Intraperitoneal anatomy

1. ANATOMY OF THE
INTRAPERITONEUM
Thorsang Chayovan, MD
R1, Radiology
Prince of Songklanagarind University
GI TOPIC
30 April 2014

2. Outline
•The peritoneum and the peritoneal spaces
•The intraperitoneal organs
•The vascular supply

3. The peritoneum
and the peritoneal spaces

4. •The peritoneum
–Parietal peritoneum
abdominal wall
–Visceral peritoneum
organs

5. •The peritoneal cavity
–Greater
•Supramesocolic
•Inframesocolic
–Lesser


•The peritoneal ligaments, mesentery, and
omentum

6. The peritoneal cavity
•potential space between the parietal and
visceral peritoneum and contains a film of
fluid that lubricates the surface of the
peritoneum and facilitates free movements of
the viscera.
•Is a completely closed sac in the male but is
open in the female through the uterine tubes,
uterus, and vagina. It is divided into the lesser
and greater sacs.

7. Definitions
•Ligament
–Two folds of peritoneum
–Supporting structures
•Mesentery
–Two folds of peritoneum
–Connecting to the posterior abdominal wall
•Omentum
–Connecting the stomach to other organs

9. •The greater omentum
–connects the stomach
to the colon
•The lesser omentum
–connects the stomach
to the liver

Omentums

10. Greater omentums
•Gastrocolic ligament
•Gastrosplenic ligament
•Gastrophrenic ligament

11. •Gastrolienal (Gastrosplenic) Ligament
–จากด้านซ้ายของ greater curvature – ขั้วม้าม contains
the short gastric and left gastroepiploic vessels.
•Lienorenal (Splenorenal) Ligament
–จากขั้วม้ามไปไตซ้าย contains the splenic vessels and
the tail of the pancreas.
•Gastrophrenic Ligament
–จากส่วนบนของ greater curvature ไป diaphragm.
•Gastrocolic Ligament
–จาก greater curvature ไป transverse colon.

12. Lesser omentums
•Gastrohepatic
ligament
•Hepatoduodenal
ligament

13. •Gastrohepatic ligament:
–connects the left lobe of the liver to the lesser
curvature of the stomach
•Hepatoduodenal ligament:
–free edge of the omentum, which contains the
portal vein, hepatic artery and common bile duct
–CBD, hepatic gasteic vv, portal vein

15. lesser omentum

• coronary veins (ที่ dilate เป็น varices ได้)
• lymph nodes (ที่โตได้จาก gastric carcinoma and
lymphoma)
•part of anterior wall of lesser sac

16. Lesser sac
•lesser sac เป็นส่วนหนึ่งในช่องท้อง ที่อยู่ระหว่าง stomach
and the pancreas
•ต่อกับภายนอกคือ greater sac ผ่านทาง foramen of
Winslow (epiploic foramen)
•aorta + celiac a อยู่ posteror to lesser sac
•ความผิดปกติใน lesser sac จะเกิดจาก organ ข้างเคียง
(pancreas, stomach) มากกว่าจากที่อื่น ปกติจะ
collapsed ยกเว้นที่ fluid fill

17. Lesser sac
•(a) superior recess, which lies behind the
stomach, lesser omentum, and left lobe of the
liver;
•(b) inferior recess, which lies behind the
stomach, extending into the layers of the
greater omentum
•(c) splenic recess, which extends to the left at
the hilus of the spleen.

30. Mesenteries
•Double folds of the peritoneum
•connect to the posterior abdominal wall
–The small bowel mesentery
–The transverse mesocolon
–The sigmoid mesentery (or mesosigmoid)

32. Root ของ transverse mesocolon แบ่ง peritoneal cavity เป็น supramesocolic and inframesocolic
space ที่ต่อถึงกันทาง paracolic gutter

33. Paracolic gutter 2 ข้าง form ขึ้นด้วย asc + des colon + lat abd wall
จะเห็นได้ว่สามารถเกิด peritoneal recess ขึ้นได้มากมายระหว่าง bowel loops และ mesentery ของมัน

34. The peritoneal spaces
Right Left

35. Right peritoneal spaces
•Right subphrenic space
•Right subhepatic space: anterior and posterior
•Bare area



- Right ant. Subhep. Space
Connecting to epiploic foramen
- posterior subhepatic space (Morison pouch) –
dependent part

36. •Right subphrenic space
•Right subhepatic space:
–Anterior right subhepatic space
–Posterior right subhepatic space
•Hepatorenal fossa (Morrison pouch)
•Bare area

37. •Immediate left subphrenic space
•Left subhepatic space

•Falciform ligament
Left peritoneal spaces

38. Left subhepatic space
•gastrohepatic recess
•affected by diseases of the duodenal bulb,
lesser curve of the stomach, gallbladder, and
left lobe of the liver.

