Mesenteric sinuses (sinuses) and abdominal canals. Paths
Spread of swelling in the abdominal cavity. Topographical
Anatomical basis for the occurrence of internal hernias
Abdominal cavity.
Right mesenteric sinus, sinus mesentericus dexter, limited superiorly
mesentery of the transverse colon, on the right - ascending colon
anterior intestine, on the left and below - the mesentery of the small intestine and termi-
nal part of the ileum. Demarcated from the pelvis
terminal part of the small intestine and its mesentery; with the left mesentery
the temporal sinus has a communication over the duodenum-jejunum from
bending of the small intestine. Left mesenteric sinus, sinus mesentericus
sinister, located to the left and downward from the root of the mesentery of the small intestine.
It is limited above by the mesentery of the transverse colon, on the left
Descending colon and mesentery of the sigmoid colon,
on the right is the mesentery of the small intestine. The left mesenteric sinus is wide
communicates with the pelvic cavity. Upper left sinus
in front is usually covered by the greater omentum, transverse colon
intestine and its mesentery. Right lateral canal, canalis lateralis dexter,
located between the lateral wall of the abdomen and the right (ascending)
part of the colon lying mesoperitoneally. Above channel
passes into the posterior part of the right subphrenic space,
below - into the right iliac fossa. Left lateral canal, canalis
lateralis sinister, limited to the left side wall of the abdominal cavity,
covered by the parietal peritoneum, and the left (descending) part
colon, also located mesoperitoneally. Diaphragm-
lesser-colic ligament, lig. phrenicocolicum, demarcates at the top
lateral canal from the bed of the spleen and the left subphrenic pro-
wanderings. Below, the left side channel freely passes into the left
iliac fossa and then into the pelvis. Transition duodenum
the intestine into the jejunum looks like a bend and is called flexura duodenojejunalis.
It is usually located on the left near the body of the II-III lumbar vertebra
under the root mesocolon transversum. Behind the bend there is usually
pocket (recess), recessus duodenojejunalis. It is limited in front
plica duodenojejunalis, fold of peritoneum between the bend and the root
mesentery of the transverse colon, posteriorly - parietal
stack of peritoneum of the posterior abdominal wall, from above - mesocolon
transversum, from below - by the upper edge of the duodenum jejunum.
In some cases, recessus duodenojejunalis can be large
size, turn into a pocket extending into the retroperitoneal tissue,
forming a hernial sac. This bag can be penetrated by loops of thin
intestines, thus forming a true internal hernia in the area
flexura duodenojejunalis, called duodenojejunal hernia
flexure, or Treitz hernia.
Peritoneal cavity. Division into floors. Subphrenic spaces. Pregastric and omental bursae. Operative access to the cavity of the omental bursa.
The peritoneal cavity is the part of the abdominal cavity limited by
parietal layer of peritoneum. The peritoneum is a serous
a new shell that covers the inner surface of the walls
abdomen and organs located in it, forming a closed cavity. IN
In connection with this, the parietal, or parietal, peritoneum is distinguished,
peritoneum parietale, and internal, or visceral, peritoneum,
peritoneum viscerale. Intraperitoneal, or intraperitoneal, location
laying organs are covered with visceral peritoneum on all sides,
mesoperitoneally - on three sides and extraperitoneally - on one side
sides. The space between the peritoneal surfaces of individual
organs and parietal layer - the abdominal cavity. Normally she has
the nature of the gap filled with serous fluid. Men have a cavity
peritoneum is closed, in women it communicates with the fallopian tubes
uterine cavity. It is conventionally divided into two floors - upper and lower.
The border between them is the transverse colon with its
mesentery, mesocolon transversum. In the upper floor of the abdominal cavity
located liver with gall bladder, stomach, spleen, upper
half of the duodenum, pancreas and four
practically important spaces: right and left sub-
phragmatic, pregastric, subhepatic, and omental
bag. Lower half of the duodenum, thin and thick
intestines occupy the lower floor of the abdominal cavity. In addition, in it you-
divides two lateral peritoneal canals (right and left) and two mesenteric
final - mesenteric sinuses (right and left). Right subdiaph-
ragmal space , or right hepatic bursa, bursa hepatica
dextra, bounded above and in front by the diaphragm, below by the superoposterior
the surface of the right lobe of the liver, behind - the right coronary and right
triangular ligament of the liver, on the left - falciform ligament of the liver.
