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Skandalakis' Surgical Anatomy > Chapter 10. Peritoneum, Omenta, and Internal Hernias >

HISTORY

The anatomic and surgical history of the peritoneum and omenta is found in Table 10-1.

Table 10-1. Anatomic and Surgical History of the Peritoneum and Omenta

Egypt 1500

B.C.

Ebers Papyrus contains first description of the peritoneum

Homer (fl. 8th cent. B.C.) "Dertron" (omentum) mentioned in The Odyssey

Hippocrates of Cos (460-370

B.C.)

Case reports of abdominal injuries in which the omentum became extruded and gangrenous

Aristotle (384-322 B.C.) Omentum composed of "warm fatty material" attached to the stomach; speeds digestion by its warmth

Eristratos (304-250 B.C.) Stated that omentum has no special function

Celsus (fl. ca. 25 A.D.) Described surgery on extruded omentum and various hernias

Galen (128-199) Anatomy of omental vasculature and peritoneal folds. Omentum serves to warm intestines, lubricate peritoneum, and store

fat

Paul of Aegina (625-690) Detailed treatment of abdominal wounds involving the omentum

Avicenna (980-1037) Detailed anatomic description of the omentum

Frugardi (12th cent.) Stressed importance of omentum in hernia repair

William of Sa liceto (12th

cent.)

Differential diagnos is of omental (called "rete" or net) and intestinal hernias

Theodoric de Mondeville

(1260-1320)

1267 Described anatomy of omentum and its vasculature

Omentum serves to aid digestion

Mondino da Luzzi (1275-

1326)

Omentum arises at peritonea l reflection in diaphragmatic region; it is attached to stomach, spleen, and colon

Brunschwig (1450-1533) Detailed description of traumatic abdominal injury

da Vinci 1504 Accurate annotated drawings of dissectedomenta; not published until 18th century

da Carp i 1523 C la imed to have performed resection w ithout ligature or caute ry; suggested tha t exposure to air causes gangrene

Vesalius 1543 Des cribed innerva tion, vas culature, and deep and superficial layers o f ome ntum

Franco (1500-1561) Repaired hern ias with adherent t issuePar (1510-1590) Described rupture of peritoneum with extrusion of omentum; recommended use of trusses

Fabricius ab Aquapendente

(1537-1590)

Omentum recipient of wastes from stomach, liver, and spleen

Riolan (1580-1657) Omentum "ruler of the whole abdomen," but not heat-regulating organ

Sennert 1628 Survey of omental diseases

van den Sp iege l 1632 Described omentum and s tructure la te r named the spigelian lobe

Ruysch (1638-1731) Omentum not a perforated net between vessels

Wharton 1659 "Confirmed" existence of omental lymph vessels

Dionis 18th

cent

First diagnosis and resection of strangulated omentum in a hernia

Douglas 1730 Best detailed description of the peritoneum

Winslow 1732 Described greater and lesser omentum, lesser sac, and foramen (of W inslow )

von Haller 1743 Described colic omentum

Mecke l (1781-1833) Omenta l embryo logy

Froriep 1812 Anatomy of peritoneum and omentum

Jobert de Lamballe 1829 Omentum will fo rm adhesions w ith injured bowel

Cruve ilhie r 1829 Pub lis hed pa tho logy atla s; de scribed omenta l s hrinkage in tube rculous pe ritonitis

Hennecke 1836 Anatomy, pathology, embryology, and function of omentum

Ranvier 1874 "Milky spots" of omentum combat disease

Wegner 1877 First to perform experimental peritoneal lavage

von Leyden 1879 First description of subphrenic abscess

Oberst 1882 Reported omental torsion

Senn 1888 Recomme nded fre e omental grafts to protect uns afe suture lines in intestinal a nd kidne y s urgery

Morison 1894 Described the right infrahepatic space (subhepatic, hepatorena l space) and vascula r regenera tive capacity o f omentum


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Starling and Tubby 1894 Studied the transference of substances from the peritoneal cavity to the blood and from the blood to the peritoneum

Milian 1899 Foreign organic material injected into peritoneal cavity absorbed by omentum

Putnam 1922 Studied the properties of the peritoneal membrane

Ganter 1923 Evaluated peritoneal dialysis for the treatment of uremia

Seligman 1946 Success ful trea tment of nephrectomized dogs by continuous flo w dialysis

Doolan & Lewis 1960 Pat ient ma intained on continuous ambula tory peritoneal d ia lys is (CAPD)

Kiricuta 1963 Pedicled omentum used for chest w all repair in breast cancer surgery

Tenckhoff et al. 1964,

1972

Advances in peritoneal dialysis equipment

Turne r-Walke r e t a l. 1967 Omentum used in urogenita l s urgery

McLean, Buncke 1972 Autotransplantation of omentum to scalp

Goldsmith 1973 Pedicled omentum used for vascular supply of brain

Lichtenstein et al. 1989 Lichtenstein repair with prosthetic screen onlay technique ("tension-free hernioplasty")

Arregui 1991 Reported the transabdominal preperitoneal (TAPP) repair

Phillips e t a l. 1993 Perfo rmed la pa ro scopic Stoppa prepe ritoneal pro sthe tic mesh re pa ir

McKernan & Laws 1993 Performed laparoscopic repair of inguinal hernia without peritoneoscopy, totally avoiding abdominal cavity

Robb ins & Rutkow 1993 Reported results o f hand-ro lled "umbre lla " plug he rnioplasty

Fitzgibbons et al. 1995 Compared transabdominal preperitoneal, intraperitoneal onlay mesh, and total extraperitoneal laparoscopic inguinal

herniorrhaphies and found them to be equally effective

History table compiled by David A. McClusky III and John E. Skandalakis.

References:

Arregui ME. Laparoscopic preperitoneal herniorrhaphy. Presented at the Society of American Endoscopic Surgeons Annual Meeting, Monterrey CA, April 1991.

Blumenkrantz MJ, Roberts M. Progress in peritoneal d ialysis: a historical perspective. Contr Nephrol 1979;17:101-110.

Fitzgibbons RJ, Camps J, Cornet DA, Ngugen NX, Litke BS, Annibali R, Salerno GM. Lapa roscopic inguinal herniorrhaphy: results of a multicenter trial. Ann Surg

1995;221:3-13.

Halliday P. The s urgical management of subphrenic abscess: a historical study. Aust NZ J Surg 1975;45:235-244.

Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension-free hernioplasty. Am J Surg 1989;157:188-93.

Liebermann-Meffert D, White H (eds). The Greater Omentum. New York: Springer-Verlag, 1983.

Mattocks AM, El-Bassiouni EA. Peritoneal dialysis: a review. J Pharmaceut Sci 1971;60:1761-1782.

McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 1993;7:26-28.

Meyers MA. Morison pouch (letter; comment). Radiology 1995;195:578.

Phillips EH, Carroll BJ, Fallas MJ. Laparoscopic preperitoneal inguinal hernia repair without peritonea l incision. Surg Endosc 1993;7:159-62.

Robbins AW, Rutkow IM. The mesh-plug he rnioplasty. Surg Clin North Am 1993;73:501.

Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins, 1994.

EMBRYOGENESIS

Normal Development

The gastrointestinal tract starts as a closed structure, fixed with the dorsal and ventral mesenteries. It can be envisioned as a downward-facing open

book (Fig. 10-1).

Fig. 10-1.


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Embryogenesis of omenta, mesenteries, ligaments, and fossae.

The development of the omentum is controversial. The theory that an independent area (recess or cleft) was the start of the lesser sac found support

around the turn of the century.2,3Liebermann-Meffert and White4stated that the omentum does not develop as a fold of the dorsal mesogastrium, but

develops independently in close relation to the spleen; the organs do not rotate. According to Krutsiak and Voitiv,5the lesser peritoneal sac develops in

three sections: the vestibulum bursae omentalis, the bursa omentalis proper, and the cavity omentum majus.

The dorsal mesentery is responsible for the genesis of the greater omentum (Fig 10-3), a double-layered evagination of that part of the dorsal

mesogastrium located between the left gastric artery and the common hepatic artery. At the fifth week, the dorsal mesentery elongates downward after

the formation of the omental bursa (lesser sac). This process forms the inferior recess. A four-layered anatomic entity -the greater omentum or fat apron

is created (Table 10-2).

