by the veins of the same name. Continuing downward, it passes into the gastrocolic ligament.
Gastrocolic ligament (lig. gastrocolicum) consists of 2 sheets of peritoneum. It is the initial section of the greater omentum and is located between the greater curvature of the stomach and the transverse colon. This is the widest ligament, which runs in the form of a strip from the lower pole of the spleen to the pylorus. The ligament is loosely connected to the anterior semi-circumference of the transverse colon, as well as to tenia omentalis. It contains the right and left gastroepiploic arteries.
Gastro-pancreatic ligament (lig. gastropancreaticum) located between the upper edge of the pancreas and the cardial part, as well as the fundus of the stomach. It is quite clearly defined if the gastrocolic ligament is cut and the stomach is pulled forward and upward.
In the free edge of the gastro-pancreatic ligament is the initial section of the left gastric artery and the vein of the same name, as well as the lymphatic vessels and gastro-pancreatic lymph nodes. In addition, at the base of the ligament along the upper edge of the pancreas, there are pancreas-splenic lymph nodes.
Pyloric-pancreatic ligament (lig. pyloropancreaticum) in the form of a duplication of the peritoneum, it is stretched between the pylorus and the right side of the body of the pancreas. It has the shape of a triangle, one side of which is fixed to the posterior surface of the pylorus, and the other to the anteroinferior surface of the body of the gland; the free edge of the ligament is directed to the left. Sometimes the connection is not expressed.
Small lymph nodes are concentrated in the pyloric-pancreatic ligament, which can be affected in cancer of the pyloric stomach. Therefore, during resection of the stomach, it is necessary to completely remove this ligament along with the lymph nodes.
Between the gastro-pancreas and the pyloric-pancreatic ligaments there is a slit-like gastro-pancreas opening. The shape and size of this hole depend on the degree of development of the mentioned ligaments. Sometimes the ligaments are so developed that they overlap or grow together, closing the gastro-pancreatic opening.
This leads to the fact that the cavity of the stuffing box is divided by ligaments into 2 separate spaces. In such cases, if there is pathological content in the cavity of the omental sac (effusion, blood, gastric contents, etc.), it will be in one or another space.
Diaphragmatic-splenic ligament (lig. phrenicolienale) located deep in the back of the left hypochondrium, between the costal part of the diaphragm and the gates of the spleen.
Between the costal part of the diaphragm and the left flexure of the colon is stretched diaphragmatic-colic ligament (lig. phrenicocolicum). This ligament, together with the transverse colon, forms a deep pocket in which the anterior pole of the spleen is located.
Duodenal-renal ligament (lig. duodenorenale) located between the posterior superior edge of the duodenum and the right kidney, limits the omental opening from below.
Supporting ligament of the duodenum or ligament of Treitz (lig. suspensorium duodeni s. lig. Treitz) formed by a fold of peritoneum covering the muscle that suspends the duodenum 12 (M. suspensorius duodeni). Muscle bundles of the latter arise from the circular muscle layer of the intestine at the site of its inflection. A narrow and strong muscle is directed from flexura duodenojejunalis upward, behind the pancreas, it fan-shaped expands and is woven into the muscle bundles of the legs of the diaphragm.
Pancreatic-splenic ligament (lig. pancreaticolienale) is a continuation of the diaphragmatic-splenic ligament and is a fold of the peritoneum that stretches from the tail of the gland to the gates of the spleen.
1. Around the beginning of the jejunum, the parietal peritoneum forms a fold that borders the intestine from above and to the left - this is the upper duodenal fold (plica duodenalis superior). In this area, the upper duodenal recess is localized (recessus duodenalis superior), on the right it is limited by a 12-colo-jejunal flexure, from above and on the left - by the upper duodenal fold, in which the inferior mesenteric vein passes.
2. To the left of the ascending part of the duodenum there is a para-duodenal fold (plica paraduodenalis). This fold limits the inconstant paraduodenal recess anteriorly. (recessus paraduodenalis), the back wall of which is the parietal peritoneum.
3. To the left and below from the ascending part of the duodenum is the lower duodenal fold (plica duodenalis inferior), which limits the lower duodenal recess (recessus duodenalis inferior).
4. To the left of the root of the mesentery of the small intestine, behind the ascending part of the duodenum 12, there is a retroduodenal depression (recessus retroduodenalis).
5. An ileocecal fold is formed at the confluence of the ileum into the blind (plica ileocecalis). It is located between the medial wall of the caecum, the anterior wall of the ileum, and also connects the medial wall of the cecum with the lower wall of the ileum above and with the base of the appendix below. Under the ileocecal fold lie the pockets located above and below the ileum: the upper and lower ileocecal recesses (recessus ileocecalis supe-rior et recessus ileocecalis inferior). The upper ileocecal recess is bounded at the top by the ileo-colon fold, at the bottom by the final section of the ileum, and from the outside by the initial section of the ascending colon. The lower ileocecal recess is bounded at the top by the terminal ileum, posteriorly by the mesentery of the appendix, and anteriorly by the ileocecal fold of the peritoneum.
6. Posterior ileum (recessus retrocecalis) limited anteriorly by the caecum, posteriorly by the parietal peritoneum, and externally by the cecum-intestinal folds of the peritoneum (plicae cecales) stretched between the lateral edge of the bottom of the caecum and the parietal peritoneum of the iliac fossa.
7. Intersigmoid recess (recessus intersigmoideus) located on the left at the root of the mesentery of the sigmoid colon.
The abdominal cavity is the part of the abdominal cavity covered by the parietal peritoneum. In men, it is closed, and in women it communicates with the uterine cavity through the openings of the fallopian tubes.
The visceral peritoneum covers the organs located in the abdominal cavity. Organs can be covered by the peritoneum on all sides (intraperitoneally), on three sides (mesoperitoneally) and extraperitoneally (on one side or lie extraperitoneally). The organs covered by the peritoneum intraperitoneally have significant mobility, which is increased by the mesentery or ligaments. The displacement of meso-peritoneal organs is insignificant (Fig. 123).
A feature of the peritoneum is that the mesothelium (the first layer of the peritoneum) forms a smooth surface that ensures the sliding of the organs during their peristalsis and changes in volume. In the peritoneal cavity, under normal conditions, there is a minimal amount of transparent serous fluid, which moisturizes the surface of the peritoneum and fills the gaps between organs and walls. The movements of organs in relation to each other and to the abdominal wall are made easily and without friction due to the fact that all contact surfaces are smooth and moist. Between the anterior wall of the abdomen and the internal organs there is a gasket-omentum. "
In the region of the diaphragm, the peritoneum becomes thinner at the site of the “suction hatches”. The lumen of the hatches changes during the respiratory movements of the diaphragm, which ensures their pumping action. "Suction hatches" are also present in the peritoneum of the rectovesical cavity in men and the recto-uterine cavity in women.
There are transuding, absorbing and indifferent to the abdominal fluid areas of the peritoneum. Transuding areas are the small intestine and broad ligaments of the uterus. The suction parts of the parietal peritoneum are the diaphragm and the iliac fossae.
The abdominal cavity of the mesentery of the transverse colon is divided into two floors: upper and lower, which communicate with each other in front through the preomental fissure and from the sides - through the right and left lateral canals. In addition, the peritoneal floor of the small pelvis is isolated
The upper floor of the abdominal cavity is located between the diaphragm and the mesentery of the transverse colon. In it, intraperitoneally covered are the stomach, spleen and mesoperitoneally - the liver, gallbladder and upper part of the duodenum. The pancreas belongs to the upper floor of the abdominal cavity, although it lies retroperitoneally, and part of the head is located below the root of the mesentery of the transverse colon. The listed organs, their ligaments and the mesentery of the transverse colon limit isolated spaces, cracks and bags in the upper floor of the abdominal cavity.
Top floor bags. The space between the diaphragm and the liver is divided by the falciform ligament into two sections: left and right.
The right liver bag, or bursa hepatica dextra, is the gap between the right lobe of the liver and the diaphragm. It is bounded above by the diaphragm, below by the right lobe of the liver, behind by the right part of the coronary ligament, and to the left by the falciform ligament of the liver. It distinguishes the right subdiaphragmatic space and subhepatic.
The right subphrenic space is located most deeply between the posterior surface of the right lobe of the liver, the diaphragm, and the coronary ligament. It is in the subdiaphragmatic space, as in the deepest place of the hepatic sac, that the fluid that has poured into the abdominal cavity can be retained. The subphrenic space in most cases directly passes into the right lateral canal of the lower floor of the abdominal cavity. Therefore, inflammatory exudate from the right iliac fossa can freely move towards the subphrenic space and lead to the formation of an encysted abscess, called a subphrenic abscess. It most often develops as a complication of perforated gastric and duodenal ulcers, destructive appendicitis, cholecystitis.
The subhepatic space is the lower section of the i fava of the hepatic sac and is located between the lower surface of the right lobe of the liver, the transverse colon and its mesentery, to the right of the gate of the liver and the hepatoduodenal ligament. In the subhepatic space, the anterior and posterior sections are distinguished. Almost the entire peritoneal surface of the gallbladder, the upper outer surface of the duodenum, faces the anterior part of this space. The posterior section, located at the posterior edge of the liver, is the least accessible part of the subhepatic space - a recess called the renal-hepatic pocket. Abscesses resulting from perforation of a duodenal ulcer or purulent cholecystitis are more often located in the anterior section, while the distribution of the periappendicular abscess occurs mainly in the posterior section of the subhepatic space.
The left subdiaphragmatic space consists of widely communicating bags: the left hepatic and pregastric.
The left hepatic bursa is a gap between the left lobe of the liver and the diaphragm, bounded on the right by the falciform ligament of the liver, behind the left part of the coronary ligament and the left triangular ligament of the liver. This bursa is much smaller in width and depth than the right hepatic bursa and is not usually identified as a distinct part of the subdiaphragmatic space.
The pregastric sac is bounded behind by the lesser omentum and stomach, the upper left lobe of the liver, the diaphragm, in front by the anterior abdominal wall, on the right by the falciform and round ligaments of the liver, on the left, the pregastric sac has no pronounced border. In the outer-posterior section of the left subdiaphragmatic space, the spleen is located with ligaments: gastrosplenic and diaphragmatic-splenic. () t of the left lateral canal, it is separated by the left phrenic-colic ligament. This ligament is often wide, it covers the lower pole of the spleen and is called the suspensory ligament of the spleen. Thus, the bed of the spleen is well demarcated from the left lateral canal, this is a blind pocket (saccus caecus lienalis). The left subdiaphragmatic space plays a much smaller role than the right one as a site of abscess formation. Purulent processes rarely developing in this space tend to spread between the left lobe of the liver and stomach down to the transverse colon or to the left to the blind sac of the spleen. Communication between the right hepatic and pregastric bags is carried out through a narrow gap between the liver and the pyloric part of the stomach, in front of the lesser omentum.
Stuffing bag (bursa omentalis) is a large closed slit-like space of the abdominal cavity, the most isolated and deep.
The anterior wall of the omental sac is formed by the lesser omentum, the posterior wall of the stomach, and the gastrocolic ligament (the initial part of the greater omentum). The lesser omentum is three ligaments that pass one into the other: hepatic-duodenal, hepatic-gastric and diaphragmatic-gastric. The lower wall of the omental sac is formed by the transverse colon and its mesentery. From above, the omental bag is bounded by the caudate lobe of the liver and the diaphragm, the posterior wall is formed by the parietal peritoneum, which covers the front of the pancreas, aorta, inferior vena cava, the upper pole of the left kidney with the adrenal gland, on the left it is limited by the spleen with the gastrosplenic ligament, and the right wall is not expressed.
In the omental bag, depressions or inversions are distinguished: the upper one is located behind the caudate lobe of the liver and reaches the diaphragm, the lower one is in the region of the mesentery of the transverse colon and the spleen.
