Peritoneal*Cavity*and*the*Esophagus*

Dr.$Banez$September$4,$2013$
Prepared$by:$Katrina$Marie$Kabigting,$1E$
$
Boundaries*of*the*abdominal*cavity:*
Superior:$Respiratory$Diaphragm$
Inferiorly:$Pelvic$diaphragm$
Anterolateral:$Flat$muscles$of$the$abdomen$
Posterior:$ Lumbovertebra,$ posterior$ origins$ of$ diaphragm,$
quadratus$lumborum,$psoas$major,$psoas$minor$
$
2$important$spaces:$
a) Abdominal$cavity$proper$
b) Pelvic$cavity$
These$cavities$are$separated$by$the$pelvic*inlet.$
!

$$$$$$$$$$$$

Figure!1.!The$pelvic$inlet$(red!dashed!line)!is!surrounded!and!defined!by!
a!bony!rim!called!the!pelvic!rim.!This!is!bounded!by!the!promontory!and!
ala!of!the!sacrum,!the!iliopectineal!line,!together!with!the!upper!portion!
of! the! pubic! symphysis.! Below! the! inlet! is! what! we! call! the! true$ pelvic$
cavity,$above!of!which!is!the!abdominal$cavity$proper.!!
!

The*true*pelvis$is$bounded$by:$
! Between$the$pelvic$inlet$and$the$pelvic$outlet.$
! Bounded$ by$ the$ pelvic$ surfaces$ of$ the$ hip$ bones,$
sacrum,$and$coccyx.$
$
The$ false* pelvis* is$ the$ space$ between$ the$ iliac$ crest$ and$ the$
pelvic$inlet.$This$is$a$part$of$the$abdominal$cavity$proper.$With$
regards$to$the$size$of$the$pelvic$cavity,$the$false$pelvis$is$bigger$
than$the$true$pelvic$cavity.$It$is$bounded$by:$
! Superior$to$the$pelvic$inlet.$
! Bounded$ by$ the$ iliac$ alae$ posterolaterally$ and$ the$
anterosuperior$aspect$of$the$S1$vertebra$posteriorly.$
! Occupied$ by$ abdominal$ viscera$ (e.g.,$ the$ ileum$ and$
sigmoid$colon).$
$
Parietal*peritoneum*$lines$the$wall$
Visceral*peritoneum*$covers$the$organs$
! These$ two$ are$ continuous:$ they$ are$ attached$ to$
each$other.$$
! The$ liver$ is$ attached$ to$ the$ diaphragm$ via$ the$
peritoneal*fold.$That$infolding$is$attached$to$the$
liver,$ this$ now$ is$ considered$ as$ visceral$
peritoneum.$
$
In$the$abdomen,$all$organs$are$outside$the$peritoneal$cavity.$It$
only$invaginates.$
$
The$ endothoracic$ fascia$ is$ continuous$ with$ the$ transversalis*
fasica$of$the$abdominal$wall.$This$is$considered$to$be$the$most$
important$ layer$ of$ the$ abdominal$ wall;$ if$ this$ layer$ is$ tough,$
hernia$will$not$be$formed.$Even$if$you$have$strong$muscles,$but$
the$transversalis$fascia$is$weak,$the$chances$of$getting$of$hernia$
are$higher.$
$

