May, 2th 2018 Lukas, Omer

Peritoneum and peritoneal cavity

- If using the last edition of Gray’s anatomy, it is possible to refer to pages 1098 to 1110 of
chapter 63, without focusing so much on the clinical issues.
- N.S. peritoneum is a very likely question for the oral exam.
The principle of the peritoneum is that of a serous membrane like the pleura and the pericadium,
and partly like the tunica vaginalis of the testis in males, which is connected to the peritoneum
before the migration of the testis to the scrotum, and becomes then independent from it, leaving
a fibrous remnant as a separation. All of them are a double membrane system, with a serous
liquid between the two layers, which has the peculiarity to facilitate the movement of the two
membranes reciprocal to one another, reducing the friction and allowing the movement of the
organs that they sourround. For example during the heart beat, the heart does not move against
the other organs occupying the nearby space, but the movement is contained within the
pericardial space. The same happens with the pleura when the lungs get smaller and bigger during
expiration and inspiration: the movement is eased by the presence of the pleura.
- The same principle applies to the peritoneum, however in this case there are numerous
organs and the space covered by this serous membrane is much bigger.
For the all serous membranes, a visceral (inner) and a parietal (outer) layer are identified, the
former adhering to the viscera (the organ that moves –in the case of the heart contraction and
relaxation, in the case of the peritoneum different types of movements, in the case of the lungs
expansion and shrinkage); the latter adhering all around to the walls of the cavity where the organs
are located, and between the two layer there's the liquid which allows the system to work very
well.

• How can the liquid be confined within the two layers, and still allow the movement of these
layers?
This can be exemplified with a loose football which you compress using your fist, the ball, if the
air inside is not too much can surround your fist, but the air can remain inside it. The reason we
can talk about serous membranes as sacks is that they contain fluid and can be deformed thanks
to it.

• How much liquid?

Depends on the membrane: in the case of the pleura and the pericardium there is very little liquid,
and in fact the two membranes are so closed that the spaced between them two is said to be
virtual; in the case of the peritoneum, as there are multiple organs in the abdominal cavity, much
more liquid is present between the two layers of the membrane, and so there is generally much
more space between the visceral and parietal layer. However, in some regions the peritoneum is
thinner, for example next to the liver.
The liquid that accumulates in the abdominal walls, between the two layers, is not always the
same, but it is constantly changed (like the synovial fluid in joints " there is the need to change
the oil in car engines "). Not only it is changed but it can also be reabsorbed to maintain the
balance. Unbalances in the amount of fluid can occur in pathology, in particular, as a response to
inflammation the production of liquid can overcome the reabsorption leading to ascites. The excess
of liquid cannot lead to an explosion of the cavity, because the local defence of tissue to the
excess deposition of liquid is regulated by a reduction of blood flow.

• How can we explain the production of the fluid?

The peritoneum is inside the abdominal-pelvic wall, and two portions, the anterior and posterior
parts.
- Organs during development migrate from the posterior part of the wall towards the
anterior.
in doing that, they behave like a person taped to the wall, the more the person tries to be away
from the wall, the freer the person is to move (the longer the ligament that links the organ to the
wall, the freer the organ is to move).
- The organs in the abdomen can be divided according to their motility in the peritoneum

1. Under peritoneum - the organ starts to project inside, but without detaching from the
peritoneum, not allowed to move inside the cavity (fixed, as the peritoneum keeps it
attached to the wall).
2. Inside peritoneum- the organs detach completely from the wall, but a ligament is
created between the organs and the wall, keeping them attached to it. These organs are
completely motile.
During the digestive tract, starting already from the stomach, through the small and large
intestine there is an alternance between the under peritoneum and inside peritoneum

inside peritoneum under peritoneum

Stomach Duodenum (mostly under)
Upper part of small intestine Small and gross intestine passages
First colon Angle between first colon and transverse
colon
Transverse colon Following flection
Anterior rectum

- The alternance makes sense because the whole system is held in place by the portion
that are under peritoneum, however the portion between any two fixed parts is free to
move as it is inside peritoneum.
The importance of the movement is due to peristalsis: there must be the possibility for
digestive tract to move freely to push food towards the following steps in digestion.
 The most important structures (see arrows) of
the peritoneum are the peritoneal ligaments:
these physical structures can be damaged
during surgery. The presence of ligaments is
peculiar to the peritoneum: the other serous
coverings (pericardium, pleura) do not have
ligaments, while here there is the need for
these to keep the organs in place or
interconnected

• How can we distinguish the ligaments?

- There're two types of ligaments in the peritoneum

1. Mesum: connection between abdominal wall and the organ (connection between
visceral and parietal layer of the peritoneum) - A type of ligament that forms when ‘’I move
from the wall toward the outside, being covered with tapestry i.e. a connection between me
and the wall, that is more or less subtle and elongated according to how much I have moved
2. Omentum or epiculum, these are the
ligaments that are found between two
visceral layers.
A more complex type, which forms during the
rotation movements from right to left and then
from left to right that occur during development:
there is the possibility of formation of ligaments
that connect two organs.

