Anatomy

of the

Peritoneum
and

Peritoneal Cavity

Lecture objectives
Understand the structure and function of the
peritoneum
Understand the nature of the innervation of both
parietal peritoneum and visceral organs covered
with peritoneum
Become familiar with potential spaces within the
greater and lesser peritoneal cavity
Understand the clinical implications of
intraabdominal fluid ascites, peritonitis and
intraabdominal abscess

Definitions
Peritoneum [Greek periteino, to stretch
over]
Parietal Peritoneum mesothelial lined
innermost surface of abdominal wall
Visceral peritoneum lining of free
surfaces of intraperitoneal viscera, liver
gallbladder stomach spleen, small and
large bowel, dome of urinary bladder,
uterus, fallopian tubes and ovaries

Peritoneum
Allows for frictionless motion of viscera in
abdominal cavity
In contact with a network of vasculature,
intercellular gaps allow monocytes and
neutrophils entry to wall-off infections
Forms fibrin (form of clot) in response to
trauma or infection which may eventually
becomes fibrous scar tissue, assists in
healing of surgical and traumatic wounds.

Peritoneal Mesothelium

Peritoneal Mesothelium

Innervation of peritoneum
Parietal peritoneum innervated by
somatic sensory nerves same segmental
distribution as abdominal wall
Visceral peritoneum (and viscera
innervated by sensory nerves which follow
sympathetic innervation of the organ

Abdominal pain pathways

visceral
Afferent nerves that travel in
same path as sympathetic
nerves of primordial gut
segment and overlying
peritoneum, cell bodies of
nerve located in dorsal root
ganglia at level of splanchnic
nerves

somatic
Afferent somatic sensory
nerve branches with nerve
endings in abdominal wall
and parietal peritoneum, cell
bodies of nerve located in
dorsal root ganglia of
abdominal wall dermatome

Visceral pain
Visceral afferent nerves travel to viscera in
association with the sympathetic nerves
which in turn enter the visceral organ along
with its arterial blood supply.
Visceral afferent nerves are NOT part of
the autonomic nervous system
Visceral afferent nerve fiber have cell
bodies in dorsal root ganglia concentrated
@ 3 major sites at the embryologic
origins of the celiac, superior mesenteric
and inferior mesenteric arteries

Visceral pain

Celiac artery supplies foregut

Superior mesenteric supplies mid gut
Inferior mesenteric artery supplies hind gut
Visceral afferent nerve fiber have cell
bodies in dorsal root ganglia concentrated
@ 3 major sites at the embryologic
origins of the celiac, superior mesenteric
and inferior mesenteric arteries
Most viscera migrate during development

Visceral pain
Fore gut distal esophagus, stomach, duodenum, biliary
+pancreas refers pain to the epigastrium T6-8
Midgut small bowel, appendix + prox colon refers to
periumbilical region T9-10
Hindgut- distal colon, rectum refers pain to hypogastrium
T11-L1
Renal and ureteral sx lateralize to flank + groin T9-L2
Three mechanisms of pain
1) distention
2) ischemia
3) mesenteric traction
No response to thermal, tactile or chemical stimulation

Visceral pain: segmental

innervation of gi tract
Foregut - Celiac axis

Midgut: SMA
Hindgut: IMA

Visceral
afferent
innervation

T 6-8

T 9-10

T 11-L1

Somatic pain
Abdominal dermatomes T6-L1
Central diaphragm C 3,4,5
Thermal, tactile and chemical irritation=peritonitis

Acid
Digestive enzymes
Blood
Bacteria
Bile
Urine
Feces

Somatic pain:
abdominal dermatomes

Referred somatic peritoneal pain:

Kehrs Sign

What is referred pain?

Pain perceived as coming from site
remote from its actual origin
Name another example

Lymphatic drainage of peritoneum

Parietal follows abdominal wall
Visceral follows attached viscera
Peritoneal cavity normally contains small volume
of peritoneal fluid (much like pleural cavity and
pericardial cavities)
Production normally = reabsorption
Numerous lymphatics in the diaphragm absorb
peritoneal fluid
Ascites [Greek askos, a bag] occurs when
production of fluid exceeds absorption as in
cirrhosis, chronic renal failure, nephrotic
syndrome

Ascites due to cirrhosis of the liver

Ascites CT and Ultrasound

Definitions
Mesentery [Greek mesenterion, mesos,
middle,+ enteron, intestine] double layer of
peritoneum extending from abdominal wall to
enclose any portion of a viscera, carries blood
and lymphatic vessels, lymph nodes and nerves
Peritoneal ligament double layer of
peritoneum that attaches an organ to abdominal
wall or another organ, e.g. falciform, round or
splenic ligaments

Definitions
Omentum [Latin, omentum, the
membrane that encloses bowels] double
layered sheet of fatty tissue attached to
greater curvature of stomach and covering
anterior aspect of abdominal cavity
Peritoneal fold raised edge of
peritoneum overlying vessels or vestigial
embryonic structures e.g. median and
medial umbilical folds

Peritoneal
folds

Definitions
Peritoneal recess cavity or potential
space lined by peritoneum e.g. subphrenic
or subhepatic space

Peritoneal cavity
Greater sac main portion of peritoneal
cavity
Lesser sac or omental bursa [Medieval
Latin, bursa purse] region enclosed by
greater omentum and posterior wall of
stomach/ Lt lobe liver
Lesser sac has superior and inferior
recesses

Omentum and mesenteries

Peritoneal cavity

Foramen of Winslow
Site of entrance into lesser sac
Anterior wall portal triad (portal vein,
hepatic artery and common bile duct)
Posterior wall inferior vena cava and
right crus [Latin , crura, leg] of diaphragm
Superior wall - caudate lobe of liver
Inferior wall duodenal bulb

Foramen of Winslow

Foramen of Winslow

Foramen of Winslow

Foramen of Winslow: Pringle maneuver

Compression of the hepatoduodenal ligament occludes both

hepatic artery and portal vn. limiting all blood flow into the liver

Free fluid in the peritoneal cavity gravitates to the most dependent sites
in the abdomen

Peritoneal spaces: clinical importance

Spaces in the peritoneal cavity become clinically
important when fluid collects from perforated
intestine or blood accumulates post-surgery.
Perforation of the gallbladder may lead to a right
subphrenic or sub hepatic abscess, whereas
removal of the spleen can cause an
accumulation of blood in the left sub phrenic
space. Accumulated blood is a bacterial culture
media and can become infected, thereby
creating an intraabdominal abscess.
Free perforation of a peptic ulcer or appendix
may cause an abscess in practically any space
in the peritoneal cavity = peritonitis

Subphrenic or suprahepatic spaces

Subhepatic spaces

Lesser sac (omental bursa)

normal

Pancreatic pseudocyst
in lesser sac

Subphrenic abscess on CT scan

Paracolic
gutters

Peritoneal spaces: clinical importance

Right and left paracolic gutters become
site of abscess loculation with perforation
of appendix and Lt colon
Many abscesses accumulate in the most
dependent region of peritoneal cavity - the
pelvis
Gravity pulls fluid into the pelvis whereas
the flow of peritoneal fluid is toward the
diaphragmatic lymphatic that absorb fluid

Right paracolic gutter:

appendiceal abscess