Peritoneum

Objectives
1. General features
2. Parietal & visceral peritoneum
3. Subdivisions & terms- Mesenteries, omenta & ligaments etc
4. Extra-peritoneal structures
5. Lesser omentum & greater omentum
6. Lesser sac- location boundaries
7. Epiploic foramen & its boundaries
8. Clinicals
Peritoneum
1. The peritoneum is a large thin serous membrane, which lines the
interior of the abdominopelvic cavity.
2. It is made up of a tough layer of elastic tissue lined with the
simple squamous epithelium and forms the largest serous sac of
the body. It is similar to the pleura and serous pericardium in
consisting of parietal and visceral layers.
3. These layers are separated from each other by a potential space
called peritoneal cavity, which is filled with a thin capillary film of
fluid. This fluid lubricates the two layers of the peritoneal cavity
and facilitates the movement of those parts of the abdominal
viscera, which are en-sheathed by the visceral layer.
4. The mobile parts of intra-abdominal digestive tube are completely
surrounded by the visceral layer of peritoneum except for a small
area where it passes from the tube to the posterior abdominal
wall as a double-layered fold called mesentery.
Peritoneum = Layers
1. Initially the peritoneum forms a closed sac, but when it
becomes invaginated by a number of abdominal viscera it is
divided into two layers: (a) an outer parietal layer and (b) an
inner visceral layer. The folds of peritoneum by which viscera
are suspended are called mesentery.
2. Thus, the peritoneum presents two layers: parietal layer called
parietal peritoneum and visceral layer called visceral
peritoneum.
3. The parietal peritoneum is a simple layer lining the internal
surface of the abdominopelvic walls.
4. The arrangement of the visceral layer is complex. It forms
folds, which surround the intricately folded and tightly packed
gut tube.
Peritoneum
In the male, the peritoneum is a
closed serous sac lined
with mesothelium (squamous
epithelium.
In the female, the peritoneum is
not a closed sac because it
communicates with the exterior
through uterine tubes, uterus,
and vagina.
It is also lined by mesothelium
as in male.
The peritoneum covering the
ovaries is lined by
cuboidal epithelium.
Peritoneum = Folds
1. Apart from allowing mobility to
organs, the peritoneal folds also
provide pathways for passage
to nerves, vessels, and
lymphatics.
2. The organs that lie outside the
peritoneal cavity (retroperitoneal
organs) are fixed and immobile.
The functions of peritoneal folds
are as follows:
1. To provide mobility to the
viscera.
2. To provide passage to vessels
and nerves.
Peritoneum = types of Folds
1. Mesentery/mesocolon: The fold suspending the small intestine is
called mesentery and the fold suspending the colon is called mesocolon.
2. Omenta (singular omentum): These are the peritoneal folds that
connect the stomach with other viscera. The examples are:
(a) Greater omentum, a fold connecting the stomach with the transverse
colon.
(b) Lesser omentum, a fold connecting the stomach with the liver.
(c) Gastrosplenic omentum, a fold connecting the stomach with the
spleen (in general usage it is termed gastrosplenic ligament).
3. Ligaments: They are the folds that connect organs to the abdominal
wall or to each other. The examples are gastrosplenic ligament (between
stomach and spleen), lienorenal ligamentum (between kidney and
spleen), and coronary ligaments (between liver and diaphragm).
1. The liver is attached to the
anterior abdominal wall by the
falciform ligament and, except
for a small area of the liver
against the diaphragm (the
bare area ), the liver is almost
completely surrounded by
visceral peritoneum.
2. Additional folds of
peritoneum connect the liver
to the stomach hepatogastric
ligament , the duodenum
(hepatoduodenal ligament ),
and the diaphragm ( right and
left triangular ligaments and
anterior and posterior
coronary ligaments
Peritoneum
The fate of dorsal mesogastrium is as under:
1. The larger caudal part becomes greatly elongated to
form the greater omentum. The smaller cranial part becomes divided
into dorsal and ventral parts by the development of spleen within it.