Unlike$ in$ the$ thorax,$ the$ transversalis$ fascia$ is$ not$ directly$
attached$to$the$parietal$peritoneum$because$of$the$presence$of$
preperitoneal*fat$in$between$them.$
$
In$ the$ males,$ the$ peritoneal$ cavity$ is$ completely$ closed.$ The$
chances$ of$ infection$ of$ the$ cavity$ in$ males$ are$ only$ possible$ if$
there$ is$ rupture$ or$ perforations$ in$ the$ hollow,$ viscous$
structures$ present$ inside$ (e.g.$ appendicitis,$ stab$ wounds).$ In$
females,$ however,$ it$ is$ possible$ to$ acquire$ pelvic*
inflammatory* disease$without$rupture$to$the$hollow,$viscous$
organs$inside.$$
Remember! that! the! fallopian$ tube$ is! open! at! the! infundibulum!
with!the!fimbriae;!therefore!its!lumen!opens!to!the!pelvic!cavity.!
The!lumen!of!the!fallopian!tube!is!continuous!with!the!lumen!of!
the! uterus,! whose! lower! part! is! the! cervical! canal.! Below! this!
canal! is! the! vaginal! canal! that! opens! to! the! exterior,! and!
therefore!increasing!the!chances!to!acquire!pelvic!inflammatory!
disease.!
!
Divisions*of*the*Peritoneal*Cavity*
1. Greater* peritoneal* cavity$$the$space$between$the$pelvic$
cavity$up$to$the$diaphragm$
2. Lesser* peritoneal* cavity$ (Omental$ Bursa)$ $ the$ space$ at$
the$ back$ of$ the$ wall$ of$ the$ stomach$ therefore$ this$ space$
cannot$be$seen$without$retracting$the$stomach$
Borders:$
a) Anterior$wall:$Posterior$wall$of$the$stomach$
b) Posterior$wall:$Pancreas,$transverse$colon$
c) Inferior$ wall:$ Transverse$ colon,$ partly$ the$
omentum$
These! two! spaces! are! connected! via! the! epiploic$ foramen$ of$
Winslow.!
$
The$ epiploic* foramen* of* Winslow$ is$ the$ communication$ or$
the$entrance$between$the$greater$and$lesser$peritoneal$cavity.$
This$ is$ situated$ posterior$ to$ the$ free$ edge$ of$ the$ lesser$
omentum.$ The$ foramen$ can$ be$ located$ by$ running$ a$ finger$
along$ the$ gallbladder$ to$ the$ free$ edge$ of$ the$ lesser$ omentum.$
The$ omental$ foramen$ usually$ admits$ two$ fingers$ (Moore,$
Dalley$&$Agur,$2010).$Its$boundaries$are:$

Anterior:$hepatoduodenal$ligament$

Posterior:$Inferior$vena$cava$

Inferior:$Duodenal$bulb$

Superior:$Caudate$lobe$of$the$liver$
$

Figure!2.!The!epiploic$foramen$of$Wnslow!is!shown!in!this!picture!to!be!
bounded! by! the! hepatoduodenal! ligament! anteriorly! and! the! duodenal!
bulb!inferiorly.!
!

In$ surgery,$ the$ peritoneal$ cavity$ is$ divided$ into* ten* (10)*
spaces.$ The$ transverse$ colon$ is$ suspended$ by$ the$ transverse$
mesocolon.$

Supramesocolic$ space$ $ space$ above$ the$ transverse$

mesocolon$

Inframesocolic$ space$ $ space$ below$ the$ transverse$

mesocolon$

$
SUPRAMESOCOLIC*SPACE*
Z
The$ supramesocolic$ space$ is$ divided$ into$ left$ and$
right$ spaces$ making$ use$ of$ the$ falciform* ligament,*
the$attachment$of$the$liver,*as$the$demarcating$point.$
Z
The$ falciform$ ligament$ then$ forms$ two$ spaces:$ the$
right$and$left$subdiaphragmatic$spaces.$
$
A. Right*subdiaphragmatic*space$
! Suprahepatic$space$
! Infrahepatic$space$(aka$Morrisons$pouch)$
!
B. Left*subdiaphragmatic*space$
! Subdiaphragmatic$ space$ $ between$ the$
diaphragm$ and$ the$ anterior$ wall$ of$ the$
stomach$
! Lesser$ peritoneal$ cavity$ $ above$ the$
transverse$colon$
$

$$$$$$$$$$$$$$$$

Figure! 3.! The! falciform! ligament! is! the! demarcation! line! between! the!
right! and! left! subdiaphragmatic! spaces.! When! there! is! accumulation! of!
fluid! in! the! suprahepatic! space,! it! can! easily! be! concluded! that! the!
primary! area! where! the! abscess! was! formed! will! be! the! liver.! However,!
the!infrahepatic!space!is!connected!to!the!lesser!peritoneal!cavity!via!the!
foramen!of!Winslow.!Therefore,!abscess!can!be!due!to!a!hepatic!abscess,!a!
ruptured! gall! bladder,! or! a! perforated! peptic! ulcer! disease! in! the!
duodenum.!

!
INFRAMESOCOLIC*SPACES$
! Right$ lateral$ paracolic$ space$ $ beside$ the$ ascending$
colon$
! Right$medial$paracolic$space$$between$the$small$and$
the$large$intestine$
! Left$ lateral$ paracolic$ space$ $ beside$ the$ descending$
colon$
! Left$medial$paracolic$space$
It$so$happens$that$the$left$paracolic$space$will$not$be$able$to$
go$ up$ to$ the$ supramesocolic$ space$ because$ the$ splenic$
flexure$ has$ a$ ligament$ that$ is$ attached$ to$ the$ diaphragm.$
Unlike$ in$ the$ hepatic$ flexure,$ there$ is$ no$ ligament$ allowing$
the$ right$ lateral$ paracolic$ space$ to$ occupy$ the$ Morrisons$
pouch.$Any$abscesses$from$the$right$lateral,$right$medial,$and$
the$interloop$spaces$will$then$proceed$to$the$pelvic$space.$
$
!
!

