ABDOMINAL CAVITY:

GENERAL
ARRANGEMENT OF
ABDOMINAL VISCERA,
PERITONEUM

ANISA Z. SADAIN, MD, FPSCRS

July 13, 2023
Scope: • Quadrants and Regions of the
Abdominal Cavity
• General arrangement of the Abdominal
Viscera
• Peritoneum
• Peritoneal Nerve Supply and Function
• Clinical Notes
• Embryology
Quadrants and
Regions of the
Abdominal
Cavity
 Four Quadrants of the Abdominal Cavity
• Right upper quadrant.
• Left upper quadrant.
• Right lower quadrant.
• Left lower quadrant.
Nine Regions of the Abdominal Cavity
General
Arrangement of
the Abdominal
Viscera
 General Arrangement of the Abdominal
Viscera
 The esophagus connects the pharynx with the
stomach.
 The stomach occupies the left upper
quadrant, epigastric, and umbilical area
 The duodenum of the small intestine is
situated in the epigastric and umbilical area
 The jejunum occupies the upper left part,
while the ileum occupies the lower right part
of the abdominal cavity and the pelvic cavity.
• The large Intestine arches around and encloses
the coils of the small intestine.
• The liver occupies the upper part of the
abdominal cavity. The gallbladder adheres to
the undersurface of the right lobe of the liver.
 General Arrangement of the Abdominal
Viscera
 The pancreas stretches obliquely
across the posterior abdominal wall
in the epigastric region.
 The spleen occupies the left upper
part of the abdomen.
 The kidneys lie high up on the
posterior abdominal wall.
PERITONEUM
Peritoneum
• a thin serous membrane that lines the
walls of the abdominal and pelvic
cavities and clothes the viscera
• parietal peritoneum - lines the walls
of the abdominopelvic cavity
• visceral peritoneum - covers the
organs
• extraperitoneal tissue - lies between
the parietal peritoneum and the fascial
lining of the abdominal and pelvic
walls.
 Peritoneum
• peritoneal cavity - potential space
between the parietal and visceral layers
• It is the largest cavity in the body and is
divided into two parts:
• the greater sac - main compartment
and extends from the diaphragm
down into the pelvis
• the lesser sac - smaller and lies
behind the stomach.
• secretes a small amount of serous fluid
(peritoneal fluid), which lubricates the
surfaces of the peritoneum and allows
free movement between viscera.
Peritoneum
• The greater and lesser sacs are in free
communication with one another through an oval
window called the opening of the lesser sac
(epiploic foramen/foramen of Winslow)
Peritoneum
 Intraperitoneal & Retroperitoneal
Relationships
• lntraperitoneal organs - is almost
totally covered with visceral
peritoneum. They are attached to other
organs or the abdominal wall by
peritoneal bridges (omenta,
mesenteries, ligaments)
• The stomach, jejunum, ileum, and
spleen.
• Retroperitoneal organs - lie behind
the peritoneum and are only partially
covered with visceral peritoneum.
• The pancreas, ascending and
descending parts of the colon
 Peritoneal Ligaments
• Peritoneal ligaments are two-layered folds
of the peritoneum that connect solid
viscera to the abdominal walls
• Liver connects to the diaphragm by the
falciform ligament, the coronary
ligament, and the right and left
triangular ligaments
Peritoneal Ligaments: Liver
Peritoneal Ligaments:
Spleen & Stomach
 Omenta
• Omenta are two-layered folds of
peritoneum that connect the stomach
to another viscus
• greater omentum - connects the
greater curvature of the stomach to the
transverse colon
• lesser omentum - suspends the lesser
curvature of the stomach and the
proximal duodenum from the fissure
of the ligamentum venosum and the
porta hepatis on the undersurface of
the liver
• gastrosplenic omentum (ligament)
connects the stomach to the hilum of
the spleen
Omenta
Omenta
Mesenteries
• Mesenteries are two-layered folds of the peritoneum connecting parts
of the intestines to the posterior abdominal wall
• mesentery of the small intestine, the transverse mesocolon, and the
sigmoid mesocolon
Mesenteries
Peritoneal Bridges
• peritoneal ligaments, omenta,
and mesenteries serve as bridges
that permit blood, lymph vessels,
and nerves to reach the viscera.
 Lesser Sac
(Omental Bursa)
• lies behind the stomach and the
lesser omentum
• extends upward as far as the
diaphragm and downward
between the layers of the greater
omentum
• Left margin of sac: the spleen,
the gastrosplenic omentum, and
the splenorenal ligament
• Right margin of sac: opens into
the greater sac through the
opening of the lesser sac
(epiploic foramen)
 Lesser Sac
• Epiploic foramen/Foramen of Winslow
boundaries:
• Anteriorly: free border of the lesser
omentum, the bile duct, the hepatic
artery, and the portal vein
• Posteriorly: inferior vena cava
• Superiorly: caudate process of the
caudate lobe of the liver
• lnferiorly: first part of the duodenum
 Abdominal Cavity
• Roof: diaphragm (also forms the upper
parts of the lateral and posterior walls)
• Floor: It is absent inferiorly as the
abdominal cavity communicates with the
pelvic cavity at the pelvic brim.
• The peritoneal cavity is divided Into an
upper part within the abdomen and a lower
part In the pelvis. The abdominal part is
further subdivided by the many peritoneal
reflections into important recesses and
spaces, which, in turn, are continued into
the paracolic gutters
Abdominal Recesses
• small pockets or fossae in
the peritoneal cavity, which are
bounded by folds of peritoneum
 Abdominal Recesses
• Duodenal Recesses - close to the
duodenojejunal junction: (4)
• superior duodenal recess
• inferior duodenal recess
• paraduodenal recess
• retroduodenal recess
 Abdominal Recesses