Entry into the omental bag is possible only through the omental opening, bounded in front by the hepatoduodenal ligament, behind by the hepatorenal ligament, in the thickness of which lies the inferior vena cava, above by the caudate lobe of the liver, below by the renal-duodenal ligament.
The stuffing hole passes one or two fingers, but in case of adhesion formation it can be closed and then the stuffing bag is a completely isolated space. In the omental bag, the contents of the stomach can accumulate when the ulcer is perforated;
nigsya purulent processes as a result of inflammatory diseases of the pancreas.
There are three operational accesses to the stuffing bag for examination, revision of organs and operations on them (Fig. 124):
1. Through the gastrocolic ligament, which is most preferable, since it can be dissected widely. It is used to examine the posterior wall of the stomach and pancreas in case of inflammation and trauma.
2. Through the hole in the mesentery of the transverse colon in an avascular place, you can examine the cavity of the omental bag, apply a gastrointestinal anastomosis.
3. Access through the hepatogastric ligament is more convenient when the stomach is prolapsed. Used in operations on the celiac artery.
Channels and sinuses of the lower floor. The lower floor of the abdominal cavity occupies the space between the mesentery of the transverse colon and the small pelvis. The ascending and descending colons, the root of the mesentery of the small intestine divide the lower floor of the abdominal cavity into four sections: the right and left side canals and the right and left (mesenteric sinuses (Fig. 125).
The right lateral canal is located between the ascending colon and the right lateral wall of the abdomen. At the top, the canal passes into the subscapular space, at the bottom - into the right iliac fossa, and then into the small pelvis.
The left lateral canal is limited by the descending colon and the left lateral wall of the abdomen and passes into
left iliac region. The deepest in the horizontal position are the upper sections of the canals.
The right mesenteric sinus is limited to the right by the ascending colon, from above by the mesentery of the transverse colon, to the left and below by the mesentery of the small intestine. This sinus is largely delimited from other parts of the abdominal cavity. In the horizontal position, the upper right angle of the sinus is the deepest.
The left mesenteric sinus is larger than the right one. From above it is bounded by the mesentery of the transverse colon, on the left by the descending colon and the sigmoid mesentery, on the right by the mesentery of the small intestine. From below, the sinus is not limited and directly communicates with the pelvic cavity. In the horizontal position, the superior angle of the sinus is the deepest. Both mesenteric sinuses communicate with each other through a gap between the mesentery of the transverse colon and the initial part of the jejunum. Inflammatory exudate from the mesenteric sinuses may spread into the lateral channels of the abdominal cavity. The left mesenteric sinus is larger than the right one, and due to the absence of anatomical restrictions in its lower sections, suppurative processes that develop in the sinus tend to descend into the pelvic cavity much more often than from the right mesenteric sinus.
Along with the tendency for inflammatory exudates to spread through all the crevices of the abdominal cavity, there are anatomical prerequisites for the formation of encysted peritonitis both in the lateral canals and in the mesenteric sinuses, especially in the right one, as it is more closed. During operations on the abdominal organs, especially with peritonitis, it is important to divert the loops of the small intestine first to the left, then to the right and remove pus and blood from the mesenteric sinuses to prevent the formation of encysted abscesses.
Abdominal pockets. The peritoneum, passing from organ to organ, forms ligaments, next to which there are recesses, called pockets (recessus).
Recessus duodenojejunalis is formed at the junction of the duodenum into the jejunum, recessus iliocaecalis superior is formed at the confluence of the ileum into the caecum in the region of the upper iliac-caecal angle, recessus iliocaecalis inferior is formed in the region of the lower ileocecal angle, recessus retrocaecalis is located behind the caecum, recessus intersigmoideus - a funnel-shaped depression between the mesentery of the sigmoid colon and the parietal peritoneum, its beginning faces the left lateral canal.
Peritoneal pockets can become the site of internal hernia formation. Peritoneal pockets with internal hernias can reach very large sizes. Internal hernias can become strangulated and cause intestinal obstruction.
Topographic anatomy of the stomach. The stomach is the main organ of the digestive system and is a mystical sac-like extension of the digestive tract located between the esophagus and the duodenum.
Holotopia. The stomach is projected onto the anterior abdominal wall in the left hypochondrium and its own epigastric region.
Departments. The inlet of the stomach is called cardiac, and the outlet is called pyloric. The perpendicular, descending from the esophagus to the greater curvature, divides the stomach into a cardial section, consisting of the fundus and body, and a pyloric section, consisting of the vestibule and pyloric canal. In the stomach, there is a greater and lesser curvature, anterior and posterior surfaces.
Syntopy. The concept of "syntopic fields of the stomach" is distinguished. These are the places where the stomach comes into contact with neighboring organs. Syntopic fields of the stomach must be taken into account in case of combined wounds, penetration of ulcers and germination of stomach tumors. Three syntopic fields are distinguished on the anterior wall of the stomach: hepatic, diaphragmatic and free, which is in contact with the anterior wall of the abdomen. This field is also called the gastric triangle. This site is commonly used for gastrotomies and gastrostomies. The size of the gastric triangle depends on the filling of the stomach. Five syntopic fields are distinguished on the posterior wall of the stomach: splenic, renal, adrenal, pancreatic, and gastrointestinal.
Position. In the abdominal cavity, the stomach occupies a central position in the upper floor. Most of the stomach is located in the left subphrenic space, limiting the pancreatic sac in the back and the omental sac in front. The position of the stomach corresponds to the degree of inclination of the longitudinal axis of the stomach. Shevkunenko, in accordance with the location of the axis of the stomach, identified three types of positions: vertical (hook shape), horizontal (horn shape), oblique. It is believed that the position of the stomach is directly dependent on the type of physique.
relation to the peritoneum. The stomach occupies an intraperitoneal position. In places of transition of the sheets of the peritoneum on the lesser and greater curvature, ligaments of the stomach are formed. Ligaments of the stomach are divided into superficial and deep. Surface bonds:
1) gastrocolic (part of the greater omentum);
2) gastro-splenic, short gastric vessels pass through it, splenic vessels are located behind the ligament;
3) gastro-diaphragmatic;
4) diaphragmatic-esophageal, in it passes the esophageal branch from the left gastric artery;
5) hepatogastric, in it along the lesser curvature is the left gastric artery and vein;
6) hepato-pyloric - continuation of the hepatic / laryngeal ligament. It has the form of a narrow strip stretched between the gates of the liver and the pylorus, is an intermediate part between the hepatic-gastric and hepato-duodenal in dogs and serves as the right border when dissecting the ligaments of the stomach.
Deep Ligaments:
1) gastro-pancreas (during the transition of the peritoneum from the upper-I icro edge of the pancreas to the posterior surface of the stomach);
2) with pyloric-pancreas (between the pyloric otic um of the stomach and the right side of the body of the pancreas);
3) lateral diaphragmatic-piciform.
Blood supply of the stomach. The stomach is surrounded by a ring
wide anastomosing vessels giving off intramural branches and forming a dense network in the submucosa (Fig. 126). The source of blood supply is the celiac trunk, from which the left gastric artery departs, which goes directly to the lesser curvature of the stomach. The right gastric artery departs from the common hepatic artery, which anastomoses with the left on the lesser curvature of the stomach, forming an arterial arc of the lesser curvature. The left and right gastroepiploic arteries form an arc of greater curvature, and there are also short gastric arteries.
Innervation of the stomach. The stomach has a complex nervous apparatus. The main sources of innervation are the vagus nerves, the celiac plexus and its derivatives: gastric, hepatic, splenic, superior mesenteric plexus. The vagus nerves, branching on the esophagus, form the esophageal plexus, I de branches of both nerves are mixed and repeatedly connected. Passing from the esophagus to the stomach, the branches of the esophageal plexus are concentrated into several trunks: the left one passes to the anterior surface of the stomach, and the right one to the posterior surface of the stomach, giving branches to the liver, solar plexus, kidney and other organs. A long branch of Latarjet departs from the left vagus nerve to the pyloric section of the stomach. vagus nerves are a complex conduction system that connects nerve fibers of various functional purposes to the stomach and other organs. Between the left and right nerves there are a large number of connections in the chest and abdominal cavities, here there is an exchange of fibers. Therefore, it is impossible to talk about the exclusive innervation of the anterior wall of the stomach by the left vagus nerve, and the posterior wall by the right one. The right vagus nerve goes more often in the form of a single trunk, and the left one forms from one to four branches, more often there are two.
Lymph nodes of the stomach. Regional lymph nodes of the stomach are located along the lesser and greater curvature, as well as along the left gastric, common hepatic, splenic and celiac arteries. According to A. V. Melnikov (1960), lymph outflow from the stomach occurs through four main collectors (pools), each of which includes 4 stages.
Collector I of the lymphatic outflow collects lymph from the pyloric-angral part of the stomach, adjacent to the greater curvature. The first stage is the lymph nodes located in the thickness of the gastrocolic ligament along the greater curvature, near the pylorus, the second stage is the lymph nodes along the edge of the pancreatic head under and behind the pylorus, the third stage is the lymph nodes located in the thickness of the mesentery of the small intestine , and the fourth - retroperitoneal para-aortic lymph nodes.
In the 7/ collector of the lymphatic outflow, lymph flows from the part of the pyloric-antral section adjacent to the lesser curvature, and partly from the body of the stomach. The first stage is the retropyloric lymph nodes, the second is the lymph nodes in the lesser omentum in the dietary part of the lesser curvature, in the region of the pylorus and duodenum, immediately behind the pylorus, the third stage is the lymph nodes located in the thickness of the hepatic o-gastric ligament. The fourth stage A. V. Melnikov considered the lymph nodes in the gates of the liver.
Collector III collects lymph from the body of the stomach and lesser curvature, adjacent sections of the anterior and posterior walls, paintings, the medial part of the fornix and the abdominal esophagus. The first stage is the lymph nodes located in the form of a chain along the lesser curvature in the fiber of the lesser omentum. The upper nodes of this chain are called paracardial; in cancer of the cardia, they are affected by metastases in the first place. Lymph nodes along the left gastric vessels, in the thickness of the gastro-pancreatic ligament, are the second stage. I third stage - lymph nodes along the upper edge of the pancreas and in the region of its tail. The fourth stage is the lymph nodes in the paraesophageal tissue above and below the diaphragm.
In the IV collector, lymph flows from the vertical part of the greater curvature of the stomach, the adjacent anterior and posterior walls, and a significant part of the fornix of the stomach. Lymph nodes located in the upper left gastrocolic ligament are the first stage. The second stage is the lymph nodes along the short arteries of the stomach, the third stage is the lymph nodes in the hilum of the spleen. A. V. Melnikov considered the defeat of the spleen to be the fourth stage.
Knowledge of the anatomy of the regional lymph nodes of all collectors is extremely important for the correct operation of the stomach in compliance with oncological principles.
Topographic anatomy of the duodenum. The duodenum (duodenum) is the initial section of the small intestine. In front, it is covered by the right lobe of the liver and the mesentery of the transverse colon, it itself covers the head of the pancreas, so the duodenum lies deep and does not directly adjoin the anterior abdominal wall anywhere. The duodenum is divided into four parts. It consists of upper horizontal, descending, lower horizontal and ascending parts. Knowing the syntopy of the duodenum helps to explain the direction of penetration of the ulcer, the germination of the tumor and the spread of phlegmon during retroperitoneal rupture of the organ.
The upper part of the duodenum, 4-5 cm long, is located between the pylorus and the upper flexure of the duodenum and goes to the right and back along the right surface of the spine, passing into the descending part. This is the most mobile section of the intestine, covered on all sides by the peritoneum. All other sections of the intestine are covered with peritoneum only in front. In the initial section of the duodenum, an extension is determined, which is called the duodenal bulb. The upper part of the duodenum from above; in contact with the square lobe of the liver, in front - with the gallbladder, behind - with the portal vein, gastroduodenal artery, common bile duct. From below and from the inside, the head of the pancreas is adjacent to the intestine.