Table 10-2. Development of the Greater Omentum from Birth to Adulthood

Age Premature Newborn Mature Newborn 3 to 4 mo 1 to 5 yr 5 to 10 yr Adult

Attachments Attached to the transverse

colon but does not reach the

colonic flexures

Further

attachment but

does not reach

the colonic

flexures

Distal to the

transverse colon

Extends beyond

the colonic

flexures; some

attachments to

the ascending and

descending colon

Resembles the

adult omentum;

insertion on the

ascending colon

and occasionally

on the cecum

Width, 20 to 46 cm

Downward

length

Just below the colon Covering approx.

of small bowel

Covering of small

bowel

Most of the

intestines are

covered by the

omentum

More downward

extension

7 to 10 cm or 14 to 35 cm

Network Fatless thin vascu lar membrane Fatless thin

vascular

membrane

Fat around the

vessels

More fat;

occasionally some

lymph nodes

More fat Volume depends on body

weight; may be fat or lean

Vascularization Vascular pattern can be seen Vascular pattern

can be seen

Vascular pattern can

be seen

Vascular pattern

can be seen

Vascular pattern

can be more

obviously see n

Wider range of varieties; no

standard pattern;

unpredictable

Observations Omentum is rudimentary fringe

and extends upward toward

the spleen. Its two pos terior

layers fused to the transverse

colon and transverse

mesocolon

Splenic ligaments

developed;

omentum

reaches the

diaphragm

Splenic ligaments,

especially

gastrosplenic and

splenorenal, are

better developed;

better formation of

omentum

Omentum well

formed

Omentum and

omental derivation

almost with

normal limits

Typical omenta l formation, fat

or lean, voluminous o r not,

according to body weight; all

parts well differentiated;

artery, veins, and lymph nodes

may be seen

Diagram

Data from Liebermann-Meffert D, White H, eds. Diseases o f the Omentum: Congenital Abnormalities and Ped iatric Disease. New York: Springer-Verlag, 1983.

Fig. 10-3.


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Formation of greate r omentum. A,Rotation of stomach and formation of omental bursa. B,Fusion of posterior wall of omental bursa to transverse colon and

mesocolon. Cand D,Fusion of anterior and posterior walls of omental bursa to form adult omentum. S, Stomach; P, Pancreas; C, Colon.

The ventral mesentery is found only above the umbilicus. The formation of the liver divides the ventral mesentery into two sections: the lesser omentum

and the three peritoneal ligaments of the liver (falciform, coronary, and triangular).

As the stomach grows, bends, rotates, or augments around the greater curvature, it finally forms a large portion of the anterior wall of the lesser sac. By

definition, the greater omentum attaches to the greater curvature of the stomach. This represents the original dorsal surface of the stomach.

By continuing growth, the omental apron forms a double-layered sac. The sac of the greater omentum is closely related to the transverse mesocolon (Fig

10-4). The adult transverse mesocolon is a fusion between the embryonic transverse mesocolon and the portion of the dorsal mesogastrium attaching to

the posterior abdominal wall.

Fig. 10-4.


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Vertical disposition o f the peritoneum (abdominopelvic cavity).

For all practical purposes, embryogenesis stops here. However, the anatomic entities derived from the peritoneum further subdivide the peritoneal cavity

into several compartments. The peritoneal cavity consists of two principal spaces, the greater sac or general peritoneal cavity and the omental bursa or

lesser sac (Fig. 10-4). These are connected by the epiploic foramen of Winslow. In the male the peritoneal cavity is truly a closed sac. However, in the

female the minute openings of the uterine tubes provide continuity with the environment external to the body.

Congenital Anomalies

Greater Omentum

Congenital anomalies in this area are rare and case reports are sporadic. This renders difficult the anatomic and embryologic understanding of these

malformations.

Absence of the greater omentum and all or part of the ligaments and folds related to it is rarely described in the literature. A case of "hypoplasia of the

greater omentum," asplenia syndrome, and multiple other anomalies was presented by Kiuchi et al.,6who witnessed striking dysplasia of length, breadth,

and thickness in the laboratory and in the operating room.

The greater omentum itself may fail to form the gastrocolic ligament or to attach to the greater curvature. This failure can be partial or total. Omental

derivatives may also present failure of attachment or unexpected attachments.

Although most congenital omental defects are asymptomatic, internal obstruction may be produced if a loop of small bowel passes through the omentum.

The senior author of this chapter, John Skandalakis, has seen symptomatic defects at the greater omentum, and asymptomatic defects at the lesser

omentum.

Bifid omentum may occur, although Skandalakis found no references in the literature to support this. Also rare are congenital adhesions between the

omentum and the abdominal wall (anterior or posterior), or between the omentum and other organs.

Skandalakis7reported a case of idiopathic segmental infarction where the lesion involved the right lower border of the omentum. The etiology could have

been embryologic; the pathogenesis was confusing.

Although many benign solid tumors of the omentum have been found in children, a congenital origin is hard to support. Benign cysts, which may be

congenital or acquired, are either lined with epithelium or endothelium (true cysts) or are pseudocysts without this lining (false cysts). A rare case of

immature omental teratoma was reported by Spurney and Mc Cormack.8A solid ovarian teratoma that metastasized to the omentum was studied by

Boehner.9

Omental pregnancy and accessory spleens in the omentum have been documented. 10Omentum can become incarcerated in congenital hernias (indirect

inguinal, diaphragmatic, etc); this can be observed in newborns and in children. Haider11reported omental herniation within the pericardium.

Lesser Omentum

Anomalies of the lesser omentum are rare; their variations are difficult to classify. Skandalakis has encountered holes of varying sizes. A male infant

lacking a lesser omentum, in conjunction with other anomalies, was reported by Hodach.12

Mesenteries

The root of the mesentery extends from the upper left quadrant (1st or 2nd lumbar vertebra) to the right sacroiliac joint, and is fused to the

retroperitoneal space. Failure to fuse, or the presence of a hole in the mesentery, can allow the herniation of small bowel (symptomatic or asymptomatic


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internal hernia). Nonfusion deformity produces a hernia of Waldeyer; this may occur in combination with nonfusion of colonic mesentery. Jejunal atresia

with agenesis of the dorsal mesentery is known as "apple peel syndrome,"13"Christmas t ree deformity,"14or "maypole at resia."15

Internal hernia can result if the transverse mesocolon fails to attach to the second part of the duodenum, the anterior border of the pancreas, or the

lower pole of the left kidney. Any defect producing a hole can have similar results. The intersigmoid fossa can be the site of an internal hernia, as can any

site on the sigmoid mesocolon.

Congenital mesenteric cysts can be categorized by origin (Fig. 10-5):

Endodermal: enteric cysts, cystic intestinal duplications

Multiple: retroperitoneal teratoma

Mesodermal: lymphatic cysts, retroperitonea l cysts of urogenital origin

Fig. 10-5.


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Topographic anatomy showing 5 omental and mesenteric cysts (dotted). (Modified from Skandalakis JE, Gray SW (Eds). Embryology for Surgeons, 2nd Ed.

Baltimore: W illiams & Wilkins, 1994; w ith pe rmission.)

Mesenteric cysts are discussed in more detail in the chapter on the small intestine, under "Surgical Applications to the Jejunum and Ileum."

Ligaments

Failure of the falciform ligament to fuse with the anterior abdominal wall causes a defect that can lead to internal herniation.16The broad ligament, being

thin and almost avascular, is also a possible site for an internal hernia.

Fossae

Moynihan17described nine paraduodenal fossae, which he theorized were "fusion folds" caused by "physiologic adhesions." We consider five (each bearing

the name of its original investigator) to be of clinical importance and consistent enough for study (Table 10-3, Fig. 10-6). 18,19,20

Table 10-3. The Paraduodenal Fossae

Fossa and Eponym Anatomic Boundaries Incidence

(%)

Surgical

Significance

1. Superior fossa of

Treitz

Behind the superior duodenal fold at the left of the fourth part of the duodenum; the cavity extends upward,

approaching the pancreas; the hernial sac is directed to the right

30-50 May contain a

right

paraduodena

hernia

2. Inferior fossa of

Treitz

Behind the inferior duodena l fold at the left o f the fourth part of the duodenum; a thumb-like cavity extending

downward, parallel to the duodenum; the hernial sac is directed to the right

50-75 May contain a

right

paraduodena

hernia

3.