• Cecal Recesses - close to the cecum: (3)

• superior ileocecal recess
• inferior ileocecal recess
• retrocecal recess
Abdominal Recesses
Abdominal Recesses

• Intersigmoid recess - situated at

the apex of the inverted, V-shaped
root of the sigmoid mesocolon
 Subphrenic Spaces
• The right and left anterior subphrenic
spaces lie between the diaphragm and the
liver, on each side of the falciform
ligament
• The right posterior subphrenic space lies
between the right lobe of the liver, the
right kidney, and the right colic flexure
• The right extraperitoneal space lies
between the layers of the coronary
ligament and is therefore situated between
the liver and the diaphragm.
Paracolic gutters
• lie on the lateral and medial
sides of the ascending and
descending colons
Subphrenic Space &
Paracolic gutters
 Peritoneal Nerve Supply
Parietal peritoneum (somatic nerve
innervation)
• sensitive to pain, temperature, touch, pressure
• Lower six thoracic and first lumbar nerve
- supply the parietal peritoneum lining the
anterior abdominal wall
• Phrenic nerves
- supply the central part of the diaphragmatic
peritoneum
• Lower six thoracic nerves
- Supply the peripheral diaphragmatic
peritoneum
• Obturator nerve, a branch of the lumbar plexus
- supplies parietal peritoneum in the pelvis
 Peritoneal Nerve Supply
Visceral peritoneum (visceral afferent
innervation)
• sensitive only to stretch and tearing
• Visceral afferent nerves supply the
viscera and also travel in mesenteries.
• Overdistension of a viscus leads to the
sensation of pain. The mesenteries of
the small and large Intestines are
sensitive to mechanical stretching.
 Peritoneal Functions
Peritoneal Fluid Peritoneal Folds
• is pale yellow & viscid, containing leukocytes • suspends the various organs within the
• secreted by the peritoneum and ensures that peritoneal cavity and serve as avenues
the mobile viscera glide easily on one another for conveying the blood vessels,
lymphatics, and nerves to these organs.
• Intraperitoneal movement of fluid toward the
diaphragm appears to be continuous and there • Large amounts of fat are stored in the
it is quickly absorbed into the subperitoneal peritoneal ligaments and mesenteries,
lymphatic capillaries and especially in the greater omentum
Peritoneal circulation: watershed regions in
the peritoneal cavity that are areas of fluid
stasis:
• Ileocolic region
• Root of the sigmoid mesentery
CLINICAL NOTES
 Peritoneum &
Peritoneal Cavity
• Peritoneal Fluid Movement
• Ascitis - excessive accumulation of peritoneal
fluid within the peritoneal cavity. It can occur
secondary to:
• hepatic cirrhosis (portal venous congestion)
• malignant disease
• congestive heart failure (systemic venous
congestion)
• In a thin patient, as much as 1500 mL has to
accumulate before ascites can be recognized
clinically.
• Paracentesis - the withdrawal of peritoneal fluid
from the peritoneal cavity
 Peritoneum & Peritoneal Cavity
Peritoneal Infection/Peritonitis
• Spontaneous bacterial peritonitis
• Secodnary peritonitis: enter the
peritoneal cavity through several
routes:
• from the interior of the GI tract
and gallbladder
• through the anterior abdominal
wall
• via the uterine tubes in females
(gonococcal peritonitis or
pneumococcal peritonitis)
• from the blood
 Peritoneum & Peritoneal Cavity
Peritoneal Infection/ Abscess