The descending part of the duodenum, 10-2 cm long, is located between the flexura duodeni superior and flexura duodeni inferior. This part of the duodenum is inactive and is covered by the peritoneum only in front. The descending part of the duodenum in front borders on the right lobe of the liver, the mesentery of the transverse colon, behind - with the gate of the right kidney, renal pedicle, inferior vena cava. Outside, the ascending part and the hepatic flexure of the colon are adjacent, from the inside, the head of the pancreas. The common bile duct and the pancreatic duct open into the descending part of the duodenum. They perforate the postero-meshal wall of the descending part of the duodenum in its middle section and open on the major (vater) papilla of the duodenum. Above it, there may be a non-permanent small duodenal papilla, on which the accessory pancreatic duct opens.
From the lower bend of the duodenum begins - 1 "and its horizontal part 2 to 6 cm long, covered in front by the peritoneum. The horizontal (lower) part lies at the level of the III and IV lumbar vertebrae, below the mesentery of the transverse colon, partly behind the root of the mesentery of the small intestine The first oriental part of the duodenum passes into the ascending part, 6-10 cm long. in front - the transverse colon, the loops of the racent intestines, the root of the mesentery of the small intestines and the superior mesenteric vessels.Behind - the right psoas muscle, the inferior vena cava, the aorta, the left renal vein.
Tie the duodenum. The hepatoduodenal ligament is located between the hilum of the liver and the initial Hi (fracture of the upper part of the duodenum. It fixes the I initial section of the intestine and limits the omental opening
In the upper part of the duodenum is covered with peritoneum from ■ h ex sides. The descending and horizontal parts are located retroperitoneally, the ascending part occupies an intraperitoneal position.
The blood supply to the duodenum (see Fig. 126) I a "strikes from the system of the celiac trunk and the superior mesenteric irgern. The upper and lower pancreatic-duodenal arteries have anterior and posterior branches. As a result of anastomosis, anterior and posterior arterial arches are formed between them, which go between the concave semicircle of the duodenum and the head of the pancreas, which makes it impossible to separate them during surgery and forces them to be removed as a single block - pancreatoduodenal resection, performed, for example, in cancer of the Vater nipple or tumor of the pancreatic head.
Large glands of the digestive tract
Topographic anatomy of the liver. The liver is one of the large glands in the digestive tract. The liver is distinguished by four morphofunctional features: 1) is the largest organ; 2) has three circulatory systems: arterial, venous and portal; 3) all substances that enter the gastrointestinal tract pass through it; 4) serves as a huge blood depot; 5) participates in all types of metabolism, synthesizes albumins, globulins, factors of the blood coagulation system, plays an important role in carbohydrate and fat metabolism and detoxification of the body, plays an important role in lymph production and lymph circulation.
Gayutopia. The liver of an adult is located in the right hypochondrium, the epigastric region proper, and partially in the left hypochondrium. The projection of the liver on the anterior abdominal wall looks like a triangle and can be built on three points: the upper point is on the right at the level of the 5th costal cartilage along the midclavicular line, the lower point is the 10th intercostal space along the midaxillary line, on the left - at the level of 6- th costal cartilage along the parasternal line. The lower border of the liver coincides with the costal arch. Behind the liver is projected onto the chest wall, to the right of the 10-11th thoracic vertebrae.
The position of the liver. The liver in relation to the frontal plane can be located: 1) in the dorsopetal position, the diaphragmatic surface of the liver is thrown back and its front edge can be located above the costal arch; 2) in the ventropetal position, the diaphragmatic surface faces forward, and the visceral surface faces backwards. In the ventropetal position, surgical access to the lower surface of the liver is difficult, and in the dorsopetal position, to the upper one.
The liver can occupy a right-sided position, then its right lobe is highly developed, and the size of the left lobe is reduced. () the organ occupies an almost vertical position, sometimes located only in the right half of the abdominal cavity. The left-sided position of the liver is characterized by the location of the organ in the horizontal plane and with a well-developed left lobe, which in some cases can go beyond the spleen.
Syntopy of the liver. The diaphragmatic surface of the right juli of the liver borders on the pleural cavity, the left lobe - on the pericardium, from which it is separated by the diaphragm. The visceral surface of the liver comes into contact with various organs, from which depressions form on the surface of the liver. The left lobe of the liver borders the lower end of the esophagus and the stomach. The pyloric part of the stomach is adjacent to the square lobe. The right lobe of the liver in the region of the neck of the gallbladder adjoins the upper horizontal part of the duodenum. 11 to the right is in contact with the transverse colon and the hepatic curvature of the colon. Posterior to this impression, the surface of the right lobe of the liver borders the right kidney and adrenal gland. Syntopy of the liver must be taken into account when assessing possible options for combined injuries of the abdominal and thoracic cavities.
The gate of the liver is an anatomical formation, which is made up of the transverse and left longitudinal grooves of the visceral surface of the liver. Here, vessels and nerves enter the liver and bile ducts and lymphatic vessels exit. In the gates of the liver, the vessels and ducts are accessible for surgical treatment, since they are located superficially, outside the parenchyma of the organ. Of practical importance is the shape of the gate: open, closed and intermediate. With an open form of the gate of the liver, the transverse sulcus communicates with the left sagittal and accessory sulci, thereby creating favorable conditions for access to the lobar and segmental ducts. With a closed form of the gate of the liver, there is no communication with the left sagittal sulcus, there are no additional grooves, the size of the gate is reduced, therefore, it is impossible to isolate segmental vessels and ducts in the gate of the liver without dissecting its perenchyma.
The gates of the liver can be located in the middle between the edges of the liver or shifted to its posterior or anterior edge. In the case of posterior displacement of the gate, more difficult conditions are created for prompt access to the vessels and ducts of the portal system during liver resections and operations on the biliary tract.
The relation to the peritoneum is mesoperitoneal, that is, the liver is covered with peritoneum on three sides. The posterior surface of the liver is not covered by the peritoneum, it is called the extraperitoneal field of the liver or pars m.ida.
The ligamentous apparatus of the liver is usually divided into true ligaments and peritoneal ligaments. True ligaments: 1) coronary, firmly fixing the posterior surface of the liver to the diaphragm, turning into triangular ligaments along the edges; 2) sickle-shaped, located in the sagittal plane at the border of the right and left lobes and turning into a steep ligament, which goes to the navel and contains a partially obliterated umbilical vein. From the visceral surface of the liver, the peritoneal ligaments are sent down to the organs: hepatogastric and hepatoduodenal. The hepatoduodenal ligament (ligament of life) is considered the most important, since the common bile duct (on the right), the common hepatic artery (on the left) and the portal vein pass through it, lies between them and posteriorly. Clamping of the hepatoduodenal ligament with fingers or a special instrument is used to temporarily stop bleeding from the liver.
Fixing apparatus of the liver. The liver is kept in the correct anatomical position: 1) extraperitoneal field (part of the posterior surface of the liver, not covered by the peritoneum); 2) the inferior vena cava, lying on the posterior surface of the liver and receiving the hepatic veins. Above the liver, the vein is fixed in the opening of the diaphragm, below it is firmly connected with the spine; 3) intra-abdominal pressure, muscle tone of the anterior abdominal wall and suction action of the diaphragm; 4) ligaments of the liver.
Blood supply to the liver. Two vessels bring blood to the liver: the hepatic artery and the portal vein, respectively 25 and 75%. The arterial supply of the liver comes from the common hepatic artery, which, after departing from it by the gastroduodenal artery, is called the proper hepatic artery and is divided into the right and left hepatic arteries.
Portal vein, v. porta, is formed behind the head of the pancreas. This is the first section of the vein, which is called the pars pancreatica. The second section of the portal vein is located behind the upper horizontal part of the duodenum and winds pars retroduodenalis. The third section of the vein is located in the head of the hepatoduodenal ligament above the upper horizontal part of the duodenum and is called pars supraduodenaiis. The portal vein collects blood from unpaired organs of the abdominal cavity: intestines, spleen, stomach, and is formed from three large trunks: the splenic vein, superior mesenteric and inferior mesenteric veins.
At the hilum of the liver, the hepatic artery, portal vein, and bile duct form the portal triad, Glisson's triad.
Liver jen, vv. hepatic i, are collected from the central lobular veins and, ultimately, form three large trunks, the right, left and middle hepatic veins, which emerge from the liver tissue on the posterior surface at the upper edge (caval portal of the liver) and flow into the inferior vena cava vein at the level of its transition through the diaphragm.
The structure of the liver, segmental division. The division of the liver into the right, left, caudate and square lobes, accepted in classical anatomy, is unacceptable for surgery, since the outer boundaries of the lobes do not correspond to the internal architectonics of the vascular and biliary systems. The modern division of the liver into segments is based on the principle of coincidence of the course of the first-order branches of the three liver systems: portal, arterial and bile, as well as the location of the main venous trunks of the liver. The portal vein, hepatic artery, and bile ducts are called the portal system (portal triad, Glisson triad). The course of all elements of the portal system inside the liver is relatively the same. The hepatic veins are called the caval system. The course of the vessels and bile ducts of the portal system of the liver does not coincide with the direction of the vessels of the caval system. Therefore, division of the liver according to the portal sign is now more common. The division of the liver along the portal system is of greater importance for the surgeon, since it is with the isolation and ligation of the vascular-secretory elements in the gates of the liver that the resection of this organ begins. However, when performing a resection based on liver division along the portal system, it is necessary to take into account the course of the hepatic veins (caval system) so as not to disturb the venous outflow. In clinical practice, the scheme of segmental division of the liver according to Quino, 1957 (Fig. 127) has become widespread. According to this scheme, the liver is divided into two lobes, five sectors and eight segments. The segments are arranged in radii around the gate. Lobe, sector and segment is called a section of the liver, which has separate blood supply, bile outflow, innervation and lymph circulation. The lobes, sectors and segments of the liver are separated from each other by four main gaps.
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Lecture on the topic:
"TOPOGRAPHY OF THE PERITONE"
LECTURE PLAN:
1. Embryogenesis of the peritoneum.
2. Functional value of the peritoneum.
3. Features of the structure of the peritoneum.
4. Topography of the peritoneum:
4.1 Top floor.
4.2 Middle floor.
4.3 Lower floor.
Embryogenesis of the peritoneum
As a result of embryonic development, the secondary body cavity is generally divided into a number of isolated closed serous cavities: in this way, 2 pleural cavities and 1 pericardial cavity are formed in the chest cavity; in the abdominal cavity - the cavity of the peritoneum.
In men, there is another serous cavity between the testicular membranes.
All these cavities are hermetically closed, with the exception of women - with the help of the fallopian tubes during ovulation and menstruation, the abdominal cavity communicates with the environment.
In this lecture, we will touch on the structure of such a serous membrane as the peritoneum.
PERITONEUM (peritoneum) is a serous membrane that is divided into parietal and visceral sheets that cover the walls and internal organs of the abdominal cavity.
The visceral peritoneum covers the internal organs located in the abdominal cavity. There are several types of relation of the organ to the peritoneum or covering the organ with the peritoneum.
If the organ is covered by the peritoneum on all sides, then they speak of an intraperitoneal position (for example, the small intestine, stomach, spleen, etc.). If the organ is covered by the peritoneum on three sides, then they mean the mesoperitoneal position (for example, the liver, ascending and descending colon). If the organ is covered by the peritoneum on one side, then this is an extraperitoneal or retroperitoneal position (for example, kidneys, lower third of the rectum, etc.).
The parietal peritoneum lines the walls of the abdominal cavity. In this case, it is necessary to define the abdominal cavity.