Interloop$ space$ $ the$ small$ intestine$ is$ 15Z17$ ft.$ in$

length$and$thus$forming$loops.$The$spaces$in$between$
the$loops$are$called$the$interloop$spaces.$
Pelvic$space$$

Even$when$lying$down$or$standing,$the$most$dependent$part$
is$ the$ pelvic$ space.$ It$ is$ the$ reason$ why$ the$ most$ common$
location$ of$ abscesses$ is$ the$ pelvic$ abscess.$ Even$ when$ the$
patient$ has$ problems$ with,$ say,$ the$ bowel,$ the$ abscess$ will$
accumulate$in$the$pelvic$space.$
*
*

PERITONEAL*ORGANS*
Z
If$ an$ organ$ is$ covered$ by$ visceral$ peritoneum$
anteriorly$ and$ laterally,$ but$ lacking$ peritoneum$
posteriorly,$ it$ is$ considered$ as$ a$ peritoneal$ organ.$
Note,$ however,$ that$ we$ do$ not$ have$ intraperitoneal$
organs.$
Z
Most$of$the$peritoneal$organs$are$digestive$organs$
1. Esophagus$
2. Stomach$
3. 1st$duodenum$(duodenal$bulb)$$except$for$this$part$of$the$
duodenum,$majority$of$it$is$retroperitoneal$
4. Jejunum$
5. Ileum$
6. Cecum$
7. Appendix$
8. Transverse$colon$
9. Sigmoid$colon$
10. Superior$rectum$
11. Liver,$biliary$tree$
12. Spleen$
$
RETROPERITONEAL*ORGANS*
Z
These$are$organs$covered$by$peritoneum$only$at$their$
anterior$surfaces.$
Z
It$has$two$subdivisions:$primary$and$secondary.$
A. Primary* retroperitoneal* organs* $ organs$ not$ part$ of$
the$GIT$
1. Kidney$
2. Ureter$
3. Urinary$bladder$
4. Uterus$
5. Fallopian$tube$
6. Abdominal$aorta$
7. Inferior$vena$cava$
8. Suprarenal$(adrenal)$glands$
9. Upper$part$of$the$vagina$
10. Ovary$
*
B. Secondary*retroperitoneal*organs$$organs$of$the$GIT$
1. 2nd$ to$ 4th$ part$ of$ the$ duodenum$ (descending,$
ascending,$transverse$duodenum)$
2. Pancreas$
3. Ascending$colon$
4. Descending$colon$
5. Middle$rectum$
$
EXTRAPERITONEAL*ORGANS$
Z
No$peritoneal$covering$at$all$(outermost$covering$will$
be$the$tunica$adventitia)$
1. Inferior$rectum$
2. Seminal$vesicles$
3. Lower$part$of$vagina$
$
From*the*lecture:*
On$ the$ posterior$ surface$ of$ the$ anterior$ abdominal$ wall,$ the$
median* and$ lateral* umbilical* ligaments$ will$ be$ found.$ Both$
of$these$are$considered$as$false!ligaments.!
$
False*ligaments$are$those$ligaments$that$were$derived$from$
hollow$ viscous$ structures$ such$ as$ arteries$ or$ the$ urachus.$
True* ligaments$ are$ those$ that$ are$ ligaments$ since$
embryological$development.$
The$median* umbilical* ligament* is$derived$from$the$urachus$
and$is$the$passageway$of$the$urine$en$route$to$the$placenta.$The$
lateral* umbilical* ligament* is$ derived$ from$ the$ lateral*
umbilical*arteries.$
$
The$ median* umbilical* fold* covers$ the$ median$ umbilical$
ligament.$ The$ medial* umbilical* fold$ covers$ the$ lateral$
umbilical$ligament.$The$inferior$epigastric$artery$is$covered$by$
the$lateral*umbilical*fold.$

From*Moore*(2010):*
The$median*umbilical*fold*extends$from$the$apex$of$the$
urinary$bladder$to$the$umbilicus$and$covers$the$median*
umbilical* ligament,* a$ fibrous$ remnant$ of$ the$ urachus!
that$joined$the$apex$of$the$fetal$bladder$to$the$umbilicus.*
Two$ medial* umbilical* folds,* lateral$ to$ the$ median$
umbilical$ fold,$ cover$ the$ medial* umbilical* ligaments,*
formed$by$occluded!parts!of!the!umbilical!arteries.*
Two$ lateral* umbilical* folds,* lateral$ to$ the$ medial$
umbilical$ folds,$ cover$ the$ inferior! epigastric! vessels! and$
therefore$bleed$if$cut.*
*

