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Peritoneal cavity , Retroperitoneum and abdominal anastomoses

Dr. Ágoston Szél. Peritoneal cavity , Retroperitoneum and abdominal anastomoses. Department of Anatomy , Histology and Embryology Semmelweis University 2019. 1. Peritoneum 2. Retroperitoneum 3. Arterial and venous anastomoses. The peritoneum. tendon sheath. pericardium.

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Peritoneal cavity , Retroperitoneum and abdominal anastomoses

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  1. Dr. Ágoston Szél Peritonealcavity, Retroperitoneum and abdominalanastomoses Department of Anatomy, Histology and Embryology Semmelweis University 2019.

  2. 1. Peritoneum • 2. Retroperitoneum • 3. Arterial and venousanastomoses

  3. The peritoneum

  4. tendon sheath pericardium peritoneum Principle of the „serous membrane” mesotendineum mesocardium mesogastrium body cavity folding, duplicate, fixation, blood supply

  5. Reflection lines of the peritoneum anterior mesogastrium posterior mesogastrium C C Domph_ent Domph_ent R R A gut tube B

  6. Reflection lines of the peritoneum C D Domph_ent DJF R A B

  7. Relation of visceral organs to the peritoneum Intraperitoneal organs totally intraperitoneal organs partially intraperitoneal organs stomach, spleen, superior part of duodenum, ileum, jejunum, transverse colon, sigmoid colon, appendix, uterine tube. liver, ascending & descending colon, uterus, ovaries. Extraperitonealorgans retroperitoneal organs infraperitoneal organs pancreas, duodenum (desc., inf. & asc. parts) – APS* kidneys, adrenal glands, ureters, inf. vena cava, abd. aorta – PPS* urinary bladder, rectum. *APS, PPS: anterior & posterior perirenal space

  8. Abdominal cavity after removal of internal organs left coronary & triangular lig. C bare area right coronary & triangular lig. hepatoduodenal lig. transverse mesocolon D transverse mesocolon DJF descending colon root of mesentery ascending colon mesosigmoideum sigmoid colon R

  9. superior recess (SR) coeliac trunk SR VOB omental bursa (OB) vestibule of omental bursa (VOB) sup. mes. a. splenic recess (SpR) SpR OB inferior recess (IR) IR inf. mes. a. Peritoneum epiploic foramen (FW)

  10. Peritoneum falciform lig. left triangular lig. right coronary lig. bare area C gastrophrenic lig. right triangular lig. lesser omentum phrenicosplenic lig. hepatoduodenal lig. greater omentum phrenicocolic lig. D transv. mesocolon DJF ascending colon descending colon root of mesentery mesoappendix mesosigmoideum R

  11. Overview of the most important peritoneal ligament (duplicates) lesser omentum omental bursa transverse mesocolon right infracolic space root of mesentery left infracolic space sigmoid mesocolon

  12. Peritoneal spaces Falciform lig. Right subphrenic space Left subphrenic space Perisplenic space Left triangular lig. Bare area C Phrenicosplenic lig. Right coronary lig. Omental bursa Right subhepatic sp. Phrenicocolic lig. Hepatoduodenal lig. D Transverse mesocolon DJF Right infracolic sp. Descending colon Root of mesentery Left paracolic space Ascending colon. Left infracolic space Right paracolic sp. Left pararectal space Right pararectal sp. R Sigmoid mesocolon

  13. left subphrenic space right subphrenic space left subhepatic space lesser omentum gastrosplenic recess omental bursa gastrosplenic lig. splenic recess perisplenic space splenorenal recess right subhepatic recess (Morison-pouch) splenorenal ligament right coronary ligament right subphrenic space bare area Recesses between liver, spleen and kidneys extraperitoneal space right adrenal gland Morison-pouch duodenum, descending part transverse colon

  14. Peritoneal spaces Supramesocolic space right subphrenic (perihepatic) space left subphrenic (perihepatic) space omental bursa subhepatic space superior recess infrior recess lienal recess perisplenic space splenorenal recess hepatorenal recess (Morison) Inframesocolic space right paracolic space left paracolic space right infracolic space left infracolic space Lesser pelvis rectovesical pouch vesicouterine pouch rectouterine pouch (Douglas) lateral inguinal fossa supravesical fossa medial inguinal fossa

