8 Mousa Salah Dr. Mohammad Al. Mohtasib 1 P a g e
In the previous lecture we talked about the peritoneum, and we said that the peritonium is a serous sac, and it consists of two layers, visceral and parietal. We said that the peritoneum cavity consists of two sacs, greater sac and lesser sac. We said also that the two layers of peritoneum together make: - 1. Omenta: greater omentum (policeman of the abdomen) or lesser omentum. 2. Mesenteries: mesentery of small intestine, mesocolon which is the mesentery of transverse colon or mesentery of sigmoid. 3. Ligaments We said also that the functions of the two layers of the peritoneum: - 1. Delivering blood supply. 2. Delivering nerve supply. 3. They contain lymph nodes, lymph vessels and fat. In this lecture we will talk about the ligaments of peritoneum. the ligaments of the liver 1. The falciform ligament of liver 2. The ligamentum teres hepatis 3. The coronary ligament 4. The right triangular ligament 5. The left triangular ligament 6. The hepatogastric ligament 7. The hepatoduodenal ligament 1 P a g e
All of these ligaments composed of two layers of peritoneum, most of them are fibrous tissue. The liver is an interperitoneal organ, because it is not covered completely by the peritoneum, the bare area of the liver is not covered. - The falciform ligament: Sickle in shape It divides the liver into right and left lobes it is attached to the anterior abdominal wall, which means that the falciform ligament divides the space under the diaphragm into subdiaphragmatic space on the right side and subdiaphragmatic space on the left side. we can notice this division between the spaces when someone for example has appendicitis and no appendectomy was done to him, in this case usually pus starts to form and move up in the right side toward the diaphragm which accumulates under it developing what we call subdiaphragmatic abscess, this abscess cannot be on the left side because there are organs that prevent the pus to reach to it and also because of the falciform ligament that divides it from the right side. - ligamentum teres In the free edge (the end) of the falciform ligament we have the ligamentum teres also called round ligament of liver, it is an obliterated umbilical vein which means that the umbilical vein was existing in the fetus but it got obliterated and transformed into a fibrous tissue which we call ligamentum teres. 2 P a g e
- The coronary ligament It consists of two layers (anterior and posterior). between the two layers there is the bare area of the liver, which means that this area doesn t have peritoneum. The connection of the coronary ligament at the edges of the liver (right or left) makes on the left side the left triangular ligament and on the right side the right triangular ligament. - The hepatogastric and the hepatodudenal ligaments Together they form the lesser omentum. The hepatogastric ligament connects to the lesser curvature of the stomach. The hepatoduodenal ligament connects to the duodenum. The foramen of winslow located under the free edge of lesser omentum, this foramen has important contents which are the portal vein, common bile duct and hepatic artery. 3 P a g e
Ligaments of spleen - Gastrosplenic ligament We said that the spleen is the lateral boundary of the lesser sac, this ligament Connects the fundus of stomach to hilum of spleen. Contents of this ligament: 1. Short gastric arteries: they are five to seven branches that arise from the splenic artery, they supply the fundus of the stomach. 2. Left gastroepiploic artery: it is also a branch from the splenic artery, runs in the greater omentum to supply the body of stomach. - Splenorenal ligament Extends between the hilum of the spleen and the left kidney. Contents: 4 P a g e 1. The splenic artery: arises from the celiac trunk which is a branch from the abdominal aorta, it supplies the foregut. 2. The splenic vein 3. Lymphatic vessels, nodes and nerve 4. The tail of pancreas
