Académique Documents
Professionnel Documents
Culture Documents
of the
Peritoneum
and
Peritoneal Cavity
Lecture objectives
Understand the structure and function of the
peritoneum
Understand the nature of the innervation of both
parietal peritoneum and visceral organs covered
with peritoneum
Become familiar with potential spaces within the
greater and lesser peritoneal cavity
Understand the clinical implications of
intraabdominal fluid ascites, peritonitis and
intraabdominal abscess
Definitions
Peritoneum [Greek periteino, to stretch
over]
Parietal Peritoneum mesothelial lined
innermost surface of abdominal wall
Visceral peritoneum lining of free
surfaces of intraperitoneal viscera, liver
gallbladder stomach spleen, small and
large bowel, dome of urinary bladder,
uterus, fallopian tubes and ovaries
Peritoneum
Allows for frictionless motion of viscera in
abdominal cavity
In contact with a network of vasculature,
intercellular gaps allow monocytes and
neutrophils entry to wall-off infections
Forms fibrin (form of clot) in response to
trauma or infection which may eventually
becomes fibrous scar tissue, assists in
healing of surgical and traumatic wounds.
Peritoneal Mesothelium
Peritoneal Mesothelium
Innervation of peritoneum
Parietal peritoneum innervated by
somatic sensory nerves same segmental
distribution as abdominal wall
Visceral peritoneum (and viscera
innervated by sensory nerves which follow
sympathetic innervation of the organ
somatic
Afferent somatic sensory
nerve branches with nerve
endings in abdominal wall
and parietal peritoneum, cell
bodies of nerve located in
dorsal root ganglia of
abdominal wall dermatome
Visceral pain
Visceral afferent nerves travel to viscera in
association with the sympathetic nerves
which in turn enter the visceral organ along
with its arterial blood supply.
Visceral afferent nerves are NOT part of
the autonomic nervous system
Visceral afferent nerve fiber have cell
bodies in dorsal root ganglia concentrated
@ 3 major sites at the embryologic
origins of the celiac, superior mesenteric
and inferior mesenteric arteries
Visceral pain
Visceral pain
Fore gut distal esophagus, stomach, duodenum, biliary
+pancreas refers pain to the epigastrium T6-8
Midgut small bowel, appendix + prox colon refers to
periumbilical region T9-10
Hindgut- distal colon, rectum refers pain to hypogastrium
T11-L1
Renal and ureteral sx lateralize to flank + groin T9-L2
Three mechanisms of pain
1) distention
2) ischemia
3) mesenteric traction
No response to thermal, tactile or chemical stimulation
Midgut: SMA
Hindgut: IMA
Visceral
afferent
innervation
T 6-8
T 9-10
T 11-L1
Somatic pain
Abdominal dermatomes T6-L1
Central diaphragm C 3,4,5
Thermal, tactile and chemical irritation=peritonitis
Acid
Digestive enzymes
Blood
Bacteria
Bile
Urine
Feces
Somatic pain:
abdominal dermatomes
Definitions
Mesentery [Greek mesenterion, mesos,
middle,+ enteron, intestine] double layer of
peritoneum extending from abdominal wall to
enclose any portion of a viscera, carries blood
and lymphatic vessels, lymph nodes and nerves
Peritoneal ligament double layer of
peritoneum that attaches an organ to abdominal
wall or another organ, e.g. falciform, round or
splenic ligaments
Definitions
Omentum [Latin, omentum, the
membrane that encloses bowels] double
layered sheet of fatty tissue attached to
greater curvature of stomach and covering
anterior aspect of abdominal cavity
Peritoneal fold raised edge of
peritoneum overlying vessels or vestigial
embryonic structures e.g. median and
medial umbilical folds
Peritoneal
folds
Definitions
Peritoneal recess cavity or potential
space lined by peritoneum e.g. subphrenic
or subhepatic space
Peritoneal cavity
Greater sac main portion of peritoneal
cavity
Lesser sac or omental bursa [Medieval
Latin, bursa purse] region enclosed by
greater omentum and posterior wall of
stomach/ Lt lobe liver
Lesser sac has superior and inferior
recesses
Peritoneal cavity
Foramen of Winslow
Site of entrance into lesser sac
Anterior wall portal triad (portal vein,
hepatic artery and common bile duct)
Posterior wall inferior vena cava and
right crus [Latin , crura, leg] of diaphragm
Superior wall - caudate lobe of liver
Inferior wall duodenal bulb
Foramen of Winslow
Foramen of Winslow
Foramen of Winslow
Free fluid in the peritoneal cavity gravitates to the most dependent sites
in the abdomen
Subhepatic spaces
normal
Pancreatic pseudocyst
in lesser sac
Paracolic
gutters