NB: Be careful when using the term ligament,

which can be misleading: these peritoneal
ligaments are completely different from the fibrous ligaments made of connective tissue,
which are also found in the abdominal cavity, like in any other part of the body.
- The mesum is found both in the small intestine and in the gross intestine.
 a. In the small intestine there is a very big peritoneal ligament called the mesentery which
is comprehensive of the totality of the small intestine, except the very first part
(duodenum that is fixed, under peritoneum) and the very last part (connection of the
small intestine to the gross intestine at the level of the ileum and the first part of the
colon- also this part is fixed). Within the two fixed parts, the small intestine is very motile.
The mesentery root is a line
connecting the upper left to the
lower right abdominal wall with a
length of about 40 cm. (arrow).
The connection between the
mesentery and the small intestine
is much longer, it has in fact to
cover the whole length of the tract
of mesenteric small intestine
(most of the small intestine). This
length is of about 8m in the
cadaver, but in the living body the
longitudinal muscles of the small
intestine is of 2-3 meters
The second part of the mesum is found in the colon. It is in relation to the colon, as it covers the
parts that are not fixed as under peritoneum. Wherever there are the not-fixed parts of the inside
peritoneum at the level of the colon, there is the mesum. The names of these areas are:
1. Transverse mesocolon,
2. Right mesocolon,
3. Left mesocolon,
4. Sigmoid mesocolon (which does not include the rectum).
The transverse mesocolon is the biggest and most
important. Its length is more or less that of the
transverse colon (which does not change between
the living and the cadaver, as it is very much fixed
between the angles). The importance of this
structure is that it contributes to the separation of the
two big regions of the abdominal wall: the upper
peritoneal cavity and the lower peritoneal cavity.
The separation serves as a protection, however there
is an anterior part in which the upper and lower
peritoneal cavities are in communication (marked by
the star in the picture).
- Peritonitis (inflammation of the peritoneum) is dramatic because it can spread in the whole
peritoneal cavity, using the liquid inside the peritoneum as a culture medium.
- The last part of the gross intestine that is in contact with the peritoneum is the sigma, where
the mesocolon is present in three different segments (right, transverse and left)
Then we have the rectum, which represents a ‘’third way’’ in which an organ can be in relation
with the peritoneum, that is the retroperitoneal relation, meaning that they basically do not
interact, despite the organs are in the peritoneum (the other organs are the kidneys, separated
by the peritoneum by a layer of adipose connective tissue that serves as a protection of the
kidneys).
The omentum (epiculum) can be of two types, one bigger and one smaller
1. Greater omentum has a different structure in the early developmental stages of the
individual as compared to an adult. In a newborn there is a very long peritoneal ligament
which connects lower part of the stomach to the upper anterior transverse colon.
What is strange of this ligament is that unlike the other peritoneal ligaments this doesn’t
connect directly two structures (stomach to colon) which are close to one another, but it
goes down almost until the pelvis and then goes
back up again. There is no apparent reason for
such a behavior (it does not increase motility of
stomach and colon), but the space between the
layers of this structure (which comprehensively
4 layers – two on the descending part and two
on the ascending part), is filled of adipose tissue,
in which fat can be accumulated as energy: the
explanation for the existence of this region could
be as a storage of energy for animals which
hibernate, however this function is not
necessary in men. In case of surgery to fix
obesity, the removal of the greater omentum
helps reducing the body fat. This is a further
prove that the region is not particularly necessary. However, it also represents a stem
cells niche
The transverse colon and its mesocolon are adherent
to the posterior two layers of the greater omentum,
which generates a thicker layer of peritoneum than any
other because four peritoneal ligaments superimpose.
(each blue line in the figure represents a peritoneal
covering, with its double membrane filled with fluid)
 2. Lesser omentum and lesser cavity.
Is connected to the liver on the upper right side
to 2+1 parts of the digestive tract: the duodenum
[1] (upper duodenum), stomach [2] (shorter
right margin) and for very little length the [3]
oesophagus (sometimes this connection is not [2]
even present).
*+
[1]
The lesser omentum can be divided according to
its consistence, because the hepatooesophageal
and hepatogastric ligaments are empty, with few
blood vessels and few lymphatic vessels (soft
lesser omentum), while the last right part that
connects the liver with the duodenum is the hard
lesser omentum. The hardness is due to the presence of the organs which go to the liver
from the pancreas: the portal vein, the coledocum and the liver artery. These three
organs run below the hepatoduodenal ligament making this part of the ligament harder.
Lesser epiploic sac (or lesser sac) is delimitated in part by the lesser omentum. This sac is
connected to the main abdominal cavity by means of a small epiploic foramen or foramen
of Winslow. [3] This foramen is located between the hepatoduodenal ligament and the
posterior abdominal wall. This foramen is clearly delimitated by two veins: anteriorly by
the portal vein that is pushing on the hepatoduodenal ligament; posteriorly by the inferior
vena cava, as we are in the abdominal wall.

- NB Bearing in mind that the lesser sac is anterior to the pancreas and posterior to the
stomach, the anterior wall of this foramen is the peritoneal ligament that covers the
posterior wall of the stomach, while, the posterior wall of this foramen is the peritoneal
ligament that covers the anterior wall of the pancreas. (clearly visible in the figure at the
beginning of this page).
When you go left the cavity is closed by another 2 ligaments which go from the pancreas and
stomach to the spleen: these ligaments are pancreatic-splenic ligament and the gastro-splenic
ligament. Superiorly is closed by the parietal peritoneum which covers the diaphragm,
inferiorly it is closed by the gastro-colic ligament.

- (Here professor says to refer to the book for the peritoneum, that his lesson is only an
insight-so also the sbobina is an insight!!+ that the peritoneum, lesser cavity, lesser
omentum, greater omentum are very likely questions for the oral exam)
When hernia occurs, the peritoneum is pushed against openings in the muscular walls
by the pressure exerted by organs, especially the intestine. The risk correlated to hernia
is that of a choked hernia.
If we keep descending, following the peritoneum, this becomes like a sort of carpet, covering
the bladder, uterus in female, last part of the sigma and the rectum. In doing this, the closing of
the peritoneum makes a complex embracement of the uterus, that is different from the other
peritoneal ligaments. The Douglas pouch (lowest part of the peritoneum is an ending between
bladder and rectum (male) or uterus and rectum (female) and is a space in which bacteria have
the potential to accumulate in case of infections- or blood can accumulate there.