Abdomen, cavitas abdominalis , is a space bounded above by the diaphragm, in front and on the sides by the anterior abdominal wall, behind by the spinal column and back muscles, and below by the perineal diaphragm. The abdominal cavity contains the organs of the digestive and genitourinary systems. The walls of the abdominal cavity and the internal organs located in it are covered with a serous membrane - peritoneum, peritoneum . The peritoneum is divided into two layers: parietal, peritone u m parietale , covering the walls of the abdominal cavity, and visceral, peritoneum visceral e , covering the abdominal organs.

Peritoneal cavity, cavitas peritonei , is a space limited by two visceral layers or visceral and parietal layers of the peritoneum, containing a minimum amount serous fluid.

The relationship of the peritoneum to the internal organs is not the same. Some organs are covered by peritoneum on only one side, i.e. located extraperitoneally (pancreas, duodenum, kidneys, adrenal glands, ureters, unfilled bladder and lower part of the rectum). Organs such as the liver, descending and ascending colons, the full bladder and the middle part of the rectum are covered by peritoneum on three sides, i.e. occupy a mesoperitoneal position. The third group of organs is covered with peritoneum on all sides and these organs (stomach, mesenteric part of the small intestine, transverse and sigmoid colons, cecum with appendix, upper part of the rectum and uterus) occupy an intraperitoneal position.

The parietal peritoneum covers the inside of the anterior and lateral walls of the abdomen and then continues to the diaphragm and the posterior abdominal wall. Here the parietal peritoneum passes into the visceral peritoneum. The transition of the peritoneum to the organ occurs either in the form ligaments, ligamentum , or in the form mesentery, mesenterium , mesocolon . The mesentery consists of two layers of peritoneum, between which there are vessels, nerves, lymph nodes And fatty tissue.

The parietal peritoneum on the inner surface forms five folds:

median umbilical fold, plica umbilicale mediana, unpaired fold, runs from the apex of the bladder to the navel, contains the median umbilical ligament - overgrown embryonic urinary duct, urachus ;

medial umbilical fold , plica umbilicalis medialis , paired fold - runs on the sides of the median fold, contains the medial umbilical ligament - an overgrown umbilical artery of the fetus;

lateral umbilical fold, plica umbilicalis lateralis , also steam room - contains the inferior epigastric artery. The umbilical folds limit the pits related to the inguinal canal.

The parietal peritoneum passes to the liver in the form of liver ligaments.

The visceral peritoneum passes from the liver to the stomach and duodenum in the form of two ligaments: hepatogastric, lig. hepatogastrium , And hepatoduodenal, lig. hepatoduodenal . The latter contains the common bile duct, portal vein and proper hepatic artery.

The hepatogastric and hepatoduodenal ligaments make up small seal, omentum minus .

Big seal, omentum majus , consists of four layers of peritoneum, between which there are vessels, nerves and fatty tissue. The greater omentum begins with two layers of peritoneum from the greater curvature of the stomach, which descend down in front of the small intestine, then rise up and attach to the transverse colon.

The peritoneal cavity is divided into three floors: upper, middle and lower:

the upper floor is bounded above by the diaphragm, below by the mesentery of the transverse colon. In the upper floor there are three bags: hepatic, pregastric and omental. Hepatic bursa, bursa hepatica , separated from pregastric bursa, bursa pregastrica , falciform ligament. The hepatic bursa is limited by the diaphragm and right lobe liver, the pregastric bursa is located between the diaphragm and the diaphragmatic surface of the left lobe of the liver and between the visceral surface of the left lobe of the liver and the stomach. Omental bag, bursa omentalis , is located behind the stomach and lesser omentum and communicates with the peritoneal cavity through gland hole, foramen epiploicum . In children, the omental bursa communicates with the cavity of the greater omentum; in adults this cavity does not exist, since the four layers of the peritoneum grow together;

The middle floor of the peritoneal cavity is located between the mesentery of the transverse colon and the entrance to the pelvis. Middle floor divided by the root of the mesentery of the small intestine, which comes from the left side of the XI lumbar vertebra to the right sacroiliac joint at right and left mesenteric sinuses, sinus mesentericus dex. et sin . Between the ascending colon and lateral wall abdominal cavity - left lateral channel, canalis lateralis sin ;

The parietal peritoneum forms several depressions (pockets), which are the site of formation of retroperitoneal hernias. During the transition of the duodenum to the jejunum, superior and inferior duodenal recesses, recessus duodenalis sup . et inf . During the transition of the small intestine to the large intestine there are superior and inferior iliocecal pouches, recessus ileocecalis sup. et inf . Behind the cecum is retrocecal fossa, recessus retrocecalis . On the lower surface of the mesentery of the sigmoid colon there is intersigmoid recess, recessus intersigmoideus;

The lower floor of the peritoneal cavity is located in the pelvis. The peritoneum covers its walls and organs. In men, the peritoneum passes from the rectum to the bladder, forming rectovesical recess, excavatio rectovesicalis . In women, there is a uterus between the rectum and the bladder, so the peritoneum forms two depressions: a) rectal-uterine, excavatio rectouterina , – between the rectum and uterus; b) vesicouterine, excavatio vesicouterina , – between the bladder and the uterus.

Age characteristics. Peritoneum of a newborn thin, transparent. Blood vessels and lymph nodes are visible through it, since the subperitoneal fatty tissue is poorly developed. The greater omentum is very short and thin. The newborn has depressions, folds and pits formed by the peritoneum, but they are weakly expressed.

Abdominal cavity and peritoneum

Organs digestive system, following the esophagus, are located in the abdominal cavity (in the abdominal cavity), and the final section - the rectum - is in the pelvic cavity.

Abdominal cavity (abdominal cavity) is the largest cavity in the human body and is located between chest cavity and the pelvic cavity. The cavity is limited from above by the diaphragm, from behind - lumbar region spinal column, quadratus lumborum muscles, iliopsoas muscles, front and sides - abdominal muscles. Below, the abdominal cavity continues into the pelvic cavity, which is limited below by the pelvic diaphragm.

The abdominal cavity contains the stomach, small and large intestines (excluding the rectum), liver, pancreas, spleen, kidneys, adrenal glands, ureters, and the pelvic cavity contains the rectum and organs urinary system and internal genital organs. In addition, on the posterior wall of the abdominal cavity, in front of the lumbar vertebral bodies, pass the abdominal part of the aorta, the lower vena cava and lie the nerve plexuses, lymphatic vessels and nodes.

The inner surface of the abdominal cavity is exposed intra-abdominal fascia or retroperitoneal fascia, the areas of which are named depending on the name of the muscles it covers. The parietal peritoneum is adjacent to the inner surface of this fascia (see below).

The entire abdominal cavity can be seen only by removing the peritoneum and internal organs. Between the peritoneum and intraperitoneal fascia there is fatty tissue. There is especially a lot of it on the back wall near the internal organs located there. The space between the fascia and peritoneum on the posterior abdominal wall is called retroperitoneal space. It is filled with fatty tissue and organs.

Peritoneum, peritoneum, is a serous membrane lining the abdominal cavity and covering the internal organs located in this cavity. It is formed by the lamina serosa itself and a single layer flat epithelium-mesothelium. The peritoneum, which lines the walls of the abdominal cavity, is called parietal peritoneum; the peritoneum that covers the organs is called visceral peritoneum. The total surface of the parietal and visceral peritoneum in an adult occupies an average area of ​​1.71 m2. Limiting the closed peritoneal cavity, the peritoneum is a continuous layer that passes from the walls of the abdominal cavity to the organs and from the organs to its walls. In women, the peritoneal cavity communicates with external environment through the abdominal openings of the fallopian tubes, the uterine cavity and vagina. The peritoneal cavity contains a small amount of serous fluid that moisturizes the peritoneum, which provides free movement adjacent organs covered with peritoneum.

The relationship of the peritoneum to the internal organs is not the same. Some organs are covered with peritoneum on only one side (pancreas, most of the duodenum, kidneys, adrenal glands, etc.), i.e., they lie outside the peritoneum, retroperitoneally (retro- or extraperitoneal). Each such organ is called retroperitoneal organ . Other organs are covered by peritoneum on only three sides and are mesoperitoneally lying organs (ascending and descending colon). The organs that make up the third group are covered with peritoneum on all sides and occupy an intraperitoneal (intraperitoneal) position (stomach, small intestine, transverse and sigmoid colon, spleen, liver).

The peritoneum, which passes from the walls of the abdominal cavity to organs or from organ to organ, in some cases forms folds and pits. When moving to some intraperitoneal organs, the peritoneum forms ligaments and doubling (duplication) of the peritoneum - mesentery. For example, mesenterium - mesentery of the small intestine (from the Greek mesos - middle, enteron - intestine), mesocolon - mesentery of the colon.

Fig.31. Section of the body in the transverse plane. Relation of internal organs to the peritoneum (diagram):

1- visceral peritoneum; 2- parietal peritoneum; 3- mesentery of the small intestine; 4- intraperitoneal position of the small intestine; 5- mesoperitoneal position of the ascending colon; 6- retro (extra)peritoneal position of the kidney; 7- abdominal cavity

The parietal peritoneum, lining the walls of the abdominal cavity, unlike the visceral peritoneum, does not form mesenteries. Covering the anterior abdominal wall, the parietal peritoneum passes at the top to the diaphragm, at the sides to the lateral walls of the abdominal cavity, and at the bottom to the organs of the pelvic cavity. In the pubic region, between the peritoneum and the retroperitoneal fascia, there is a small amount of adipose tissue, due to which the peritoneum here is pushed upward by the bladder when it is filled (Fig. 31).