Inflammatory exudate rises here most often along the right
lateral canal from the right iliac fossa or from the subhepatic
spaces along the outer edge of the liver. Left subphrenic
space consists of two widely communicating with each other
departments: pregastric bursa, bursa pregastrica, and left hepatic
bags, bursa hepatica sinistra. Space between the left lobe of the liver
below and diaphragm above and in front, bursa hepatica sinistra, right
limited by the falciform ligament, posteriorly - by the left part of the coronary
ligament and left triangular ligament of the liver. Pregastric bursa ,
bursa pregastrica, limited posteriorly by the lesser omentum and stomach,
in front and above - the diaphragm, the left lobe of the liver and the anterior abdominal
wall, on the right - the falciform and round ligaments of the liver. Late-
the oral section of the bursa pregastrica, located lateral to the greater
curvature of the stomach and enclosing the spleen, limited to the left and
back lig. phrenicolienale, above - lig. gastrolienale and diaphragm, below
Lig. phrenicocolicum. The left subphrenic space is separated
but from the left lateral canal there is a well-defined left diaphragmatic
nocolic ligament, lig. phrenicocolicum sinistrum, and free
has no communication with him. Occurring in the left subdiaphragmatic
space abscesses as a result of complications of perforated ulcers of the stomach
ka, purulent liver diseases, etc. can spread to the left in
blind sac of the spleen, and in front descend between the anterior wall
stomach and the upper surface of the left lobe of the liver to the transverse
colon and below. Subhepatic __________ space, bursa subhepatica,
located between the lower surface of the right lobe of the liver and
mesocolon with the transverse colon, to the right of the portal of the liver and
stuffing box hole. Divided into anterior and posterior sections. IN
the anterior section of this space faces almost the entire peritoneum
the surface of the gallbladder and the upper outer surface of the twelve-
typus. The posterior section, located at the posterior edge of the oven
nor, to the right of the spine is the hepatorenal recess. Abscesses,
resulting from perforation of a duodenal ulcer
or purulent cholecystitis, are most often located in the anterior section;
periappendiceal abscess spreads mainly in
posterior section of the subhepatic space. Omental bursa, bursa
omentalis, is located behind the stomach, looks like a slit and is
the most isolated space of the upper floor of the abdominal
cavities. It is limited anteriorly by the hepatoduodenal
ligament, lig. hepatoduodenale, behind - parietal peritoneum, covered
v. cava inferior, and hepatorenal ligament, lig, hepatorenale;
above - the caudate lobe of the liver and below - the renal
duodenum, ligament, lig. duodenorenale, and pars superior duodeni.
You can distinguish front, back, top, bottom and left
walls, and on the right - the vestibule of the omental bursa. The vestibule of the omentum
bursa, vestibulum bursae omentalis, its rightmost part, located
lies behind the hepatoduodenal ligament and is limited
above the caudate lobe of the liver and the peritoneum covering it, below -
duodenum, behind - parietal peritoneum, covered
of the inferior vena cava. The anterior wall of the omental bursa
are the lesser omentum (lig. hepatogastricum and lig. hepatoduodenale),
posterior wall of the stomach and lig. gastrocolicum; posterior - parietal
a layer of peritoneum covering the pancreas, aorta,
inferior vena cava and nerve plexuses of the upper floor of the abdominal
cavities; upper - the caudate lobe of the liver and partially the diaphragm;
lower - mesentery of the transverse colon; left - spleen
and its ligaments - lig. gastrolienale et phrenicolienale.
Operative access to the omental bursa is more often carried out
by cutting lig. gastrocolicum is closer to the left bend of the colon
intestines, through mesocolon transversum.
Pancreas located retroperitoneally, behind the stomach, in
upper half of the abdomen. Functionally and anatomically it is connected with
duodenum, liver and stomach. Pancreas
gland is projected onto the anterior abdominal wall horizontally
line connecting the ends of the VII-VIII ribs, or along a horizontal
line passing through the middle of the distance between the xiphoid
process and navel, which corresponds to the level of the body of the first lumbar
vertebra. The shape can be elongated, arched, youthful
toe-shaped and angular. The pancreas is conventionally divided
into three sections: head, body and tail, neck of the gland. Head of the pancreas
the breast gland is thickened and approaches irregular in shape
quadrangle; occupying the inner flexure of the duodenum
intestines, it is firmly fixed together with the common bile and pancreas
drainage ducts to its descending part. In the anteroposterior direction-
The head is flattened. It distinguishes between anterior and posterior
surfaces, as well as the upper and lower edges. Body of the pancreas
represents the middle, largest part of the organ. Right side front
on its surface protrudes somewhat forward, forming an omental
tubercle, tuber omentale pancreatis. On the back surface there is
longitudinal depression for the splenic vein passing here. Tail
The pancreas is flattened and has no edges. It distinguishes
front and back surfaces, as well as top and bottom edges.
Its shape is usually cone-shaped or pear-shaped. Output system
The pancreas contains small lobular ducts that
empty into the main and accessory pancreatic ducts. Duct
pancreas, ductus pancreaticus, formed by fusion
lobular ducts of most of the organ and can be traced along the
the entire gland, located at an equal distance from the upper and
its lower edges. In the area of the major duodenal papilla, it co-
unites with the common bile duct or opens independently.
At the junction, the pancreatic duct has its own
smooth muscle sphincter. Accessory duct of the pancreas
PS, ductus pancreaticus accessorius, located in the upper anterior
parts of the head of the gland. It connects to the main duct in the head,
drains independently on the small duodenal papilla of the twelve-
duodenum. There are gastro-pancreas, pyloric
pancreatic and pancreasplenic ligaments. Krovosnab-
The movement of the head of the pancreas is carried out mainly
from the anterior and posterior arterial arches formed by the two upper
(from a. gastroduodenalis) and two lower ones (from the initial section of a. mesenterica
superior) pancreaticoduodenal arteries. Body and tail
pancreas are supplied with blood from rr. pancreatici from the spleen-
nocturnal artery. The outflow of venous blood occurs directly in
the portal vein and its main tributaries - vv. lienalis et mesenterica
superior. Regional lymph nodes of the first stage for
pancreas are pyloric, pancreatoduodenal-
nal, upper and lower pancreatic, as well as splenic nodes.