  15. The retroperitoneum

  16. Fasciae and capsules of the kidney

  17. Retroperitoneal topography peritoneal space retromesenteric space transversalis fascia peritoneum L S perirenal space (PS) P anterior pararenal space (APS) anterior renal fascia (Gerota) lateroconal space Rs Rd posterior pararenal space (PPS) posterior renal fascia (Zuckerkandl) Esp Esp transversalis fascia

  18. Topography and fasciae of the kidney stomach ureter pancreas renal a.& v. colon peritoneum abdominal muscles small intestine transversalisfascia *Camper’s fascia aorta thoracolumbar fascia inf. vena cava adipose tissue *Scarpa’s fascia vertebra anterior renal fascia (Gerota) spinal medulla spleen left kidney capsula fibrosa posterior renal fascia (Zuckerkandl) psoas major quadratus lumborum pararenal adipose body adipose capsule *superficial abdominal fascia

  19. Retroperitoneal spaces kidneys, adrenal glands, ureters perirenal space (PS) ant. pararenal space (APS) adipose capsule Pancreas, duodenum (pars desc., inf. et. asc.), colon (asc. et desc.)* renal capsule Gerota’s fascia (ant. renal fascia) Zuckerkandl’s fascia (post. renal fascia) common fascia The three spaces (APS, PPS, PS) do not communicate in the antero-posterior plane, however the perirenal space is open for the ureter at the level of the iliac crest, thus the spaces unite in the caudal direction. post. pararenal space (PPS) connective tissue, fat

  20. Fasciae and capsules of the kidney Scarpa’s fascia Camper’s fascia diaphragm lung diaphragmatic fascia liver costo-diaphrag- matic recess bare area Morison-pouch adrenal gland fibrous capsule perirenal fat peritoneum 12th rib ant. & post. renal fascia pararenal fat right kidney transversalis fascia thoracolumbarfascia right colic flexure quadratus lumborum iliac crest

  21. Fasciae and capsules of the kidney stomach liver pancreas spleen posterior pararenal space (PPS) colon perirenal space anterior pararenal space (APS Gerota’s fascia left kidney right kidney

  22. Surgical access of the pancreas lesser omentum gastrocolic ligament transverse mesocolon

  23. Operationmal access of kidneys with the liberation of colon flexure and mesentery medial or lateral to the colon flexure behind colon lateral to fascia of erector spinae muscle through the fascia of erector spinae

  24. The vascularanastomoses in theabdominalcavity

  25. left inferior phrenic right inf. phrenic coeliac trunk left middle suparenal right middle suparenal superior mesenteric right lumbar 1 left lumbar 1 right renal left renal left lumbar 2 right lumbar 2 left testicular (ovaric) right testicular (ovaric) left lumbar 3 right lumbar 3 Unpaired and pairedvisceral and parietalbranches of abdominal aorta inferior mesenteric left lumbar 4 right lumbar 4 median sacral right lumbar 5 left lumbar 5 right common iliac left common iliac right external iliac left external iliac left internal iliac right internal iliac

  26. splenic left gastric short gastric inferiorphrenic right gastric cystic splenicbranches hepaticproper gastroduodenal superiorpancreatico-duodenal left gastroepiploic common hepatic right gastroepiploic Anastomoses within the system of the coeliac trunk coeliac trunk abdominal aorta

  27. Anastomoses between coeliac trunk and superior mesenteric arteries splenic left gastric common hepatic coeliac trunk hepatic proper gastroduodenal superior pancraticoduodenal left gastroepiploic Bühler’s anastomosis superior mesenteric inferior pancraticoduodenal

  28. Anastomosis between superior & inferior mesenteric arteries sup. mesenteric artery inf. mesenteric artery *arch of RIOLANUS middle colic artery midle colic artery (right branch) superior mesenteric artery right colic artery left colic artery paracolic arch inferior mesenteric artery ileocolic artery appendicular artery ant. & post cecal arteries sigmoid arteries *„intermesenteric artery” „Cannon-Böhm’s point” „Griffith’s-point” inferior rectal artery lowest sigmoid artery