Throughout the entire length between the navel and the pubic symphysis, the peritoneum covering the anterior abdominal wall forms 5 folds: unpaired median umbilical fold, doubles medial and lateral umbilical folds. In the median umbilical fold there is an overgrown urinary duct (urachus), which runs in the fetus from the top of the bladder to the navel; in the medial umbilical folds there are overgrown umbilical arteries, through which blood from the fetus is directed to the placenta, and in the lateral ones - the lower epigastric arteries.

Above the bladder on the sides of the median umbilical fold there are small depressions - right and left supravesical fossae. Between the lateral and medial umbilical folds on each side there is medial inguinal fossa. The superficial inguinal rings of the right and left inguinal canals are projected into them. Outward from the lateral umbilical fold is located lateral inguinal fossa, corresponding to the deep inguinal ring of the inguinal canal.

Heading upward, the peritoneum of the anterior wall of the abdominal cavity passes to the lower surface of the diaphragm, and then from the diaphragm to the internal organs (liver, stomach, spleen) and to the posterior abdominal wall.

The peritoneum of the anterior abdominal wall also passes to the lateral walls of the abdominal cavity, and then to the posterior wall. On the posterior wall of the abdominal cavity, the peritoneum covers the retroperitoneal (retroperitoneal) organs (kidneys, adrenal glands, ureters, pancreas, most of the duodenum, aorta, inferior vena cava, etc., vessels and nerves, lymph nodes) and passes to other organs, lying meso- and intraperitoneally. On three sides (mesoperitoneally), the peritoneum covers the ascending and descending parts of the colon, and on all sides covers the cecum, which lies intraperitoneally, but does not have a mesentery.

The vermiform appendix, also located intraperitoneally, has mesentery of the appendix. In the left part of the abdominal cavity, two layers of peritoneum approach the sigmoid colon, cover it on all sides and form mesentery of the sigmoid colon. On the border of the upper and lower sections of the abdominal cavity in the transverse direction there is mesentery of the transverse colon, represented by two layers of peritoneum extending from the posterior wall of the abdominal cavity to the transverse colon. Below the mesentery of the transverse colon, it originates from the posterior abdominal wall mesentery of the small intestine into which the parietal peritoneum passes. Root of the mesentery of the small intestine, located obliquely, from top to bottom and from left to right, from the duodenum-jejunal flexure (to the left of the body of the II lumbar vertebra) to the transition of the ileum to the cecum (the level of the right sacroiliac joint). Its length is 15-17 cm. The edge of the mesentery opposite to the root, which approaches the small intestine and then envelops it on all sides (intraperitoneal position of the intestine), is equal to the total length of the jejunum and ileum. Between the two serous layers of the mesentery there pass the superior mesenteric artery with branches and nerves heading to the small intestine, as well as veins and veins emerging from the walls of the intestine. lymphatic vessels. The superior mesenteric lymph nodes, loose connective and adipose tissue are also located there.

Much more difficult is the transition of the parietal peritoneum to the visceral peritoneum and the formation of mesenteries in the upper floor of the peritoneal cavity (above the transverse colon and its mesentery) (Fig.). From the lower surface of the diaphragm, the peritoneum passes to the diaphragmatic surface of the liver, forming the liver ligaments: sickle-shaped, coronal, right and left triangular ligaments. Wrapping around the sharp edge of the liver in front and the back of the liver, the peritoneum covers the visceral surface of the organ. Then, from the gate of the liver, the peritoneum is directed in two sheets to the lesser curvature of the stomach and the upper part of the duodenum. Thus, between the portal of the liver at the top, the lesser curvature of the stomach and top part of the duodenum, a duplication of the peritoneum is formed below, called lesser omentum. Left side lesser omentum represents hepatogastric ligament, and the right one - hepatoduodenal ligament. In the right edge of the lesser omentum (in the transverse duodenal ligament) between the layers of the peritoneum there are located, from right to left, the common bile duct, the portal vein and the proper hepatic artery.

Approaching the lesser curvature of the stomach, the two layers of peritoneum of the hepatogastric ligament diverge and cover the posterior and anterior surfaces of the stomach. At the greater curvature of the stomach, these two layers of peritoneum converge and go down in front of the transverse colon and in front of the small intestine. Then these sheets of peritoneum together bend sharply posteriorly, tuck in and rise upward behind the descending sheets

Fig.32. Section of the body in the median (sagittal) plane. Relation of internal organs to the peritoneum (diagram).

1 - liver; 2 – hepatogastric ligament; 3 – omental bag; 4 – pancreas; 5 – duodenum; 6 – mesentery of the small intestine; 7 – rectum; 8 – bladder; 9 – jejunum; 10 – transverse colon; 11 - cavity of the greater omentum; 12 – mesentery of the transverse colon; 13 - stomach.

and anterior to the transverse colon. Above the mesentery of the transverse colon, the layers pass into the parietal peritoneum, covering the posterior abdominal wall. The upper layer goes up, covering the upper surface of the pancreas, and then passes to the posterior wall of the abdominal cavity and to the diaphragm. The lower leaf turns down and passes into the upper (anterior) leaf of the mesentery of the transverse colon. The long fold of peritoneum hanging in front of the transverse colon and loops of the small intestine in the form of an apron and formed by four layers of peritoneum is called greater omentum, which in origin is the posterior (dorsal) mesentery of the stomach. Between the layers of the peritoneum of the greater omentum there is a small amount of fatty tissue. The four layers of the peritoneum of the greater omentum in an adult fuse two at a time into two plates - anterior and posterior. The anterior plate begins from the greater curvature of the stomach and, together with the posterior plate of the greater omentum, in turn fuses with the anterior surface of the transverse colon at the level of the omental band. The posterior plate of the greater omentum also fuses with the mesentery of the transverse colon.

The part of the greater omentum (anterior plate), stretched between the greater curvature of the stomach and the transverse colon, is called gastrocolic ligament. Two layers of peritoneum extending from the greater curvature of the stomach to the left to the hilum of the spleen form gastrosplenic ligament, going from the cardiac part of the stomach to the diaphragm - gastrophrenic ligament.

The peritoneal cavity can be divided into three floors, or sections: upper, middle and lower. Top floor bounded above by the diaphragm, on the sides by the lateral walls of the abdominal cavity, covered with the parietal peritoneum, and below by the transverse colon and its mesentery.

The upper floor contains the stomach, liver with gall bladder, spleen, upper part of the duodenum and pancreas. The upper floor of the peritoneal cavity is divided into three relatively delimited sacs, or bursae: hepatic, pregastric and omental. Hepatic bursa located to the right of the falciform ligament of the liver and covers the right lobe of the liver. The retroperitoneal upper pole protrudes into the hepatic bursa right kidney and adrenal gland. Pregastric bursa located in the frontal plane, to the left of the falciform ligament of the liver and anterior to the stomach. In front, the pregastric bursa is limited by the anterior abdominal wall. The upper wall of this bag is formed by the diaphragm. The pregastric bursa contains the left lobe of the liver and the spleen.

Omental bag located behind the stomach and lesser omentum. It is bounded above by the caudate lobe of the liver, below by the posterior plate of the greater omentum, fused with the mesentery of the transverse colon, in front by the posterior surface of the stomach, lesser omentum and gastrocolic ligament, and behind by the sheet of peritoneum covering the aorta, lower vena cava, upper pole of the left kidney, left adrenal gland and pancreas. The cavity of the omental bursa is a slit located in the frontal plane. The outlines of the cavity of the omental bursa are uneven. At the top she has upper gland recess, which is located between the lumbar part of the diaphragm behind and the posterior surface of the caudate lobe of the liver in front. To the left, the omental bursa extends all the way to the hilum of the spleen, forming splenic recess. The walls of this recess are ligaments: in front - the gastrosplenic, in the back - the diaphragmatic-splenic, which is a duplication of the peritoneum running from the diaphragm to the posterior end of the spleen. The omental bag also has lower gland recess, which is located between the gastrocolic ligament in front and above and the posterior plate of the greater omentum, fused with the transverse colon and its mesentery, behind and below. Omental bag through gland hole(foramen of Winslow), communicates with the hepatic bursa. The hole is small, 2-3 cm in diameter (1-2 fingers fit into it), located behind the hepatoduodenal ligament, at its free right edge. The omental foramen is bounded above by the caudate lobe of the liver, below by the upper part of the duodenum, and behind by the parietal peritoneum covering the inferior vena cava.

Middle floor the peritoneal cavity is located downward from the transverse colon and its mesentery, passes into ground floor located in the pelvic cavity. Between the right lateral wall of the abdominal cavity, on the one hand, and the cecum and ascending colon, on the other, there is a narrow vertical gap, called right paracolic sulcus, which is also called the right side channel. Left paracolic sulcus(left lateral canal), located between the left wall of the abdominal cavity on the left, the descending colon and sigmoid colon on the right.