The lymph nodes of the second stage are pre-aortic,
lateral caval, postcaval, located at the level of the hilum
both kidneys. The sources of innervation of the gland are the celiac,
hepatic, superior mesenteric, splenic and left renal plexus
nia. The nerve plexuses of the pancreas are
powerful reflexogenic zone, irritation of which can cause
state of shock.
After opening the abdominal cavity, you can approach the gland
three ways. 1. Through the gastrocolic ligament, why is it
dissected in an avascular area, closer to the greater curvature
stomach. Having penetrated the omental bursa, the stomach is pushed aside
xy, and the transverse colon with its mesentery - downwards. 2.Via
mesentery of the transverse colon. 3. By separating the large
omentum from the transverse colon. In addition, it applies
access through the lesser omentum by dissection of the hepatic
gastric __________ligament between the lower edge of the liver and the lesser curvature
8029 0
Limited forms of purulent peritonitis (abdominal abscesses) occur in 30-70% of patients [V.L. Fedorov, 1974; In D. Savchuk, 1979]. Their occurrence is mainly due to a decrease in the effectiveness of antibiotics, an increase in the proportion of elderly and senile patients, a decrease in the reactivity and defense mechanisms of the body, allergization of the population, an overestimation in some cases of the possibilities of antibacterial therapy, an increase in the number of staphylococcal diseases, and the progression of purulent-inflammatory diseases, for which the first operation was performed, insufficient sanitation of the abdominal cavity during the first operation, NSA, the presence of FB in the abdominal cavity left after the first operation, insufficiently complete drainage of the abdominal cavity during the previous intervention, etc.
Abdominal abscesses (ABA) are more often observed after destructive forms of appendicitis complicated by peritonitis, trauma to the abdominal organs, perforated ulcers of the stomach and duodenum, destructive pancreatitis, cholecystitis, etc. ABP arise as a result of the accumulation of inflammatory exudate in one of the abdominal pouches, canals and sinuses (under the diaphragm, under the liver, between the intestinal loops, in the pouch of Douglas) of the abdominal cavity and its delimitation (bursalization).
We provide a brief description of the most likely places in the abdominal cavity where accumulation and delimitation (enclosure) of pathological fluids (infected effusion) occurs, and the ways of their possible spread.
In the upper floor of the abdominal cavity, located above the transverse OC and its mesentery, the hepatic, pancreatic and omental bursae are distinguished. The hepatic bursa is divided by the liver into two parts: suprahepatic (right subphrenic space) and subhepatic. The suprahepatic space, in turn, is divided by the falciform ligament into two halves: right and left, with the right being divided by the frontally located right coronary ligament of the liver into anterior and posterior parts.
Most often, ulcers form in the right posterosuperior space, located above the liver behind the right coronary ligament, but they can also be localized in the right anterosuperior space, located above the liver in front of this ligament. In the subhepatic space, pus is encapsulated between the lower surface of the liver, the anterior surface of the right kidney, the right flexure of the liver and the round ligament of the liver. The right posterosuperior and subhepatic spaces behind the liver easily communicate with each other and with the right lateral canal of the lower floor of the abdominal cavity [O.B. Milonov et al, 1990].
The left subdiaphragmatic space is located in front of the stomach, which, together with the lesser omentum, forms its posterior and lower walls. In front and above, the left subdiaphragmatic space is limited by the liver and diaphragm, and on the right by the falciform ligament, which passes onto the anterior abdominal wall, and the round ligament of the liver. With the patient in the supine position, the deepest section of the left subphrenic space is located above the lesser curvature of the stomach and to the left of the porta hepatis.
The left subdiaphragmatic space is not as limited as the right one. Fluids that enter here during surgery (blood, gastric contents, peritoneal exudate, etc.) rarely remain under the diaphragm. They flow down between the interchangeable organs located here (the left lobe of the liver, the spleen with its ligaments, the anterolateral surface of the stomach) and are retained only at the lower pole of the spleen above the diaphragmatic-colic ligament. This explains the reason for the significant predominance of right-sided subphrenic abscesses over left-sided ones.
The omental bursa is also part of the upper floor of the abdominal cavity, its most isolated section. The walls of the omental bursa are formed anteriorly by the lesser omentum, the posterior surface of the stomach and gastrocolic ligament, and posteriorly by the transverse mesentery, the anterior surface of the pancreas and the parietal peritoneum lining the posterior wall of the abdominal cavity.
The upper boundary of the omental bursa is the caudate lobe of the liver and the area of the posterior part of the diaphragm and esophagus, the lower boundary is the area of the transverse OC. The part of the omental bursa located under the edge of the liver is its deepest section in the horizontal position of the patient. If the patient is given a semi-vertical or vertical position, then the liquid contents of the omental bursa flow into its lower section, where abscesses can form between the adjacent layers of the gastrocolic ligament and the mesentery of the transverse OC.
The omental bursa communicates with the free abdominal cavity through a slit-like opening located behind the right edge of the lesser omentum. The opening is limited in front by the hepatoduodenal ligament, located between the hilum of the liver and the posterosuperior edge of the duodenum, behind - by the hepatorenal ligament, located between the posterior edge of the liver and the medial edge of the kidney, above - by the caudate lobe of the liver and below - by the duodenal ligament in the form of a fold of the peritoneum, stretched between the upper edge of the duodenum and the kidney.
