局部解剖學(xué)-結(jié)腸上區(qū)課件

局

部

解

剖

學(xué)Topographical

AnatomyDepartment

of

Anatomy

, Jilin

University石岫昆

XiukunShi

2019.02.081Section

4 Peritoneum

andPeritoneal

CavityI.Introduction1.

Peritoneum

is

a

serousmembranewhich

lines

abdominopelvic

cavity,andcan

be

likened

to

a

slack

balloon

intowhich

organs

areinvaginated.Parietal

peritoneum

lines

abdominaland

part

of

pelvic

walls,

while

Visceralperitoneum

covers

viscera.2Peritoneal

cavity

is

potentialspace

between

parietal

and

viscerallayer

of

peritoneum.

In

male,

is

aclosed

sac;

but

in

female,

there

is

acommunication

with

outsidethrough

uterine

tubes,

uterus,andvagina.A

film

of

fluid

lubricates

surfacesof

peritoneum

and

facilitatesfreemovement

of

viscera,

one

againstanother

or

against

abdominal

orpelvic

walls.32.The

most

importantfunctions

of

peritoneumare

Absorption

,

Secretion

and

Supporting

viscera.①

Peritoneum

has

capacity

of

absorption.Soluble

substances

and

water

are

probably

absorbed

directly

intoblood.

Peritoneum

in

subphrenic

region

has

a

greaterabsorptive

capacity

than

other

regions.After

abdominal

or

pelvicoperations,

it

has

been

customaryto

put

patient

in

Fowler's

position,so

that

anyinflammatoryintraperitoneal

effusion

willgravitate

into

pelvis.Fowler'sposition4②

Peritoneum

may

secrete

a

lubricating

serous

fluid

that

continuously

moistens

associated

organs

to

minimizefriction

and

to

resist

infection.Under

certain

pathological

conditions,

potential

space

ofperitoneal

cavity

may

form

an

actual

spacecontainingseveral

liters

of

fluid.Ascites

is

an

accumulation

of

serous

fluid

in

peritonealcavity

(

hydroperitoneum

).5③

The

peritoneum

surrounds

and

supports

viscera

in

a

number

of

different

ways,

which

may

be

characterised

asfollows:

mesentery,

ligament, omentum,

and

so

on.6Treatment

of

Renal

Failure7Continuous

Ambulatory

Peritoneal

Dialysis3.

Based

on

covering

of peritoneum,

viscera

in

abdominal

and

pelvic

cavities

can

be

divided

intothreekinds:①

Intraperitoneal

viscera

→

viscera

arealmost

completely

invested

by

peritoneum

and

more

mobile

thanother

viscera,

such

as

spleen,

stomach,small

intestine,

transverse

colonandsigmoid

colon,etc.Intraperitonealviscera8②

Interperitoneal

viscera

→

viscera

are

covered

by

peritoneum

on

their

three

aspects,

such

as

gall-bladder,liver,

ascending

colon,

uterus

and

urinary

bladder.③

Retroperitoneal

viscera

→

visceraare

covered

by

peritoneum

only

ontheirone

aspect,

such

as

pancreas,

ureter,kidney

and

suprarenal

gland.InterperitonealvisceraRetroperitonealviscera9II.

Main

ContentsStructures

which

are

formed

by

peritoneumOmenta

are

folds

of peritoneum

between

stomach

andother

abdominal

viscera.

There

are

two

omenta,

lesser

andgreater.Lessor

omentum

→

two-layeredfold

of

peritoneum

which

extends

fromporta

hepatis

to

lesser

curvature

ofstomach

and

superior

part

ofduodenum.The

portion

of

lesser

omentumextending

between

the

liver

and

stomachis

named

Hepatogastric

ligament.10Hepatoduodenal

ligamentextends

from

porta

hepatis

to

superior

part

of

duodenum.