Mesentericoparietal

fossa of Waldeyer

At the base of the mesentery of the first part of the jejunum, behind the superior mesenteric artery and below the

duodenum; more common in fetuses than in adults; the hernial sac is directed to the right

1

(Parsons,

1953)

May contain a

right

paraduodena

hernia

4. Intermesocolic

fossa of Brsike

At the base of the transverse mesocolon which together with the pancreas forms the upper wall of the fossa ; the

lower wall is formed by the duodenojejunal junction and fourth part of the duodenum; the anterior wall is formed

by a peritoneal fold between the transverse mesocolon and mesentery of the upper jejunum; the middle colic

artery lies to the right of the orifice; the hernial sac is directed to the right

Rare May contain a

right

paraduodena

hernia

5. Paraduodenal

fossa of Landzert

Under the fold, bridging the left end of the superior and inferior fossae (Treitz); the fold contains the inferior

mesenteric vein and left colic artery; psoa s muscle and hilum of left kidney lie posterior; the hernial sac is directed

to the left

2

(Parsons,

1953)

May contain a

left

paraduodena

hernia

Source:Skandalakis JE, Gray SW. Embryology for Surgeons , 2nd Ed. Baltimore: Williams & W ilkins, 1994.

Fig. 10-6.


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Major paraduodenal fossae (transverse colon reflected upward; duodenum reflected to right). Numbers refer to Table 10-3. (Modified from Skandalakis LJ, Gadacz

TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skanda lakis JE. Modern Hernia Repa ir: The Embryological and Anatomical Basis of Surgery. New York: Parthenon

1996; with permission.)

These fossae seem to be of congenital origin. The paraduodenal fossae may form during the 10th week when the mesenteries of the ascending and

descending colon fuse to the parietal peritoneum of the posterior abdominal wall. With the peritoneum and duodenojejunal junction as co-conspirators, a

congenital hernia may result at the time of formation of the fossae, or an acquired hernia may occur later. When internal herniation takes place, the sac i

directed to the right or to the left; hence, the identification of right or left hernia.

There are a number of intraperitoneal fossae and apertures through which peritoneal contents may protrude. These internal hernias account for less than

1%21of intestinal obstructions; of these, paraduodenal hernias account for more than 50%.

Congenital hernial sacs open at the sites of the fossae, but there is no evidence that a congenital fossa becomes a hernial sac later in life. A

paraduodenal fossa is not the site of a potential acquired hernia; instead, it marks the location where a congenital hernia might have occurred, but failed

to do so.

In a left paraduodenal hernia, an intestinal loop enters a pocket of yet-unfused descending mesocolon during the return of the intestines to the abdomen

in the 10th week; during subsequent fusion of the mesocolon, a hernial sac is produced. The same process under the ascending mesocolon produces a

right paraduodenal hernia.

Laslie et al.22suggested that the hernial sac is not formed by the mesocolon, but represents the lining of the extraembryonic coelom, which envelops the

intestinal loops while they are in the umbilical cord and which entered the abdomen with them. This avascular coelomic sac fuses secondarily with the

ascending or descending mesocolon to form a right or left paraduodenal hernia. In some cases, this fusion does not take place and the anomalous sac

remains more evident. This condition has been called internal omphalocele.

SURGICAL ANATOMY OF THE PERITONEUM

The peritoneum is the largest serous membrane in the body, with a surface area of about 22,000 cm2. It can be divided into parietal and visceral portions

The parietal layer lines the abdominal and pelvic cavities and the abdominal surface of the diaphragm. The visceral layer covers the abdominal and pelvic

viscera and includes the mesenteries.

The parietal peritoneum is only loosely connected with the body wall, separated from it by an adipose layer, the tela subserosa; whereas the visceral

peritoneum is usually tightly attached to the organs it covers. The peritoneum consists of a fibrous layer (the tunica subserosa) and a surface layer of

mesothelium (the tunica serosa).

The peritoneal cavity is a potential space. It normally contains only a thin film of fluid which lubricates the surfaces, allowing frictionless movements of th

gastrointestinal tract. Under the effec ts of certain pathologic conditions, great quantities of fluid can occupy the peritoneal cavity.

Peritoneum does not line the entirety of the abdominopelvic cavity. It is lifted from the body wall, especially posteriorly, by organs located against the wa

during embryologic development. This chain of events causes the formation of a retroperitoneal space between the peritoneum and the body wall, with


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organs situated within the space. An organ that is covered only in part by the peritoneum is referred to as a retroperitoneal organ. An organ that is

covered by peritoneum essentially everywhere except for the site of entrance of vessels is referred to as an intraperitoneal organ.

The purpose of this chapter is to remind surgeons of the anatomy of the peritoneal compartments (Fig. 10-7) and to emphasize some of the newer

concepts, with the hope that this will help in the agonizing treatment of peritoneal collections. In spite of sonograms, CAT scans, fluoroscopic

localizations, MRIs, laparoscopies, etc., which are tremendously helpful, an anatomic knowledge of the spaces is necessary to reduce morbidity, or even

catastrophe, in the operating room.

Fig. 10-7.

Arbitrary compartments o f abdominal cavity. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-

Hill, 1983; with permission.)

The abdominal surgeon must understand the development of the peritoneum and its peculiar attachments. The formation of the omentum and its various

folds and ligaments must be studied if anatomic complications are to be avoided (Table 10-4).

Table 10-4. Parts of the Peritoneum

Omenta Great omentum

Lesser omentum

Mesenteries Mesentery of the small bowel

Mesoappendix

Transverse mesocolon

Pelvic mesocolon

L igaments Of liver

Of urinary bladder

Of uterus

Fossae Duodenal

Cecal

Intersigmoid

Source:Skandalakis JE, Gray SW. Embryology for Surgeons , 2nd Ed. Baltimore: Williams & W ilkins, 1994.

Peritoneal Dispositions

Vertical Disposition in the Abdominopelvic Cavity

In most anatomy books, the starting point for the study of the vertical disposition of the peritoneum is the umbilical area (Fig. 10-4). On its way up, the


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parietal peritoneum forms the falc iform ligament. This is a roughly triangular, bilaminar structure, which passes from the posterior surface of the abdomina

wall and inferior surface of the diaphragm to the anterosuperior surface of the liver. The ligament is not oriented strictly in an anterior-posterior direction;

rather, as can be seen easily in transverse sectional images, it is inclined to the right in a nearly coronal plane as it passes upward from the umbilicus.

The falciform ligament is a thin, bilaminar peritoneal membrane with loose connective tissue separating the two layers and conveying the ligamentum teres

hepatis in its free inferior edge. At the liver, the two peritoneal laminae are continuous with the visceral peritoneum covering the liver. Upon reaching the

intersection of the diaphragm and liver, the two layers separate. The right layer passes across the hepatic surface to the right forming the anterior

(superior) lamina of the coronary ligament (Fig. 10-8); the left layer passes to the left over the lateral segment of the left lobe, forming the anterior layer

of the left triangular ligament.

Fig. 10-8.

Peritonea l reflections o f diaphragm show ing bare area, coronary, triangular, and falciform ligaments.Arrowrepresents pa thway behind abdominal esophagus

where surgeon may pass finger through posterior layer of coronary ligament. (From Gray SW, Rowe JS Jr, Skandalakis JE. Surgical anatomy of the

gastroesophageal junction. Am Surg 45(9):575-587, 1979; redrawn from Hollinshead. Anatomy for Surgeons. Hoeber-Harper, 1956; with pe rmission.)

The free, crescentic, inferior margin of the falciform ligament is characterized by the firm, cordlike thickening caused by the presence of the ligamentum

teres hepatis (round ligament) of the liver. This structure is the remnant of the left umbilical vein of intrauterine development, the right umbilical vein

having disappeared early in embryonic development. The round ligament passes from the umbilicus to the inferior border and inferior surface of the liver,

where it ends at the umbilical segment of the left portal vein. Also within the falciform ligament, the paraumbilical veins (of Sappey) pass from the liver to

the integument surrounding the umbilicus.

Continuing upward from the left portal vein to the inferior vena cava just below the diaphragm is another cordlike or bandlike structure, the vestige of the

embryonic continuation of the left umbilical vein, the ligamentum venosum. This, in intrauterine life, is the ductus venosus. Maternal blood passes from th

left umbilical vein to the liver, where some of the blood is shunted into the liver by the portal venous system, the remainder passing to the inferior vena

cava by way of the ductus venosus. The three ligaments falciform, round, and venosum divide the left lobe of the liver into two segments, the media

and the lateral.

The visceral peritoneum continues over the inferior margin of the liver, passing from the diaphragmatic surface to the visceral surface of the right and left

lobes. On the right, parietal peritoneum leaves the visceral surface of the liver to cover the right adrenal gland and the upper part of the right kidney,

forming the hepatorenal ligament. It passes then to the left as the posterior (inferior) layer of the hepatic coronary ligament.