The ventral part forms the gastrosplenic ligament whereas the
dorsal part forms the lienorenal and gastrophrenic ligaments.
The fate of ventral mesogastrium is as under
The ventral part forms the falciform and coronary ligaments
between the body wall and the liver;
and dorsal part forms the lesser omentum between the liver and the
curvature of the stomach.
The abdominal part of the
peritoneal cavity is divided into
anterosuperior supracolic and
posteroinferior infracolic
compartments by transverse
colon and its mesentery—the
transverse mesocolon.

The infracolic compartment below

the level of transverse
mesocolon is divided into right
and left infracolic spaces by
the root of the mesentery of the
small intestine.
Peritoneum
SUBDIVISIONS OF THE PERITONEAL CAVITY
The peritoneal cavity may be broadly divided into two parts:
1. Greater sac.
2. Lesser sac (or omental bursa).
The greater sac is the larger (main) compartment of the
peritoneal cavity and extends across the whole breadth and
length of the abdomen.
The lesser sac is the smaller compartment of the peritoneal
cavity, which lies behind the stomach, liver, and lesser omentum as
a diverticulum from the greater sac.
The two sacs communicate with each other through the
foramen epiploicum
Peritoneum
Greater Omentum (L.
Omentum = Apron)
The greater omentum is a large
thick fold of peritoneum, which
hangs from the greater
curvature of stomach and the
adjacent part of the duodenum
like an apron and covers the
loops of intestine to a variable
extent.
The greater omentum is made
up of four layers of
peritoneum, which are fused
together to form a thin
fenestrated membrane
containing variable amount of
fat.
Peritoneum

Lesser
omentum
Peritoneum
The lesser omentum is a double-layered fold of peritoneum
between the lesser curvature of stomach and the inferior surface of
the liver.
Contents
1. Along the lesser curvature of the stomach the lesser omentum
contains: (a) Right and left gastric vessels and associated gastric
lymph nodes. (b) Branches of the left gastric nerve.
2. The right free margin of the lesser omentum contains:
(a) Portal vein.
(b) Hepatic artery and bile duct anterior to the portal vein, with duct
to the right of the artery.
(c) Autonomic nerves.
(d) Lymphatic and lymph nodes.
An omentum- greater omentum
1. An omentum is a double-layered extension or fold of peritoneum
that passes from the stomach and proximal part of the duodenum
to adjacent organs in the abdominal cavity.
2. The greater omentum is a prominent, four-layered peritoneal fold
that hangs down like an apron from the greater curvature of the
stomach and the proximal part of the duodenum. After
descending, it folds back and attaches to the anterior surface of
the transverse colon and its mesentery.
3. The lesser omentum is a much smaller, double-layered peritoneal
fold that connects the lesser curvature of the stomach and the
proximal part of the duodenum to the liver. It also connects the
stomach to a triad of structures that run between the duodenum
and liver in the free edge of the lesser omentum
An
omentum
(Latin for
"apron") is a
layer of
peritoneum
that
surrounds
abdominal
organs
The omental bursa
1. The omental bursa is an extensive sac-like cavity that lies
posterior to the stomach, lesser omentum, and adjacent
structures. The omental bursa has a superior recess, limited
superiorly by the diaphragm and the posterior layers of the
coronary ligament of the liver, and an inferior recess between the
superior parts of the layers of the greater omentum.
2. The omental bursa permits free movement of the stomach on the
structures posterior and inferior to it because the anterior and
posterior walls of the omental bursa slide smoothly over each
other.
3. Most of the inferior recess of the bursa becomes sealed off from
the main part posterior to the stomach after adhesion of the
anterior and posterior layers of the greater omentum
Epiploic foramen or Foramen of Winslow
1. The omental bursa communicates with the greater sac through the
omental foramen (epiploic foramen), an opening situated posterior to
the free edge of the lesser omentum(hepatoduodenal ligament). The
omental foramen can be located by running a finger along the
gallbladder to the free edge of the lesser omentum.