ABDOMINAL CAVITY - this is the space of the body, located below the diaphragm and filled with internal organs, mainly the digestive and genitourinary systems.
The abdominal cavity has walls:
top is diaphragm
inferior - pelvic diaphragm
posterior - spinal column and posterior abdominal wall.
anterolateral - these are the abdominal muscles: straight, external and internal oblique and transverse.
The parietal sheet lines these walls of the abdominal cavity, and the visceral sheet covers the internal organs located in it, and a narrow gap is formed between the visceral and parietal sheets of the peritoneum - the PERITONEAL CAVITY.
Thus, summing up what has been said, it should be noted that a person has several separate serous cavities, including the peritoneal cavity, lined with serous membranes.
Speaking of serous membranes, it is impossible not to touch on their functional significance.
FUNCTIONAL SIGNIFICANCE OF THE PERITONE
1. Serous membranes reduce friction between internal organs, since they secrete a fluid that lubricates the contact surfaces.
2. The serous membrane has a transuding and exuding function. The peritoneum secretes up to 70 liters of fluid per day, and all this fluid is absorbed by the peritoneum itself during the day. Different parts of the peritoneum can perform one of the above functions. So, the diaphragmatic peritoneum has a predominantly suction function, the serous cover of the small intestine has a transuding ability, the serous cover of the anterolateral wall of the abdominal cavity, and the serous cover of the stomach are referred to as neutral areas.
3. Serous membranes are characterized by the performance of a protective function, tk. they are a kind of barriers in the body: sero-hemolymphatic barrier (eg, peritoneum, pleura, pericardium), sero-hematic barrier (eg, greater omentum). A large number of phagocytes are localized in the serous membranes.
4 The peritoneum has great regenerative abilities: the damaged area of the serous membrane is first covered with a thin layer of fibrin, and then simultaneously along the entire length of the damaged area - with mesothelium.
5. Under the influence of external stimuli, not only the functions, but also the morphology of the serous cover change: adhesions appear - that is, serous membranes are characterized by delimiting abilities; but at the same time, adhesions can lead to a number of pathological conditions requiring repeated surgical interventions. And, despite the high level of development of surgical techniques, intraperitoneal adhesions are frequent complications, which made it necessary to single out this disease as a separate nosological unit - adhesive disease.
6. Serous membranes are the basis in which the vascular bed, lymphatic vessels and a huge number of nerve elements lie.
Thus, the serous membrane is a powerful receptor field: the maximum concentration of nerve elements, and in particular receptors, per unit area of the serous cover is called the REFLEXOGENIC ZONE. These zones include the umbilical region, the ileocecal angle with the appendix.
7. The total area of the peritoneum is about 2 square meters. meters and is equal to the area of the skin.
8. The peritoneum performs a fixation function (attaches organs and fixes them, returns to their original position after displacement).
That. serous membranes perform several functions:
protective
trophic,
fixative,
restrictive, etc.
HISTOLOGICAL STRUCTURE OF THE PERITONE
The histological structure of the peritoneum deserves attention: we will consider it using the example of the parietal leaf.
Based on the new nomenclature, three main morphologically pronounced layers are distinguished in the peritoneum:
Mesothelium
Boundary basement membrane
Own plate.
According to the old nomenclature, six layers are distinguished in the peritoneum.
1. Mesothelium - is part of the serous integument. There are two views on the nature of mesothelium: some refer mesothelium to epithelial tissues, others consider mesothelium to be a type of connective tissue. (This is a single-layer row of cells that passes serous fluid through itself; the mesothelium can be sloughed off, has a high degree of reactivity).
2. A layer of fibrillar fibers adjoins the mesothelium - the basement membrane - it has the appearance of either a continuous layer or a fenestrated structure. The basement membrane prevents the formation of folds on the surface of the mesothelium.
3. The superficial fibrous collagen layer consists of unidirectional bundles of collagen fibers. This layer promotes stretching of the peritoneum.
4. The superficial non-oriented elastic network consists of thin and thick elastic fibers without a specific orientation. This network contributes to the gradual unfolding of the folds when the peritoneum is stretched.
5. A deep oriented elastic network is built from parallel oriented bundles. This network is adapted to stretch the peritoneum in only one direction.
6. Deep lattice collagen elastic layer reaches a thickness of 50-60 microns. The basis of the layer is collagen and elastic fibers. This layer of the peritoneum contains blood and lymphatic vessels, as well as nerve elements.
In some areas of the parietal peritoneum, a layer of loose retroperitoneal tissue may adjoin this layer.
Thus, the peritoneum has a complex structure and consists of 6 morphologically pronounced layers, the histological features of which determine the function of this cover.
As already noted, the peritoneum covers the walls and organs of the abdominal cavity. When moving from the wall to parts of the intestinal tube, serous folds are formed, which are called the mesentery (mesenterium), and when moving from the wall to the organ, or organ to organ (parenchymal) - ligaments.
Ligaments of the peritoneum are PRIMARY and SECONDARY.
PRIMARY originated from the ventral and dorsal mesentery and consist of two sheets: lig. hepatoduodenale, lig. falciforme hepatis
SECONDARY ligaments are formed during the transition of the peritoneum from organ to organ: lig. coronarium hepatis, lig. hepatorenale.
For the convenience of studying and mastering the topography, syntopy, holotopy of the abdominal organs, the features of the course of the peritoneum, the abdominal cavity is divided into floors:
UPPER FLOOR - it contains the liver, spleen, stomach, kidneys, adrenal glands, pancreas.
MIDDLE FLOOR - there are loops of the small and large intestines, kidneys, large vessels.
LOWER FLOOR - organs of the urinary system (bladder), the final section of the digestive tube (rectum), internal genital organs.
TOP FLOOR limited:
top - diaphragm,
in front - parietal peritoneum anterior abdominal wall,
behind - posterior abdominal wall,
below - colon transversum and its mesentery.
In the upper floor of the abdominal cavity there are three bags:
Bursa pregastrica
bursa omentalis
BURSA OMENTALIS
Has 6 walls:
1. The upper wall is the caudate lobe of the liver.
2. The lower wall is the mesentery of the transverse colon.
3. Left wall - lig. gastrolienale, lig. phrenicolienale.
4. Right - foramen epiploicum (Winslow hole).
5. Posterior - parietal peritoneum covering the pancreas, inferior vena cava, aorta.
6. Front wall
upper third - omentum minus: lig. hepatoduodenale, lig. hepatogastricum.
middle third - back wall of the stomach
lower third - lig. gastrocolicum
The foramen epiploicum is located on the right wall of the stuffing bag. Through this hole, the stuffing bag communicates with the common cavity of the peritoneum; when inspecting the abdominal organs, surgeons perform a digital examination of the stuffing bag through this hole.
WINSLOW HOLE WALLS
Front - limited lig.hepatoduodenales in this bundle from right to left lies ductus choledochus, v. portae, a. hepatica propria.
Behind - parietal peritoneum covering v.cava inferior., lig hepatorenale.
Above, the caudate lobe of the liver.
Below - pars superior duodeni.
ATursa hepatica
Above - diaphragm, lig. coronarium, lig triangulare.
On the left is the falciform ligament of the liver.
Front and right - the parietal peritoneum of the anterior wall.
Behind - the right kidney and adrenal gland.
Contains the right lobe of the liver.
It communicates with the stuffing bag and with the right lateral canal (located on the middle floor of the abdominal cavity)
Bursapregatrica
Covers the left lobe of the liver.
Above - limited by the diaphragm;
In front - parietal peritoneum covering the anterior abdominal wall;
Left - lig. gastrolienale, lig. phrenicolienale;
Behind - the stomach, its anterior wall.
This bag communicates with the peritoneal cavity. In the upper floor, the greater omentum originates, consists of 4 layers of the peritoneum and sometimes reaches the pubic bones.
MIDDLE FLOOR the abdominal cavity is limited
above mesocolon transversum
on the sides and in front of the parietal peritoneum to linea bispinata (outside) or linea terminalis (inside).
It contains loops of the small and large intestines, covered with an omentum.
On the middle floor between the mesentery and directly the intestines there are two mesenteric sinuses: right and left.
The right mesenteric sinus is limited:
on the right - the ascending colon;
on the left and below - the mesentery of the small intestine;
above - the mesentery of the transverse colon.
It is closed, abscesses do not spread.
The left mesenteric sinus is limited:
on the right and above - the mesentery of the small intestine;
on the left - descending colon;
from below - passes into the cavity of the small pelvis.
In addition to the sinuses, there are also two lateral canals in the middle floor.
The RIGHT LATERAL CANAL is located between the ascending colon (left) and the parietal peritoneum of the anterolateral walls of the abdominal cavity (right).
The LEFT LATERAL CANAL is located respectively between the descending colon (on the right) and the parietal peritoneum (on the left).
Two bags of the upper floor communicate with the right lateral canal: b.omentalis, b. hepatica; and ends in the right iliac fossa.
The left channel begins blindly: the ligament is located at the top. phrenicocolicum, and below it opens into the cavity of the small pelvis.
In addition to the sinuses and canals, a number of peritoneal depressions are noted on the posterior parietal sheet of the peritoneum:
They are of practical importance: sometimes they serve as an exit site for a retroperitoneal hernia.
LOWER FLOOR.
Descending into the lower floor of the abdominal cavity, the peritoneum covers the organs of the small pelvis: the bladder and rectum; y women - the uterus and fallopian tubes. When moving from organ to organ, the peritoneum forms depressions or pockets:
In women, the excavation of the rectouterina is of practical importance; from the side of the vagina, it corresponds to its posterior fornix. When performing a puncture of the posterior fornix of the vagina, they fall into the excavatio rectouterina - during pathological processes in the abdominal cavity (for example, an ectopic pregnancy), blood accumulates there.
Peritoneum, peritoneum, represents a closed serous sac, which only in women communicates with the outside world through a very small abdominal opening of the fallopian tubes. Like any serous sac, the peritoneum consists of two sheets: parietal, parietal, peritoneum parietale, and visceral, peritoneum viscerale. The first lines the abdominal walls, the second covers the insides, forming their serous cover over a greater or lesser extent. Both sheets are in close contact with each other, between them, with an unopened abdominal cavity, there is only a narrow gap called the peritoneal cavity, cavitas peritonei, which contains a small amount of serous fluid, moisturizing the surface of the organs and thus facilitating their movement around each other. When air enters during an operation, or an autopsy, or when pathological fluids accumulate, both sheets diverge and then the peritoneal cavity takes the form of a real, more or less voluminous cavity.
Parietal peritoneum lines the anterior and lateral walls of the abdomen with a continuous layer from the inside and then continues to the diaphragm and the posterior abdominal wall. Here it meets the viscera and, wrapping itself on the latter, directly passes into the visceral peritoneum covering them. Between the peritoneum and the walls of the abdomen there is a connective tissue layer, usually with a greater or lesser content of adipose tissue, tela subserosa, - subperitoneal fiber, which is not equally pronounced everywhere. In the region of the diaphragm, for example, it is absent; on the back wall of the abdomen, it is most developed, covering the kidneys, ureters, adrenal glands, abdominal aorta and inferior vena cava with their branches.
Along the anterior abdominal wall, for a large extent, the subperitoneal tissue is poorly expressed, but below, in the regio pubica, the amount of fat in it increases, the peritoneum here connects to the abdominal wall more loosely, due to which the bladder, when stretched, pushes the peritoneum away from the anterior abdominal wall and its anterior the surface at a distance of about 5 cm above the pubis comes into contact with the abdominal wall without the mediation of the peritoneum. The peritoneum in the lower part of the anterior abdominal wall forms five folds converging to the navel, umbilicus; one median unpaired, plica umbilicalis mediana, and two paired, plicae umbilicales mediales and plicae umbilicales laterales. These folds delimit on each side above the inguinal ligament two fossae inguinales related to the inguinal canal. Immediately below the medial part of the inguinal ligament is the fossa femoralis, which corresponds to the position of the inner ring of the femoral canal.