Part of the middle floor of the peritoneal cavity, limited to the right, above and left by the colon, is divided by the mesentery of the small intestine into two fairly large fossae - the right and left mesenteric sinuses (sinuses). Right mesenteric sinus has the outline of a triangle, the apex of which faces down and to the right, towards the final section of the ileum. The walls of the right mesenteric sinus are formed on the right by the ascending colon, on top by the root of the mesentery of the transverse colon, on the left by the root of the mesentery of the small intestine. In the depth of this sinus, retroperitoneally, there are the final section of the descending part of the duodenum and its horizontal (lower) part, the lower part of the head of the pancreas, a segment of the inferior vena cava from the root of the mesentery of the small intestine below to the duodenum above, the right ureter, vessels, nerves and lymph nodes. Left mesenteric sinus also has the shape of a triangle, but its apex faces up and to the left, towards the left bend of the colon. The boundaries of the left mesenteric sinus are on the left - the descending colon and the mesentery of the sigmoid colon, on the right - the root of the mesentery of the intestine. Below, this sinus does not have a clearly defined boundary and communicates freely with the pelvic cavity (with the lower floor of the peritoneal cavity). Within the left mesenteric sinus, retroperitoneally, are the ascending part of the duodenum, the lower half of the left kidney, the terminal part of the abdominal aorta, the left ureter, vessels, nerves and lymph nodes.

The parietal layer of the peritoneum, covering the posterior wall of the abdominal cavity, forms folds and depressions - pits - in the places of transition from one organ to another or between the edge of the organ and the abdominal wall. These depressions are the site of possible formation of retroperitoneal hernias.

Thus, between the duodenum-jejunal flexure on the right and the upper duodenal fold on the left there are small amounts superior and inferior duodenal recesses. At the point where the ileum enters the cecum, the peritoneum forms folds that limit superior and inferior ileocecal recesses, located respectively above and below the terminal ileum. The cecum, covered on all sides by peritoneum, is located in the right iliac fossa. The posterior surface of the intestine, covered with peritoneum, can be seen when it is pulled anteriorly and upward. At the same time, they are clearly visible cecal folds of peritoneum, running from the surface of the iliacus muscle to the lateral surface of the cecum. Available here retrocolic recess located under the lower part of the cecum.

The sigmoid colon has a mesentery, the size of which varies depending on the size of the colon. On the left side of the mesentery of this intestine, at the place where the left leaf of the mesentery is attached to the wall of the pelvis, there is a small intersigmoid recess.

Downstairs peritoneal cavity The peritoneum, descending into the pelvic cavity, covers not only the upper and partially middle sections of the rectum, but also the organs of the genitourinary apparatus.

In men, the peritoneum covering the anterior surface of the rectum passes to the posterior, and then upper wall bladder. Further, the peritoneum continues into the parietal peritoneum of the anterior abdominal wall. Forms between the bladder and rectum rectovesical recess, limited on the sides rectovesical folds. These folds run in the anteroposterior direction from the lateral surfaces of the rectum to the bladder. In women, the peritoneum from the anterior surface of the rectum passes to the posterior wall of the upper part of the vagina, and then rises upward, covers the back and then the front of the uterus and fallopian tubes and passes to the bladder. Forms between the uterus and rectum rectouterine recess. It is limited on the sides rectal-uterine folds. Forms between the uterus and bladder vesicouterine recess(Fig. 32).

Abdomen ( cavitas abdominis) - a space limited at the top by the diaphragm, at the bottom - by the pelvic cavity, behind - by the lumbar spine with the adjacent quadratus lumborum muscles, iliopsoas muscles, in front and on the sides - by the abdominal muscles.

The abdominal cavity contains the digestive organs (stomach, small and large intestines, liver, pancreas), spleen, kidneys, adrenal glands and ureters, blood vessels and nerves.

The inner surface of the abdominal cavity is lined internally with the abdominal fascia ( fascia endoabdominalis), inward from which the peritoneum is located.

Diagram of the relationship of organs to the peritoneum (cross section)

Peritoneum ( peritoneum) - serosa lining the walls of the abdominal cavity (parietal peritoneum) and internal organs (visceral peritoneum). Between the visceral and parietal layers of the peritoneum there is a peritoneal cavity ( cavitas peritonei). The peritoneum secretes a serous fluid that moisturizes it and ensures the free movement of organs covered by the peritoneum:

1- peritoneum parietale- parietal peritoneum - covers the walls of the abdominal cavity;

2 - peritoneum viscerale- visceral peritoneum, which covers the organ in various ways;

3 - mesoperitoneal position. The organ is covered by peritoneum on three sides (for example, ascending and descending colons, liver);

4 - extraperitoneal position. The organ is covered by peritoneum on one side (for example, the pancreas and partially the duodenum) or not covered at all (for example, the kidney), which is called the retroperitoneal position;

5 - intraperitoneal position. The organ is covered by peritoneum on all sides (for example, the stomach, the mesenteric part of the small intestine);

6 - mesenterium- mesentery of the small intestine;

7 -cavitas peritonei- peritoneal cavity.

Diagram of the course of the peritoneum in a sagittal section (in men)

The peritoneum, passing from the walls of the abdominal cavity to the organs and when moving from organ to organ, forms ligaments that represent a duplication of the peritoneum (two leaves):

1 -lig. coronarium hepatis- coronary ligament of the liver, which is formed during the transition of the peritoneum from the diaphragm to the liver;

2 - hepar- liver - covered with peritoneum mesoperitoneally. The peritoneum passes from the visceral surface of the liver to the duodenum ( lig. hepatoduodenal) and lesser curvature of the stomach ( lig. hepatogastricum);

3 - lig. hepatogastricum- hepatogastric ligament, which, together with lig. hepatoduodenal forms the lesser omentum ( omentum minus). Behind the lesser omentum and stomach is the omental bursa;

4 - bursa omentalis - omental bursa - limited: above - by the caudate lobe of the liver, below - by the posterior plate of the greater omentum or, taken as a whole, by the mesentery of the transverse colon, in front - by the stomach and lesser omentum, behind - by the parietal peritoneum and the organs that it covers ( v. cava inferior, aorta, corpus pancreatis);

5 - gaster- stomach - covered with peritoneum intraperitoneally. At the transition point lig. hepatoduodenal on the stomach, between the two layers of peritoneum and the lesser curvature of the stomach, there is an area not covered by peritoneum, or a bare area;

6-pars nuda (curvatura ventriculi minor) - bare area (lesser curvature of the stomach);

7- pars nuda (curvatura ventriculi major) - bare area (greater curvature of the stomach). Along the greater curvature of the stomach, two layers of peritoneum connect and descend down in front of the transverse colon and the loops of the small intestine (anterior plate of the greater omentum). Then these two layers of peritoneum are folded posteriorly and rise upward (posterior plate of the greater omentum). Thus, the greater omentum is formed from the four layers of peritoneum.

8 - omentum majus- large oil seal. The posterior plate of the greater omentum (two posterior layers of peritoneum) is directed towards the posterior abdominal wall and splits. One leaf passes to the posterior wall of the peritoneal cavity, the other - to the transverse colon, connecting with another layer of peritoneum - the mesentery of the transverse colon is formed, which will thus consist of four layers of peritoneum;

9- mesocolon transversum- mesentery of the transverse colon;

10 - colon transversum- transverse colon - covered with peritoneum intraperitoneally. The lower layer of the mesentery of the transverse colon passes to the posterior wall of the peritoneal cavity. The pancreas and most of the duodenum are located retroperitoneally (extraperitoneal);

11 - pancreas- pancreas;

12 - duodenum- duodenum - parietal peritoneum, covering the duodenum on the anterior side; passes to the small intestine. Its two leaves form the mesentery of the small intestine;

13 - mesenterium- mesentery of the small intestine;

14 - jejunum- jejunum - located intraperitoneally in relation to the peritoneum; has one bare spot ( pars nuda) in the area of ​​attachment of the mesentery;

15 - rectum- rectum;

16 - vesica urinaria- bladder;

17- spatium retroperitoneale- retroperitoneal space - filled with fatty tissue. It contains the kidneys and ureters;

18 - excavatio rectovesicale- rectovesical recess;

19 - os pubis- pubic bone.

The abdominal cavity is the largest cavity of the human body. It is surrounded by intra-abdominal and intra-pelvic fascia, covering the following anatomical formations from the inside: at the top - the diaphragm, in front and on both sides - the muscles of the abdominal wall, at the back - the lumbar vertebrae, the quadratus lumborum and iliopsoas muscles, at the bottom - the pelvic diaphragm.

In the abdominal cavity there is the peritoneal cavity (cavitas peritonei) - a slit-like space between the layers of the parietal (peritoneum parietale) and visceral (peritoneum viscerale) peritoneum, containing a small amount of serous fluid. It should be noted that in practical surgery the concept of “abdominal cavity” is often used instead of “peritoneal”. At the initial stages of development, the organs of the abdominal cavity are located next to the peritoneal sac and, gradually rotating, are immersed into it. The leaf of the parietal peritoneum lines the walls of the abdominal cavity, and the leaf of the visceral peritoneum covers the organs: some on all sides (the so-called intraperitoneal arrangement of organs), others on only three (mesoperitoneal), some on only one side (retroperitoneal). If the organs are not covered with a layer of visceral peritoneum, we are talking about their extraperitoneal location.

