Operative Surgery and Topographic Anatomy - 2016

Content Module No. 3. Topographic Anatomy and Operative Surgery of the Abdominal Regions and Organs

Topic 13. Topographic Anatomy of the Abdominal Cavity. Peritoneal Reflection Relative to Abdominal Organs. Peritoneal Canals, Recesses, and Spaces, and Their Significance. Pathways of Spread of Inflammatory Processes

1. Relevance of the topic: acute Peritonitis continues to be the most frequent cause of mortality resulting from acute surgical Diseases of the Abdominal cavity. Acute inflammatory conditions, traumatic injuries, neoplasms, and developmental anomalies are quite common Pathologies of the abdominal Organs. Timely topical Diagnostics and successful Treatment are possible only with a detailed knowledge of the Topographic anatomy of the Peritoneum and abdominal organs by the physician.

2. Specific objectives:

1. Explain the Topography of the peritoneum and its derivatives (greater and lesser omentum ligaments, canals, sinuses, recesses).

2. Analyze the pathways of purulent process spread within the ABDOMINAL CAVITY AND The formation of abscesses in localized peritonitis. Justify the potential formation of internal hernias.

3. Tasks for independent work in preparation for the Class.

3.1. List of basic terms, parameters, and characteristics that the student must master in preparation for the class:

3.2. Theoretical questions for the class:

1. Topography of the peritoneum and its arrangement relative to the Organs of the peritoneal cavity.

2. Explain the terms "abdominal cavity" and "peritoneal cavity".

3. Which peritoneal spaces are located in the upper floor of the peritoneal cavity, and what is their topography?

4. How is the omental foramen formed, and what is its practical significance?

5. What forms the right and left lateral channels, and the right and left mesenteric sinuses? What is their practical significance?

3.3. Practical skills acquired during the class:

1. Exploration of the organs of the upper floor of the peritoneal cavity.

2. Exploration of the hepatic, pregastric, and omental bursae, mesenteric sinuses, and the right and left mesenteric canals.

3. Isolation of the celiac trunk.

4. Isolation of the elements of the hepatoduodenal ligament.

4. Topic content:

The following concepts are defined: abdominal cavity, belly cavity, peritoneal cavity, and retroperitoneal space. Attention is drawn to the mismatch between the external BOUNDARIES OF THE abdomen and the boundaries of its cavity (high standing of the diaphragm and the absence of a lower abdominal wall).

After making two incisions directed from the xiphoid process parallel to the right and left costal arches, and then downwards to the anterior superior iliac spine, the peritoneal cavity is opened by reflecting the entire anterior wall. The arrangement of the organs of the peritoneal cavity and its floors is examined. Students' attention is drawn to the mobility of the organs and their individual, age, and sex-related differences. General Principles for the exploration of the peritoneal cavity in trauma are indicated.

General Information: The abdominal cavity (cavitas abdominalis) is bounded anteriorly and laterally by the anterolateral abdominal wall; posteriorly by the lumbar region; superiorly by the diaphragm; inferiorly it continues into the lesser pelvis cavity. The abdominal cavity includes the peritoneal cavity and the retroperitoneal space.

The peritoneal cavity is enclosed by a serous membrane known as the peritoneum. It contains all the organs enveloped by the peritoneum. The peritoneum consists of two layers: the parietal layer and the visceral layer. The former lines the inner abdominal wall, while the latter covers the abdominal viscera; together, they form a continuous Structure as they transition into one another. Between the peritoneal layers, there is constantly about 30 ml of serous fluid.

Regarding their relation to the peritoneum, abdominal organs may be located intraperitoneally, mesoperitoneally, or retroperitoneally.

Most of these organs are completely surrounded by the peritoneum (Stomach, Small Intestine, cecum, transverse colon, sigmoid colon, Spleen), meaning they lie intra-peritoneally (intraperitoneally). If organs are covered by the peritoneum on three sides (Liver, Gallbladder, ascending and descending colons, PARTS OF THE duodenum and rectum), they are classified as mesoperitoneally positioned organs.

Retroperitoneally positioned organs are located behind the peritoneum (part of the duodenum, Pancreas, Kidneys, Ureters, Abdominal Aorta, and INFERIOR VENA CAVA).