2. The omental foramen usuall yadmits two fingers. The boundaries of
the omental foramen are
• Anteriorly: the hepatoduodenal ligament (free edge of lesser omentum),
containing the hepatic portal vein, hepatic artery, and bile duct
Posteriorly: the IVC and a muscular band, the right crus of the
diaphragm, covered anteriorly with parietal peritoneum. (They are
retroperitoneal.)
• Superiorly: the liver, covered with visceral peritoneum.
• Inferiorly: the superior or first part of the duodenum.
Omental (epiploic) foramen and omental bursa.
The index fi nger is passing from the greater sac through the omental foramen into the omental bursa
(lesser sac). The hepatoduodenal ligament is being pinched between thumb and index fi nger, which would
compress the structures of the portal triad (portal vein, hepatic artery, and bile duct).
Peritoneal fold & recess,
1. A peritoneal fold is a reflection of peritoneum that is raised from
the body wall by underlying blood vessels, ducts, and ligaments
formed by obliterated fetal vessels
2. (e.g., the umbilical folds on the internal surface of the
anterolateral abdominal wall.
3. Some peritoneal folds contain blood vessels and bleed if cut,
such as the lateral umbilical folds, which contain the inferior
epigastric arteries.
4. A peritoneal recess, or fossa, is a pouch of peritoneum that is
formed by a peritoneal fold
5. (e.g., the inferior recess of the omental bursa between the layers
of the greater omentum, and the supravesical and umbilical
fossae between the umbilical folds;
Peritoneum Functions of the Peritoneum
1. The peritoneal fluid, which is pale yellow and somewhat viscid,
contains leukocytes. It is secreted by the peritoneum and
ensures that the mobile viscera glide easily on one another.
2. As a result of the movements of the diaphragm and the
abdominal muscles, together with the peristaltic movements of
the intestinal tract, the peritoneal fluid is not static.
3. Experimental evidence has shown that particulate matter
introduced into the lower part of the peritoneal cavity reaches the
subphrenic peritoneal spaces rapidly, whatever the position of
the body.
4. It seems that intraperitoneal movement of fluid toward the
diaphragm is continuous, and there it is quickly absorbed into
the subperitoneal lymphatic capillaries.
Peritoneum = Nerve Supply of the Peritoneum
1. The parietal peritoneum is sensitive to pain, temperature,
touch, and pressure. The parietal peritoneum lining the
anterior abdominal wall is supplied by the lower six
thoracic and 1st lumbar nerves—that is, the same nerves
that innervate the overlying muscles and skin.
2. The central part of the diaphragmatic peritoneum is
supplied by the phrenic nerves; peripherally, the
diaphragmatic peritoneum is supplied by the lower six
thoracic nerves.
3. The parietal peritoneum in the pelvis is mainly supplied
by the obturator nerve, a branch of the lumbar plexus.
Peritoneum = Nerve Supply of the Peritoneum
1. The visceral peritoneum is sensitive only to stretch and
tearing and is not sensitive to touch, pressure, or
temperature.
2. It is supplied by autonomic afferent nerves that supply
the viscera or are traveling in the mesenteries.
3. Overdistention of a viscus leads to the sensation of pain.
The mesenteries of the small and large intestines are
sensitive to mechanical stretching.
Clinical Aspects
1. Pneumoperitoneum is the presence of gas within the peritoneal cavity,
as may occur when a perforation forms in the stomach or intestines,
and heralds a perilous situation.
2. Peritonitis refers to inflammation of the peritoneal lining or cavity, as
may occur with either a perforation or by spread of infection through
the wall of one of the abdominal organs. This too is a serious
condition, and often requires emergency surgery.
3. Ascites is an accumulation of excess fluid within the peritoneal cavity.
4. Peritoneal dialysis= In one form of dialysis, the peritoneal dialysis, a
glucose solution is run through a tube into the peritoneal cavity. The
fluid is left there for a prescribed amount of time to absorb waste
products, and then removed through the tube. The reason for this
effect is the high number of arteries and veins in the peritoneal cavity.
Through the mechanism of diffusion, waste products are removed
from the blood.
Peritoneum