The peritoneum continues inferiorly from the vicinity of the right kidney, investing the first part of the duodenum and the hepatic flexure of colon and that

part of the inferior vena cava that forms the posterior border of the epiploic foramen of Winslow. This peritoneal covering continues to the left, forming

the floor of the lesser omental bursa.

At the right margin of the liver, the reflection of the coronary ligament from anterior to posterior forms a relatively sharply bordered right triangular

ligament (Fig. 10-8) which secures the right lobe to the diaphragm. This ligament forms the apex of the large posterosuperior bare area of the liver. At th

bare area, peritoneum reflects from the superior surface of the liver to the inferior surface of the diaphragm, leaving this portion of the upper surface of

the liver devoid of peritoneal covering, separated from the diaphragm only by areolar tissue. The base of the roughly triangular bare area is situated to th

left, at the groove for the inferior vena cava.

The fundus and inferior surface and sides of the gallbladder are covered with peritoneum that is continuous over the visceral surface of the right lobe of

the liver and the quadrate lobe to the porta hepatis, and the visceral surface of the lateral segment of the left lobe. At the sharp left margin of the liver,

the peritoneal attachment of the left lobe to the diaphragm forms the left triangular ligament (Fig. 10-8). From this region laterally, the peritoneum passe

freely around the lateral abdominal wall and over part of the posterior wall until it becomes continuous with the gastrophrenic and splenophrenic ligaments

The caudal part of the splenophrenic ligament continues inferiorly over the left kidney as the splenorenal ligament and thence to the splenic flexure of the

colon, there forming the narrow phrenicocolic ligament.

From the left portion of the inferior margin of the diaphragmatic surface of the liver, the peritoneum passes cranially over its inferior visceral surface.


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Reaching the anterior border of the porta hepatis and the left side of the fissure for the ligamentum venosum, peritoneum continues freely downward to

the duodenum and the lesser curvature of the stomach, forming the anterior layer of the lesser omentum, the inferior extent of the primitive ventral

mesentery. Peritoneum continuous with the posterior layer of the coronary ligament covers the caudate lobe and its process and then passes inferiorly

from the posterior margin of the porta and the right side of the fissure for the ligamentum venosum, forming the posterior layer of the lesser omentum.

The left margin of the two-layered lesser omentum connects to the esophagus; the right free margin forms the anterior border of the epiploic foramen of

Winslow. The free border collectively ensheathes the hepatic arteries, extrahepatic biliary vessels, portal vein, lymph nodes and vessels, and the hepatic

plexus of nerves. Behind this ligament lies the epiploic foramen, the sole passageway between the greater peritoneal cavity and the lesser omental bursa.

The anterior and posterior laminae of the lesser omentum separate at the lesser curvature of the stomach, investing the left gastric vessels and nerves as

they approach the lesser curvature. This part of the lesser omentum is the hepatogastric ligament. After incorporating the stomach and the first part of

the duodenum, the anterior and posterior layers of gastric peritoneum leave the greater curvature of the stomach and duodenum as the anterior layer of

the greater omentum.

The double layer of peritoneum forming the anterior layer of the greater omentum descends across the transverse colon and passes inferiorly for a variabl

distance to the lower end of this apronlike fold. The posterior layer of the greater omentum then ascends, passing superior to the transverse colon and

lying against the superior layer of the transverse mesocolon, with which it fuses to a variable degree, then attaches to the anterior aspect of the head

and body of the pancreas. The more inferior layer of peritoneum then descends, forming the superior layer of the peritoneum of the transverse colon; the

more superior layer becomes continuous with the peritoneal floor of the lesser omental bursa.

The surgeon uses this special anatomic relationship to secure a bloodless route to the lesser sac and the pancreas. The greater omentum is lifted up to

expose its posterior surface, a variable number of adhesions to the transverse colon are divided, and the plane between the posterior aspect of the fused

layers of the greater omentum lying anteriorly and the anterior layer of the peritoneum of the mesocolon is entered. Separation of these two layers leads

to the lesser sac. The greater omentum/stomach can be lifted cephalad over the costal margin for wide exposure of the pancreas.

That part of the greater omentum between the greater curvature of the stomach and the transverse mesocolon forms the gastrocolic ligament. The

ligament often includes both the anterior and posterior layers of the greater omentum, which have undergone fusion. It may consist primarily of the

anterior layer of the greater omentum if the omental bursa continues from behind the stomach at the greater curvature, intervening between the anterior

and posterior layers of the greater omentum as the inferior recess of the lesser omental bursa.

The anterior peritoneal layer of the transverse mesocolon continues inferiorly, passing about the transverse colon to ascend as the posterior peritoneal

layer. After reaching the head and body of the pancreas, this peritoneal layer continues inferiorly over the pancreas and the third and fourth parts of the

duodenum. To the right, peritoneum leaves the duodenum to reach the posterior abdominal wall. Near the midline, the peritoneum is carried away by the

superior mesenteric artery and vein and their branches as the radix or root of the mesentery, forming the right side of the mesentery of the small

intestine.

Continuing about the jejunum and ileum, peritoneum thereafter covers the left side of the mesentery of the small intestine. This peritoneum continues to

the left over the secondarily retroperitoneal descending colon to the lateral abdominal wall. Below and to the left, this peritoneal layer is elevated from the

posterior abdominal wall and pelvic sidewall as the anterior layer of the sigmoid mesocolon. Then, after investing the sigmoid colon, it ascends as the

posterior layer of the sigmoid mesocolon to reach the lateral wall of the pelvis and left iliac fossa. Inferiorly from the mesentery of the small intestine,

peritoneum covers the lower abdominal segments of the aorta, inferior vena cava, and their respective branches and tributaries.

The peritoneum continues downward into the pelvis. It covers the ventral surface and lateral aspects of the first part of the rectum, the ventral surface

alone of the second part of the rectum, and then forms the floor of the rectovesical pouch in the male, the rectouterine pouch of Douglas in the female.

Lateral to the rectum, the peritoneum forms right and left pararectal fossae, the depths of which vary, in keeping with the degree of rectal distension.

MALE PELVIS

In the male pelvis, the lateral boundaries of the pararectal fossae continue forward toward the urinary bladder as the sacrogenital folds. These folds are

formed by the peritoneal covering over relatively dense connective tissues, the ureter, and nerves and vessels passing ventrally from the sacrum and

pelvic sidewall toward the urogenital organs. The peritoneum of the rectovesical pouch ascends over the superior portions of the seminal vesicles, not

coming into contact with the prostate gland. It then sweeps upward over the base and superior surface of the urinary bladder to reach the anterior

abdominal wall.

Lateral to the urinary bladder, the pelvic peritoneum provides floors for the right and left paravesical fossae. Laterally in each pararectal fossa, the ductus

deferens raises a fold of peritoneum as it passes upward toward the pelvic brim and the deep inguinal ring. When the urinary bladder is empty, a variably

present, transverse vesical fold can be seen to pass medially from the pelvic sidewall. This fold extends between the paravesical fossae, crossing the

urinary bladder anterior to the fold over the ductus deferens.

Superior to the urinary bladder, the peritoneum upon the anterior abdominal wall is lifted by the underlying presence of t he fibrous midline urachus or

remnant of the embryonic a llantois. It extends upward from the apex of the bladder to t he umbilicus, t hus forming the median (middle) umbilical fold.

Lateral to this on both sides, and also directed toward the umbilicus, medial umbilical folds are formed as peritoneum crosses the obliterated segments of

the umbilical arteries. Further laterally, the inferior epigastric artery and vein and their coverings of peritoneum form less distinct lateral umbilical folds

which, though passing toward the rectus muscles, are not in reality directed to the umbilicus, but more laterally; therefore, they are probably named

inappropriately.

Between the median and medial umbilical folds are the supravesical fossae, the depths of which are dependent upon the degree of fullness of the urinary

bladder. Below these, the anterior surface of the bladder is in direct contact with the pubis and the lower extent of the anterior abdominal wall, separated

from them by the retropubic space of Retzius and its extension upward into the space of Bogros. 23For some distance above the pubic crest, the

peritoneum is only loosely attached to the abdominal wall so that, as the bladder fills, it carries the peritoneum away from the wall.

Lateral to the medial umbilical ligament is the shallow, medial inguinal fossa. Just lateral to the lateral umbilical ligament is the lateral inguinal fossa. The

lateral inguinal fossa is the site of the deep, or internal inguinal ring, at which one may see more or less distinctly the convergence of the ductus deferen

and the testicular vessels. Below and medial to the beginning of the lateral umbilical ligament is a relatively indistinct and shallow femoral fossa, overlying

the abdominal surface of t he femoral ring.