This ligament is important in surgeries (splenectomy). Any trauma in the left side of the body especially on the level of the 9 th, 10 th and 11 th ribs, can cause rupture in the spleen, the spleen is considered the reservoir of the blood so any trauma in it can cause bleeding, also we cannot place stiches in it, so the only solution is splenectomy, in this surgery the doctors open the splenorenal (lienorenal) ligament and they find between the two layers the splenic vessels, so they do two ligations (to prevent bleeding) and a cut to each vessel and by that there is no more blood supply to the spleen, after that they will find in their way the tail of pancreas which is friable, so it secretes whenever there is trauma or friction, this secretion causes peritonitis, so the surgeon must be cautious in dealing with it, at the end the surgeon removes the spleen, the patient can live without it because it is considered a lymphatic organ and there are other organs that can do the rest of its functions. - Phrenicosplenic ligament: it is between the diaphragm and the spleen, it keeps the spleen in its place. - Splenocolic ligament: it is between the spleen and the left colic flexure of the transverse colon, it keeps the spleen in its place above it. 5 P a g e
These two legaments keep the spleen above and separate it from the other organs like the descending colon. Also they prevent the pus from accumulation on the left side of the subdiaphragmatic space, we said before it is because of the organs but now it is much clearer that the ligaments that connect between the diaphragm and the spleen and the left colic flexure prevent the formation of the abscess on the left side. Ligaments of stomach They are important to hold the stomach in its place 1. Hepatogastric ligament 2. Gastrosplenic ligament: between greater curvature of the stomach and the spleen. 3. Gastrophrenic ligament: between the stomach and diaphragm. 4. Gastrocolic ligament: between the stomach and transverse colon. 5. Gastropancrestic ligament: connects the stomach from behind with the pancreas. 6 P a g e
The suspensory ligament of duodenum It is also called ligament of Treitz, it is placed at the junction between jejunum and last inch of duodenum, it ascends upward and to the right because it is attached to the right crus of diaphragm. The diaphragm has vertebral, costal and sternal origins, the right crus originates from the lateral side of the bodies of the upper three lumber vertebra while the left crus originates from the upper two lumber vertebra, so the right crus has a bigger origin which gives it two features: 1. Sling around the esophagus which means its fibers goes around the esophagus. 2. It attaches to the ligament of Treitz This ligament is considered the landmark to the beginning of the jejunum, so it is important in the gastrojejunostomy operation, so basically the surgeon makes an opining in the stomach and the jejunum and connects the two openings together so the food begins to go directly from the stomach to the jejunum. So how the surgeon knows where the jejunum is? He goes to ligament of Treitz which is placed in the beginning of the jejunum and in the end of the duodenum. The duodenum is retroperitoneal so the surgeon cannot move it while the jejunum has mesentery so the surgeon can move it and connect it to the stomach. 7 P a g e
The phrenicocolic ligament It connects the left colic flexure to the diaphragm, it is related to the 10 th, 11 th and 12 th ribs on the lateral side. This ligament is important in separation, so no material can go up under the diaphragm. The peritoneal recesses and fossa Recess or fossa means if the organ was retroperitoneal (peritoneum only on the anterior wall) and becomes intraperitoneal (peritoneum completely surrounds the organ) like duodenojejunal or iliocical, this conversion forms fossa or recess which is space surrounded by peritoneum. For example, the appendix can be in many places, it can be parailial which means next to the ilium, or It can be rertocecal which means behind the cecum there is a recess that can enter in it. Another example, surrounding the duodenum we can find paraduodenal recess or space. The recesses have disadvantages, sometimes the small intestine either the jejunum or ilium goes in the recess and puts pressure on it, this might lead to something we call an internal hernia, the internal hernia is entering of the small intestine (mostly) in the recesses either the paraduodenal or retrocecal recess, this may cause cut in the blood supply of the intestine, by that the internal hernia becomes strangulated hernia (degeneration also called gangrene), so if the surgeon found out that some of the intestine had become gangrene, he remove it and connect the two ends of intestine together, if it was viable the surgeon get it out of the fossa then he close it (the fossa). These recesses mainly exist around the duodenum, cecum and sigmoid colon in the pelvis, sometimes around the epiploic foramen. 8 P a g e