Intraperitoneally located the following bodies or parts of the abdominal organs: stomach, jejunum, ileum, transverse colon, sigmoid colon, as well as the cecum with the appendix, the upper part of the duodenum, fallopian tubes.

Mesoperitoneally located are the liver, gallbladder, descending duodenum, ascending colon and descending colon, middle third of the rectum, uterus and bladder. The pancreas is covered by peritoneum only in front and occupies a retroperitoneal position. The prostate gland, the horizontal part of the duodenum and the lower third of the rectum, kidneys, adrenal glands and ureters are located extraperitoneally.

Floors of the abdominal cavity

The abdominal cavity is divided into two floors: upper and lower. Between them pass the transverse colon with mesentery (mesocolon transversum) or the line of fixation of the mesentery of the transverse colon to the posterior wall of the abdomen.

The upper floor of the abdominal cavity contains the liver, gallbladder, stomach, spleen, upper part of the duodenum and most of the pancreas. In addition, there are vital relatively limited spaces, or bags, connected to each other using narrow slits. These include the omental, hepatic and pregastric bursae.

The omental bursa (bursa omentalis), which looks like a slit, is located behind the stomach and lesser omentum. The omental bursa contains the anterior, posterior, inferior and left walls.

The anterior wall of the bursa consists of the lesser omentum (omentum minus), the posterior wall of the stomach and the gastrocolic ligament, which begins the part of the greater omentum located between the stomach and the transverse colon. Sometimes (if it is clearly visible) the gastrosplenic ligament is visible in the anterior wall of the omental bursa.

The lesser omentum is a duplication of the peritoneum, starting from the porta hepatis and ending in the lesser curvature of the stomach and the adjacent part of the duodenum. The omentum is divided into the hepatoduodenal, hepatogastric and gastrophrenic ligaments.

The posterior wall of the omental bursa is the parietal peritoneum, behind which are the pancreas, the upper part of the duodenum, the left kidney, the left adrenal gland, the inferior vena cava, the abdominal aorta and the abdominal trunk. On top of the bursa is the caudate lobe of the liver and part of the diaphragm, and on the left side are the spleen and gastrosplenic ligament (lig. gastrolienale).

The lower wall of the omental bursa is formed by the transverse colon and its mesentery.

Through the cavity of the said bursa in the radial direction (back to front) from the pancreas, two ligaments pass in the form of the letter “V”: gastropancreatic (lig. gastropancreaticum) and pyloropancreaticum (lig. pyloropancreaticum), separating the vestibule of the omental bursa from its cavity itself. The gastropancreatic ligament contains the left gastric artery. The cavity of the omental bursa is connected to the upper floor of the peritoneal cavity by the omental opening (foramen epiploicum), which represents the right wall of the bursa cavity. The width of the omental opening is 3-4 cm, and, if there are no adhesions, 1-2 fingers fit into it. Injuries to its anterior and posterior walls are especially dangerous, since in the thickness of the hepatoduodenal ligament there are large vessels, nerves and bile ducts, and behind - the inferior vena cava.

In addition, the omental bursa has a vestibule (vestibulum bursae omentalis), bounded above by the caudate lobe of the liver, below by the duodenum, and behind by the parietal peritoneum, which covers the inferior vena cava. This bag has an upper gland pocket (recess). Being in pre-

The omental bursa can be accessed by cutting the lesser omentum or gastrocolic ligament (the most commonly used method) or the mesentery of the transverse meningeal colon, as well as through the omental foramen.

The hepatic bursa is located between the right lobe of the liver and the diaphragm. Above and in front of it is the diaphragm, below is the superoposterior surface of the right lobe of the liver, behind is the right part of the coronary ligament of the liver (lig. coronarium), on the left is the falciform ligament dig. falciforme). The part of the hepatic bursa between the posterior surface of the right lobe of the liver, the diaphragm and the coronary ligament is called the right subphrenic (suprahepatic) space. Inferiorly it passes into the right lateral cable of the lower floor of the abdominal cavity.

Within the right subdiaphragmatic space, subdiaphragmatic abscesses can form as a complication of purulent, cholecystitis, perforated ulcer stomach and duodenum.

As a result of injury to hollow organs, perforated stomach ulcers and other pathological conditions, air penetrates into the abdominal cavity, which, when the body is in an upright position, accumulates in the hepatic bursa. It can be detected during fluoroscopy.

The pregastric bursa (bursa pregastrica) is located in front of the stomach, and on top are the diaphragm and the left lobe of the liver, behind - the lesser omentum and the anterior wall of the stomach, in front - the anterior wall of the abdomen. On the right, the pregastric bursa is separated from the hepatic bursa by the falciform ligament and round ligament of the liver, and on the left it has no pronounced border.

Between the upper surface of the left lobe of the liver and the lower surface of the diaphragm, a gap is formed, or the left subphrenic space, delimited from the left lateral canal of the lower floor of the abdominal cavity by the permanent diaphragmatic-colic ligament.

The lower floor of the abdominal cavity is the space between the mesentery of the transverse colon and the pelvic cavity. The ascending colon and descending colon and the root of the mesentery of the small intestine divide it into 4 sections: the right and left lateral canals and the right and left mesenteric sinuses.

The right lateral canal is located between the right lateral abdominal wall and the ascending colon. At the top it reaches the right subdiaphragmatic space, at the bottom it continues into the right iliac fossa and into the small pelvis, since the right phrenic-colic ligament is weakly expressed and sometimes completely absent. During the movement of the diaphragm, a suction action occurs in the hepatic bursa, so the infection in the right lateral canal spreads from bottom to top, into the right subdiaphragmatic space.

The left lateral canal passes between the descending colon and the left lateral abdominal wall. At the top it is covered by a well-defined and permanent left diaphragmatic-colic ligament, and at the bottom it passes into the left iliac fossa and the small pelvis.

The right mesenteric sinus (sinus mesentericus dexter) has the shape of a right triangle with the base directed upward. The boundaries of the sinus are: above - the transverse colon with mesentery, on the left and below - the mesentery of the small intestine, on the right - the ascending colon. In front, the mesenteric sinus is surrounded by a greater omentum. This anatomical formation is filled with loops of the small intestine.

The left mesenteric sinus (sinus mesentericus sinister) also has the shape of a right triangle, but with the base directed downward. It is larger in size than the right mesenteric sinus. The boundaries of this anatomical formation are: at the top - a small area of ​​the transverse colon, on the left - the descending colon, on the right - the mesentery of the small intestine. In front, the left mesenteric sinus is covered with a greater omentum; from below it is open and passes directly into the pelvic cavity. This sinus is filled with loops of the small intestine. At vertical position of the body, the deepest parts are the upper sections of the sinuses.

The mesenteric sinuses are connected through a gap between the mesentery of the transverse colon and the duodenojejunal flexure (flexura duodenojejunalis).

In places where the peritoneum passes from the walls of the abdominal cavity to the organs or from one organ to another, abdominal pockets are formed.

The upper and lower duodenal recess (recessus duodenalis superior et inferior) are located at the junction of the duodenum and the jejunum. Their depth varies within centimeters, but sometimes can increase sharply, as a result of which the depressions turn into a pocket located towards the retroperitoneal space. Thus, a hernial sac is formed into which loops of the small intestine can enter - a true internal or Treitz hernia.

The superior and inferior ileocecal pouches form where the ileum meets the cecum. In this case, the upper one is located between the upper edge of the terminal part of the ileum and inner surface the ascending colon, and the lower - between the lower surface of the terminal part of the ileum and the wall of the cecum.

The postcolic recess (recessus retrocaecalis) in the form of a depression in the parietal peritoneum on the posterior wall of the abdomen is located behind the cecum.

The intersigmoid recess (recessus intersigmoideus) is a funnel-shaped or cylindrical formation with a round or oval inlet.

It is surrounded in front by the mesentery of the sigmoid colon, and behind by the parietal peritoneum, opening slightly into the left lateral canal of the peritoneal cavity. In the intersigmoid recess, as in those described above, an internal hernia can form.

Abdomen limited in front, from the sides and behind by the abdominal walls, from above - by the diaphragm, from below it passes into the pelvic cavity. From the inside abdominal wall lined with intra-abdominal fascia. The abdominal cavity is divided into the abdominal cavity, limited by the peritoneum, and the retroperitoneal space. There are two floors in the abdominal cavity: upper and lower. The border between them is the mesentery of the transverse colon (TC).

The abdominal wall is divided into two sections: anterior (abdominal) and posterior, or lumbar region. The boundaries between them are the right and left posterior axillary lines.

When diagnosing diseases of the abdominal organs, in order to identify the localization of the pathological process, the doctor must mentally imagine the spatial relationships of the organs with each other and their projections onto the abdominal wall. In clinical practice, the abdomen is divided into areas formed by drawing two conventional horizontal and two vertical lines. The upper horizontal line connects the lowest points of the X ribs, the lower horizontal line is drawn through the highest points of the ridges iliac bones. Thus, three regions are distinguished: upper - epigastric (regio epigastrium), middle - celiac (regio mesogastrium) and lower - hypogastric (regio hypogastrium).

Lines drawn along the outer edges of the rectus abdominis muscles divide each of these areas into three more areas.