FEMALE PELVIS


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In the female pelvis the peritoneum of the rectouterine pouch or cul-de-sac (pouch of Douglas) ascends over the posterior fornix and apex of the vagina

to reach the uterine cervix. Laterally in the pararectal fossae and rectouterine pouch, uterosacral folds are prominent. These consist of peritoneum and

underlying connective tissue, smooth muscle, and elements of the pelvic nerve plexus which pass forward from the sacrum to the posterior fornix and

uterine cervix.

After covering the fundus and the ventral surface of the body of the uterus, peritoneum is reflected from the uterus at the region of the isthmus, the area

of junction of the body and cervix, toward the bladder. Between the uterus and the urinary bladder is the relatively shallow vesicouterine pouch. The mor

anterior disposition of the peritoneum is similar to that of the male pelvis.

Peritoneum continues laterally from the uterine fundus and body. Anteroinferior and posterosuperior layers of peritoneum ensheathe the uterine tubes on

their anterior, superior, and posterior surfaces, being suspended from the tubes as the broad ligament.

The peritoneum immediately adjacent to the uterine tube is called the mesosalpinx. The peritoneum by which the ovary and proper ligament of the ovary

are suspended is the mesovarium. The ovary itself is not covered by the peritoneum; the peritoneum is continuous with the germinal layer of epithelium of

the ovary (a misnomer).

Laterally, peritoneum continues to the brim of the pelvis over the ovarian vessels and nerves as the infundibulopelvic ligament, suspensory ligament, or

suspensory ligament of the ovary. Anterolaterally on each side, the round ligament of the uterus raises a fold of peritoneum in the paravesical fossa as the

round ligament ascends toward the brim of the pelvis, in its course to the deep inguinal ring.

After its reflection upward from the urinary bladder to the anterior abdominal wall, the vertical disposition of the peritoneum terminates at the umbilical

area. With this termination, the greater peritoneal sac is formed.

Transverse (Horizontal) Disposition in the Abdominal Cavity

The disposition of the peritoneum is quite different in degree of complexity in the upper abdomen, lower abdomen, and pelvis.

The pathway of the peritoneum transversely at the level of the spleen is as follows (Fig. 10-9): From the linea alba anteriorly, the peritoneum can be

followed to the right laterally and posteriorly, where it sequentially covers the right kidney and right suprarenal gland, inferior vena cava, and aorta. The

peritoneum then passes ventral to the pancreas, duodenum, and left kidney, having formed the posterior wall of the omental bursa. Here it reflects

upward as the right side of the splenorenal and gastrosplenic ligaments to attain and cover the posterior wall of the stomach. The peritoneum then

courses to the right, enveloping the hepatic roots and forming the anterior wall of the omental bursa. Proceeding medially, peritoneum covers the anterior

gastric wall, leaving it as the left side of the gastrosplenic ligament. After forming the gastrosplenic ligament, the peritoneum covers the spleen. It forms

the left side of the splenorenal ligament, covers the left kidney and proceeds to the posterior lateral and anterior wall toward the linea alba.

Fig. 10-9.

Transverse section through spleen.

In the lower abdomen, the peritoneum is raised by a median fold and two bilateral lateral folds. The result is five folds or plica (also called ligaments) (Fig.

10-10): a median umbilical fold, two medial umbilical folds, and two lateral umbilical folds. These c onverge toward the umbilicus.

Fig. 10-10.


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Bladder and anterior abdominal wall (posterior view). Possible pathways of external supravesical hernias shown on left; internal supravesical hernias shown on

the right. A,Supravesical fossa with mouth of supravesical hernia. B,Medial fossa. C,Lateral fossa. D,Inguinal ligament. E,Umbilicus. F,Middle (median) umbilica

ligament (ob literated urachus). G,Lateral (medial) umbilical ligament (obliterated umbilical artery). H,Inferior (deep) e pigastric artery. (Modified from Skandalakis

PN, Skandalakis LJ, Gray SW, Skandalakis JE. Supravesical hernia. In: Nyhus LM, Condon RE. Hernia (4th ed). Philadelphia: JB Lippincott, 1995; with pe rmission.)

The median umbilical fold of peritoneum results from the peritoneal coverage of the underlying urachus, which extends from the apex of the bladder below

to the umbilicus above.

Somewhat laterally, leaving the pelvic brim medial to the position of the femoral fossa (under which lies the femoral ring) and adjacent to the lateral

aspect of the bladder, the left and right medial umbilical folds of peritoneum are elevated by the obliterated portions of the left and right umbilical arteries

These also pass superiorly toward the umbilicus, invested by the vesicoumbilical fascia.

On each side, at the site of exit of the external iliac artery and vein from the abdomen, the inferior epigastric artery and vein pass upward and somewhat

medially to reach the rectus abdominis muscle. These vessels usually cause a slight ridge in the peritoneum, forming the lateral umbilical folds. These

course just medial to the dimple marking the position of t he deep ( internal) inguinal ring.

The two supravesical fossae, right and left (Fig. 10-10), are located between the median umbilical fold and the medial umbilical folds. The depths of these

fossae are related to the degree of fullness of the urinary bladder. The medial inguinal fossae are situated between the medial and lateral umbilical folds.

The lateral umbilical fossa is less distinct than the supravesical and medial inguinal fossa, and includes the deep inguinal ring, through which the embryonic

processus vaginalis and testis pass to enter the inguinal canal.

In the region of the inframesocolic compartment, peritoneum can be followed to the right laterally from the linea alba to the vicinity of the lateral border o

the quadratus lumborum muscle. Here the peritoneum is reflected forward over the right side of the ascending colon, lining the right paracolic gutter.

Passing across the ventral surface and the left side of the secondarily-retroperitoneal ascending colon, and investing the cecum and appendix, peritoneum

passes medially over the psoas muscle, the duodenum, and the inferior vena cava.

Passing ventrally from the posterior abdominal wall as the radix of the mesentery, peritoneum invests the superior mesenteric vessels, lymphatic elements

and nerves, ileum, and jejunum. The peritoneum then courses in a dorsal path toward the vertebral column. Thereafter the peritoneum can be followed to

the left as it passes across the aorta, the left psoas muscle, and the right side and ventral surface of the retroperitoneally-situated descending colon.


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er coverng e e s e o e escen ng coon, orms e oor o e e paraco c gu er an en nes e e s e o e n eror o e

abdominal wall to t he linea alba.

MALE PELVIS

Within the true (lesser or minor) pelvis of males, peritoneum forms a mesentery for the sigmoid colon, which extends from the left sacroiliac joint diagonal

to the front of the sacrum. Peritoneum covers the right and left sides of the first part of the rectum, but only the ventral surface of the second part of

the rectum, before it reflects upward to the bladder. On either side of the rectum, peritoneum lines the pararectal fossae and is elevated laterally as the

sacrogenital folds. Passing forward from the pararectal fossa and across the rectovesical fossa toward the bladder, the ureter causes a slight elevation of

the peritoneum. The depths of the pararectal fossae are variable, depending upon the degree of distension of the organ.

Somewhat further forward, peritoneum lines the rectovesical pouch between the bladder and rectum. The peritoneum then sweeps upward over the

superior portions of the seminal vesicles and the fundus and superior surface of the bladder. The rectovesical pouch is shallow enough that the peritoneum

does not contact the prostate gland.

On each side of the bladder is a paravesical fossa, where a peritoneal fold limiting the posterior extent of the fossa overlies the course of the ductus

deferens as it passes t oward the posterior aspect of the bladder to reach the prostate gland. Like the supravesical fossae, the depths of the paravesical

fossae are related to the degree of fullness of the bladder. When the bladder contains little or no urine, the transverse vesical fold may be seen crossing

its superior surface.

FEMALE PELVIS

The disposition of peritoneum in the posterior portion of the true pelvis in females is comparable to that in males, except that the uterosacral folds are

somewhat more prominent than the sacrogenital folds in the lateral aspects of the pararectal fossae. The uterosacral folds are formed by the coalescence

of the fascia of Waldeyer from the ventral surface of the sacrum and piriformis muscle fascia, together with underlying pelvic nerve elements which pass

lateral to the rectum toward the posterior fornix of the vagina and uterine cervix.

Between the rectum and the uterus, peritoneum lines the rectouterine pouch (cul de sac, or pouch, of Douglas), covering the posterior aspect of the

uterus and the posterior fornix of the vagina.