Up from the navel, the peritoneum passes from the anterior abdominal wall and diaphragm to the diaphragmatic surface of the liver in the form of a falciform ligament, lig. falciforme hepatis, between the two leaves of which in its free edge is laid a round ligament of the liver, lig. teres hepatis (overgrown umbilical vein). The peritoneum behind the falciform ligament from the lower surface of the diaphragm wraps onto the diaphragmatic surface of the liver, forming the coronary ligament of the liver, lig. coronarium hepatis, which at the edges looks like triangular plates, called triangular ligaments, lig. triangulare dextrum et sinistrum.
From the diaphragmatic surface of the liver, the peritoneum through the lower sharp edge of the liver bends to the visceral surface; from here it departs from the right lobe to the upper end of the right kidney, forming lig. hepatorenale, and from the gate - to the lesser curvature of the stomach in the form of a thin lig. hepatogastricum and on the part of the duodeni closest to the stomach in the form of lig. hepatoduodenale. Both of these ligaments are duplications of the peritoneum, since two layers of the peritoneum meet in the region of the gate of the liver: one - going to the gate from the front of the visceral surface of the liver, and the second - from its back. Lig. hepatoduodenale and lig. hepatogastricum, being a continuation of one another, together make up the lesser omentum, omentum minus. On the lesser curvature of the stomach, both sheets of the lesser omentum diverge: one sheet covers the anterior surface of the stomach, the other - the back. On the greater curvature, both sheets converge again and descend down in front of the transverse colon and loops of the small intestine, forming the anterior plate of the greater omentum, omentum majus. Going down, the leaves of the greater or lesser height are wrapped back up, forming its back plate (the greater omentum, thus, consists of four leaves). Having reached the transverse colon, the two sheets that make up the posterior plate of the greater omentum fuse with the colon transversum and with its mesentery and, together with the latter, then go back to the margo anterior of the pancreas; from here the leaves diverge; one is up, the other is down. One, covering the anterior surface of the pancreas, goes up to the diaphragm, and the other, covering the lower surface of the gland, passes into the mesentery of the colon transversum. In an adult, with complete fusion of the anterior and posterior plates of the greater omentum with the colon transversum on the tenia mesocolica, 5 sheets of the peritoneum are thus fused: four sheets of the omentum and the visceral peritoneum of the intestine. Let us now trace the course of the peritoneum from the same sheet of the anterior abdominal wall, but not in the upward direction to the diaphragm, but in the transverse direction.
From the anterior abdominal wall, the peritoneum, lining the lateral walls of the abdominal cavity and passing to the posterior wall on the right, surrounds the caecum with its appendix on all sides; the latter receives the mesentery - mesoappendix. The peritoneum covers the colon ascendens in front and from the sides, then the lower part of the anterior surface of the right kidney, passes in the medial direction through m. psoas and ureter and at the root of the mesentery of the small intestine, radix mesenterii, folds into the right leaf of this mesentery. Having supplied the small intestine with a complete serous cover, the peritoneum passes into the left leaf of the mesentery; at the root of the mesentery, the left sheet of the latter passes into the parietal sheet of the posterior abdominal wall, the peritoneum further covers the lower part of the left kidney to the left and approaches the colon descendens, which belongs to the peritoneum, as well as the colon ascendens; further, the peritoneum on the lateral wall of the abdomen is again wrapped on the anterior abdominal wall. The entire peritoneal cavity, in order to facilitate the assimilation of complex relationships, can be divided into three areas, or floors:
- the upper floor is bounded from above by the diaphragm, from below by the mesentery of the transverse colon, mesocolon transversum;
- the middle floor extends from the mesocolon transversum down to the entrance to the small pelvis;
- the lower floor starts from the line of entry into the small pelvis and corresponds to the cavity of the small pelvis, which ends downward with the abdominal cavity.
Upper floor of the peritoneal cavity breaks up into three bags: bursa hepatica, bursa pregastrica and bursa omentalis. Bursa hepatica covers the right lobe of the liver and is separated from bursa pregastrica by means of lig. falciforme hepatis; behind it is limited lig. coronarium hepatis.
In the depths of the bursa hepatica, iodine by the liver, the upper end of the right kidney with the adrenal gland is palpated. Bursa pregastrica covers the left lobe of the liver, the anterior surface of the stomach and spleen; the left part of the coronary ligament passes along the posterior edge of the left lobe of the liver; the spleen is covered on all sides by the peritoneum, and only in the region of the gate does its peritoneum pass from the spleen to the stomach, forming lig. gastrolienale, and on the diaphragm - lig. phrenicolienale.
Bursa omentalis, stuffing bag, is a part of the common cavity of the peritoneum, lying behind the stomach and lesser omentum. The composition of the lesser omentum, omentum minus, includes, as indicated, two ligaments of the peritoneum: lig. hepatogastricum, running from the visceral surface and the gate of the liver to the lesser curvature of the stomach, and lig. hepatoduodenale, connecting the gates of the liver with the pars superior duodeni. Between leaves lig. hepatoduodenale pass the common bile duct (right), common hepatic artery (left) and portal vein (posteriorly and between these formations), as well as lymphatic vessels, nodes and nerves. The cavity of the omental bag communicates with the common cavity of the peritoneum only through a relatively narrow foramen epiploicum. Foramen epiploicum is bounded above by the caudate lobe of the liver, in front by the free edge of lig. hepatoduodenale, from below - by the upper part of the duodenum, from behind - by a sheet of peritoneum covering the inferior vena cava passing here, and more outwards - by a ligament passing from the posterior edge of the liver to the right kidney, lig. hepatorenale. Part of the stuffing bag, directly adjacent to the stuffing hole and located behind lig. hepatoduodenale, is called the vestibule - vestibulum bursae omentalis; it is bounded above by the caudate lobe of the liver, and below by the duodenum and head of the pancreas. The lower surface of the caudate lobe of the liver serves as the upper wall of the stuffing bag, and the processus papillaris hangs in the bag itself.
The parietal sheet of the peritoneum, which forms the posterior wall of the omental sac, covers the aorta, inferior vena cava, pancreas, left kidney and adrenal gland located here. Along the anterior edge of the pancreas, the parietal sheet of the peritoneum departs from the pancreas and continues forward and downward as the anterior sheet of the mesocolon transversum or, more precisely, the posterior plate of the greater omentum, fused with the mesocolon transversum, forming the lower wall of the omental bag. The left wall of the stuffing bag is made up of ligaments of the spleen: gastro-splenic, lig. gastrolienale, and diaphragmatic-splenic, lig. phrenicosplenicum. The greater omentum, omentum majus, hangs down from the colon transversum in the form of an apron, covering the loops of the small intestine for a greater or lesser extent; It got its name from the presence of fat in it. It consists of 4 sheets of peritoneum, fused in the form of plates. The anterior plate of the greater omentum is served by two sheets of peritoneum extending downward from the greater curvature of the stomach and passing in front of the colon transversum, with which they fuse, and the transition of the peritoneum from the stomach to the colon transversum is called lig. gastrocolicum. These two sheets of the omentum can descend in front of the loops of the small intestine almost to the level of the pubic bones, then they are bent into the posterior plate of the omentum, so that the entire thickness of the greater omentum consists of four sheets; with loops of small intestines, the leaves of the omentum do not normally grow together. Between the sheets of the anterior plate of the omentum and the leaves of the posterior there is a slit-like cavity that communicates with the cavity of the omental bag at the top, but in an adult the leaves usually fuse with each other, so that the cavity of the greater omentum is obliterated over a large extent. Along the greater curvature of the stomach, the cavity sometimes continues in an adult for a greater or lesser extent between the leaves of the greater omentum. In the thickness of the greater omentum, there are lymph nodes, nodi lymphatici omentales, which drain lymph from the greater omentum and the transverse colon.
Middle floor of the peritoneal cavity becomes available for review if the greater omentum and transverse colon are raised upward.
Using the ascending and descending colons on the sides and the mesentery of the small intestines in the middle as boundaries, it can be divided into four sections: between the lateral walls of the abdomen and the colon ascendens and descendens are the right and left lateral canals, canales laterales dexter et sinister; the space covered by the colon is divided by the mesentery of the small intestine, going obliquely from top to bottom and from left to right, into two mesenteric sinuses, sinus mesentericus dexter and sinus mesentericus sinister. On the posterior parietal sheet of the peritoneum, a number of peritoneal pits are noted, which are of practical importance, since they can serve as a site for the formation of retroperitoneal hernias. At the point of transition of the duodenum into the jejunum, small pits are formed - depressions, recessus duodenalis superior et inferior. These pits are limited on the right by the bend of the intestinal tube, flexura duodenojejunalis, on the left by the fold of the peritoneum, plica duodenojejunalis, which goes from the top of the bend to the posterior abdominal wall of the abdomen immediately below the body of the pancreas and contains v. mesenterica inferior.
In the area of transition of the small intestine into the large intestine, there are two pits: recessus ileocaecalis inferior et superior, below and above the plica ileocaecalis, passing from the ileum to the medial surface of the caecum. The deepening of the parietal sheet of the peritoneum, in which the caecum lies, is called the fossa of the caecum and is noticeable when the caecum and the nearest section of the ileum are pulled upwards. The resulting fold of the peritoneum between the surface of m. iliacus and the lateral surface of the caecum is called plica caecalis. Behind the caecum, in the fossa of the caecum, there is sometimes a small opening leading to the recessus retrocaecalis, extending upward between the posterior abdominal wall and the colon ascendens. On the left side there is a recessus intersigmoideus; this fossa is noticeable on the lower (left) surface of the mesentery of the sigmoid colon, if you pull it up. Lateral to the descending colon, sometimes there are peritoneal pockets - sulci paracolici. Above, between the diaphragm and flexura coli sinistra, there is a fold of the peritoneum, lig. phrenicocolicum; it is located just under the lower end of the spleen and is also called the splenic sac.
Lower floor. Descending into the cavity of the small pelvis, the peritoneum covers its walls and the organs lying in it, including the genitourinary ones, so the relationship of the peritoneum here depends on gender. The pelvic section of the sigmoid colon and the beginning of the rectum are covered with peritoneum on all sides and have a mesentery (located intraperitoneally). The middle section of the rectum is covered with peritoneum only from the anterior and lateral surfaces (mesoperitoneally), and the lower one is not covered by it (extraperitoneally). Passing in men from the anterior surface of the rectum to the posterior surface of the bladder, the peritoneum forms a recess located behind the bladder, excavatio rectovesicale. With an unfilled bladder, on its upper posterior surface, the peritoneum forms a transverse fold, plica vesicalis transversa, which is smoothed out when the bladder is filled.
In women, the course of the peritoneum in the pelvis is different due to the fact that between the bladder and the rectum is the uterus, which is also covered by the peritoneum. As a result, in the pelvic cavity in women there are two peritoneal pockets: excavdtio rectouterina - between the rectum and the uterus and excavatio vesicouterina - between the uterus and the bladder. In both sexes, there is a prevesical space, spatium prevesicale, formed in front of the fascia transversalis, covering the back of the transverse abdominal muscles, and the bladder and peritoneum behind. When the bladder is filled, the peritoneum moves upward, and the bladder is adjacent to the anterior abdominal wall, which allows it to penetrate into the bladder through its anterior wall during surgery without damaging the peritoneum. The parietal peritoneum receives vascularization and innervation from parietal vessels and nerves, and the visceral peritoneum receives blood vessels and nerves branching in the organs covered by the peritoneum.