Duodenal Recesses 1. The superior duodenal recess 2. The inferior duodenal recess 3. The paraduodenal recess 4. The duodenojejunal recess Cecal recesses 1. The superior ileocecal recess 2. The inferior ileocecal recess 3. The retrocecal recess: we said that the appendix goes in this fossa in 70% of the cases, this does not lead into any complications because it has the mesoappendix, but when we want to do appendectomy we should get it out from the fossa. 4. The rectocolic recess: between the sigmoid colon and the rectum. The intersigmoid recess: exists in the pelvis, it has a V shape attachment, we will talk about it with the sigmoid colon. Hepatorenal recess: it exists between the liver and the right kidney, it is important because sometimes when pus forms from the appendix, instead of going in the subdiaphragmatic space, it may go between the right kidney and the liver in what we call Morison s pouch. 9 P a g e
The pouches The peritoneum contains pouches, the pouch is a large fossa, clinically important because it may cause internal abdominal hernia and pus can accumulate in it. rectovesical pouch (in male) the rectum is divided into upper middle and lower thirds, the upper third is surrounded completely by peritoneum, in the middle third the peritoneum is only anterior, the lower third has no peritoneum. When the peritoneum goes in front of the middle third of the rectum toward the superior border of urinary bladder, before the urinary bladder there is the rectovesical pouch. Or when the peritoneum goes from the anterior abdominal wall to the upper surface of urinary bladder, it forms the rectovesical pouch then it goes posteriorly. The sigmoid colon or the ilium may fill up this pouch, or the pus may also do so. 10 P a g e
Pouches in female - Rectouterine pouch (Douglas pouch) between rectum and uterus, it also covers the posterior fornix of vagina - Vesicouterine pouch (Uterovesical pouch): between bladder and uterus Peritoneal subdivisions When the peritoneum goes from the transverse colon and transverse mesocolon to the anterior border of pancreas it divides the greater sac into: - Supracolic compartments: divided into Subphrenic space: it is located under the diaphragm, Divided by the attachment of Falciform ligament into: 1. Right subphrenic space: it is opened 2. Left subphrenic space: it is closed Subhepatic space: it is located under the liver, divided into: 1. right subhepatic space (morison s pouch): the pus accumulates in it. 2. left subhepatic space (lesser sac) 11 P a g e
When someone sleeps on the back, the two biggest cavities will be in the pelvis and the thorax because the lumber vertebra will be raised upward, in contrast when someone sits with his back straight, the biggest cavity will be in the pelvis. So when someone has chronic appendicitis, the pus starts to accumulate, so this patient always sleeps on his right side with his knees on his abdomen by that the fluid instead of staying in the pelvis, it goes to the,(قرفصاء) subhepatic or subphrenic space on right side. - Infracolic compartments The ascending and descending colons are retroperitoneal which means the peritoneum covers them anteriorly and laterally, by that they are fixed in the posterior abdominal wall. Around them there will be what we call gutters. Gutter means groove around the ascending or descending colon, the fluids run in this groove, the peritoneum fixes these grooves (gutters) in their places. Infracolic compartments are divided into: - Right paracolic sulcus (gutter): Subdivided into: - 1. Right medial paracolic 2. Right Lateral paracolic 12 P a g e
Left paracolic gutter: Subdivide into: - 1. Left medial paracolic 2. Left Lateral paracolic The Right medial paracolic gutter is closed by the transversed colon and the ilium, while the Left medial paracolic gutter is open so the fluid can move toward the pelvis from it. In the Left Lateral paracolic gutter, the fluid cannot go upward because there is the phrenicocolic ligament between the diaphragm and the left colic flexure, so it goes downward to the pelvis. But in the appendicitis case, the right lateral paracolic gutter is open so the pus goes upward to the subdiaphragmatic space or morison s pouch. So, if acute appendicitis develops into chronic appendicitis, there will be accumulation of pus in the subdiaphragmatic space which will cause subdiaphragmatic abscess or it will accumulate in morison s pouch which will cause morison s abscess, the only solution is drainage of the pus. 13 P a g e BEST OF LUCK