Close

to

its

right

freemarginthe

two

layers

of

lesser

omentum

enclose

proper

hepaticartery

(left

anterior),

hepatic

portalvein

(posterior)

and

common

bile

duct

(rightanterior).11(2)

Greater

omentumconsists

of

a

double

sheet,foldedon

itself

so

that

it

is

made

up

of

four

layers.Anterior

two

layers

descend

fromgreater

curvature

ofstomach

and

superior

part

ofduodenum

andpass

downwardslike

an

apron

in

front

of

coils

ofsmall

intestine,for

avariabledistance,

and

then turns

upwardthemselves

as

far

as

to

attachanterosuperior

aspect

oftransverse

colon.12The

part

between

greater

curvature

of

stomach

andtransverse

colon

is

referred

to

as

gastrocolic

ligament.If

an

infection

occurs

in

intestine,

plasma

cells

ingreater

omentum

combat

infection

and

help

prevent

itfrom

spreading

toperitoneum.13(3)

Omental

bursa

(lesser

sac)lies

behind

stomach

andlesseromentum.Its

superiorwall

isperitoneum

which

coversthecaudate

lobe

of

liver

anddiaphragm;

Inferior

wall

istransverse

colon

and

itsmesocolon;

Anterior

wall

isformed

by

lesser

omentum,posterior

wall

of

stomach

andgastrocolic

ligament;14Posterior

wall

is

formed

by

peritoneum

coveringdiaphragm,

pancreas,

left

kidney

and

suprarenal

gland;Left

wall

is

bounded

by

spleen,

gastrosplenic

ligamentand

splenorenal

ligament;On

the

right,

omental

bursacommunicates

with

greater

sac

through

omental

foramen.15(4)

Omental

foramen(Winslow's

foramen)

lies

behindfree

edge

of

hepatoduodenal

lig.

and

it

can

admit

twofingers.

It

is

a

channel

between

omental

bursa

andgreatersac.Its

anterior

wall

is

formed

by

hepatodudenal

lig.;Peritoneum

covering

inferior

vena

cava

lies

its

behind;Caudate

lobe

of

liver

forms

its

roof;Superior

part

ofduodenum

is

its

inferior

wall.162.

Mesenteries

or

mesocolons

aretwo-layered

fold

of

peritoneum

that

attach

part

of

intestines

to

posteriorabdominal

wall.(1)

mesentery

(ofsmallintestine)is

a

broad,

fan-shaped

fold

ofperitoneumconnecting

coils

of

jejunumand

ileum

to

posteriorabdominal

wall.Root

ofmesentery(attached

border)

is

about15cm

long

and

is

directed17obliquely

from

left

side

of

L2

to

in

front

of

rightsacroiliac

joint.

Intestinal

border

of

mesentery

is

folded

about

7

mlong

and

contains

superior

mesentery

vessels,

lymphnodes,

nerve

and

a

certain

amount

of

fat.18(2)

Transverse

mesocolon

is

a

double

fold

of

peritoneum

which

connects

transverse

colon

to

posteriorabdominal

wall.

Between

two

layers

are

blood

vessels,nerves

and

lymphatics

of

transverse

colon.(3)Sigmoidmesocolon

is

afold

ofperitoneumwhich

attachessigmoid

colonto

thepelvicwall.19Its

line

of

attachment

has

the

form

of

an

inverted

V-shaped,

with

apex

located

in

front

of

left

ureter

anddivision

of

common

iliac

a..(4)

Mesoappendixis

a

triangular

fold

ofperitoneumand

extends

from

terminal

part

ofileum

toappendix.Appendicular

a.

runs

in

freemargin

ofmesoappendix.20Ligaments

aretwo-layered

folds

of

peritoneum

thatattached

the

lesser

mobile

solid

visera

to

abdominal

wall.Falciform

lig.of

liver

is

asickle-shaped

fold,extendsfrom

anterior

abdominal

wall

(umbilicus)

to

live.Free

border

of

ligament

site

of

ligamentum

teres.21(2)

Coronary

lig.

formed

by

the

reflexion

of

peritoneumfrom

diaphragm

to

upper

and

posterior

parts

of

right

andlobes

of

liver.Its

anterior

layer

is

continuous

with

falciform

lig.

whichdivides

it

into

left

and

right

coronary

ligaments.

Itsposterior

layer

can

be

followed

to

inferior

surface

ofdiaphragm.22The

area

between

upper

and

lower

parts

of

coronary

lig.is

bare

area

of

live,

this

area

is

devoid

of

peritoneum

andlies

in

contract

with

diaphragm.(3)

Ligamentumteres (acord-like

structure)

site

freemargin

of

falciform

lig.

and

is

remnant

of

embryonicumbilical

vein.