The peritoneum, peritoneum, is a thin serous membrane of the abdominal cavity, has a smooth, shiny, uniform surface. The peritoneum covers the walls of the cavity of the abdomen and small pelvis and, to one degree or another, the organs enclosed in it on their free surfaces facing the abdominal or pelvic cavity. The surface of the peritoneum is 20400 cm2 and is equal to the area of the skin. The peritoneum has a complex microscopic structure.
Its main elements are the connective tissue base, which consists of many strictly oriented layers of a certain structure, and the layer of mesothelial cells covering it. The peritoneum lining the walls of the abdomen is called the parietal peritoneum, peritoneum parietale, or parietal sheet; the peritoneum covering the organs is the visceral peritoneum, peritoneum viscerale, or splanchnic leaf; the part of the peritoneum between the parietal peritoneum and the serous cover of organs or between individual organs is called a ligament, ligamentum. fold, plica, mesentery, mesentcrium. The visceral peritoneum of any organ is connected with the parietal peritoneum, as a result of which all organs are to some extent fixed by the peritoneum to the walls of the abdominal cavity. Most of the organs are connected with the posterior wall of the abdominal cavity. The organ, covered on all sides by the peritoneum, is located intraperitoneally, or intraperitoneally; an organ covered with peritoneum on three sides and not covered with peritoneum on one side is located mesoperitoneally; an organ covered with only one, outer, surface, is located retroperitoneally (or extraperitoneally).
Organs located intraperitoneally may have a mesentery that connects them to the parietal peritoneum. The mesentery is a plate consisting of two connected sheets of the peritoneum - duplication; one, free, edge of the mesentery covers the organ (intestine), as if suspending it, and the other edge goes to the abdominal wall, where its sheets diverge in different directions in the form of a parietal peritoneum. Usually, between the sheets of the mesentery (or ligament), blood, lymphatic vessels and nerves approach the organ. The line of attachment (beginning) of the mesentery on the abdominal wall is called the root of the mesentery, radix mesenterii; approaching the organ (for example, the intestine), its leaves diverge on both sides, leaving a narrow strip at the point of attachment - the extramesenteric field, area nuda.
The serous cover, or serous membrane, tunica serosa, does not directly adjoin the organ or abdominal wall, but is separated from them by a layer of connective tissue subserous base. tela suhserosa, which, depending on the location, has a different degree of development. For example, it is poorly developed under the serous membrane of the liver, diaphragm, upper part of the anterior abdominal wall and, conversely, it is strongly developed under the parietal peritoneum lining the posterior wall of the abdominal cavity (subperitoneal tissue), for example, in the region of the kidneys, etc., where the peritoneum very movably connected to the underlying organs or their parts through a loose subserous base. Organs located intraperitoneally, intraperitoneally include: stomach, small intestines (except duodenum), transverse colon and sigmoid colon, proximal rectum, appendix, spleen, uterus, fallopian tubes; mesoperitoneally located organs include: liver, gallbladder, ascending and descending colon, middle (ampullar) part of the rectum; to retro. peritoneal organs include: duodenum (except for its initial section), pancreas (except for the tail), kidneys, adrenal glands, ureters. The space of the abdominal cavity limited by the peritoneum is called the peritoneal, or peritoneal cavity, cavum peritonei.
The parietal peritoneum of the posterior wall of the abdominal cavity delimits the peritoneal cavity from the retroperitoneal space, spatium retroperitorieale: both of these spaces form the abdominal cavity, cavum abdominale. Since the peritoneum is a continuous cover both on the walls and on the organs, the peritoneal cavity is completely closed. The only exception is communication through the fallopian tubes in women; one end of the fallopian tubes opens into the peritoneal cavity, the other through the uterine cavity leads out. The organs of the abdominal cavity are adjacent to each other, and the space between them and the walls of the abdominal cavity, as well as between the organs themselves, is slit-like and contains a very small amount of serous fluid (liquor peritonei). The peritoneal cover and peritoneal folds. The parietal peritoneum of the anterior abdominal wall forms a series of folds. Below the navel in the midline is the median umbilical fold, plica umhilicalis mediana, which stretches from the navel to the top of the bladder; in this fold is a connective tissue cord, which is an obliterated urinary duct, urachus. From the navel to the lateral walls of the bladder go medial umbilical folds, plicae umbilicales mediates, in which strands of the empty anterior sections of the umbilical arteries are laid. Outside of these folds are the lateral umbilical folds, plicae umbilicales laterales, stretching from the middle of the inguinal ligament obliquely upward and medially to the posterior wall of the sheath of the rectus abdominis muscles. These folds enclose the lower epigastric arteries, aa .. epigastricae inferiores, which feed the rectus abdominis muscles. At the base of these folds, pits are formed. On both sides of the median fold, between it and the medial, above the upper edge of the bladder, there are supravesical fossae, fossae supravesicales; between the medial and lateral folds are the medial inguinal fossae, fossae inguinales mediates: outward from the lateral folds lie the lateral inguinal fossae, fossae inguinales laterales; these pits are located against the deep inguinal rings.
The parietal peritoneum of the anterior wall of the abdomen above the level of the navel forms a sickle-shaped (suspending) ligament of the liver, lig. falciforme hepatis. It is a protrusion of the peritoneum of the anterior wall of the abdominal cavity near the lower surface of the diaphragm, located in the form of a median sagittal fold; from the abdominal wall and diaphragm, the falciform ligament follows down to the diaphragmatic surface of the liver, where both of its leaves pass into the visceral peritoneum of the diaphragmatic surface of the liver. In the free lower edge of the falciform ligament passes the strand of the round ligament, lig. teres hepatis, which is an obliterated umbilical vein. The round ligament runs along the visceral surface of the liver, into the fissura lig. teretis, to the gates of the liver.
Leaves of the falciform ligament posteriorly pass into the coronary ligament of the liver, lig. cogonarium hepatis. The coronary ligament is the transition of the visceral peritoneum of the diaphragmatic surface of the liver to the parietal peritoneum of the posterior abdominal wall. The sheets of the coronary ligament along the edges of the liver form the right and left triangular ligaments, lig. triangulare dextrum and lig. triangular sinistrum. The visceral peritoneum facies visceralis of the liver covers the gallbladder from the underside. From the visceral peritoneum of the facies visceralis of the liver, the peritoneal ligament is directed to the lesser curvature of the stomach and the upper part of the duodenum; it is a duplication of the peritoneal sheet, starting from the edges of the gate (transverse groove) and from the edges of the fissure of the venous ligament. The left side of this ligament (from the gap of the venous ligament) goes to the lesser curvature of the stomach and is called the hepatogastric ligament, lig. hepalogastricum; it is a thin web-like plate. Between the sheets of the hepatogastric ligament, along the lesser curvature, are the arteries and veins of the stomach, arteriae et venae gastricae dextra et sinistra, and nerves, as well as regional lymph nodes.
The right part of the ligament, more dense, goes from the gate of the liver to the upper edge of the pylorus and duodenum; its last section is called the hepatoduodenal ligament, lig. hepatoduodenale, and includes the common bile duct, the common hepatic artery and its branches, the portal vein, lymphatic vessels, nodes and nerves. On the right, the hepatoduodenal ligament forms the anterior edge of the omental opening, foramen epiploicum. Approaching the edge of the stomach and duodenum, the sheets of the ligament diverge and lie on the anterior and posterior walls of these organs. Both ligaments - lig. hepatogastricum and lig. hepatoduodenale, as well as a small ligament from the diaphragm to the lesser curvature of the stomach, gastro-phrenic ligament, lig. gaslrophrenicum, make up the lesser omentum, amentum minus.
The crescent ligament and the lesser omentum are ontogenetically the anterior, ventral, mesentery of the stomach, mesogastrium ventrale. Between the lower edge of the right lobe of the liver and the adjacent upper end of the right kidney, the peritoneum forms a transitional fold, the hepato-renal ligament, lig. hepatorenale. The leaves of the visceral peritoneum of the anterior and posterior surfaces of the stomach pass into the lig along the greater curvature of the stomach. gastrocolicum, continue down in the form of a greater omentum, omentum majus. A large omentum in the form of a wide plate ("apron") follows down to the level of the upper aperture of the small pelvis. Here the two leaves that form it return, heading upwards behind the descending two leaves. These return two sheets are fused with the front sheets.
At the level of the transverse colon, all four sheets of the greater omentum adhere to the tenia omentalis, located on the anterior surface of the intestine. Here, the posterior (recurrent) sheets of the omentum depart from the anterior ones, connect with the mesentery of the transverse colon, mesocolon transrersum, and go together dorsally to the line of attachment of the mesentery along the posterior abdominal wall to the margo anterior pancreatis. Thus, a pocket is formed between the anterior and posterior sheets of the omentum at the level of the transverse colon (see below). Approaching the margo anterior pancreatis, the two posterior sheets of the omentum diverge: the upper sheet passes into the posterior wall of the omental sac (on the surface of the pancreas) in the form of a parietal sheet of the peritoneum, the lower sheet passes into the upper sheet of the mesentery of the transverse colon. The area of the greater omentum between the greater curvature of the stomach and the transverse colon is called the gastrocolic ligament, lig. gastrocolicum; this ligament fixes the transverse colon to the greater curvature of the stomach. Between the sheets of the gastrocolic ligament, along the greater curvature, the right and left gastroepiploic arteries and veins pass, regional lymph nodes lie.
The gastrocolic ligament covers the transverse colon from the front; in order to see the intestine when the abdominal cavity is opened, it is necessary to pull the large omentum up. The greater omentum covers the front of the small and large intestines; it lies behind the anterior abdominal wall. A narrow gap is formed between the omentum and the anterior abdominal wall - the preomental space. The greater omentum is a distended mesentery of the stomach, the mesogastrium. Its continuation to the left is the gastro-splenic ligament, lig. gastrolienale, and splenic-phrenic ligament, lig. phrenicolienale, which pass one into another. Of the two sheets of the peritoneum of the gastrosplenic ligament, the anterior one passes to the spleen, surrounds it from all sides, returns back to the gates of the organ, and then continues in the form of a sheet of the splenic-phrenic ligament. The posterior leaf of the gastrosplenic ligament, having reached the hilum of the spleen, turns directly to the posterior abdominal wall in the form of the second leaf of the splenic-phrenic ligament.
As a result of these relationships, the spleen is, as it were, included from the side in a ligament connecting the greater curvature of the stomach with the diaphragm. The mesentery of the transverse colon begins on the posterior abdominal wall at the level of the descending part of the duodenum, head and body of the pancreas, left kidney; approaching the intestine in tenia mesocolica, two sheets of the mesentery diverge and cover the intestine in a circle (see "Colon"). The width of the mesentery from the root to the attachment to the intestine at its widest point is 15 cm and decreases towards the edges. On the sides, the mesentery of the transverse colon begins from the bends of the colon located in the hypochondria, flexurae colicae, and extends to the entire width of the abdominal cavity. The transverse colon with mesentery lies horizontally, at the level of the ends of the X ribs, and divides the abdominal cavity into two floors: the upper floor, where the stomach, liver, spleen, pancreas, upper duodenum are located, and the lower floor, where the small intestines with the lower half of the duodenum and large intestine. The left bend of the colon is connected to the diaphragm by a horizontally located peritoneal fold, the diaphragmatic-colon ligament, lig. phrenicocolicum.