The stomach, lesser omentum, part of the duodenum (DU) and pancreas, the left lobe of the liver and part of the right lobe of the liver, and the gallbladder (GB) are projected into the epigastric region proper; aorta, celiac artery with arteries branching from it, portal vein (PV), inferior vena cava (IVC). The right lobe of the liver, the gallbladder, part of the duodenum, the hepatic flexure of the lungs, and the upper part of the right kidney are projected onto the right hypochondrium.

A part of the stomach, the spleen, the tail of the pancreas, the splenic flexure of the bladder, and the anterior part of the left kidney are projected onto the left hypochondrium region.

4. if more than 6 hours have passed since the perforation;

5. with insufficient experience of the surgeon.

The innervation of the small intestine is provided by nerve conductors arising from the superior mesenteric plexus.

Topographic anatomy of the colon

External features of the structure of the large intestine that make it possible to distinguish it from the small intestine during surgery:

1. longitudinal muscle layer in the form of three longitudinal ribbons that begin at the base of the appendix and stretch to the beginning of the rectum;

2. haustra – are formed due to the fact that muscle

3. ribbons shorter than the length of the colon;

4. omental processes - weakly expressed or completely absent on the cecum, along the transverse colon they are located only in one row, and are most pronounced on the sigmoid colon;

5. color – has a gray-bluish tint (for the small intestine

6. characteristic pink color;

7. larger diameter.

Caecum

Holotopy: right iliac fossa. Relation to the peritoneum: covered with peritoneum on all sides, however, there is a mesoperitoneal position of the organ.

Syntopy: in front - the anterolateral wall of the abdomen, on the right - the right lateral canal, on the left - the loops of the ileum, behind - the right ureter, the iliopsoas muscle.

Ileocecal section - is the place of transition of the small intestine to the large intestine, includes the cecum with the vermiform appendix and the ileocecal junction with the bauginian valve. It provides isolation of the small and large intestines.

Appendix

Variants of the position of the peripheral part of the process

1. descending - the apex of the process is turned down and to the left and reaches the border line, and sometimes descends into the pelvis (the most common option);

2. medial – along end section ileum;

3. lateral – in the right lateral canal;

4. ascending – along the anterior wall of the cecum;

5. retrocecal and retroperitoneal - in the retroperitoneal tissue.

Depending on its position, the appendix may be adjacent to the right kidney, right ureter, bladder and rectum. In women, it can reach the right ovary, right tube and uterus.

Projection of the base of the process

1. McBurney point – the boundary between the outer and middle third linea spinoumbilicalis on the right;

2. Lanza point – the border between the right outer and middle third of the linea bispinalis.

Ascending colon

The ascending colon extends upward from the ileocecal angle to the right flexure of the colon.

Holotopy: right lateral region.

Relation to the peritoneum: covered mesoperitoneally (the posterior wall devoid of peritoneum is covered with the retrocolic fascia). Syntopy: on the right - the right lateral canal, on the left - the right mesenteric sinus, behind - the iliopsoas muscle, the quadratus lumborum muscle, the paracolic and retroperitoneal tissues, the lower part of the right kidney, the right ureter.

The right bend of the colon is located in the right hypochondrium, in contact with the lower surface of the right lobe of the liver, the bottom of the gallbladder, behind the peritoneum - with the lower pole of the right kidney; located intraperitoneally or mesoperitoneally.

Transverse colon

The transverse colon extends transversely between the right and left flexures of the colon.

Holotopia: umbilical region.

Relation to the peritoneum: located intraperitoneally.

Syntopy: in front - the right lobe of the liver, above - the greater curvature of the stomach, below - the loops of the small intestine, behind - the descending part of the duodenum, the head and body of the pancreas, the left kidney.

The left bend of the colon is located in the left hypochondrium and covers the left kidney in front. The most constant flexural ligament is the left diaphragmatic-colic ligament, which is well defined and delimits the left lateral canal of the abdominal cavity from the pregastric bursa.

Descending colon

Holotopy: left lateral region.

Relation to the peritoneum: covered mesoperitoneally (the posterior wall devoid of peritoneum is covered with the retrocolic fascia).

Syntopy: on the right - the left mesenteric sinus, on the left - the left lateral canal, behind the intestine - paracolic tissue, lumbar muscles, left kidney and ureter.

Sigmoid colon

Holotopia: left inguinal and partially pubic regions. Relation to the peritoneum: covered intraperitoneally.

Rectum

Rectum - due to its position, it is studied together with the pelvic organs.

Blood supply of the large intestine

The colon is supplied with blood by the superior and inferior mesenteric arteries. Branches of the superior mesenteric artery:

1. Ileocolic artery - gives off branches to the terminal ileum, appendix, anterior and posterior cecal arteries and the ascending artery, supplying the initial part of the ascending colon and anastomosing the descending branch of the right colon artery.

2. Right colon artery – is divided into descending and ascending branches, supplying blood to the ascending colon and anastomosing with the ascending branch of the ileocolic artery and right branch middle colic artery, respectively.

3. Middle colic artery - is divided into right and left branches that supply blood to the transverse colon and anastomose with the right and left colic arteries, respectively. The anastomosis between the left branch of the middle colic artery and the left colic artery connects the basins of the superior and inferior mesenteric arteries and is called the Riolan arch.

Branches of the inferior mesenteric artery:

1. Left colic artery - is divided into an ascending branch, supplying blood to the upper part of the descending colon and anastomosing at the level of the splenic flexure of the colon with the left branch of the middle colon artery to form the Riolan arch, and a descending branch, supplying blood to the lower part of the descending colon and anastomosing with the first sigmoid artery.

2. Sigmoid arteries (2–4) anastomose with each other (anastomosis between the last sigmoid and superior rectal arteries, as a rule, does not occur).

3. The superior rectal artery supplies the lower part of the sigmoid colon and the upper part of the rectum. The branching of the superior rectal and last sigmoid arteries is called Sudeck's critical point, since ligation of the superior rectal artery below this branch during rectal resection can lead to ischemia and necrosis of the lower part sigmoid colon due to the lack of anastomosis between the last sigmoid and superior rectal arteries.

The venous bed of the colon is formed from veins that accompany the arteries of the same name and their branches.

The imposition of an unnatural anus is the creation of an opening in the colon through which all intestinal contents are discharged outside without entering the underlying sections of the intestine.

Indications: tumors, wounds, cicatricial narrowing of the rectum, rectal amputation.

Classification: temporary and permanent, single-barrel (Hartmann operation) and double-barrel (Maidl operation).

Technique for applying a single-barreled unnatural anus:

1. layer-by-layer opening of the abdominal cavity with an oblique variable incision in the left groin area;

2. piercing the intestinal mesentery in the avascular zone and passing a rubber tube through the window;

3. suturing the afferent and efferent loops together under the tube with 3–4 interrupted seromuscular sutures (formation of a “spur”);

4. suturing the parietal peritoneum to the edges of the skin incision;

5. suturing the “double-barreled shotgun” removed from the abdominal cavity with serous-muscular sutures along the entire circumference to the parietal peritoneum;

6. transverse dissection of the anterior wall of the sutured colon (the resulting “spur” protrudes upward and eliminates the possibility of feces getting into the outlet loop.

Features of the jejunum and ileum in newborns and children

The initial section of the small intestine, as well as its terminal section, is located much higher in children than in adults: the initial section lies at the level of the XII thoracic vertebra, and the terminal section at the level of the IV lumbar vertebra. With age, these sections gradually descend, and by the age of 12–14 years, the duodenum-jejunal flexure is located at the level of the second lumbar vertebra, and the ileocecal angle is in the right iliac region.

The loops of the small intestine in children of the first year of life are covered in the upper section by the liver, and throughout the rest of the length they are directly adjacent to the anterior abdominal wall. With the development of the greater omentum, the area of ​​contact of the small intestine with the anterior abdominal wall gradually decreases. By the age of 6–7 years, the omentum completely covers the intestinal loops in front. The relative length of the small intestine in children under 3 years of age is greater than in adults.

Developmental defects

Malformations of the jejunum and ileum

1. Meckel's diverticulum.

2. Atresias - can be single or multiple, combined with various anomalies in the development of the mesentery (mesentery defects) and blood vessels, and have different localizations.

3. Stenosis - associated with the formation of membranes from the mucous membrane, and sometimes from other layers of the intestinal wall with more or less holes.

4. Duplication of the small intestine - in the form of thick-walled cystic formations or elongated additional segments of the intestine in the form of a horn or double-barreled gun (located on the mesenteric edge or side wall).

The base of the appendix in children is funnel-shaped, and the border between it and the cecum is smoothed. The hole leading to the vermiform appendix gapes, and only by the end of the first year of life its sphincter is formed.

Transverse colon in newborns it has additional curves, its mesentery is mobile, its length is 1.5–2 cm. Then the mesentery gradually thickens, lengthens, and by 1.5 years it reaches 5–8 cm.

Colon malformations

1. Megacolon (Hirschsprung's disease) - a sharp expansion of the entire colon or its individual sections. The muscle fibers, as well as the mucous layer of the expanded part of the intestine, are sharply thickened. It is currently believed that the main cause of megacolon is underdevelopment of the nodes of the Auerbach plexus. As a result, the tone of the sympathetic nerve plexus predominates, which leads to a state of constant spasm of this part of the intestine. These changes are most pronounced in the distal sigmoid and rectum. Dilatation of the proximal intestine is secondary due to constant overcoming of resistance. There are four types of megacolon: gigantism, megadolichocolon, mechanical megacolon, Favali-Hirschsprung disease itself with the presence of a spastic zone and an expansion of the diameter of the proximal part.