• Collection of infected peritoneal fluid in
one of the subphrenic spaces is often
accompanied by infection of the pleural
cavity  localized pus in a pleural
space (empyema) with a subphrenic
abscess
• Spread from the peritoneum to the
pleura via the diaphragmatic lymph
vessels.
• Subphrenic abscess/blood under
diaphragm  pain over the shoulder
 Peritoneum & Peritoneal Cavity
Peritoneal Infection/ Abscess
• sit patient up in bed with the back at a 45◦ angle
 infected peritoneal fluid gravitates downward
into the pelvic cavity (rate of toxin absorption is
slow)
 Greater Omentum
Localization of infection:
• “abdominal policeman”
• Poorly developed during the first 2 years
of life
• Infection is often localized to a small area
of the peritoneal cavity, thus saving the
patient from a serious diffuse peritonitis
(ie. appendicitis)
Greater Omentum
Hernia Plug:
• can plug the neck of a hernial sac and
prevent the entrance of coils of small
intestine
 Greater Omentum
Greater Omentum used in Surgery:
• Surgeons sometimes use the omentum
to buttress an intestinal anastomosis, in
the closure of a perforated gastric or
duodenal ulcer or in fistula repairs.
Omental patching
in dudoenal or
gastric ulcer
Omentum used to buttress an
anastomosis in the esophagus
Omentum used in fistula repair
 Greater Omentum
Torsion:
• The greater omentum may undergo
torsion, and if extensive, the blood
supply to a part of It may be cut off,
causing necrosis.
Abdominal Pain
• Abdominal peritoneal pain
• Pelvic peritoneal pain
• Referred visceral pain
Abdominal Peritoneal Pain
• Abdominal pain originating from the
parietal peritoneum is somatic and can be
precisely localized and is usually severe
• The lower six thoracic nerves and the first
lumbar nerve supply the parietal
peritoneum lining the anterior abdominal
wall
• An inflamed parietal peritoneum is
extremely sensitive to stretch.
 Abdominal Peritoneal Pain
• To diagnose peritonitis:
pressure is applied to the
abdominal wall over the
site of the inflammation.
The pressure is then
removed by suddenly
withdrawing the finger 
abdominal wall rebounds
 extreme local pain
“rebound tenderness”
 Pelvic Peritoneal Pain
• The parietal peritoneum in the
pelvis can be palpated by means of
a pelvic (rectal or vaginal)
examination
• An Inflamed appendix may hang
down into the pelvis and irritate the
parietal peritoneum there.
• Pelvic examination can detect
extreme tenderness of the parietal
peritoneum on the right side
Referred Visceral Pain
• Stretch caused by
overdistension of a viscus or
pulling on a mesentery gives
rise to the sensation of pain,
which is commonly referred to
a characteristic site in the skin.
• GI tract arises embryonically as
a midline structure and receives
a bilateral nerve supply, pain
may be referred to the midline
 Peritoneal Dialysis
• a treatment for kidney failure that uses the
peritoneum to filter the blood inside the body
• A watery solution, the dialysate, is introduced
through a catheter through a small midline
incision through the anterior abdominal wall
below the umbilicus.
 Peritoneal Dialysis
• The products of metabolism, such as urea,
diffuse through the peritoneal lining cells
from the blood vessels into the dialysate and
are removed from the patient
Internal Abdominal Hernia
• Occasionally, a loop of intestine enters
a peritoneal pouch or recess (eg. the