In the lower floor of the abdominal cavity, located between the transverse mesentery and the plane of entry into the pelvis, there are four important spaces through which pathological fluids can spread. Residual interloop abscesses are often localized in them. The right lateral canal is located between the right part of the OC and the right lateral wall of the abdominal cavity.
The length of the channel is from SK to the right bend OK. The right lateral canal freely communicates with the lateral part of the right subphrenic space. The deepest section of the canal in a horizontal position of the patient is the area located outside the ascending ventricle and slightly above the iliac crest.
The left lateral canal is located between the left part of the OC and the left lateral wall of the abdominal cavity. The length of the canal is from the left bend of the OC to the end of the peritoneum of the S-shaped intestine.
Its deepest section is located in the upper part, at the level of the 11th rib. The canal is fenced off from the upper floor of the abdominal cavity by the diaphragmatic-colic ligament and opens freely in the direction of the iliac fossa of the pelvic cavity, just like the right canal. The right and left lateral canals are characteristic pathways for the spread of pus during peritonitis. Through the left lateral canal, pus can penetrate into the left subphrenic area.
The right mesenteric sinus is delimited on all sides from the rest of the abdominal cavity. In a horizontal position of the body, the deepest section of the right mesenteric sinus is the upper right angle. The left mesenteric sinus is larger than the right. The right mesenteric sinus is separated from the left by the TC mesentery. Unlike the right sinus, the left mesenteric sinus is not delimited below, but directly communicates with the pelvic cavity. In a horizontal position of the body, the deepest section is the upper left angle of the sinus. If you raise the upper part of the body, the fluid from the left sinus flows freely into the pelvic cavity.
The pelvic cavity is the lower part of the abdominal cavity, where the loops of the colon are located, and in some cases the sigmoid colon, PR, transverse OK and greater omentum. The parietal peritoneum, when transitioning from the anterior abdominal wall to the bladder, opens it from above and partially from the sides and in front, forming a transverse vesical fold.
In men, behind the bladder, the peritoneum covers the inner edges of the ampullae of the vas deferens at the top of the seminal vesicles, passing onto the rectum and forming the vesico-rectal recess.
In women, during the transition from the bladder to the uterus and from the uterus to the rectum, the peritoneum forms the vesicouterine recess, or anterior Douglas pouch, and the rectal uterine recess, or posterior Douglas pouch. In these depressions, usually in the back, so-called pelvic abscesses of the abdominal cavity are formed.
However, it should be remembered that in the adhesive fibrinous process and already formed adhesions, the topographic-anatomical relationships of the spaces and crevices of the abdominal cavity can change significantly [O.B. Milonov et al., 1990]. Areas of the abdominal cavity appear completely isolated from each other, in which pus can accumulate and an abscess can form (Figure 8-11).
Figure 8. Localization of postoperative intra-abdominal abscesses (front view):
1 - right-sided subphrenic; 2.3 - pre-treatment; 4-6—left-sided lower subphrenic; 7—interintestinal; 8—left lateral canal of the abdominal cavity: 9—right lateral canal of the abdominal cavity; 10 - right iliac region: 11, 12 - left iliac region
Figure 9. Localization of postoperative intra-abdominal abscesses (right sagittal section):
1.3 - right-sided subdiaphragmatic and subhepatic; 2 - liver: 4 - omental bursa; 5 - interintestinal; 6 - pelvic
Figure 10. Localization of postoperative intra-abdominal abscesses (left-side sagittal section):
1,2,4,6—left-sided upper subphrenic and subhepatic; 5 - liver; 3.7— omental bursa, or retrogastric; B - interintestinal; 9 - pericolonic; 10 - pelvic
Figure 11. Localization of postoperative ulcers in the abdominal cavity: a - intraperitoneal (subphrenic and interintestinal); b - retroperitoneal and pelvic
This is especially important to consider in cases of LC and multiple ALD, when only a thorough inspection of all floors of the abdominal cavity, canals and mesenteric sinuses allows not to miss a single isolated abscess. Typically, ALDs form within the first 3 weeks. after surgery on the abdominal organs [S. Popkirov, 1974; D.P. Chukhrienko, Ya.S. Bereznitsky, 1977]. Most often they occur near the source of infection or directly in the organ on which the operation was performed. After appendectomy, gynecological operations, and intestinal operations, ALD most often occurs in the pelvis; after surgery on the stomach, biliary tract, and pancreas, in the subdiaphragmatic space.
The occurrence of abscesses in the first days after surgery is most often due to untimely surgical intervention for a destructive purulent process, insufficient inspection of the abdominal organs and sanitization of its pockets (residual accumulations of exudate).
Figures 12 and 13 show the most common locations of residual abscesses and the spread of infection with them.
Figure 12. Most common locations of residual abscesses
Figure 13. Spread of infection with residual abscesses
Associations of pathogens of aerobic and non-aerobic non-spore-forming (non-clostridial) infections play an important role in the occurrence and development of ALD [M.I. Kuzin et al., 1983; IN AND. Struchkova et al., 1984; H.H. Malinovsky, BD. Savchuk, 1986, etc.].