More anteriorly in the pelvis, the peritoneum is draped over the uterus and its appendages, forming the broad ligament. The superior part of the broad

ligament which is elevated by the uterine tubes is called mesosalpinx; the portion attached to the ovary and ovarian ligament is named mesovarium; that

which extends laterally from the ovary to the pelvic brim covers the ovarian vessels, lymphatics, and nerves and is referred to as the infundibulopelvic

ligament, or suspensory ligament of the ovary. Between this fold of peritoneum and the ureteric ridge provided by the peritoneum overlying the ureter is

the ovarian fossa. This fossa lies at the site of divergence of the internal iliac (hypogastric) and external iliac arteries.

The remainder of the broad ligament, covering most of the uterus and suspended like a blanket from one pelvic sidewall to the other is generally termed

the mesometrium. From the anterior aspect of each side of the body of the uterus, the round ligament elevates the peritoneum to a variable degree as it

passes forward and upward from the uterus to cross the pelvic brim in its passage to the deep inguinal ring.

Between the uterus and the urinary bladder, peritoneum lines the shallow vesicouterine pouch. The disposition of the peritoneum over the bladder in the

female is similar to that in the male, with lateral paravesical fossae which are limited posteriorly by the elevation of peritoneum over the round ligaments o

the uterus. A transverse vesical fold of peritoneum may, likewise, be seen in the female pelvis when the bladder is not distended. Laterally, beginning at

the pelvic sidewall in the paravesical fossae, the obliterated umbilical arteries pass medially and upward toward the umbilicus, passing close to the bladder

and raising the bilateral ridges of peritoneum, the medial umbilical folds, or ligaments.

Vascular Supply of the Peritoneum

The blood supply to the abdominal parietal peritoneum is from the branches of the arteries of the abdominal wall. The blood supply of the pelvic parietal

peritoneum is from the blood vessels of the pelvic wall. Blood to the visceral peritoneum is from branches of the celiac trunk and from branches of the

superior and inferior mesenteric arteries, or the pelvic visceral blood vessels.

Lymphatics of the Peritoneum

The lymphatics of the parietal peritoneum join the lymphatics of the body wall, and all drain to parietal lymph nodes. However, the lymphatics of the

visceral peritoneum join the lymphatics of the related organs and are drained accordingly.

Allen and Weatherford24described the removal of particles of 10-20 microns from the peritoneal cavity through openings of the basement membrane with

the help of the peritoneal lymphatics. These peculiar lymphatics were found only in the peritoneum covering the abdominal surface of the diaphragm.

In 1863, Von Recklinghausen25was the first to describe the modified lymphatics which are able to remove particles from the peritoneal fluid during the

process of respiration. The relaxed diaphragm permits opening of the stomata of these lymphatic vessels, and the fluid enters the lymphatic circulation.

Higgins et al.26reported that contractions of the diaphragm pump the lymph and its contents (particulate matter and molecular substances) upward,

aided by one-way valves which are located within the lymphatics of the retrosternal area.

Innervation of the Peritoneum

The parietal peritoneum contains somatic afferent nerves. The peritoneum contains many sensory fibers for the sensation of pain; the anterior portion of

the parietal peritoneum is especially sensitive. The parietal peritoneum, therefore, is similar in sensitivity to the parietal pleura of the thorax.

In contrast, the visceral peritoneum has no somatic afferent nerves and is relatively insensitive to pain. Sensations which do occur are poorly perceived

and not clearly localized by the brain, as is characteristic of visceral afferent fibers carried by autonomic nerves to viscera in general. The principal

stimulus which can evoke pain from visceral peritoneum is tension upon or stretching of the tissue, or ischemia. A perforated viscus may, perhaps, produc

anterior abdominal wall rigidity, and an intraperitoneal fluid collection may produce painlike sensations of traction or tension on the mesentery in the

retroperitoneal space, but not localized pain. A similarity can be seen here also between visceral pleura and visceral peritoneum, in that the visceral pleura

which invests the lungs is relatively insensitive to pain.

Remember

The innervation of the parietal peritoneum, from above downward, is as follows.


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The peritoneum that covers the abdominal surface of the diaphragm is innervated at the pe riphery by the lower six pairs of intercosta l nerves and the sub costa

nerves

Phrenic nerves convey sensory fibers from the peritoneum over the more centrally-disposed parts of the diaphragmatic peritoneum. Pathological process of the

centrally-located peritoneum over the diaphragm is referred as pain by the phrenic nerves to the distribution of spinal nerve levels C3, C4, and C5 over the

shoulder regions

The lower 6 intercostal and lumbar nerves innervate the parietal peritoneum of the abdominal cavity

The pelvic peritoneum is innervated by the ob turator nerve

The innervation of the visceral peritoneum is uncertain, but sensory fibers for pain are carried by thoracic and lumbar splanchnic nerves.

Peritoneal Fossae and Recesses

Paraduodenal Fossae

The peri- or paraduodenal fossae (Fig. 10-6, Table 10-3) are "pockets" of the peritoneum on the posterior abdominal wall adjacent to the duodenal-jejuna

junction, part icularly to the left of the junct ion. These fossae are enigmatic embryologically, anatomically, and c linically. They are inconstant: that is, any

all, or none can be found in any one person. The boundaries of these fossae are complex; size, length, depth, and direction are all involved in naming the

actual anatomic entities related to them. Remember, the paraduodenal fossa may be intimately related with the inferior mesenteric vein.

Foramen of Winslow

The epiploic foramen of Winslow (Fig. 10-4) is an open, normal aperture. It has the following boundaries:16

Superior:Caudate process of liver and inferior layer of coronary ligament (rare extension to left coronary ligament with hernia)

Anterior:Hepatoduodenal ligament and hepatic triad (portal vein, hepatic artery, common bile duct; cystic duct also present in free edge of lesser omentum)

Posterior:IVC

Inferior:First part of duodenum and transverse part of hepatic artery

Ileocecal Fossae

The superior and inferior ileocecal folds form the ileocecal fossae (Fig. 10-11). A third fossa, known as the retrocecal or subcecal fossa, may occasionally

appear.

Fig. 10-11.


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Hernia into the superior ileocecal fossa. A,Superior and inferior ileocecal folds fo rming fossae. B,The intestinal loop has been trapped by the right mesocolon

during the fusion with the peritoneum of the body w all. (Modified from Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skandalakis JE.

Modern Hernia Repa ir: The Embryological and Anatomical Basis of Surgery. New York: Parthenon, 1996; with permission.)

The superior ileocecal fossa has the following boundaries:

Anterior:Ileocecal fold and ileocecal artery

Posterior:Mesentery of te rminal ileum and late ral right (ascending) colon

Medial:Below the terminal ileum

The inferior ileocecal fossa has the following boundaries:

Anterior:Ileocecal fold

Posterior:Mesoappendix

Inferior:Medial continuation of ileocecal fold

Superior:Terminal ileum and mesentery

The retrocecal or subcecal fossa, when present, has inconstant boundaries which depend on both its depth and its medial and lateral expansion. It is

found between the right colic gutter and the posterior surface of the cecum at the ileocecal gutter. It does not exist in the presence of a mobile cecum.

The senior author of this chapter (JES) has seen a herniation of the terminal ileum behind the cecum.

Intersigmoid Fossa

The intersigmoid fossa (Fig. 10-12A & B) is located in the pelvic mesocolon, which occupies the space from the pelvic wall to S3. The pelvic mesocolon

has the shape of the Greek letter LAMBDA ( ).

Fig. 10-12.


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A, Average measurements of sigmoid mesocolon. B, Relation of base of sigmoid mesocolon to left urete r. (Modified from Skanda lakis JE, Gray SW, Rowe JS Jr.

Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission; data in Fig. 10-12A from Vaez-Zadeh K, Dutz W. Ileos igmoid knotting

Ann Surg 1970;172:1027.)

The attachment of the mesosigmoid to the body wall most commonly starts in the left iliac fossa, extending downward and to the right on a diagonal. The

attachment may also be sinuous, or shaped like a "C," "S," or inverted "U." Variations in length and breadth of this mesentery may occur by race and/or

diet.

The left ureter passes through the base of the sigmoid mesocolon in its course through the intersigmoid recess (Fig. 10-12B). The mouth of the fossa is

directed downward and to the left. The anatomic entities thus associated with the intersigmoid recess are the left ureter and the exterior iliac vessels.

Supravesical Fossae

The supravesical fossae (Fig. 10-10) are located between the median umbilical ligament (obliterated or non-obliterated urachus) and the medial umbilical

ligament (obliterated umbilical arteries). It partially overlies the area of the modern perception of the boundaries of the triangle of Hesselbach (Fig. 10-13

Fig. 10-13.