  29. Anastomosis between superior rectal and sigmoid arteries Ligation above Sudeck’s point ensures the supply of the rectum via anastomoses. SUDECK’s point Junction of superior rectal artery and the anas tomosis between the lowest branch of sigmoid artery and superior rectal artery. left colic artery (marginal artery of Drummond) inf. mesenteric artery sigmoid arteries SUDECK’s point superior rectal artery sigmoid artery (inferiormost)

  30. lefthepaticvein righthepaticvein. middlehepaticvein Abdominal part of inferior vena cava caudalhepaticvein rightsuprarenalvein leftrenalvein rightrenalvein lefttesticular (ovaric) vein left lumbar vein 3 righttesticular (ovaric) vein right lumbar vein 3 left lumbar vein 4 right lumbar vein 4 left iliolumbar vein right iliolumbar vein left common iliac vein right common iliac vein median sacral vein

  31. Heart Body wall Somatic (non visceral) circulation Thoracic aorta, renal erteries,common iliac artery, etc. Inferior vena cava, renal veins, common iliac vein, etc.

  32. Heart Liver Gut Portal circulation Inferior vena cava (hepatic veins) Hepatic artery proper Abdominal aorta (coeliac trunk, sup. & inf. mesenteric artery) Portalvein (splenic, superior & inferiormesentericveins)

  33. Heart Liver Gut Body wall Venous drainage

  34. Heart Liver Gut Body wall Portocaval anastomoses obstruction

  35. Esophageal veins Left & right gastric veins B Paraumbilical veins A Retroperitoneal veins* Inf. epigastric vein inf. Left colica vein D C Sup. rectal vein Middle & inf. rectal veins Portocaval anastomoses Azygos vein Sup. vena cava Vv. hepaticae Short gastricae veins Portal vein Left gastroepiploic vein Sup. mesenteric vein Splenic vein Gastroduodenal vein Right gastroepiploic vein Renal vein Jejunal & ileal veins Inf. mesenteric vein Middle colic vein Sigmoid vein Right colic vein Ileocolic vein Inf. vena cava *internal vertebral venous plexus – Batson-veins – deep perineal veins External iliac vein Common iliac vein Internal iliac vein

  36. Portocaval anastomoses (obstruction results in severe congestion) Left & right gastric veins Esophageal veins B Esophageal varix: scar formation, bleeding, rupture Paraumbilical veins Inf. epigastric vein Retroperitoneal veins Left colic vein A Head of Medusa D Paradoxical metastases Caravaggio Haemorrhoidal nodes, overdose of medicines (suppository) Vesical, prostatic, uterovaginal, rectal venous plexuses V. rectalis sup. V. rectalis media et inf. C

  37. Caput medusae (Head of Medusa) Obstruction of portal vein (distension of paraumbilical veins) Obstruction of inferior vena cava (distension of inferior epigastric vein)

  38. Ascites

  39. Ascites

  40. Esophageal varix esophageal balloon gastric balloon gastric tube Sengstaken-Blakemore’s tube

  41. Hepatic vein Hepatic artery Hepatic duct

  42. Bibliography • Lippert H: Lehrbuch Anatomie, Urban & Fischer, München, 2000 • Mac Kinnon P, Morris J: Oxford Lehrbuch der klinischen Anatomie, Hans Huber, Bern, 1997 • Moore KL, Dalley AF: Clinically Oriented Anatomy, Lippincott, 1999 • Putz R, Pabst R: Sobotta. Alliter, Budapest, 2004. • Patel R: Applied Peritoneal Anatomy, www.myESRorg. • Renz-Polster H, Krautzig S, Braun J: Innere Medizin, Urban & Fischer, München, 2004 • Snell RS, Clinical Anatomy, Little, Brown & Co, Boston, 1995 • Tirkes T et al: Peritoneal Anatomy. Gastrointestinal Imaging, https://doi.org/10.1148/rg.322115032. • https://www.kenhub.com/en/start/anatomy.

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