Figure!4.!The!posterior!surface!of!the!abdominal!wall.!A!ligament!will!be!
seen! beginning! at! the! umbilicus! down! to! the! symphysis! pubis.! This! is!
known!as!the!median$umbilical$ligament!and!is!covered!by!a!fold!of!the!
paritetal!peritoneum!known!as!the!median$umbilical$fold.!!
$

PERITONEAL*INFOLDINGS$
Z
Extensions$of$the$visceral$peritoneum$
Z
Attaches$the$solid$organs$to$the$wall.$
Z
Can$ either$ be$ called$ mesentery,* ligaments,* or$
omentum$
*
1.*Mesentery*
Z$ A$ structure$ that$ connects$ a$ hollow$ viscous$ organ$ to$ the$
abdominal$wall$
$
Mesentery*of*the*small*intestine*(or$simply$mesentery)$
Z
2$layers$
Z
$Attaches$the$jejunum$and$ileum$to$the$wall$
Z
The$ attachment$ to$ the$ posterior$ wall$ is$ only$ 10Z12$
inches$from$L1$to$the$right$iliosacral$joint.$$
Z
Allow$ a$ space$ where$ the$ blood$ vessels$ can$ pass$
through$ to$ supply$ and$ drain$ the$ intestine.$ These$
vessels$are$called$the$intestinal*branches.$$
Z
$
Transverse*Mesocolon*
Z
Supports$the$transverse$colon$
Z
The$ middle$ colic$ artery$ (a$ branch$ of$ superior$
mesenteric$artery)$passes$through$this$mesentery$
$
Mesosigmoid*
Z
Structures$ that$ pass$ within$ the$ mesosigmoid$ are$ the$
sigmoid$and$the$superior$rectal$arteries.$
Z
Most$common$part$that$causes$volvulus$
$
Volvulus* of$the$sigmoid$colon$is$the$rotation$and$twisting$of$
the$ mobile$ loop$ of$ the$ sigmoid$ colon$ and$ mesocolon$ that$
results$ in$ obstruction$ of$ the$ lumen$ of$ the$ descending$ colon$
and$ any$ part$ of$ the$ sigmoid$ colon$ proximal$ to$ the$ twisted$
segment$(Moore,$Dalley$&$Agur,$2010).$

Figure! 5.! The! mesentery! of!

the! small! intestine.! The!
intestinal! arteries! present!
in! the! mesentery! provide! a!
demarcation!
for!
the!
jejunum! and! the! ileum!
based! on! the! number! of!
arches! of! the! intestinal!
branches.! 1L2!arches! before!
the!vasa!recta!is!the!area!of!
the! jejunum.! 3L7! arches!
before!the!vasa!recta!is!now!
the!area!of!the!ileum.!This!is!
important!
especially!
because! unlike! between! the!
duodenum! and! jejunum!
which! is! separated! by! the!
ligament$of$Treitz,!there!is!
not!
other!
landmark!
* structure! to! separate! the!
jejunum!and!ileum.!!