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Part of the supravesical fossa lies within the Hesselbach triangle. The triangle as originally described is shown in the left of the diagram; and as accepted today

on the right. (Modified from Skandalakis PN, Skandalakis L J, Gray SW, Skanda lakis JE. Supravesical hernia. In: Nyhus LM, Condon RE. Hernia (4th ed).

Philadelphia: JB Lippincott, 1995; with pe rmission.)

The floor of each supravesical fossa is formed in part by contributions of the endopelvic fascia, the transversalis fascia, and preperitoneal connective

tissue. In the presence of an empty bladder, the proximal part of the supravesical fossa is formed by the transversalis fascia. The vesical fascia and the

vesicoumbilical fascia, which continues upward to the umbilicus, is derived from preperitoneal connective tissue. This tissue continues into the pelvis

where it is continuous with the endopelvic fascia of the so-called lateral pillars of the bladder.

The upward continuation of the vesical fascia gradually becomes united with the transversalis fascia somewhere between the umbilicus and the

semicircular line of Douglas. Keynes27considered the transverse fold of the bladder the lower limit of the supravesical fossa; we concur. Although the

transverse fold of the bladder is more marked in certain individuals, to go beyond this more typical line would unnecessarily expand the concept of the

supravesical fossa.

Rare and Abnormal Peritoneal Folds

Occasionally adhesions, bands, and folds may be present in a virgin peritoneal cavity (one without previous surgery or inflammatory process). In most

cases their presence is quite benign. At times, they can be the cause of partial or complete intestinal obstruction.

The embryogenesis of these entities is enigmatic. Their location, size, length, width, etc., are not always constant. The following bands have been noted,

beginning from above and proceeeding downward.

At the right upper quadrant and the gallbladder area (on the right): In surgery and disse ction, Skandalakis has viewed different anomalous or variable peritonea

(lesser omental) folds from the gallbladder. In order of frequency, they are the cholecystoduodenal fold, the cholecystocolic fold, and the cholecystogastric fold

(Fig. 10-14).

On the left: A band which is unrelated to the ligament of Treitz or to the paraduodenal fossae may occasionally bridge the duodenojejunal junction to the

transverse mesocolon.28

At the right lower quadrant: The membrane of Jackson is a thin sheet of peritoneum occasionally containing small blood vessels. It spreads from the right lateral

gutter to the right edge of the greater omentum, or occasionally, to the mesentery of the small bowel, partially covering the ascending colon, cecum and appendix

It may be narrow or wide.

A thin band may run from the te rminal ileum to the ret roperitonea l space.28

The so-called sustentaculum hepatis is a band that anchors the right wall of the ascending colon to the lateral abdominal wall at about the level of the iliac

crest.28

At the left lower quadrant: At the proximal and distal ends of the sigmoid colon, a fibrous band brings the ends together.28

There may be another band which fixes the proximal sigmoid colon to the posterior abdominal wall.28

Fig. 10-14.


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Inconstant peritoneal folds o f gallbladder to duodenum, colon, or stomach. (Modified from Skanda lakis JE, Gray SW. Surgical anatomy of intestinal obs truction. In:

Fielding LP, We lch JP. Intestinal Obstruction. Edinburgh: Churchill Livingstone , 1987; with permission.)

Compartments of the Peritoneum

The peritoneal cavity can be divided into two major compartments by an imaginary cross-sectional plane that passes through the transverse mesocolon.

This division defines a supracolic and an infracolic compartment (see Fig. 10-7).

Within the supracolic compartment, the liver determines a right and left suprahepatic (subdiaphragmatic) space and a right and left infrahepatic space.

The infracolic compartment is divided by the mesentery of the small bowel into a right infracolic (supramesenteric) compartment, a left infracolic

(inframesenteric) compartment, and the pelvic cavity (compartment). In addition, there are right and left paracolic gutters, discussed later in this

chapter. The left gutter is infracolic only, being interrupted by the phrenicocolic ligament. The right gutter extends upward into the supracolic

compartment. There is no right phrenicocolic ligament.

The pelvic cavity is divided into right and left spaces by the sigmoid colon and the rectum. It is further subdivided in the female into anterior and posterio

spaces by the broad ligament, uterine tubes, and uterus.

Supracolic Compartment

MESOGASTRIA

Ventral Mesogastrium

From a technical standpoint, there is no question that the supracolic compartment is the most difficult surgical area of the peritoneal cavity. Our

description is based on the work of Livingston,1Ochsner and Graves,29Mitchell,30Autio,31Boyd,32Whalen,33Harley,34and Meyers.35

Early in development there is a dorsal and a ventral mesentery. The ventral mesentery disappears, except for that of the foregut. Its persisting segment

extends from the umbilicus to the abdominal esophagus. The liver divides the ventral mesentery into the falciform ligament anteriorly and the lesser

omentum posteriorly. The falciform, coronary, and hepatogastric ligaments are derivatives of the primitive ventral mesogastrium. The greater omentum an

the gastrophrenic ligament are derivatives of the dorsal mesogastrium.

The falciform ligament begins at the umbilicus. It is attached to the abdominal wall and passes to the superior surface of the left lobe of the liver, where it

separates the lateral and medial segments of the left lobe.

The free edge of the falciform ligament contains the paraumbilical veins (of Sappey) and the cordlike round ligament (ligamentum teres) of the liver. This i

the remnant of the left umbilical vein. The right umbilical vein disappears early in development. The left umbilical vein carries placental blood to the fetus

and closes at birth. This vascular remnant is often patent for much of its length. 36The intrahepatic portion of the left umbilical vein becomes the

ligamentum venosum, which connects the left branch of the portal vein with the left hepatic vein or the inferior vena cava. The falciform ligament is thus

the mesentery of the left umbilical vein.

The lesser omentum is divided into the hepatogastric ligament and the hepatoduodenal ligament (Fig. 10-15). The hepatogastric ligament extends from th

porta hepatis to the lesser curvature of the stomach and the abdominal esophagus. The ligament encloses the gastroesophageal junction on the right.The two leaves rejoin on the left as the gastrosplenic ligament, a portion of the embryonic dorsal mesentery. The posterior leaf does not reach the

gastroesophageal junction, so there is a small bare area on the posterior wall of the stomach that lies on the left crus of the diaphragm. It is related to

the left adrenal gland and the left gastric artery and vein.37

Fig. 10-15.


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Mesente ries o f the stomach. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with

permission.)

The hepatogastric ligament contains the left gastric artery and vein and the hepatic division of the anterior vagal trunk. Occasionally, it may contain the

right gastric artery and vein and both vagal trunks. In about one-fourth of subjects, it contains the aberrant left hepatic artery, which arises from the lef

gastric artery.38This aberrant left hepatic artery is liable to injury in the now rarely performed highly selective vagotomy operation or other procedures fo

benign disease in the perigastric region, such as gastric devascularization for portal hypertension.

The hepatoduodenal ligament extends between the liver and the first portion of the duodenum, practically forming the right border of the hepatogastric

ligament. It contains the common bile duct, the hepatic artery, and the portal vein. In about one-fifth of patients, it contains an aberrant right hepatic

artery, usually arising from the superior mesenteric artery. This aberrant right hepatic artery invariably lies behind the portal vein as it passes upwardtoward the liver, and therefore contrary to expectations is not usually in danger of injury during resection of the bile duct or hepatoduodenal ligament in

pancreaticobiliary operations. The prudent surgeon will, however, check for its presence once the posterior aspect of the portal vein has been exposed.

The hepatoduodenal ligament can be considered the mesentery of the portal triad. It is also the anterior boundary of the epiploic foramen of Winslow.

The coronary ligaments, as indicated previously, also are remnants of the embryonic ventral mesentery (Fig. 10-15). Their outer surface is peritoneum,

whereas their inner surface forms the boundary of the bare area. The right and left lateral extremities of the coronary ligaments are the triangular

ligaments. They are not located linearly: the right is more posterior and lateral; the left is more superior and medial. The coronary and triangular ligaments

are described in more detail in the chapter on the stomach.

Dorsal Mesogastrium

The primitive dorsal mesentery (Fig. 10-16A), unlike the ventral mesentery, persists in the adult. In the supracolic compartment, it forms the greater

omentum. Originally, the dorsal mesentery extended from the dorsal border of the stomach to the midline of the dorsal (posterior) body wall (Fig. 10-16A)

This simple relationship becomes altered by the counterclockwise rotation of the stomach through 90, and by the developing spleen.

Fig. 10-16.