The lower sheet of the mesentery of the transverse colon, downward from the root, passes into the parietal sheet of the peritoneum, lining the posterior wall of the mesenteric sinuses of the abdomen. The peritoneum, lining the posterior wall of the abdominal cavity in the lower floor, in the middle passes into the mesentery of the small intestine, mesenterium. The parietal peritoneum of the right and left sinuses, passing to the mesentery of the small intestine, forms the right and left sheets of its duplication. The root of the mesentery, radix mesenterii, stretches from the top of the posterior wall of the abdominal cavity in the region of the II lumbar vertebra on the left (the end of the upper duodenal fold, plica duodenojejunalis) down and to the right to the sacroiliac joint (the place where the ileum flows into the blind). The length of the root reaches 17 cm, the width of the mesentery is 15 cm, however, the latter increases in the areas of the small intestine most distant from the posterior wall of the abdomen. In its course, the root of the mesentery crosses the ascending part of the duodenum at the top, then the abdominal aorta at the level of the IV lumbar vertebra, the inferior vena cava and the right ureter. Along the root of the mesentery go, following from top to left down and to the right, the upper mesenteric vessels; mesenteric vessels give intestinal branches between the sheets of the mesentery to the intestinal wall. In addition, lymphatic vessels, nerves and regional lymph nodes are located between the sheets of the mesentery. All this largely determines that the duplication plate of the mesentery of the small intestines becomes dense, thickened. Thus, through the mesentery of the small intestine, the peritoneum of the posterior wall of the abdominal cavity is divided into two sections: the right and left mesenteric sinuses, sinus mesenterici dexter el sinister.
The parietal peritoneum of the right sinus passes to the right into the visceral peritoneum of the ascending colon, to the left and downwards - into the right leaf of the mesentery of the small intestine, upwards - into the mesocolon transversum. The parietal peritoneum of the left mesenteric sinus passes to the left into the visceral peritoneum of the descending colon, upwards into the mesocolon transversum; below, bending over the cape, into the pelvic peritoneum, and down and to the left, in the iliac fossa, into the mesentery of the sigmoid colon. The peritoneum covers the ascending colon on the right from three sides, lines the posterior and lateral walls of the abdomen to the right of it, forming the right lateral canal, canalis lateralis dexter, passes forward into the parietal peritoneum of the anterior abdominal wall, upwards into the peritoneum of the right half of the diaphragm; below, it passes into the peritoneum of the right iliac fossa and below the caecum, in the region of the inguinal fold, onto the anterior wall of the abdomen; to the medial side, it bends over the border line into the small pelvis. To the right of the ascending colon, it forms transverse folds connecting the top of the flexura colica dextra with the lateral wall of the abdomen, and the right phrenic-colic ligament, usually weakly expressed, sometimes completely absent.
Below, at the place where the ileum flows into the blind, an ileocecal fold, plica ileocecalis, is formed. It is located between the medial wall of the caecum, the anterior wall of the ileum and the parietal peritoneum, and also connects the medial wall of the cecum with the lower wall of the ileum - above and with the base of the appendix - below. Between the upper edge of the appendix, the ileum and the wall of the medial portion of the bottom of the caecum is the mesentery of the appendix, mesoappendix. Feeding vessels pass through the mesentery, a. et v. appendiculares, and regional lymph nodes and nerves. Between the lateral portion of the bottom of the caecum and the parietal peritoneum of the iliac fossa are the intestinal folds, plica cecales. The parietal peritoneum of the left mesenteric sinus passes to the right into the left leaf of the mesentery of the small intestine. In the flexura duodenojejunalis region, the parietal peritoneum forms a fold around the initial loop of the jejunum, bordering the intestine from above and to the left, the upper duodenal fold (duodenojejunal fold), plica duodenalis superior (plica duodenojejunalis). To the left of the descending colon there is a fold of the peritoneum connecting the left bend of the colon with the diaphragm, the diaphragmatic-colon ligament, lig. phrenicocolicwn; in contrast to the right ligament of the same name, the left one is constant and well expressed.
To the left, the parietal peritoneum passes into the visceral peritoneum, which covers the descending colon on three sides (except the posterior one). To the left of the descending colon, forming the left lateral canal, canalis lateralis sinister, the peritoneum lines the posterior and lateral walls of the abdominal cavity and passes to its anterior wall; downward, the peritoneum passes into the parietal peritoneum of the iliac fossa, the anterior wall of the abdomen and the small pelvis. In the left iliac fossa, the peritoneum forms the mesentery of the sigmoid colon, mesocolon sigmoideum. The root of this mesentery goes from top to bottom and to the right to the border line and reaches the anterior surface of the III sacral vertebra; here a short mesentery is formed for the uppermost part of the rectum. Feeding vessels enter the mesentery of the sigmoid colon, a. et vv. sigmoideae; it also contains lymphatic vessels, nodes and nerves. Peritoneal folds, ligaments, mesentery and organs create in the peritoneal cavity relatively isolated from each other and from the common peritoneal cavity gaps, pockets, sinuses, bags. As shown above, the peritoneal cavity is subdivided into three main areas: upper floor, lower floor, pelvic cavity. The upper floor is separated from the lower one at the level of the II lumbar vertebra by the horizontally located mesentery of the transverse colon. The lower floor is separated from the small pelvis by a boundary line (the upper edge of the pelvic ring).
The border of the upper floor at the top is the diaphragm, below is the transverse colon with its mesentery; the lower boundary of the pelvic cavity is the peritoneal fold of its bottom (rectal-vesical in men, recto-uterine, plica rectouterina, in women). Three peritoneal bags are distinguished in the upper floor of the peritoneal cavity: hepatic, bursa hepatica, located mainly in the right half of the upper floor , pregastric, bursa pregastrica, located mainly in the left half of the upper floor, and the most pronounced stuffing bag, bursa omentalis, lying behind the stomach. Hepatic bag, bursa hepatica, slit-like space covering the free part of the liver. It distinguishes between the suprahepatic fissure and the subhepatic fissure (in practical medicine, the terms subphrenic space and subhepatic space are accepted). The suprahepatic fissure on the left is separated from the adjacent pregastric sac by a falciform ligament; behind it is limited by a sheet of the coronary ligament. It communicates with the lower peritoneal spaces: in front along the free lower edge of the liver - with the subhepatic fissure, preomental fissure (see below); through the free edge of the right lobe of the liver - with the right lateral canal, then with the iliac fossa, and through it - with the small pelvis. The subhepatic fissure is formed from above by the visceral surface of the liver, from behind by the parietal peritoneum and the hepato-renal ligament, lig. hepatorenale.
Laterally, the subhepatic fissure communicates with the right lateral canal, anteriorly with the preomental space, in depth through the omental opening with the omental bursa, to the left with the pregastric bursa. Pregastric bursa, bursa pregastrica. located under the left dome of the diaphragm, surrounds the left lobe of the liver on the right, and the spleen on the left. The pancreatic sac is bounded from above by the diaphragm, on the right by the falciform ligament, on the left by the phrenic-colic ligament, behind by the lesser omentum (all three of its parts) and the gastrosplenic ligament. In front, the pancreatic bursa communicates with the preomental fissure, on the right - with the subhepatic and omental bursae; to the left it communicates with the left lateral canal. Stuffing bag, bursa omentalis, is located behind the stomach. To the right, it extends to the omental opening, to the left - to the gates of the spleen. The anterior wall of the omental sac, if you go from top to bottom, is the lesser omentum, the posterior wall of the stomach, the gastrocolic ligament, and sometimes the upper part of the greater omentum, if the descending and ascending leaves of the greater omentum are not fused and there is a gap between them, which is considered as continuation of the stuffing bag down.
The back wall of the omental bag is the organs covered with the parietal peritoneum, located on the back wall of the abdominal cavity, on the right - the inferior vena cava, the abdominal aorta with the celiac trunk extending from it here, the left adrenal gland, the upper end of the left kidney, the splenic vessels and below the body of the pancreas, occupying the largest space of the rear wall of the stuffing bag. The upper wall of the omental bag is the caudate lobe of the liver; the lower wall can be considered the transverse colon and its mesentery. Thus, the stuffing bag is a peritoneal fissure, closed on all sides, except for one; the exit or, rather, the entrance to it is the omental opening, foramen epiploicum, located on the right side of the bag behind the hepatoduodenal ligament. This hole allows 1-2 fingers through. Its anterior wall is the hepatoduodenal ligament with the vessels located in it and the common bile duct. The posterior wall is the hepato-renal peritoneal ligament, behind which are the inferior vena cava and the upper end of the right kidney. The lower wall is the upper edge of the upper part of the duodenum. The narrow section of the bag closest to the opening is called the vestibule of the stuffing bag, vestibulum bursae omentalis; it is bounded by the caudate lobe of the liver above and the head of the pancreas below.
Behind the caudate lobe of the liver, between it and the medial pedicle of the diaphragm covered with the parietal peritoneum, there is a pocket, the superior omental recess, recessus superior omentalis. which is open at the bottom towards the vestibule. Down from the vestibule, between the posterior wall of the stomach - in front and the pancreas covered with parietal peritoneum and mesocolon transversum - behind, is the lower omental recess recessus inferior omentalis. To the left of the vestibule, the cavity of the omental bag is narrowed by the gastropancreatic fold of the peritoneum, plica gastropancreatica, running from the upper edge of the omental tubercle of the pancreas upward and to the left, to the lesser curvature of the stomach (it contains the left gastric artery, a. gastrica sinistra). The continuation of the lower recess to the left is the sinus located between the lig. gastrolienale and lig. phrenicolienale, which is called the splenic recess, recessus lienalis. In the lower floor of the abdominal cavity on the back wall there are two large mesenteric sinuses and two lateral canals. The mesenteric sinuses are located on both sides of the mesentery of the small intestines: on the right is the right mesenteric sinus, on the left is the left mesenteric sinus.
The right mesenteric sinus is bounded: from above by the mesentery of the transverse colon, to the right by the ascending colon, to the left and below by the mesentery of the small intestine. Thus, the right mesenteric sinus has a triangular shape and is closed on all sides. Through the parietal peritoneum lining it, the lower end of the right kidney (to the right) is contoured and translucent at the top under the mesocolon; adjacent to it is the lower part of the duodenum and the lower part of the pancreatic head bordered by it. Below in the right sinus, the descending right ureter and the iliococolic artery with a vein are visible. The left mesenteric sinus is limited: from above - by the mesentery of the transverse colon, on the left - by the descending colon, on the right - by the mesentery of the small intestine. From top to bottom, the left mesenteric sinus communicates through the promontory with the peritoneal cavity of the small pelvis. The left mesenteric sinus has an irregular quadrangular shape and is open downwards. Through the parietal peritoneum of the left mesenteric sinus, the following are translucent and contoured: above - the lower half of the left kidney, below and medially - in front of the spine - the abdominal aorta and to the right - the inferior vena cava with their bifurcation and the initial segments of the common iliac vessels. A cape is visible below the bifurcation.
To the left of the spine, the left testicular artery (ovary), the left ureter, and branches of the inferior mesenteric artery and vein are visible. At the top of the left mesenteric sinus, around the beginning of the jejunum, between the flexura duodenojejunalis and the plica duodenalis superior (plica duodenojejunalis) bordering it, there is a narrow gap in which the upper and lower duodenal recesses, recessus duodenales superior et inferior, are distinguished. Under the ileocecal fold lie located above and pockets under the ileum: upper and lower ileocecal recesses, recessus ileocecalis superior, recessus ileocecalis inferior. Sometimes under the bottom of the caecum there is a retroceneal recess, recessus retrocecalis. To the right of the ascending colon is the right lateral canal; it is limited outside by the parietal peritoneum of the lateral wall of the abdomen, on the left - by the ascending colon; downwards, the canal communicates with the iliac fossa and the peritoneal cavity of the small pelvis. At the top, the right canal communicates with the subhepatic and suprahepatic slit-like spaces of the hepatic sac. To the left of the descending colon is the left lateral canal; it is limited to the left (laterally) by the parietal peritoneum lining the lateral wall of the abdomen. From top to bottom, the canal is open into the iliac fossa and further into the cavity of the small pelvis. Above, at the level of the left colic flexure, the canal is crossed by the already described diaphragmatic-colic ligament; upward and to the left, it communicates with the pregastric sac. Below, between the knees of the mesentery of the sigmoid colon, there is a peritoneal intersigmoid depression, recessus intersigmoideus. Throughout the ascending and descending colons, the lateral canals are sometimes blocked from the outside by more or less pronounced peritoneal folds and the near-colon sulci, suici paracolici, present around them. Topography of the peritoneum in the cavity of the small pelvis in a man and a woman, see "Urinary Apparatus" in the same volume.
