Peritoneal Cavity

I. PERITONEAL CAVITY (Figure 7-1 A) is a potential space between the visceral and parietal peritoneum. It is divided into the lesser and greater peritoneal sacs.

A. The lesser peritoneal sac (omental bursa) is an irregularly shaped sac that communicates with the greater peritoneal sac through the omental (Winslow) foramen

(see I C). The lesser peritoneal sac forms as a result of the 90c clockwise rotation of the stomach that occurs during embryologic development. Its boundaries are as follows:

1. Anterior: liver, stomach, and lesser omentum

2. Posterior: diaphragm

3. Right side: liver

4. Left side: gastrosplenic and splenorenal ligaments

B. The greater peritoneal sac is the remainder of the peritoneal cavity, extending from the diaphragm to the pelvis. The greater peritoneal sac contains a number of pouches, recesses, and paracolic gutters through which peritoneal fluid circulates.

1. Paracolic gutters are channels that run along the ascending and descending colon. Normally, peritoneal fluid flows upward through the paracolic gutters to the subphrenic recess, where it enters the lymphatics associated with the diaphragm.

2. Excess peritoneal fluid as a result of peritonitis or ascites flows downward through the paracolic gutters to the rectovesical pouch (in males) or the rectouterine pouch (in females) when the patient is sitting or standing.

3. Excess peritoneal fluid as a result of peritonitis or ascites flows upward through the paracolic gutters to the subphrenic recess and the hepatorenal recess when the patient is in the supine position. The hepatorenal recess is the lowest part of the peritoneal cavity when the patient is in the supine position. The patient may have shoulder pain (referred pain) caused by irritation of the phrenic nerve (nerve roots C3, C4, and C5).

C. The omental (Winslow) foramen is the opening, or connection, between the lesser and greater peritoneal sacs. If the surgeon places a finger in the omental foramen, the inferior vena cava lies posterior and the portal vein lies anterior to his or her finger.

II. OMENTUM (Figure 7-1B)

A. The lesser omentum is a fold of peritoneum that extends from the porta hepatis of the liver to the lesser curvature of the stomach. It consists of the hepatoduodenal ligament and the hepatogastric ligament. The portal triad lies in the free margin of the hepatoduodenal ligament. It consists of:

Figure 7-1. (A) Cross-section of the abdomen showing the peritoneal cavity. The greater peritoneal sac (GS) and lesser peritoneal sac (LS) are connected by the omental foramen (OF; arrow). The portal triad is shown at the free margin of the hepatoduodenal ligament of the lesser omentum (LO). A = aorta; BD = common bile duct; HA = hepatic artery; IVC = inferior vena cava; K = kidney; PV = portal vein; SP= spleen; ST= stomach. (B) Anterior dissection of the stomach. The lesser omentum, consisting of the hepatoduodenal ligament (HD) and the hepatogastric ligament (HG), and the greater omentum (GO) are shown. The left part of the liver is cut away to expose the omental foramen (OF) and the portal triad (X). E = esophagus; GB = gallbladder; L = liver; ST= stomach. (A and B adapted with permission from Moore KL: Clinically Oriented Anatomy, 3rd ed, Baltimore, Williams & Wilkins, 1992, pp 153, 157.)

1. The portal vein, which lies posterior

2. The common bile duct, which lies anterior and to the right

3. The hepatic artery, which lies anterior and to the left.

B. The greater omentum is a fold of peritoneum that hangs down from the greater curvature of the stomach. It is known as the "abdominal policeman" because it adheres to areas of inflammation.

III. INTRAPERITONEAL AND EXTRAPERITONEAL VISCERA are listed in Table 7 1.

Table 7-1.

Intraperitoneal and Extraperitoneal Viscera

Table 7-1.

Intraperitoneal and Extraperitoneal Viscera

Intraperitoneal

Retroperitoneal

Stomach

Parts 2, 3, and 4 of duodenum

Part 1 of duodenum

Ascending colon

Jejunum

Descending colon

Ileum

Rectum

Cecum

Head, neck, and body of pancreas

Appendix

Kidneys

Transverse colon

Ureters

Sigmoid colon

Suprarenal gland

Liver

Abdominal aorta

Gallbladder

Inferior vena cava

Tail of pancreas

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