The transverse colon, along with its mesentery, divides the abdominal cavity into two floors: upper and lower. Externally, this boundary corresponds to a horizontal line drawn through the ends of the 10th Ribs (linea bicostarum).

In the upper floor, three recesses are distinguished: the hepatic, pre-gastric, and omental bursae. Located between the right lobe of the liver, the diaphragm, and the anterior abdominal wall is the hepatic bursa (bursa hepatica). The pre-gastric bursa (bursa praegastrica) lies anterior to The Stomach and its ligaments, bounded on the right by the left lobe of The Liver and on the left by the spleen. These bursae are separated from each other by the falciform ligament. The omental bursa (bursa omentalis) is a slit-like space bounded anteriorly by the stomach and its ligaments, to the left by the spleen and its ligaments, inferiorly by the left part of the transverse colon and its mesentery, and posteriorly by the peritoneum of the posterior abdominal wall covering the pancreas, the left Kidney with the Adrenal gland (glandula suprarenalis), the aorta, and the inferior vena cava. Superiorly, the omental bursa is adjacent to the caudate lobe of the liver. It communicates with the general peritoneal cavity via the omental foramen (foramen epiploicum Winslowi), which is 3–4 cm wide and may be absent in the presence of adhesions.

The omental foramen is bounded anteriorly by the hepatoduodenal ligament, posteriorly by the inferior vena cava covered with peritoneum, superiorly by the caudate lobe (lobus caudatus) of the liver, and inferiorly by the initial part of the duodenum.

In the lower floor of the abdominal cavity, two lateral channels and the right and left mesenteric sinuses are distinguished.

The right lateral channel (canalis lateralis dexter) is medially bounded by the ascending colon and laterally by the lateral abdominal wall; the left lateral channel (canalis lateralis sinister) is bounded on the right by the descending colon and on the left by the lateral abdominal wall. Superiorly, these channels communicate with the upper floor of the peritoneal cavity, though the left channel is shorter as it is bounded by the phrenicocolic ligament (lig. phrenicocolicum); inferiorly, the channels communicate with the pelvic cavity.

Inflammatory processes can spread via the lateral channels into both the upper floor of the peritoneal cavity and the pelvic cavity.

The right mesenteric sinus (sinus mesentericus dexter) is bounded superiorly by the mesentery of the transverse colon, on the right by the ascending colon, on the left and inferiorly by the mesentery of the small intestine, and anteriorly by the greater omentum. The left mesenteric sinus (sinus mesentericus sinister) is likewise bounded superiorly by the mesentery of the transverse colon, on the right by the mesentery of the small intestine, on the left by the descending colon, and anteriorly by the greater omentum. The right mesenteric sinus communicates with the left slit located between the initial part of the small intestine and the mesentery of the transverse colon. Unlike the right sinus, the left sinus opens inferiorly into the pelvic cavity, which may facilitate the spread of pus and Blood into this region.

Recesses within the peritoneal cavity typically form at the sites where the peritoneum transitions from the walls of the peritoneal cavity onto the organs or from one organ to another.

The duodenojejunal recess forms at the transition of the duodenum into the jejunum. Hernias that may develop in this recess are called Treitz hernias and are usually diagnosed as intestinal obstruction. Superior and inferior ileocecal recesses are also distinguished. They are formed at the transition of the ileum into the cecum. The retrocecal recess can be observed by lifting the initial mobile section of the cecum upward. The intersigmoidal recess is bounded by the mesentery of the sigmoid colon and the parietal peritoneum.

5. Self-Control Materials

A. Self-Control Tasks

Test No. 1

To explore the omental bursa and examine the posterior wall of the stomach, the surgeon proposed performing an approach through the anterior wall of the omental bursa at the safest site for incision. Which ligament did the surgeon suggest incising?

a. Nephroduodenal

b. Gastrosplenic

c. Gastrocolic

d. Hepatogastric

e. Hepatoduodenal

Test No. 2

In a patient, pathological contents from the right lateral channel entered the subdiaphragmatic space. To which part of the abdominal cavity does this space belong?

a. Hepatic bursa b. Omental bursa

c. Pregastric bursa

d. Left mesenteric sinus

e. Right mesenteric sinus

Test No. 3

A surgeon is examining the left lateral channel of the abdominal cavity. What is the medial boundary of this channel?