41. Peritoneal
circulation
•Predominantly to right
paracolic gutter
–deeper and wider than
the left
–partially cleared by the
subphrenic lymphatics.

•Watershed regions - fluid
stasis:
–Ileocolic region
–Root of the sigmoid
mesentery
•Malignancy staging

44. GASTROINTESTINAL TRACT

45. Stomach

46. Small
intestine

47. Duodenum
1
st
part อยู่ intraperitoneum
2
nd
part มุดลง retro; ติดกับ pancreatic head อย่ใกล้ขั้วไตขวา; มี Root of trannsverse mesocolon +
mesentery cross ทับ
3
rd
part cross หน้า aorta + IVC หลัง SMA + SMV
Jejunum กลับมาอยู่ intraperitoneum

49. Jejunum





Ileum

50. Large
intestine

51. Cecum

52. Posterior peritoneal attachment

55. LIVER

59. Note
•Falciform Ligament
–Is a sickle-shaped peritoneal fold connecting the liver to the diaphragm and
the anterior abdominal wall.
–Contains the ligamentum teres hepatis and the paraumbilical vein, which
connects the left branch of the portal vein with the subcutaneous veins in the
region of the umbilicus.
•Ligamentum Teres Hepatis (Round Ligament of the Liver)
–Lies in the free margin of the falciform ligament and ascends from the
umbilicus to the inferior (visceral) surface of the liver, lying in the fissure that
forms the left boundary of the quadrate lobe of the liver.
–Is formed after birth from the remnant of the left umbilical vein, which
carries oxygenated blood from the placenta to the left branch of the portal
vein in the fetus. (The right umbilical vein is obliterated during the embryonic
period.)

60. Note

•Coronary Ligament
–Is a peritoneal reflection from the diaphragmatic surface of
the liver onto the diaphragm and encloses a triangular
area of the right lobe, the bare area of the liver.
–Has right and left extensions that form the right and left
triangular ligaments.
•Ligamentum Venosum
–Is the fibrous remnant of the ductus venosus.
–Lies in the fissure on the inferior surface of the liver,
forming the left boundary of the caudate lobe of the liver.

61. PV HA BD ไปด้วยกันตลอด -> เรียก Portal triad
แต่ละ segment จะถูกเลี้ยงด้วยแขนงเหล่านี้
HV จะอยู่ระหว่าง hepatic segment แต่ PT เข้าไปใน segment

63. ตับด้านหลังเห็น caudate อยู่ entirely posterior ติดกับ IVC, ligamentum venosum, porta hepatis
Plane ที่ผ่าน IVC + gallbladder แบ่ง Lt/Rt lobe

65. •Each segment has its own vascular inflow, outflow and biliary
drainage.
•ด้านในเลี้ยงด้วย PT ด้านนอก ด้วย hepatic veins.
•Right hepatic vein divides the right lobe into anterior and posterior
segments.
Middle hepatic vein divides the liver into right and left lobes (or
right and left hemiliver). This plane runs from the inferior vena cava
to the gallbladder fossa.
Left hepatic vein divides the left lobe into a medial and lateral part.

66. •Portal vein divides the liver into upper and lower
segments.
The left and right portal veins branch superiorly and
inferiorly to project into the center of each segment.
•Because of this division into self-contained units, each
segment can be resected without damaging those
remaining. For the liver to remain viable, resections
must proceed along the vessels that define the
peripheries of these segments. This means, that
resection-lines parallel the hepatic veins,
The centrally located portal veins, bile ducts, and
hepatic arteries are preserved

67. GALLBLADDER

70. Variation 20%
Most accessory duct on the right side เข้า common hepatic duct (/cystic/CBD)
Accessory Lt duct enter CBD

71. PANCREAS

75. SPLEEN

76. Spleen วางบน diaph level rib 9-10
ติด stomach ด้วย gastrosplenic (short gastric, gastroomental a)
ติดไตซ้ายด้วย splenorenal (splenic vv)

79. VASCULATURE

82. Celiac trunk

85. SMA

93. References
•Gray, Henry, Richard L. Drake, Wayne Vogl, Adam W. M. Mitchell, Richard
Tibbitts, and Paul Richardson. Gray's Anatomy for Students. Philadelphia:
Elsevier/Churchill Livingstone, 2010.
•"Imaging Anatomy: Chest, Abdomen, Pelvis | Amirsys Publishing." Amirsys
Publishing. N.p., n.d.
•Knipe, Henry, MD, and Jeremy Jones, MD. "Peritoneum." Radiopaedia Blog
RSS. N.p., n.d. Web. 21 Apr. 2014.
•Devy, Angela D., MD. "Peritoneum and Mesentery - Part I: Anatomy." The
Radiology Assistant :. N.p., n.d. Web. 21 Apr. 2014.
•Smithuis, Robin, MD. "Anatomy of the Liver Segments." The Radiology
Assistant :. N.p., n.d. Web. 26 Apr. 2014.

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