Postoperative ABP can cause severe complications, for example, breakthrough of an abscess into the pleural cavity, into the free abdominal cavity (diffused peritonitis), arrosive profuse bleeding, metastasis of an abscess, NK, eventration, etc.
The clinical picture of postoperative ALD differs from the picture of widespread peritonitis. If the clinical picture of RP, in particular with NSA, usually manifests itself clearly, then the formation of ALD often manifests itself with less intensity, veiled, hidden due to long-term use of antibiotics, the presence in patients of a kind of barrier formed from organs fused to each other, fibrin, subsequently and granulation tissue. In this regard, the absorption of bacteria and their toxins occurs more slowly and on a smaller scale.
Body temperature in patients with ALD is usually elevated, often of the hectic type. However, in some cases it can be low-grade and even normal. As a result, they are often diagnosed late, resulting in missed time for the necessary surgery.
Recognition of ALD, especially in the early stages (stages) of its formation, presents significant difficulties. Clinical symptoms of ALD, as a rule, manifest themselves on the 5-7th day of the postoperative period with deterioration of the condition - general weakness, chills, high fever, tachycardia, sweating, loss of appetite, low-grade fever, moderate intestinal paresis, abdominal pain, deterioration of blood counts.
The latter is manifested by an increase in ESR, a neutrophil shift in the leukocyte formula, and toxic granularity of neutrophils. The formed abscess is characterized by sharp temperature fluctuations between morning and evening.
The symptoms of postoperative ALD and their various complications are so variable that some authors [A.P. Mintzer et al, 1983; Yu.N. Mokhnyuk et al., 1984] for diagnostic purposes propose to use a specially designed algorithm developed on the basis of a probabilistic assessment of clinical information. This algorithm allows you to shape the clinical thinking of the doctor and speed up the recognition of postoperative abscesses. The number of correct diagnostic conclusions when using this technique exceeds 80%.
After the formation of ABP, local symptoms appear, depending on the location of the lesion and the phase of abscess formation. Abdominal pain and local tenderness upon palpation are quite common. Tension of the abdominal wall muscles is usually noted in this same place. Often an inflammatory painful infiltrate (inflammatory tumor) and a symptom of peritoneal irritation are found there. This occurs when the abscess is located on the anterior abdominal wall. Percugorno marked pain. Abdominal bloating and weakened intestinal motility are often observed.
Continued fever in the postoperative period and changes in the blood in the absence of suppuration in the wound are evidence of unfavorable postoperative period and the possibility of development of purulent-septic processes in the abdominal cavity.
Interintestinal forms of abscess in the initial stages of development, especially if the inflammatory focus is not located in the peritoneum of the anterior abdominal wall, often manifest as slight cramping pain in the abdomen.
Diagnosis of intra-abdominal abscesses does not present much difficulty. The diagnosis is made only when the general condition and other symptoms are accompanied by the phenomena of partial NK, and in some patients an infiltrate begins to be palpated.
Plain X-ray, ultrasound and CT scan of the abdominal organs help make the correct diagnosis. A survey radiography of the abdominal organs in these patients reveals darkened zones against the background of intestinal pneumatosis. Plain radiography and tomography of the abdominal cavity should be used in patients with interloop abscesses, especially those that are deeply located and inaccessible to palpation. Clinical manifestations of mature ALD also do not always allow a correct diagnosis to be made.
Ultrasound (echolocation) greatly reduces the time required for diagnosing ALD, which helps to carry out RL in a timely manner. The simplicity of the method, the absence of contraindications to its use, and high information content make it possible to diagnose the localization of the process, determine the volume and nature of LC, avoid extensive revisions of the abdominal cavity and significantly reduce treatment time. The great advantage of the method is its non-invasiveness, the ability to repeat studies many times, observing patients over time.
Intra-abdominal non-clostridial abscesses are characterized by particularly mild clinical symptoms. The temperature with these abscesses is often low-grade, there is no high leukocytosis with a shift to the left, and abdominal pain is constantly aching. The infiltrate that forms around the abscess is “loose” and is rarely detected by palpation. The paucity of clinical manifestations of such ALD leads to late diagnosis, sometimes after their opening into the free abdominal cavity [B.K. Shurkalin et al., 1988]. ALP adjacent to the surgical wound, which can be identified during its revision, is relatively easy to diagnose.
The abdominal cavity is limited in front and on the sides by the abdominal walls, behind by the lumbar region, and above by the diaphragm; from below it passes into the pelvic cavity. It contains the abdominal cavity and abdominal organs.
Abdomen(cavum peritoneale) is represented by a space surrounded by a serous membrane - the peritoneum (peritoneum). It includes all organs covered by the peritoneum (Fig. 133). The serous layer covering the walls of the abdomen from the inside is called parietal, or parietal, and the layer adjacent to the organs is called splanchnic, or visceral. Both sheets are one whole; they directly transform into one another. Between the layers of the peritoneum there is a small amount of serous fluid - up to 30 ml.
Rice. 133. Sinuses and canals of the abdominal cavity.