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A,Primitive embryonic relations. B,Adult relations. Note location of ligaments. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in

General Surgery. New York: McGraw-Hill, 1983; with permission.)

For all practical purposes, the embryonic dorsal mesogastrium is the adult greater omentum. It can be divided into three parts:

Upper: gas trophrenic ligament

Middle: gastrosplenic ligament

Lower: gastrocolic ligament

The gastrophrenic ligament extends from the proximal greater curvature of the stomach, the gastroesophageal junction, and the abdominal esophagus to

the diaphragm. The upper part is avascular; the lower part contains some short gastric vessels and lymph nodes.

The middle portion of the dorsal mesentery is interrupted by the spleen to form a posterior splenorenal ligament and a more anterior gastrosplenic ligamen

(Fig. 10-16B, Fig. 10-17A). Together, these form the splenic pedicle (Fig. 10-17A & B).

Fig. 10-17.


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Splenic ped icle. A,Long pedicle with a presplenic fold. B,Short pedicle. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General

Surgery. New York: McGraw-Hill, 1983; with permission.)

The splenorenal ligament contains the splenic artery and vein and the tail of the pancreas. The gastrosplenic ligament contains the short gastric and left

gastroepiploic vessels. These relationships are described in more detail in the chapter on the spleen.

The gastrocolic ligament is the part of the dorsal mesogastrium between the greater curvature of the stomach and the transverse colon. At its earliest

appearance, the mesogastrium includes the duodenum and the pancreas; it attaches to the posterior body wall (Fig. 10-18A). By the fourth month of

gestation, the duodenum and the pancreas have become retroperitoneal (Fig. 10-18B and 10-19A-C). The future omentum has formed a sac, the omenta

bursa, that extends in front of the transverse colon (Fig. 10-18B). Fusion of the anterior and posterior walls of the dependent portion of the omental

bursa obliterates most of the lower recess of the bursa, leaving only the superior portion of the cavity behind the stomach and in front of the colon (Fig.

10-18C).

Fig. 10-18.

Development of omentum and lesser sac. A,At two months. Duodenum and pancreas are contained in dorsal mesogastrium. Arrow indicates opening of epiploic

foramen into lesser sac. B,At four months. Duodenum and pancreas are retroperitoneal; greater omentum is elongating. C,Adult configuration. Cavity of greate romentum is ob literated; pos terior wall has fused w ith transverse colon (TC) and transverse mesocolon. L, liver; S, stomach; J, jejunum; P, pancreas; D,

duodenum. Dashed line indicates p lane of fusion. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York:

McGraw-Hill, 1983; with permission.)

Fig. 10-19.


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Changing relations of duodenum, pancreas, and posterior body wall in developing embryo. A,Primitive ventral mesente ry and dorsa l and ventral pancrea tic

primordia are present. B,Disappearance of ventral mesentery and fusion of pancreatic primordia. C,Final retroperitoneal position of duodenum and pancreas.

Compare w ith Figure 10-18C. (Modified from Skanda lakis JE, Gray SW, Row e JS, Skandalakis LJ. Anatomical complications of pancreatic surge ry. Contemp Surg

15:17-40, 1979; with pe rmission.)

The anterior wall of the sac in the adult remains free; the posterior layer fuses with the transverse colon and the mesocolon. Only with this fusion does it

become entitled to the name gastrocolic ligament. The size and extent of the omental bursa depends on the degree of fusion of the two walls of the sac

below, as well as on the fusion of the posterior wall of the sac with the transverse mesocolon. The right portion, which arises from the antrum of the

stomach, is frequently fused with the anterior surface of the head of the pancreas. The omentum should be freed from the pancreas from left to right. 39

Where two peritoneal layers of the posterior wall of the bursa fuse with two peritoneal layers of the transverse mesocolon, there are, at first, four

peritoneal layers. Only the two outer layers, above and below, are found in the adult mesocolon.

SPACES OF THE SUPRACOLIC COMPARTMENT

The several spaces formed by the peritoneum around the organs of the supracolic compartment are extremely important to radiologists and surgeons. We

are concerned here with those above and below the liver, the perihepatic spaces.

Suprahepatic (Subphrenic) Spaces

Parts of the superior surface of the liver and the inferior surface of the diaphragm are in direct contact with one another, and are thus barren of

peritoneal covering. This is the bare area. The margins of the bare area are the falciform, coronary, and triangular ligaments of the liver (see Fig. 10-8).

Except over this bare area, the serous surfaces of the liver and the diaphragm are in apposition, with a potential space between. This potential space may

become the site of intraperitoneal fluid collection and of suprahepatic (subphrenic) abscesses. The potential space is divided into right and left spaces by

the falciform ligament.

The right suprahepatic space (Fig. 10-20) lies between the diaphragm and the anterosuperior surface of the right lobe and the medial segment of the left

lobe of the liver. The medial boundary is the falciform ligament; the posterior boundary is composed of the right anterior coronary and right triangular

ligaments. The inferior boundary is the right lobe and the medial segment of the left lobe of the liver. The space opens into the general peritoneal cavity

anteriorly and inferiorly.

Fig. 10-20.


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Parasagittal section through right upper abdomen showing potential right suprahepatic and subhepatic spaces. Thick black line represents diaphragm. (Modified

from Skanda lakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

The corresponding suprahepatic space on the left (Fig. 10-21) is between the diaphragm and the superior surface of the lateral segment of the left lobe

of the liver and the fundus of the stomach. Medially, the left suprahepatic space is bounded by the falciform ligament and, posteriorly, by the left

coronary and triangular ligaments. Anteriorly and laterally, the space communicates with the infrahepatic space and the general peritoneal cavity.

Remember: on the left, the anterior and posterior leaves of the coronary ligament are in apposition.

Fig. 10-21.

Parasagittal section through left upper abdomen showing potential left suprahepatic and subhepatic spaces. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr.

Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

Each of these spaces may be divided into anterior and posterior portions. The distinction is unimportant in the absence of disease. On the right (Fig. 10-

22), fluid may collect or an abscess may form between the liver and the diaphragm anteriorly, just beneath the sternum (right anterior suprahepatic

abscess), or it may form at the reflection of the anterior leaf of the coronary ligament (right posterior suprahepatic abscess) (Fig. 10-23). The single

space of the anatomist may thus be divided by pseudomembranes into two spaces.

Fig. 10-22.


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Relations of abscess in anterior portion of right suprahepat ic space. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General


Fig. 10-23.

Relations of abscess in poste rior portion of right suprahepatic space. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General


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The left suprahepatic space (Figs. 10-24, 10-25) may be similarly compartmentalized by pseudomembranes between the liver and the diaphragm or the

abdominal wall. The left suprahepatic and left anterior infrahepatic spaces are not separated anatomically, but they may become separated pathologically

by pseudomembranes. Large accumulations of fluid may extend into the subhepatic space, where the stomach, spleen, and liver participate in walling off

the infection. The diaphragm is usually elevated over the abscess or fluid collection.

Fig. 10-24.

Relations of abscess in anterior portion of left suprahepatic space. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General


Fig. 10-25.


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Relations of abscess in poste rior portion of left suprahepatic space. (Modified from Skanda lakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General


Localization, extension, and size of the suprahepatic abscess or collection will determine the surgical approach. The surgeon and the radiologist mustcooperate to evaluate the anatomy that is altered by the formation of membranes and the pressure of the abscess.

Anteriorly, the approach from beneath the costal margin presents no anatomic complications. Posteriorly, the approach must be by an incision at the leve

of the spinous process of the first lumbar vertebra to avoid entering the pleura. Remember the relationship of the pleura and the 12th rib at the vertebral

spine. Do not open the bed of the 12th rib.

Nowak et al.40advocated the dorsolateral approach to the left subphrenic area as well as to the omental bursa and the tail of the pancreas. This is a

particularly useful approach by a surgeon or radiologist for the drainage of a left-sided pancreatic abscess complicating acute pancreatitis. The approach

does not violate the peritoneal cavity and provides dependent drainage in the recumbent patient.

Infrahepatic Spaces

The right infrahepatic space (subhepatic space, hepatorenal space, pouch of Morison) (Fig. 10-26) is bounded superiorly and anteriorly by the right lobe

and the medial segment of the left lobe of the liver and the gallbladder, and superiorly and posteriorly by the posterior layer of the coronary and right

triangular ligament. Inferiorly, the space opens into the general peritoneal cavity and is partly bounded by the hepatic flexure of the colon and the

transverse mesocolon and, medially, by

chapter 10 peritoneium, omenta, and internal

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