Abdomen ( cavitas abdominis) - a space bounded at the top by the diaphragm, at the bottom - by the cavity of the small pelvis, behind - by the lumbar spine with the square muscles of the lower back adjacent to it, the iliopsoas muscles, in front and from the sides - by the abdominal muscles.
In the abdominal cavity are the digestive organs (stomach, small and large intestines, liver, pancreas), spleen, kidneys, adrenal glands and ureters, blood vessels and nerves.
The inner surface of the abdominal cavity is lined internally by the abdominal fascia ( fascia endoabdominalis), medially from which the peritoneum is located.
Scheme of the relationship of organs to the peritoneum (cross section)
Peritoneum ( peritoneum) - a serous membrane lining the walls of the abdominal cavity (parietal sheet of the peritoneum) and internal organs (visceral sheet of the peritoneum). Between the visceral and parietal layers of the peritoneum is the peritoneal cavity ( cavitas peritonei). The peritoneum secretes a serous fluid, which moisturizes it and ensures the free sliding of the organs covered with the peritoneum:
1- peritoneum parietale- parietal peritoneum - covers the walls of the abdominal cavity;
2 - peritoneum viscerale- visceral peritoneum, which differently covers the organ;
3 - mesoperitoneal position. The organ is covered by the peritoneum on three sides (eg, ascending and descending colon, liver);
4 - extraperitoneal position. The organ is covered by the peritoneum on one side (for example, the pancreas and part of the duodenum) or not covered at all (for example, the kidney), which is called the retroperitoneal position;
5 - intraperitoneal position. The organ is covered with peritoneum on all sides (for example, the stomach, the mesenteric part of the small intestine);
6 - mesenterium- mesentery of the small intestine;
7 -cavitas peritonei- peritoneal cavity.
Scheme of the course of the peritoneum on the sagittal section (in men)
The peritoneum, passing from the walls of the abdominal cavity to the organs and when moving from organ to organ, forms ligaments, which are a duplicate of the peritoneum (two sheets):
1 -lig. coronarium hepatis- the coronary ligament of the liver, which is formed during the transition of the peritoneum from the diaphragm to the liver;
2 - hepar- liver - mesoperitoneally covered with peritoneum. The peritoneum passes from the visceral surface of the liver to the duodenum ( lig. hepatoduodenale) and lesser curvature of the stomach ( lig. hepatogastricum);
3 - lig. hepatogastricum- hepatogastric ligament, which, together with lig. hepatoduodenale forms a small omentum ( omentum minus). Behind the lesser omentum and stomach is the stuffing bag;
4 - bursa omentalis - stuffing bag - limited: above - by the caudate lobe of the liver, below - by the posterior plate of the greater omentum or, taken as a whole, by the mesentery of the transverse colon, in front - by the stomach and lesser omentum, behind - by the parietal peritoneum and the organs that it covers ( v. cava inferior, aorta, corpus pancreatis);
5-gaster- stomach - covered with peritoneum intraperitoneally. At the point of transition lig. hepatoduodenale on the stomach between the two layers of the peritoneum and the lesser curvature of the stomach there is an area not covered by the peritoneum, or a bare spot;
6- pars nuda (curvatura ventriculi minor) - a bare place (small curvature of the stomach);
7- pars nude (curvatura ventriculi major) - a bare place (greater curvature of the stomach). Along the greater curvature of the stomach, two sheets of peritoneum are connected and descend down in front of the transverse colon and loops of the small intestine (the anterior plate of the greater omentum). Then these two sheets of peritoneum are tucked backwards and rise up (the posterior plate of the greater omentum). Thus, a large omentum is formed from the four sheets of the peritoneum.
8 - omentum majus- big omentum. The posterior plate of the greater omentum (two posterior layers of the peritoneum) goes to the posterior abdominal wall and splits. One sheet passes to the back wall of the peritoneal cavity, the other - to the transverse colon, connecting with another sheet of the peritoneum - the mesentery of the transverse colon is formed, which, thus, will consist of four sheets of peritoneum;
9- mesocolon transversum- mesentery of the transverse colon;
10 - colon transverse- transverse colon - covered by the peritoneum intraperitoneally. The lower sheet of the mesentery of the transverse colon passes to the posterior wall of the peritoneal cavity. The pancreas and most of the duodenum are located retroperitoneally (extraperitoneally);
11 - pancreas- pancreas;
12 - duodenum- duodenum - parietal peritoneum, covering the front side of the duodenum; passes to the small intestine. Its two leaves form the mesentery of the small intestine;
13 - mesenterium- mesentery of the small intestine;
14 - jejunum- jejunum - located in relation to the peritoneum intraperitoneally; has one bare spot ( pars nude) in the area of attachment of the mesentery;
15 - rectum- rectum;
16 - vesica urinaria- urinary bladder;
17- spatium retroperitoneale- retroperitoneal space - filled with fatty tissue. It contains the kidneys and ureters;
18 - excavatio rectovesicale- rectovesical deepening;
19 - os pubis- pubic bone.
As noted above, peritoneum(peritoneum) it is a serous membrane consisting of two layers parietal (parietal) and visceral, between which there is a slit-like space - peritoneal cavity- filled with a small amount of serous fluid.
function of the peritoneum. 1.Fixation of the abdominal organs. 2. The visceral layer, which is rich in blood vessels, secretes serous fluid, and the parietal layer, due to the lymphatic vessels, absorbs it. Serous fluid relieves friction between organs. An imbalance between absorption and excretion can lead to accumulation of fluid in the peritoneal cavity (ascites). With peritonitis (inflammation of the peritoneum), early drainage of the peritoneal cavity is necessary in order to remove the resulting toxic products. 3. The peritoneum performs a protective function through the formation of adhesions and thereby limits the spread of infection during the inflammatory process.
By development, peritoneal ligaments are distinguished: primary, formed due to duplication (doubling) of the peritoneum - falciform, hepatogastric and hepatoduodenal; secondary, formed by only one leaf and representing the transition of the peritoneum from organ to organ ( hepato-renal).
The course of the peritoneum (Fig.).
The parietal sheet covers the anterior and posterior abdominal walls, at the top passes to the lower surface of the diaphragm, and then to the diaphragmatic surface of the liver, thus forming falciform, coronary and triangular ligaments. The visceral peritoneum covers the liver intraperitoneally(on all sides), except for the area adjacent to the diaphragm - bare field. On the visceral surface, both sheets converge at the gate and go to the lesser curvature of the stomach and upper part of the duodenum, where they diverge, covering them from all sides (intraperitoneally).
Rice. 1 - falciform ligament of the liver (lig. falciforme hepatis); 2 - liver (hepar); 3 - small omentum (omentum minus); 4 - stuffing bag (bursa omentalis); 5 - stomach (gaster); 6 - pancreas (pancreas); 7 - mesentery of the transverse colon (mesocolon); 8 - duodenum (duodenum); 9 - mesentery of the small intestine (mesenterium); 10 - mesentery of the sigmoid colon (mesosigma); 11 - rectum (rectum); 12 - recto-uterine cavity (excavation rectouterina (Douglassi)); 13 - bladder (vesica urinaria); 14 - vesicouterine cavity (excavation vesicouterina); 15 - uterus (uterus); 16 - a large omentum (omentum majus); 17 - gastrocolic ligament (lig. gastrocolicum).
In this case, between the gates of the liver, the lesser curvature of the stomach and the upper part of the duodenum, a duplication of the peritoneum is formed - small omentum, which is represented by two bundles: hepatogastric and hepatoduodenal. In the latter, from right to left, there is an important vital triad of the liver: bile duct, portal vein, own hepatic artery. At the greater curvature of the stomach, both sheets of the peritoneum converge again and go down in front of the transverse colon and loops of the small intestine, thus forming anterior plate of the greater omentum. Having reached the level of the navel, and sometimes even lower, these two sheets are tucked back and rise up, forming rear plate of the greater omentum. Then the anterior leaflet of the posterior plate covers the anterior surface of the pancreas and passes to the posterior wall of the abdominal cavity and the diaphragm. The rear sheet covers the lower surface of the pancreas and returns to the transverse colon, which it covers from all sides, forming at the same time mesentery. The posterior leaf, returning to the posterior abdominal wall, covers the small intestine intraperitoneally, ascending and descending colon - mesoperitoneally(from three sides), the sigmoid colon and the upper part of the rectum - intraperitoneally. The middle part of the rectum is covered mesoperitoneally, and the lower part - extraperitoneally(one side). In men, the peritoneum passes from the anterior surface of the rectum to the upper wall of the bladder and continues into the parietal peritoneum, which lines the anterior wall of the abdominal cavity. A rectovesical depression forms between the bladder and the rectum. In women, the peritoneum from the anterior surface of the rectum passes to the back wall of the upper part of the vagina, then rises, covering the back and then the front of the uterus, and passes to the bladder. Between uterus and rectum recto-uterine cavity (Douglas space)- the lowest point of the peritoneal cavity, and between the uterus and the bladder - vesicouterine cavity.
In the peritoneal cavity, the upper, middle and lower (pelvic) floors are distinguished. The upper floor is bounded from above by the parietal peritoneum adjacent to the diaphragm, and from below by the transverse colon and its mesentery. This floor is divided into three relatively limited bags: hepatic, omental, pregastric. Liver bag is located to the right of the falciform ligament and covers the right lobe of the liver and gallbladder. Pregastric bag located to the left of the falciform ligament, it contains the stomach, the left lobe of the liver and spleen.
Stuffing bag located behind the stomach and lesser omentum. It is bounded above by the caudate lobe of the liver, below by the posterior plate of the greater omentum, fused with the mesentery of the transverse colon. In front of the omental bag is the posterior surface of the stomach, the lesser omentum, gastro-transverse ligament, which is 5 sheets of peritoneum (4 sheets of the greater omentum and 1 sheet of the mesentery of the transverse colon), and is the site of operational access to the omental bag, and behind - a sheet of peritoneum covering the aorta, inferior vena cava, upper pole of the left kidney, left adrenal gland and pancreas. Stuffing bag by means of gland hole (Winslow hole) communicates with the hepatic sac. The omental opening is bounded from above by the caudate lobe of the liver, from below - by the upper part of the duodenum, from behind - by the parietal peritoneum, which forms hepato-renal ligament. The middle floor of the peritoneal cavity is located downward from the transverse colon and its mesentery and extends to the entrance to the small pelvis (border line). In this floor, the right lateral canal is isolated, which is limited by the parietal peritoneum, on the one hand, the blind and ascending colon, on the other. This canal communicates with the hepatic and omental bags, which is important to know in surgical practice, because. with inflammation of the appendix, purulent contents can flow into the above bags, causing abscesses.
Left side channel located between the descending, sigmoid colon and the parietal peritoneum. Unlike the previous channel, it does not communicate with the upper floor, because. separated from him diaphragmocolic ligament. The space enclosed between the ascending, transverse and descending colons is divided by the root of the mesentery of the small intestine into two sinuses: right and left mesenteric sinuses. The right mesenteric sinus is closed, and the left one communicates with the pelvic cavity. In the left sinus there are loops of the jejunum, and in the right - the ileum. The peritoneum, descending into the lower floor of the abdominal cavity or the cavity of the small pelvis, covers not only the upper, partially middle and lower sections of the rectum, but the organs of the genitourinary apparatus, thus forming depressions (see above).