I - hepatic bursa; II - pregastric bursa; III - right mesenteric sinus; IV - left mesenteric sinus; V - right channel; VI - left channel, 1 - diaphragm; 2 - coronary ligament of the liver; 3 - liver; 4 - stomach; 5 - spleen; 6 - transverse colon: 7 - duodenal-small intestinal bend; 8 - descending colon: 9 - sigmoid colon; 10 - bladder; 11 - terminal ileum; 12 - cecum with vermiform appendix; 13 - root of the mesentery of the small intestine; 14 - ascending colon; 15 - duodenum; 16 - gallbladder.
Most organs (stomach, small intestine, cecum, transverse colon and sigmoid colon, spleen) are enveloped by the peritoneum on all sides, i.e. they lie intraperitoneally, or intraperitoneally. They are supported by the mesentery or ligaments formed by the layers of the peritoneum. Other organs (liver, gall bladder, ascending and descending colon, part of the duodenum, pancreas, rectum) are covered by the peritoneum on three sides, with the exception of the posterior one, i.e. they are located mesoperitoneally. A small number of organs (duodenum, pancreas, kidneys, ureters, large blood vessels) lie behind the peritoneum - they occupy a retroperitoneal position.
Using the position of the transverse colon with its mesentery, the abdominal cavity is divided into upper and lower floors, which approximately corresponds to the plane passing through the ends of the X ribs. In the upper floor there are three sacs (or bursae): hepatic, pregastric and omental. The hepatic bursa (bursa hepatica) is located between the diaphragm, the anterior wall of the abdomen and the right lobe of the liver. The pregastric bursa (bursa pregastrica) is located in front of the stomach with its ligaments and is adjacent to the left lobe of the liver and spleen. These bags are separated from each other by the falciform ligament of the liver. The omental bursa (bursa omentalis) is represented by a slit-like space limited in front by the stomach with its ligaments, below by the left part of the transverse colon with its mesentery, on the left by the spleen with its ligaments and behind by the peritoneum of the posterior abdominal wall covering the pancreas, left kidney with the adrenal glands, aorta and inferior vena cava; on top, the omental bursa adjoins the caudate lobe of the liver (Fig. 134). This bag communicates with the common cavity through the omental foramen of Winslowi (for. epiploicum Winslowi), bounded by the peritoneum-covered right kidney with the adjacent inferior vena cava behind, the initial part of the duodenum below, the caudate lobe of the liver above and the hepatoduodenal ligament in front.
Rice. 134. The course of the peritoneum on a sagittal section of the abdomen (semi-schematic). The abdominal aorta is slightly displaced to the right and left undissected. 1 - diaphragm; 2 - small oil seal; 3 - gland hole; 4 - truncus coeliacus; 5 - a. mesenterica superior; 6 - pancreas; 7 - a. renalis; 8 - cisterna chyli and a. testicularis; 9 - duodenum; 10 - a. mesenterica inf.; 11 - latero- and retroaortic lymph nodes; 12 - mesenterium; 13 - vasa iliaca communia; 14 - greater omentum: 15 - colon transversum; 16 - mesocolon transversum; 17 - stomach; 18 - liver.
In the lower floor of the abdominal cavity, the right and left mesenteric sinuses and lateral canals are distinguished. The right sinus (sinus mesentericus dexter) is bounded above by the mesentery of the transverse colon, on the right by the ascending colon, on the left and below by the mesentery of the small intestine and in front by the greater omentum. The inflammatory processes occurring here are to a certain extent confined within the sinus. The left mesenteric sinus (sinus mesentericus sinister) is bounded above by the mesentery of the transverse colon, on the right by the mesentery of the small intestines, on the left by the descending colon and in front by the greater omentum. At the bottom, the sinus is open into the pelvic cavity, which makes it possible for pus or blood to spread here. Both mesenteric sinuses communicate through a gap limited by the initial part of the small intestine and the mesentery of the transverse colon. The right lateral canal (canalis lateralis dexter) is limited by the side wall of the abdomen and the ascending colon, the left (canalis lateralis dexter) is limited by the side wall of the abdomen and the descending colon. Both canals at the top communicate with the upper floor of the abdominal cavity, but on the left this communication is limited due to the existence of lig. phrenicocolicum. Inflammatory processes can spread through these channels.
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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. Y. DOROSHKEVICH, S. V. DOROSHKEVICH,
I. I. LEMESHEVA
SELECTED ISSUES
TOPOGRAPHIC ANATOMY
AND OPERATIVE SURGERY
Educational and methodological manual
To practical classes on topographic anatomy
And operative surgery for 4th year medical students,
Medical diagnostic faculties and faculty of training
Specialists for foreign countries studying in their specialty
"General Medicine" and "Medical Diagnostics"
Gomel
GomSMU
CHAPTER 1
SURGICAL ANATOMY OF THE ABDOMINAL CAVITY
TOPOGRAPHY OF UPPER FLOOR BODIES
ABDOMINAL
1.1 Abdomen (cavitas abdominis) and its floors (boundaries, contents)
Borders of the abdominal cavity.
The upper wall of the abdominal cavity is formed by the diaphragm, the posterior wall is formed by the lumbar vertebrae and muscles of the lumbar region, the anterolateral wall is formed by the abdominal muscles, the lower border is the terminal line. All these muscles are covered by the circular fascia - the fascia of the abdomen, which is called the intra-abdominal fascia (fascia endoabdominalis); it directly limits the space called the abdominal cavity (or abdominal cavity).