*
*
Mesoappendix*
Z
Where$the$appendicial$artery$and$vein$passes$through.$
Z
The$ mesoappendix$ does$ not$ fulfill$ the$ definition$ of$ a$
mesentery.$A$mesentery$is$defined$as$a$structure$that$
attaches$a$hollow$viscous$organ$to$the$posterior$wall.$
The$ mesoappendix,$ however,$ only$ attaches$ the$
appendix$ to$ the$ ileum.$ Nonetheless,$ it$ is$ called$ a$
mesentery,$moreover,$considered$as$the$smallest.$
$
2.*Ligaments*
!
TwoZlayered$
!
No$blood$vessels$passing$through$
!
Attaches$viscera$to$each$other$
$
Liver*
! Falciform*ligament*
o Supports$ the$ ligamentum* teres,$ the$ latter$
attaching$the$liver$to$the$anterior$abdominal$wall$
! Coronary*ligament$
! Triangular*ligament$
! Inferior* vena* cava* $ attached$ to$ the$ liver$ via$ the$
hepatic$ vein$ preventing$ the$ liver$ from$ going$ to$ the$
pelvic$cavity$
*
The$ bare$ area$ of$ the$ liver$ is$ demarcated$ by$ the$
reflection$of$peritoneum$from$the$diaphragm$to$it$as$the$
anterior$ (upper)$ and$ posterior$ (lower)$ layers$ of$ the$
coronary* ligament.$ These$ layers$ meet$ on$ the$ right$ to$
form$the$right*triangular*ligament*and$diverge$toward$
the$left$to$enclose$the$triangular$bare$area.$The$anterior$
layer$ of$ the$ coronary$ ligament$ is$ continuous$on$ the$left$
with$ the$ right$ layer$ of$ the$ falciform$ ligament,$ and$ the$
posterior$ layer$is$continuous$ with$the$right$layer$ of$the$
lesser$ omentum.$ Near$ the$ apex* (the$ left$ extremity)$ of$
the$ wedgeZshaped$ liver,$ the$ anterior$ and$ posterior$
layers$ of$ the$ left$ part$ of$ the$ coronary$ ligament$ meet$ to$
form$ the$ left* triangular* ligament* (Moore,$ Dalley$ &$
Agur,$2010).$
*
Spleen*
! Splenophrenic*ligament*$attaches$the$spleen$to$the$
diaphragm$
! Splenogastric* ligament* $ attaches$ the$ spleen$ to$ the$
stomach$
! Splenocolic* ligament$ $ attaches$ the$ spleen$ to$ the$
colon$
! Splenolienal* ligament$ $ attaches$ the$ spleen$ to$ the$
adrenal$gland$
Among! the! four! splenic! ligaments,! only! the! splenogastric!
ligament! contains! blood! vessels! (i.e.! short! gastric! artery! and!
vein).!These!vessels!supply!and!drain!the!fundus!of!the!stomach.!!

3.*Omentum*
!
Anything$ that$ attaches$ the$ stomach$ to$ other$
structures$
$
Greater*omentum*
!
Attached$to$the$greater$curvature$of$the$stomach*
!
Considered$ as$ the$ policeman$ of$ the$ abdominal$
cavity*
o Isolates$an$inflamed$structure,$therefore$any$
abscess$ that$ will$ form$ will$ be$ contained$
within$ that$ area$ preventing$ its$ spread$
throughout$the$rest$of$the$abdominal$cavity.*
!
FourZlayered$ and$ can$ even$ extend$ up$ to$ the$ pelvic$
cavity*
!
Formed$by$the$gastrocolic,$duodenocolic,$phrenocolic$
ligaments*
*
Lesser*omentum*
!
TwoZlayered*
!
Attached$to$the$lesser$curvature$of$the$stomach*
!
Connects$the$stomach,$duodenum,$and$the$esophagus$
to$the$liver*
!
Formed$ by$ the$ hepatoduodenal,$ hepatogastric,$ and$
hepatoesophageal$ligaments*
o The$ hepatoduodenal* ligament* contains$
the$ common$ bile$ duct,$ hepatic$ artery,$ and$
the$portal$vein.*
*
ESOPHAGUS$
!
1.5$to$2.5$cm$
!
No$digestion$or$absorption$takes$place$
!
Once$ it$ passes$ through$ the$ esophageal$ hiatus,$ it$ now$
becomes$the$abdominal$esophagus$
!
At$ the$ junction$ of$ the$ esophagus$ and$ the$ cardiac$
orifice$ of$ the$ stomach,$ the$ esophagogastric*
sphincter$will$be$found.$This$is$not$a$true$sphincter,$
however,$ but$ rather$ a$ mucosal$ fold$ (i.e.$ if$ it$ is$ a$ true$
sphincter,$ we$ should$ not$ be$ able$ to$ vomit).$ The$
diaphragm$strengthens$this$mucosal$fold$because$of$
the$fibers$from$the$central$tendon$attached$to$the$wall$
of$the$esophagus.$
!
Nerve*innervation:$
o Sympathetic$chain$$
o Parasympathetic:$ Vagus$ nerve$ which$ is$
located$beside$the$esophagus$
!
Blood*supply:*
o Left$ gastric$ artery$ $ comes$ from$ the$ celiac$
artery$
o Inferior$ phrenic$ artery$ $ paired$ parietal$
branch$and$supplies$the$diaphragm.$The$left$
inferior$ phrenic$ artery,$ however,$ has$ an$
esophageal$branch.$
The$ celiac$ artery$ is$ a$ branch$ of$ the$ aorta.$ It$ gives$ off$ the$
splenic,$common$hepatic,$and$the$left$gastric$arteries.$
$
$