a. Ascending colon

b. Transverse mesocolon

c. Descending colon

d. Mesentery of the small intestine

e. Cecum

Test No. 4

During surgery, the surgeon performed an exploration of the upper floor of the abdominal cavity. The peritoneum covered the patient's stomach on all sides. Which organ of the upper abdominal floor is also located intraperitoneally?

a. Spleen

b. Gallbladder

c. Liver

d. Sigmoid colon

e. Duodenum

Test No. 5

A 40-year-old man was admitted to the surgical department with a Diagnosis of ruptured spleen. In which anatomical space will blood accumulate?

a. Pregastric bursa

b. Hepatic bursa

c. Omental bursa

d. Rectovesical pouch

e. Right lateral channel

Test No. 6

A patient with a perforated ulcer of the posterior gastric wall was admitted to the hospital. Through which peritoneal element, having dissected it during surgery, can the surgeon reach the damaged wall?

a. Lesser omentum

в. Falciform ligament of the liver

c. Gastrosplenic ligament

d. Coronary ligament of the liver

e. Greater omentum

Test No. 7

A patient with a perforated ulcer of the posterior gastric wall was admitted to the hospital. Which peritoneal structure must the surgeon thoroughly examine during the operation?

а. Omental bursa

в. Hepatic bursa

c. Pregastric bursa

d. Left paracolic gutter

e. Right mesenteric sinus

Test No. 8

Following surgery to suture a penetrating wound of the small intestine, a patient developed an interloop abscess that ruptured into the right mesenteric sinus. Where can the purulent exudate spread next? а. Remain within the sinus

в. Enter the pelvic cavity

c. Penetrate into the cecal recess

d. Spread into the right lateral groove

e. Descend into the intersigmoid recess

Test No. 9

A 40-year-old patient presents with a perforation of an ulcer on the posterior gastric wall. Into which anatomical space will blood and gastric contents escape?

а. Omental bursa

в. Pregastric bursa

c. Right paracolic gutter

d. Left paracolic gutter

e. Hepatic bursa

Test № 10

A patient with destructive appendicitis has developed a subdiaphragmatic abscess as a complication. In which peritoneal recess is it localized?

a. Hepatic bursa

в. Pregastric bursa

c. Omental bursa

d. Right lateral channel

e. Left lateral channel

B. Self-Assessment Tasks

Task 1. A 53-year-old patient is undergoing surgery for a perforated gastric ulcer. During the exploration of the peritoneal cavity, the perforation site was not visualized. Gastric contents are present in the right lateral channel. What should be the surgeon's next steps?

Task 2. A 65-year-old patient presented with hematemesis. The medical history includes alcoholic liver cirrhosis. The patient was diagnosed with bleeding from esophageal varices. What TOPOGRAPHIC AND ANATOMICAL Features of the venous System of the upper storey of the peritoneal cavity underlie this complication?

Task 3. An abscess is located in the left mesenteric sinus. What are the possible complications of this condition?

References

Basic

1. Operative Surgery and Topographic Anatomy; ed. by M.S. Skrypnikov. — K.: Vyshcha Shkola, 2000. — P. 294-312.

2. Operative Surgery and Topographic Anatomy; ed. by M.P. Kovalsky. — K.: Medytsyna, 2010. — P. 198-222.

Supplementary

1. Kovanov V.V. Operative Surgery and Topographic Anatomy / V.V. Kovanov. — M., 2001. — P. 151-179.

2. Operative Surgery and Topographic Anatomy; ed. by K.I. Kulchytsky. — K., 1994. — P. 176-192.

3. Elizarovsky S.I. Operative Surgery and Topographic Anatomy / S.I. Elizarovsky, R.N. Kalashnikov. — M., 1979.

4. Matyushin I.F. Introduction to the Course of Operative Surgery and Topographic Anatomy / I.F. Matyushin. — Gorky, 1976.

5. Tomashuk I.P. Guide to Operative Technique for Beginner Surgeons / I.P. Tomashuk, I.I. Tomashuk. — K.: Publishing House of the European University, 2001. — 860 p.

6. Frautschi V.Kh. Course of Topographic Anatomy and Operative Surgery / V.Kh. Frautschi. — M., 1976.