The abdominal cavity is divided into 2 sections:
peritoneal cavity (cavitas peritonei)- a slit-like space located between the layers of the parietal and visceral peritoneum and containing intraperitoneal and mesoperitoneal organs;
retroperitoneal space (spatium retroperitoneale)- located between the parietal layer of 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 there are: liver, stomach, spleen, pancreas, upper half of the duodenum. The subgastric gland is located behind the peritoneum; however, it is considered as an organ of the abdominal cavity, since surgical access to it is usually carried out by transection. In the lower floor there are loops of the small intestine (with the lower half of the duodenum) and the large intestine.
Topography of the peritoneum: course, canals, sinuses, bags, ligaments, folds, pockets
Peritoneum (peritoneum)– a thin serous membrane with a smooth, shiny, uniform surface. Consists of parietal peritoneum (peri-toneum parietale) lining the abdominal wall, and visceral peritoneum (peritoneum viscerale) covering the abdominal organs. 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 inside of the anterior and lateral walls of the abdomen, at the top it goes to the diaphragm, at the bottom to the large and small pelvis, at the back it does not reach the spine, limiting the retroperitoneal space.
The relationship of the visceral peritoneum to the organs is not the same in all cases. Some organs are covered with it on all sides and are located intraperitoneally: the stomach, spleen, small, cecum, transverse and sigmoid colons, and sometimes the gall bladder. They are completely covered with peritoneum. Some organs are covered with visceral peritoneum on 3 sides, i.e. they are located mesoperitoneally: liver, gall bladder, ascending and descending colons, initial and final sections of the duodenum.
Some organs are covered by peritoneum on only one side - extraperitoneally: duodenum, pancreas, kidneys, adrenal glands, bladder.
Course of the peritoneum
The visceral peritoneum, covering the diaphragmatic surface of the liver, passes to its lower surface. The leaves of the peritoneum, one coming from the front part of the lower surface of the liver, the other from the back, meet at the gate and descend down towards the lesser curvature of the stomach and the initial part of the duodenum, participating in the formation of the ligaments of the lesser omentum. The leaves of the lesser omentum diverge at the lesser curvature of the stomach, cover the stomach in front and behind, and, reuniting at the greater curvature of the stomach, descend downwards, forming the anterior plate of the greater omentum (omentum majus). Having gone 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 layers of the peritoneum bend around its anterosuperior surface and go to the posterior wall of the abdominal cavity. At this point they diverge, and one of them rises upward, covering the pancreas, the posterior wall of the abdominal cavity, partially the diaphragm and, having reached the posteroinferior edge of the liver, passes to its lower surface. The other layer 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 layers of peritoneum. From the root of the mesentery of the transverse colon, the layer of peritoneum descends and, as the parietal peritoneum, lines the posterior wall of the abdomen, then covers the ascending (right) and descending (left) colons on 3 sides. Inward from the ascending and descending colons, the parietal layer of the peritoneum covers the organs of the retroperitoneal space and, approaching the small intestine, forms its mesentery, enveloping the intestine on all sides.
From the posterior wall of the abdomen, the parietal layer 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 abdominal canals (canalis lateralis dexter et sinister), formed as a result of the transition of the peritoneum from the side wall of the abdomen to the colon. The right channel has a connection between the upper floor and the lower one. In 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).
Abdominal sinuses(sinus mesentericus dexter et sinus mesentericus sinister)
The right sinus is limited: on the right - by the ascending colon; 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 pelvic cavity, on the right - the mesentery of the small intestine.
Bags
Omental bag(bursa omentalis) limited: anteriorly by the lesser omentum, posterior wall of the stomach and gastrocolic ligament; behind - the parietal peritoneum, covering the pancreas, part of the abdominal aorta and the inferior vena cava; above - the liver and diaphragm; below - the transverse colon and its mesentery; on the left - the gastrosplenic and diaphragmatic-splenic ligaments, the hilum of the spleen. Communicates with the peritoneal cavity through stuffing box hole(foramen epiploicum, foramen of Winslow), bounded in front by the hepato-duodenal ligament, below by the duodenal-renal ligament and the upper horizontal part of the duodenum, behind by the hepatorenal ligament and parietal peritoneum covering the inferior vena cava, above by the caudate lobe of the liver.
Right hepatic bursa(bursa hepatica dextra) It is bounded above by the tendon center of the diaphragm, below by the diaphragmatic surface of the right lobe of the liver, behind by the right coronary ligament, on the left by the falciform ligament. It is the site of subphrenic abscesses.
Left hepatic bursa(bursa hepatica sinistra) bounded 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 bursa(bursa pregastrica) It is limited from above 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.
Peritoneal ligaments
In places where the peritoneum transitions from the abdominal wall to an organ or from organ to organ, ligaments are formed (ligg. peritonei).
Hepatoduodenal ligament(lig. hepatoduodenale) stretched between the porta hepatis and the upper part of the duodenum. On the left it passes into the hepatogastric ligament, and on the right it ends with a free edge. Between the leaves 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 proper 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) It is 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.