Surgeries for Hirschsprung's disease are performed at 2–3 years of age using the abdominal-perineal method. The intervention includes resection of the entire aganglionic zone and the adjacent section of the dilated intestine for 6–12 cm with the formation of an anastomosis between proximal part resected intestine and the final section of the rectum. The large intestine is brought down to the perineum through the distal rectum or through a tunnel formed in the retrorectal tissue.

2. Atresia of the colon - manifests itself in two forms: membranous (there is a membrane of varying thickness that covers the entire lumen of the intestine) and saccular (one of the segments ends in a blind pouch, and the rest retains its normal shape).

3. Colon stenosis - narrowing of the intestinal lumen, as a result of the presence of a thin membrane or local thickening intestinal wall.

4. Duplication of the colon - cystic, diverticular and tubular (tubular) forms.

Lecture No. 8. Topographic anatomy and operations on parenchymal organs

Topographic anatomy of the liver

Holotopia: located mostly in the right hypochondrium, occupies the epigastric region and partially the left hypochondrium

Inside the abdominal cavity there is a cavity of the peritoneum (cavum peritonei), which is a serous sac formed by the continuous transition of the peritoneum from the walls to the organs, from organs to organs and consisting of a set of slits connected to each other and located between the parietal and visceral layers of the peritoneum. Parietal is the peritoneum that covers the walls of the abdominal cavity, visceral isabdominal organs. In men, the peritoneal cavity is closed; in women, through the openings of the fallopian tubes, the uterine cavity and the vagina, it communicates with the external environment.

Abdominal organs, covered with peritoneum on all sides, except for the attachment points of the mesenteries and ligaments (stomach, mesenteric small intestine, transverse colon, etc.), are located intraperitoneally in relation to the peritoneum. Organs covered by the peritoneum on three sides (liver, ascending and descending colons) are located mesoperitoneally in relation to it and protrude into the peritoneal cavity. The organs lying in the retroperitoneal space (pancreas, kidneys, abdominal aorta, etc.) are located extraperitoneally, more precisely retroperitoneally, in relation to the peritoneum, and are covered with peritoneum mainly in front.

The abdominal cavity is divided into two floors by the transverse colon and its mesentery - upper and lower.

The upper floor of the abdominal cavity contains the liver, stomach with the abdominal part of the esophagus, spleen, and upper part of the duodenum. The lower floor houses the small and large intestines. Organs lying in the retroperitoneal space can be located above the level of attachment of the mesocolon transversum (adrenal glands, the beginning of the abdominal aorta, the celiac trunk, the site of formation of the portal vein, the celiac plexus), above and below this level (kidneys, pancreas, duodenum, aorta, lower vena cava, superior mesenteric artery and vein) and below the level of attachment of the mesentery of the transverse colon (ureters, inferior mesenteric artery and vein, iliac arteries and veins).

Both floors of the abdominal cavity, forming a single whole, are connected in front by a gap (spatiuin preepiploicum), located between the omentum and the inner surface of the anterior wall of the abdomen, and on the sides - through lateral canals.
If, after removing the anterior wall of the abdomen, you look at the upper floor of the abdominal cavity, you will see that in the epigastric region, from under the costal arches and the xiphoid process, the anterior-inferior edge of the left and right lobes of the liver protrudes. At the level of the intersection of the costal arch with the outer edge of the right rectus abdominis muscle, the bottom of the gallbladder is located. Sometimes visible below the liver lower section small omentum. Here lie the upper part of the duodenum, the pyloric part and the lower right part of the body of the stomach. The greater omentum hangs down from the greater curvature of the stomach. The bulk of the liver, part of the body and fundus of the stomach, the abdominal part of the esophagus and the spleen are located under the diaphragm behind the lower anterior section chest.

When the peritoneum passes from the walls of the abdominal cavity to the organs of the abdominal cavity and from organ to organ, it forms folds and ligaments.

Rice. 120. View of the right half of the abdominal cavity and the pelvic cavity on the median sagittal cut (1/8).

From the upper surface of the liver to the diaphragm and the anterior abdominal wall, the peritoneum passes in the form of a thin oblique lig. falciforme hepatis, running almost from the navel upward to the level of the posterior surface of the liver, where it continues in front of the inferior vena cava into the coronary ligament of the liver. In the lower part of the falciform ligament is located lig. teres hepatis (obliterated v. umbilicalis). Lig. coronarium hepatis, passing from the liver to the diaphragm and the inferior vena cava, limits the posterior part of the liver, not covered by the peritoneum (extraperitoneal subphrenic space). Along the edges the coronary ligament passes into the ligg. triangularia dextrum and sinistrum. From the gate of the liver the peritoneum is in the form of lig. hepatogastricum and lig. hepatoduodenale, which together make up the lesser omentum (omentum minus), passes to the lesser curvature of the stomach and the upper part of the duodenum. Lig. hepatorenale goes from the posterior part of the margo inferior of the right lobe of the liver to the upper pole of the right kidney.

Covering the stomach from the front and back, the visceral layers of the peritoneum unite at its greater curvature and, bypassing the transverse colon, descend down in the form of the greater omentum (omentum majus).

At the free edge of the latter, the leaves fold back and return upward to the transverse colon, where along the taenia omentalis they fuse with it, and above - with the anterosuperior surface of the mesocolon transversum, at the base of which the upper of the leaves continues into the parietal peritoneum of the posterior wall of the cavum peritonei. Below the transverse colon in newborns, between the descending and ascending leaves of the greater omentum, there is a cavity, which then becomes overgrown, and the greater omentum in adults is 4 fused layers of visceral peritoneum. Above the transverse colon, the greater omentum consists of. 2 leaves and, since it connects the greater curvature of the stomach with the transverse colon, this section is called lig. gastrocolicum. Up and to the left, the gastrocolic ligament continues into the lig. gastrolineale, which is located between the fundus of the stomach and the hilum of the spleen. The outer layer of the peritoneum of this ligament covers the spleen and, meeting on the other side of the hilum of the spleen with the inner layer, continues as lig. phrenicolenale. Even higher, the gastrosplenic ligament passes into the lig. gastrophrenicum, which connects the cardiac part of the stomach with the diaphragm.

Omental bag(bursaomentalis) is located behind the lesser omentum and stomach, which serves as the anterior wall of the bag. The other walls of the bursa are: at the back - the parietal peritoneum, covering the front of the pancreas, inferior vena cava, left adrenal gland, part of the upper pole of the left kidney, diaphragm, celiac trunk and its branches; above - the caudate lobe of the liver and the fornix, which forms the parietal peritoneum of the posterior wall of the bursa during the transition to the liver (part of the coronary ligament), esophagus and stomach (lig. gastrophrenicum); below - the transverse colon and its mesentery; on the left - the gate of the spleen and lig. gastroliennale and lig. phrenicolenale; on the right is a fold of peritoneum formed during the transition of the parietal peritoneum of the posterior wall to the duodenum and gastrocolic ligament. In the upper part of the right wall there is an omental (Winslov) opening (foramen epiploicum), connecting the cavity of the bursa with the other, larger part of the upper floor of the peritoneal cavity. The hole, which allows 1-2 fingers to pass through in the absence of adhesions, is limited: in front by the hepatoduodenal ligament, behind by the parietal peritoneum covering the inferior vena cava, above by the caudate lobe of the liver and the vault, which forms the peritoneum at the transition from the lig. hepatoduodenale on the liver, from below - by the upper edge of the upper part of the duodenum.

Rice. 121. Upper floor of the abdominal cavity. Front view.
The anterior abdominal wall, anterior chest and diaphragm were removed. The diaphragm is pulled up.

On the posterior wall of the omental bursa there are folds of the peritoneum (plicae gastro-pancreaticae), of which the left, upper, formed due to protrusion of the peritoneum above the left gastric artery, is directed to the lesser curvature of the stomach, and the right, lower, formed as a result of protrusion of the peritoneum above the common hepatic artery, goes to the hepatoduodenal ligament. The part of the omental bursa between the folds and the omental foramen is called the vestibule (vestibulum bursae omentalis). Above the vestibule, behind the caudate lobe of the liver, is the recessus superior omentalis; downwards, between the posterior surface of the stomach and the gastrocolic ligament in front and the omental tubercle of the pancreas and the mesocolon transversum in the back, there is the recessus inferior omentalis. To the left of the vestibule lies the recessus lienalis.

In addition to the omental bursa, in the upper floor of the abdominal cavity there are also bursa hepatica and bursa pregastica. The hepatic bursa is located between the diaphragm above and the flexura coli dextra and the upper part of the duodenum below. The bursa contains the right lobe of the liver. In front, it is limited by the anterior abdominal wall, covered with the parietal peritoneum. Between the diaphragmatic surface of the right lobe of the liver and the diaphragm there is a slit-like right subdiaphragmatic space, and between its visceral surface and the right flexure of the colon and the upper part of the duodenum there is a subhepatic slit-like space.

Both of these gaps, as well as the gap between the right lobe of the liver and the anterior abdominal wall, make up the hepatic bursa. In a downward direction, the bag passes into the right lateral canal and the preepiploic fissure; V medial direction through the omental foramen it communicates with the bursa omentalis.

Rice. 122. Lesser omentum, omental bursa and omental (Winslov) hole. Organs of the upper floor of the abdominal cavity. Front view.
Same as in fig. 121. In addition, the stomach, the middle part of the transverse colon and its mesenteries, and part of the lesser omentum were removed.

The pregastric bursa is located between the diaphragm at the top and the anterior wall of the stomach and flexura coli sinistra and lig. phrenicocolicum below. In front it is limited by the anterior abdominal wall, covered with the parietal peritoneum. The bag contains the left lobe of the liver and the spleen. Inferiorly, the pregastric bursa passes into the left lateral canal and the preepiploic fissure. Both bags are separated by the falciform ligament of the liver. Below the liver, the bags communicate with each other through a gap located between the liver and lig. teres hepatis in front and above and the pyloric part of the stomach and the lesser omentum behind and below. Taken together, the three bursae described above form an intraperitoneal subdiaphragmatic space, within which abscesses can develop as complications after perforation of gastric and duodenal ulcers, after appendicitis, paracolitis, paranephritis, etc.

The lower floor of the abdominal cavity is located below the transverse colon and its mesentery and is more or less closed in front by the greater omentum, hanging from the greater curvature of the stomach. After the greater omentum, and with it the transverse colon, is retracted upward, the lower floor of the abdominal cavity opens completely. It is made of loops of the small intestine, along the edges and behind which are located the ascending and descending parts of the colon. Skinny and ileum, vermiform appendix, cecum, transverse colon and sigmoid colon, to the number of places where mesenteries are fixed to them, covered with peritoneum on all sides. The ascending and descending parts of the colon are covered with peritoneum, usually on three sides, except for the posterior surface. If you take the loops of the small intestine to the side or remove them, then between the colon ascendens and colon descendens and the side walls of the abdomen, the right and left lateral canals become clearly visible, connecting the upper floor of the abdominal cavity with the iliac fossae. The left lateral canal, thanks to the constantly present lig. phrenicocolicum, is more isolated from the upper floor of the abdominal cavity than the right one, where the same ligament is absent in most cases. However, the right lateral canal at the level of the cecum may be interrupted to some extent by the plicae caecales. Through the lateral canals (especially the right one), when a gastric or duodenal ulcer is perforated, gastric and intestinal contents can penetrate into the iliac fossae, and from there into the small pelvis. Pus and blood can spread through the side canals in both directions.

Rice. 123. Topography of the organs of the thoracic and abdominal cavities on a horizontal cut. Top view.
The cut was made at the level of the X thoracic vertebra.

Inward from the ascending and descending colon, to the right and left of the root of the mesentery of the small intestine, the right and left mesenteric sinuses are located. The right mesenteric sinus (sinus mesentericus dexter) is smaller in area than the left and is limited: on the right - by the ascending colon, on the left and below - by the root of the mesentery of the small intestine, on top - by the mesentery of the transverse colon. The left mesenteric sinus (sinus mesentericus sinister) is limited: above by the mesentery of the transverse colon, on the right by the root of the mesentery of the small intestine, on the left by the descending colon, and on the left and below by the mesentery of the sigmoid colon. The left sinus is more extensive and somewhat elongated in an oblique direction, from left to right and from top to bottom.

To the right of the rectum, the left sinus directly passes into the pelvic cavity. The sinuses communicate with each other at the top by a gap between the mesocolon transversum and the beginning of the jejunum.

The deepest are the lateral sections of the sinuses at the medial edges of the ascending and descending colon.

However, the deepest areas on the posterior wall of the abdominal cavity, along with the posterior sections of the right and left subphrenic spaces, are the lateral canals. In them, just like in the mesenteric sinuses and in the pelvic cavity, free fluid (pus, blood, transudate) can accumulate.

Peritoneal pockets may be the site of origin internal hernias. The most constant are those located in the right iliac fossa, above and below the place where the ileum flows into the caecum, recessus ileocaecalis superior and recessus ileocaecalis inferior; behind the caecum there is recessus retrocaecalis. No less often there are pockets of the peritoneum between the flexura duodenojejunalis and plica duodenojejunalis - recessus duodenalis superior and at the base of the mesocolon sigmoideum - recessus intersigmoideus.

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Often people receive a doctor's referral for an abdominal ultrasound. Of course, everyone follows doctor's orders. But what is the abdominal cavity, after all? In fact, this concept unites a fairly large group of organs.

Below we will talk about the location, structure and contents of the human abdominal cavity.

Let us first understand what the abdominal cavity is in spatial location. From above it is delimited from other sections of the human body by the diaphragm - behind it the thoracic section of the body begins. Below is the pelvic cavity. Sometimes the abdominal and pelvic areas are combined. At the back, along the back, the dividing line is the lumbar part adjacent to the column of the spine. In front, the entire system is supported by the abdominal muscles. On the sides, the abdominal cavity is also limited by tendons and muscles - this time the lateral ones. The space limited by these organs and zones is what the abdominal cavity is. It is filled with a variety of organs that play a vital role in the functioning of the human body.

As the main contributor. The basic principle is similar to formation elsewhere in the body due to a pressure imbalance between the inside of the circulation and the outside, in this case the abdominal cavity. An increase in portalness and a decrease in albumin may cause the formation of a pressure gradient leading to withdrawal ascites.

Other factors that may contribute to ascites are salt and water retention. Circulating blood volume may be sensed as low by sensors in the kidneys because ascites formation may deplete some blood volume. This signals the kidneys to reabsorb salt and water to compensate for the loss of volume.

Three abdominal zones

If we take the abdominal cavity as a whole, it is covered, as it were, with a special covering called the peritoneum. And this shell divides the cavity itself into three sections:

1. peritoneal space: it is located in front, directly behind the muscular soft wall;
2. retroperitoneal - located behind, closer to the spine;
3. pelvic cavity - the lower section of the entire peritoneal cavity.

What is located in the peritoneal space

The entire cavity contains the maximum number of organs fundamentally important for the life of the body - only the brain and spine remained independent. In the anterior part lie all the components of the intestine, including the now considered useless appendix and excluding some part of the duodenum, stomach, gall bladder and spleen.

Some other causes of ascites associated with increased pressure gradient are congestive and progressive renal failure due to generalized fluid retention in the body. In rare cases, increased portal system pressure may be caused by internal or external portal vessel obstruction, resulting in a portal without cirrhosis. Examples of this would be mass compression on the portal vessels from within the abdominal cavity or masses in the portal vessel obstructing normal flow and increasing pressure in the vessel.

In the retroperitoneal section - the pancreas, kidneys with ureters, accompanying adrenal glands and the remaining (it should be noted, the largest) part of the duodenum.

The pelvic cavity contains the excretory organs - the rectum and bladder, plus the internal reproductive organs. That is, in women the vagina and uterus with appendages are located in the pelvic cavity, and in men - the prostate gland.

Ascites can also occur as a result of a cancer called ascites. This type of ascites is usually a manifestation of progressive cancer diseases abdominal organs such as or. Pancreatic ascites can be observed in people with chronic or inflammatory processes of the pancreas. The most common reason for prolongation. Pancreatic aciditis can also be caused by both the pancreas.

What are the types of ascites?

Traditionally, ascites is divided into 2 types; transudative or exudative. This classification is based on the amount of protein contained in the liquid. A more useful system has been developed based on the amount of albumin in ascites fluid compared to serum albumin.

Based on this information about what the abdominal cavity is, it is worthwhile to become even more aware of how carefully it should be treated. After all, negligence can lead to the fact that one of your vital systems stops working, disruption of the functionality of which can lead to consequences, even fatal.

Abdomen ( cavitas abdominis) - a space limited at the top by the diaphragm, at the bottom - by the pelvic cavity, behind - by the lumbar spine with the adjacent quadratus lumborum muscles, iliopsoas muscles, in front and on the sides - by the abdominal muscles.

What are the risk factors for developing ascites?

Ascites associated with portal hypertension are usually larger than ascites due to other causes, lower than. The most common cause of ascites is cirrhosis of the liver. Many of the risk factors for ascites and cirrhosis are similar. The most common risk factors include long periods of time.

What are the symptoms of ascites?

There may be no symptoms associated with ascites, especially if it is mild. As more fluid accumulates, an increase in abdominal girth and size is usually seen. discomfort and is also often seen as ascites becomes larger. may also occur with large ascites due to increased pressure on the diaphragm and fluid migration across the diaphragm, causing pleural effusions. Cosmetologically disfiguring big belly caused by ascites is also common problem some patients.

The abdominal cavity contains the digestive organs (stomach, small and large intestines, liver, pancreas), spleen, kidneys, adrenal glands and ureters, blood vessels and nerves.

The inner surface of the abdominal cavity is lined internally with the abdominal fascia ( fascia endoabdominalis), inward from which the peritoneum is located.

Diagram of the relationship of organs to the peritoneum (cross section)

When should I see a doctor about ascites?

People with ascites should be monitored regularly by their primary care physician and any specialists who may be involved in their care. Gastroenterologists and hepatologists commonly see patients with ascites due to liver disease. Other specialists may also care for patients with ascites based on the possible cause and underlying condition. Specialists usually ask the patient to first contact their primary care physician if the ascites gets worse. If ascites causes symptoms of shortness of breath, abdominal discomfort, or inability to perform normal daily tasks such as primary doctor the patient should be notified of this.

Peritoneum ( peritoneum) - serous membrane lining the walls of the abdominal cavity (parietal peritoneum) and internal organs (visceral peritoneum). Between the visceral and parietal layers of the peritoneum there is a peritoneal cavity ( cavitas peritonei). The peritoneum secretes a serous fluid that moisturizes it and ensures the free movement of organs covered by the peritoneum:

The diagnosis of ascites is based on a physical examination combined with a detailed medical history to determine possible causes, as ascites is often considered a nonspecific symptom of other diseases. If ascites fluid exceeds 500 ml, it can be demonstrated on physical examination by flanking and fluid waves performed by a physician examining the abdomen. A smaller amount of fluid may be detected in the abdomen. Sometimes ascites is found incidentally by ultrasound or done to evaluate other conditions.

Lower right ribs

Diagnosis of the underlying conditions causing ascites is the most important part understanding the reasons for the development of ascites in humans. The medical history can provide clues to the underlying cause and usually includes questions about a previous diagnosis of liver disease, infection and its risk factors, alcohol abuse, family history of liver disease, heart failure, history and treatment history.

1- peritoneum parietale- parietal peritoneum - covers the walls of the abdominal cavity;

2 - peritoneum viscerale- visceral peritoneum, which covers the organ in various ways;

3 - mesoperitoneal position. The organ is covered by peritoneum on three sides (for example, ascending and descending colons, liver);

4 - extraperitoneal position. The organ is covered by peritoneum on one side (for example, the pancreas and partially the duodenum) or not covered at all (for example, the kidney), which is called the retroperitoneal position;

Blood work can make a difference important role in assessing the cause of ascites. A complete metabolic panel can detect patterns of liver injury, liver and kidney functional status, and electrolyte levels. It is also useful in providing hints for basic terms. Coagulation panels may be abnormal due to liver dysfunction and inadequate production of clotting proteins.

Sometimes possible causes of ascites may not be identified based on history, examination, and analysis of laboratory and imaging studies. Fluid analysis may be required to provide additional diagnostic information. This procedure is called paracentesis and is performed by trained doctors. It involves sterilizing the area on the abdomen and, using ultrasound, inserting a needle into the abdomen and removing fluid for further analysis.

5 - intraperitoneal position. The organ is covered by peritoneum on all sides (for example, the stomach, the mesenteric part of the small intestine);

6 - mesenterium- mesentery of the small intestine;

7 -cavitas peritonei- peritoneal cavity.

Diagram of the course of the peritoneum in a sagittal section (in men)

How is the abdominal cavity limited?

For diagnostic purposes, a small amount may be sufficient for adequate testing. If necessary, larger amounts up to several liters can be withdrawn to relieve symptoms associated with withdrawal ascites. The test is performed by sending the collected fluid to the laboratory immediately after drainage. Typically, the laboratory will analyze white blood cell counts and components, albumin levels, gram stains and cultures for any possible organisms, amylase levels, glucose, total protein and cytology.

The peritoneum, passing from the walls of the abdominal cavity to the organs and when moving from organ to organ, forms ligaments that represent a duplication of the peritoneum (two leaves):

1 -lig. coronarium hepatis- coronary ligament of the liver, which is formed during the transition of the peritoneum from the diaphragm to the liver;

2 - hepar- liver - covered with peritoneum mesoperitoneally. The peritoneum passes from the visceral surface of the liver to the duodenum ( lig. hepatoduodenal) and lesser curvature of the stomach ( lig. hepatogastricum);

What is the treatment for ascites?

The results are then analyzed by the treating physician to further evaluate and determine the possible cause of the ascites. Treatment of ascites largely depends on the underlying cause. For example, peritoneal carcinomatosis or malignant ascites can be treated with surgical resection and, while treatment for ascites associated with heart failure aims to treat heart failure with medical department and dietary restrictions.

Since liver cirrhosis is the main cause of ascites, it will be the main focus of this section. Management of ascites in patients with cirrhosis usually involves limiting dietary sodium intake and administering diuretics. Limiting dietary sodium intake to less than 2 grams per day is very practical, successful, and widely recommended for patients with ascites. In most cases, this approach must be combined with the use of diuretics, since salt restriction alone is usually not an effective way to treat ascites.

3 - lig. hepatogastricum- hepatogastric ligament, which, together with lig. hepatoduodenal forms the lesser omentum ( omentum minus). Behind the lesser omentum and stomach is the omental bursa;

4 - bursa omentalis - omental bursa - limited: above - by the caudate lobe of the liver, below - by the posterior plate of the greater omentum or, taken as a whole, by the mesentery of the transverse colon, in front - by the stomach and lesser omentum, behind - by the parietal peritoneum and the organs that it covers ( v. cava inferior, aorta, corpus pancreatis);

Consulting an expert regarding daily salt restriction can be very helpful for patients with ascites. Diuretics increase the excretion of water and salt from the kidneys. A typical daily dose of 100 milligrams of spironolactone and 40 milligrams of furosemide is the usual recommended starting dose. This can be gradually increased to obtain an appropriate response to a maximum dose of 400 milligrams of spironolactone and 160 milligrams of furosemide until the patient can tolerate the dose increase without any side effects.

5 - gaster- stomach - covered with peritoneum intraperitoneally. At the transition point lig. hepatoduodenal on the stomach, between the two layers of peritoneum and the lesser curvature of the stomach, there is an area not covered by peritoneum, or a bare area;

6-pars nuda (curvatura ventriculi minor) - bare area (lesser curvature of the stomach);

7- pars nuda (curvatura ventriculi major) - bare area (greater curvature of the stomach). Along the greater curvature of the stomach, two layers of peritoneum connect and descend down in front of the transverse colon and the loops of the small intestine (anterior plate of the greater omentum). Then these two layers of peritoneum are folded posteriorly and rise upward (posterior plate of the greater omentum). Thus, the greater omentum is formed from the four layers of peritoneum.

Taking these medications together in the morning is generally recommended and prevented during the night. For patients who do not respond well or cannot tolerate the above regimen, frequent therapeutic paracentesis may be performed to remove large amounts of fluid. This procedure can be removed safely with a few liters of liquid. For patients with malignant ascites, this procedure may also be more effective than using a diuretic.

For more refractory cases, surgical procedures may be required to control the ascites. Transjugular intrahepatic portosystemic shunts are a procedure performed through the internal jugular vein under local anesthesia interventional radiologist. The shunt is placed between the portal venous system and the systemic venous system, thereby reducing the pressure in the portal. This procedure is intended for patients who have minimal response to aggressive treatment. It has been shown to reduce ascites and limit or eliminate the use of diuretics in most cases.

8 - omentum majus- large oil seal. The posterior plate of the greater omentum (two posterior layers of peritoneum) is directed towards the posterior abdominal wall and splits. One leaf passes to the posterior wall of the peritoneal cavity, the other - to the transverse colon, connecting with another layer of peritoneum - the mesentery of the transverse colon is formed, which will thus consist of four layers of peritoneum;

More traditional shunt sites were essentially abandoned due to high level complications. Finally, liver transplantation for advanced cirrhosis may be considered as a treatment for ascites due to liver failure. requires a very complex and lengthy process and requires very careful monitoring and management by transplant specialists.

What are the complications of ascites?

Some complications of ascites may be related to the amount of ascites. Infections are another serious complication ascites. In patients with portal-associated ascites, bacteria from the intestine may spontaneously invade the peritoneal fluid and cause infection. This is called spontaneous bacterial.

9- mesocolon transversum- mesentery of the transverse colon;

10 - colon transversum- transverse colon - covered with peritoneum intraperitoneally. The lower layer of the mesentery of the transverse colon passes to the posterior wall of the peritoneal cavity. The pancreas and most of the duodenum are located retroperitoneally (extraperitoneal);

You may be wondering what organs are in the abdominal cavity and where they come from in the abdominal cavity. This article describes the various organs of the abdominal cavity. In this article you will find a description of the different organs and locations. The organs located in the abdominal cavity are: liver, spleen, stomach, small intestine and large intestine and gall bladder. Below is an overview of the different abdominal organs.

Gallbladder and bile ducts

Liver The abdominal cavity is bounded above by the diaphragm. The diaphragm is located directly below the lungs. The liver is located on the right side directly below the diaphragm. The liver is shaped like a triangle with its widest side lying directly below the diaphragm and the apex pointing down. The liver is the chemical factory of the body.

11 - pancreas- pancreas;

12 - duodenum- duodenum - parietal peritoneum, covering the duodenum on the anterior side; passes to the small intestine. Its two leaves form the mesentery of the small intestine;

13 - mesenterium- mesentery of the small intestine;

14 - jejunum- jejunum - located intraperitoneally in relation to the peritoneum; has one bare spot ( pars nuda) in the area of ​​attachment of the mesentery;

15 - rectum- rectum;

16 - vesica urinaria- bladder;

17- spatium retroperitoneale- retroperitoneal space - filled with fatty tissue. It contains the kidneys and ureters;

18 - excavatio rectovesicale- rectovesical recess;

19 - os pubis- pubic bone.