Paraumbilical

veins

run

along

either

sideof

this

lig.

and

empty

into

portalvein.23Gastrosplenic

lig.

is

a

double

layer

ofperitoneumthat

connects

fundus

of

stomach

to

hilum

of

spleen.

Itcontains

short

gastric

and

left

gastroepiploic

vessels.Splenorenal

lig.

extends

between

hilum

of

spleenandanterior

aspect

of

left

kidney.

The

splenic

vesselslieswithin

this

ligament,

as

well

as

tail

ofpancreas.24(6)

Suspensory

lig.

of

duodenum

(Treitz's

lig.)

consistsof

suspensory

muscle

of

duodenum

and

fold

ofperitoneumwhich

invests

it.It

lies

on

left

side

of

2ndlumbar

vertebra,

ascendingfrom

posterior

aspect

ofduodenum

to

right

crus

ofdiaphragm.This

ligament

is

used

toidentify

duodenojejunalflexure.254.Recesses

In

certain

part

of

abdomen,

peritoneal

fold

may

sometimes

be

found

which

bound

fossae

or

recesses

ofperitoneal

cavity.

These

recesses

are

of

surgicalimportance

since

they

may

become

site

of“internal”hernia.(1)

Superior

andInferiorduodenal

recesses

They

occur

mostcommonly

and

are

formed

byfoldsof

peritoneum

stretching

fromascending

part

of

duodenum

toposterior

abdominal

wall,

left

toduodenojejunal

junction.26Intersigmoid

recesslies

behind

apex

of

inverted

V-shaped

attachment

of

sigmoid

mesocolon

and

forms

afunnel-shaped

recess;

its

orifice

opens

downwards.Leftureter

passes

behind

this

recess.Hepatorenal

recess

liesbetween

right

lobe

of

liver,rightkidney,

and

right

colic

flexure

andis

lowest

parts

of

theperitonealcavity

when

subject

is

supine275.

Pouches

In

the

lesser

pelvis,

peritoneumdips

downwards

forming

a

large

fossa,

named

pouch.In

male,

rectovesical

pouchlies

between

rectum

andurinary

bladder.

In

the

female,

rectouterine

pouch

(Douglas'

pouch

)

lies

between

rectum

and

uterus,

andvesicouterine

pouch

is

formed

between

uterus

and

urinarybladder.28Rectouterine

pouch

in

female

is

lowest

part

ofperitoneal

cavity

in

anatomical

position,

and

rectovesical

pouch

inmale.When

patient

is

operated

onorgans

in

peritoneal

cavity,

patient

may

bepropped

in

semi-sittingposition.Fluid

in

peritoneal

cavity

maydescend

either

to

relatively

accessiblerectovesical

pouch

or

rectouterinepouch

so

that

fluid

in

pouch

may

beapproached

surgically

through

rectumorvagina.29Ⅱ)

Divisions

of

peritoneal

cavityPeritoneal

cavity

is

divided

into

supracolicandinfracolic

compartments

by

transverse

colon

and

itsmesocolon.1.Supracolic

compartments(subphrenic

space

)lies

betweendiaphragm

and

transverse

colonand

itsmesocolon.It

includes

some

spaces,forexample,

Suprahepatic

andInfrahepatic

recess.302.

Infracolic

compartmentslies

below

transverse

colon

and

its

mesocolon.

It

has

four

spaces:

right

and

leftparacolic

sulci

(gutters),

right

and

left

mesenterial

sinuses(infracolic

spaces).(1)

Right

paracolicsulcus(gutter)

lies

lateral

to

ascendingcolon.

It

communicates

withhepatorenal

recess

and

pelviccavity.It

provides

a

route

for

spread

ofinfection

between

pelvic

and

upperabdominal

region.31(2)

Left

paracolic

sulcus

(gutter)

lies

along

lateral

side

of

descending

colon

and

opens

freely

into

the

pelvis

at

itslower

end.

It

is

separated

above

fromsupracoliccompartment

by

phrenicocolic

ligament.32(3)

Right

mesenteric

sinus

(right

infracolic

space