The hepatic branches of the anterior vagus trunk pass through the upper part of the ligament. At the base of this ligament, in some cases, there is the left gastric artery, accompanied by a vein of the same name, but more often these vessels lie on the wall of the stomach along the lesser curvature. In addition, often (in 16.5%) an accessory 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 passes here.
When mobilizing the stomach along the lesser curvature, especially if the ligament is dissected near the portal of the liver (for stomach cancer), it is necessary to take into account the possibility of the left accessory hepatic artery passing 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. hepatorenal) is formed at the site of transition of the peritoneum from the lower surface of the right lobe of the liver to the right kidney. The inferior vena cava passes through the medial part of this ligament.
Gastrophrenic ligament(lig. gastrophrenicum) located to the left of the esophagus, between the bottom of the stomach and the diaphragm. The ligament has the shape of a triangular plate and consists of one layer of peritoneum, at the base of which there is loose connective tissue. On the left, the ligament passes into the superficial layer of the gastrosplenic ligament, and on the right - onto 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 cardiac part of the stomach. At its base in loose tissue along the anterior surface of the esophagus there are r. esophageus from a. gastrica sinistra and the trunk of the left vagus nerve.
Gastrosplenic ligament (lig. gastrolienale), stretched between the fundus of the stomach and the upper part of the greater curvature and the hilum of the spleen, is located below the gastrophrenic ligament. It consists of 2 layers of peritoneum, between which short gastric arteries pass, accompanied by veins of the same name. Continuing downwards, it passes into the gastrocolic ligament.
Gastrocolic ligament (lig. gastrocolicum) consists of 2 layers 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 semicircle of the transverse colon, as well as to tenia omentalis. It contains the right and left gastroepiploic arteries.
Gastropancreatic ligament (lig. gastropancreaticum) located between the upper edge of the pancreas and the cardiac 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 anteriorly and upward.
In the free edge of the gastro-pancreatic ligament there is the initial section of the left gastric artery and the vein of the same name, as well as lymphatic vessels and gastro-pancreatic lymph nodes. In addition, at the base of the ligament along the upper edge of the pancreas there are pancreasplenic lymph nodes.
Pyloropancreatic ligament (lig. pyloropancreaticum) in the form of a duplication of the peritoneum, it is stretched between the pylorus and the right part 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 ligament is not expressed.
Small lymph nodes are concentrated in the pyloropancreatic ligament, which can be affected by cancer of the pyloric part of the stomach. Therefore, during gastric resection it is necessary to completely remove this ligament along with the lymph nodes.
Between the gastropancreatic and pyloric-pancreatic ligaments there is a slit-like gastropancreatic 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 each other or grow together, closing the gastro-pancreatic opening.
This leads to the fact that the cavity of the omental bursa is divided by ligaments into 2 separate spaces. In such cases, if there is pathological content in the cavity of the omental bursa (effusion, blood, gastric contents, etc.), it will be located in one or another space.
Phrenic-splenic ligament (lig. phrenicolienale) located deep in the posterior part of the left hypochondrium, between the costal part of the diaphragm and the hilum of the spleen.
There is tension between the costal part of the diaphragm and the left flexure of the colon 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 posterosuperior edge of the duodenum and the right kidney, limits the omental foramen from below.
Suspensory 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 (m. suspensorius duodeni). The muscle bundles of the latter arise from the circular muscular layer of the intestine at the point of its inflection. The narrow and strong muscle is directed from flexura duodenojejunalis upward, behind the pancreas it expands fan-shaped and is woven into the muscle bundles of the legs of the diaphragm.
Pancreasplenic ligament (lig. pancreaticolienale) is a continuation of the diaphragmatic-splenic ligament and is a fold of peritoneum that stretches from the tail of the gland to the gate of the spleen.
1. Around the beginning of the jejunum, the parietal peritoneum forms a fold bordering the intestine from above and to the left - this is the superior duodenal fold (plica duodenalis superior). The superior duodenal recess is localized in this area (recessus duodenalis superior), on the right it is limited by the duodenum-jejunal flexure 12, on the top and on the left - by the superior duodenal fold, in which the inferior mesenteric vein passes.
2. To the left of the ascending part of the duodenum there is a paraduodenal fold (plica paraduodenalis). This fold limits the inconstant paraduodenal recess anteriorly. (recessus paraduodenalis), the posterior wall of which is the parietal peritoneum.
3. To the left and below from the ascending part of the duodenum passes the lower duodenal fold (plica duodenalis inferior), which limits the inferior 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, there is a retroduodenal recess (recessus retroduodenalis).
5. At the point where the ileum enters the cecum, an ileocecal fold is formed (plica ileocecalis). It is located between the medial wall of the cecum, the anterior wall of the ileum, and also connects the medial wall of the cecum with the lower wall of the ileum at the top and with the base of the appendix at the bottom. Under the ileocecal fold lie the pockets located above and below the ileum: the upper and lower ileocecal recesses (recessus ileocecalis superior et recessus ileocecalis inferior). The superior ileocecal recess is bounded at the top by the ileocolic fold, at the bottom by the terminal section of the ileum, and externally by the initial section of the ascending colon. The lower ileocecal recess is limited at the top by the terminal ileum, behind - by the mesentery of the appendix and in front - by the ileocecal fold of the peritoneum.
6. Postcolic recess (recessus retrocecalis) bounded anteriorly by the cecum, 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 cecum 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.
