Lecture 3: Peritoneum

Question 1

Discuss the location, neurovasculature, sensitivity, and pain localization of the parietal peritoneum

Answer 1

Location = lines body wall

Neurovasculature = supplied by same blood, nerve, and lymphatics as the region of the wall it lines

Sensitivity = to pressure, pain, and temperature

*Pain is well localized

Question 2

Discuss the location, neurovasculature, sensitivity, and pain localization of the visceral peritoneum

Answer 2

Location: covers the organs

Neurovasculature: same blood, nerve, and lymph supply as the organ it covers

Sensitivity: stretch and chemical irritation

*Pain is poorly localized

Question 3

How do we differentiate intraperitoneal vs. retroperitoneal?

Answer 3

Intraperitoneal: completely covered w/ visceral peritoneu

Retroperitoneum: outside the peritonal cavity and are only partially covered w/ peritoneum

Question 4

Describe the greater omentum (layers, ligaments)

Answer 4

• Four-layered peritoneal fold
• Gastrophrenic lig.
• Gastrosplenic (gastrolienal) lig.
• Gastrocolic lig.

Question 5

Describe the lesser omentum (layers, ligaments).

Answer 5

• Double-layered peritoneal fold
• Hepatoduodenal lig.
• Gastrohepatic lig.

Question 6

How is the liver connected to the anterior abdominal wall, stomach, and duodenum?

Answer 6

Anterior abdominal wall –> Falciform lig.

Stomach –> Hepatogastric lig.

Duodenum –> Hepatoduodenal lig.

Question 7

What’s significant about the hepatoduodenal lig?

Answer 7

Conducts the portal triad: portal vein, hepatic artery, bile duct

Question 8

How is the stomach attached to the inferior diaphragm, spleen, and transverse colon?

Answer 8

Inferior diaphragm –> Gastrophrenic lig

Spleen –> Gastrosplenic lig

Transverse colon –> Gastrocolic lig

Question 9

What is the Pringle Manuever?

Answer 9

To stop blood in the portal triad during a liver procedure you stick your fingers into the epiploic foramen and this will ligate the blood supply to the liver

Question 10

How does the lesser sac (omental bursa) communicate w/ the greater sac?

Answer 10

Via the epiploic foramen (omental foramen/foramen of Winslow)

Question 11

What are the anterior, posterior, superior, and inferior boundaries of the epiploic foramen (aka foramen of Winslow)?

Answer 11

Anterior: hepatoduodenal lig and portal triad

Posterior: IVC and Rt. crus of diaphragm

Superior: Caudate lobe pf liver

Inferior: 1st part of duodenum

Question 12

What is found anterior and posterior to the lesser sac?

Answer 12

Anterior: Lesser omentum, stomach, gastrocolic lig

Posterior: Pancreas, Lf. suprarenal gland, Lf. kidney, aorta, IVC, splenic a. and v.

Question 13

What is found superior and inferior to the lesser sac?

Answer 13

Superior: Liver and diaphragm

Inferior: Transverse mesocolon, 1st part of duodeum

Question 14

What is found to the left and right of the lesser sac?

Answer 14

Left: hilum of spleen, gastrosplenic lig

Right: Epiploic foramen

Question 15

If you had a peptic ulcer and the stomach ruptured posteriorly, where would the contents spill?

Answer 15

Into the lesser sac

Question 16

With a stomach rupture is it better to be anterior or posterior?

Answer 16

A posterior rupture is ideal, because the stomach contents will be confined in the lesser sac.

Question 17

Where will pancreatic enzymes go if the pancreatic pseudo-cyst ruptured anteriorly?

Answer 17

Into the lesser sac, because the pancreas sits posterior to this area.

Question 18

Can any of the boundaries of epiploic foramen be cut to release a hernia within the lesser sac?

Answer 18

No, instead you would need to try and do a needle decompression of the lesser sac

Question 19

There are subdivisions of the peritoneal cavity, what structure divides the cavity and into what compartments?

Answer 19

Transverse mesocolon divides cavity into:

• Supracolic compartment
• Infracolic compartment

Root of mesentery of small intestine divides infracolic compartment into:

• Left and Right infracolic space

Question 20

Contents of the supracolic compartment?

Answer 20

Stomach, liver and spleen

Question 21

Contents of the infracolic compartment?

Answer 21

Small intestine, ascending and descending colon

Question 22

How are the supracolic and infracolic compartments able to communicate?

Answer 22

Freely via the paracolic gutters

Question 23

How do the sizes of the paracolic gutters differ and why is this significant?

Answer 23

• Left paracolic gutter is narrowed due to phrenicolic ligament
• Compresses and kind of limits the movement of substances on the left

Question 24

Significance of the rectouterine pouch (females) and rectovesical pouch (males)?

Answer 24

• Lowest part of the peritoneal cavity
• Peritoneal fluid and other fluids that enter the peritoneal cavity, including ascites, blood and pus, tend to collect in this pouch.

Question 25

Why is large invasive surgery more painful in the peritoneum; can result in?

Answer 25

• Well innervated by the thoraco-abdominal nerves
• Can result in adhesions (we saw this is lab)

Question 26

What is ascites?

Answer 26

Excess fluid in the peritoneal cavity

Question 27

Where is a good location for Paracentesis?

Answer 27

• Rectouterine pouch
• Drainage of abcesses possible w/o causing generalize peritonitis

Question 28

What is the clinical significance of the SMA and SMV being posterior to the pancreas?

Answer 28

If these vessels are compromised due to pancreatic cancer, you CANNOT remove the pancreas surgically, and will have to opt for chemo/radiation therapy.

Question 29

What is found anterior to the pancreas?

Answer 29

Lesser sac and stomach

Question 30

What is found posterior to the pancreas?

Answer 30

Aorta and IVC, splenic vein, bile duct, right crus of diaphragm, left kidney/vessels, left suprarenal gland, SMA/SMV

Question 31

What is found to the right and left of the pancreas?

Answer 31

Right = 2nd part of duodenum

Left = spleen

Question 32

What is found inferior to the pancreas?

Answer 32

3rd part of the duodenum

Question 33

What kind of periotneum is the pancreas?

Answer 33

All retroperitoneum, EXCEPT the tail (intraperitoneal)