lesser sac of the duodenal recess) and
becomes strangulated at the edges of
the recess
• Uncommon
• Can be congenital or acquired
Internal Abdominal Hernia
• strangulating SBO, that occurs
after a closed-loop obstruction
• Most common: Paraduodenal
hernias, foramen of Winslow
hernias
EMBRYOLOG
Y NOTES
 Peritoneum and Peritoneal Cavity
Development
• By the end of the 4th week of embryonic
development, the intraembryonic coelomic
cavity has been formed by folding of the
embryonic disc.
• The intraembryonic coelomic cavity is lined
by mesoderm which encloses the primitive
gut and forms the peritoneum.
• The outer or somatic mesoderm, lining
the cavity, forms the parietal layer (lining
the peritoneal cavity)
• The inner or splanchnic mesoderm forms
the visceral layer (covering abdominal
organs).
Peritoneum and Peritoneal Cavity
Development
Peritoneum and Peritoneal Cavity
Development
• Early in development, the peritoneal
cavity is divided into right and left
halves by a central partition formed by
the dorsal mesentery, the gut, and the
small ventral mesentery. However, the
ventral mesentery extends only for a
short distance along the gut so that the
right and left halves of the peritoneal
cavity are in free communication.
Peritoneal Ligaments and Mesenteries
Formation
• The peritoneal ligaments are
developed from the ventral and dorsal
mesenteries.
• The ventral mesentery is formed from
the mesoderm of the septum
transversum (derived from the cervical
somites, which migrate downward).
• The ventral mesentery forms:
• the falciform ligament
• the lesser omentum
• the coronary and the triangular ligaments
of the liver.
Peritoneal Ligaments and Mesenteries
Formation
• The dorsal mesentery is formed from
the fusion of the splanchnopleuric
mesoderm on the two sides of the
embryo. It extends from the posterior
abdominal wall to the posterior border
of the abdominal part of the gut
• The dorsal mesentery forms:
• the gastrophrenic ligament
• the gastrosplenic omentum
• the splenorenal ligament
• the greater omentum
• the mesenteries of the small and large
intestines.
 Lesser and Greater Sac Formation
• The extensive growth of the
right lobe of the liver pulls
the ventral mesentery to the
right and causes rotation of
the stomach and duodenum
• The remaining part of the
peritoneal cavity, which is
not included In the lesser sac,
would become the greater sac
 Greater Omentum Formation
• The spleen is developed in the upper part of
the dorsal mesentery, and the greater
omentum is formed as a result of the rapid
and extensive growth of the dorsal mesentery
caudal to the spleen. To begin with, the
greater omentum extends from the greater
curvature of the stomach to the posterior
abdominal wall superior to the transverse
mesocolon
• Later, the posterior layer of the omentum
fuses with the transverse mesocolon.
• The inferior recess of the lesser sac extends
inferiorly between the anterior and the
posterior layers of the greater omentum.
- END OF LECTURE -
1. What is the communication between the lesser sac and
greater sac called?
2. What is the abdominal policeman?
3. What is another name of the lesser omentum?
4. Name one viscera/organ
contained in each region
5. Name the following structures:
6. Name a few functions of the peritoneum
7. Name 2 ligaments from each
major peritoneal ligament: