The beginning of the jejunum is the way of liparev. Small intestine
25.06.2013
Lecture 32. Topographic anatomy of the small and large intestine
1. Small intestine (topography) Small intestine - site digestive tract between the stomach and colon. It is divided into three departments- duodenal, skinny and iliac. The beginning and end of the intestine is fixed by the mesentery root to the posterior wall abdominal cavity... The rest of the mesentery provides its mobility and position in the form of loops. On three sides they are bordered by the sections of the colon; from above - transverse colon, on the right - ascending, on the left - descending, turning into sigmoid. Intestinal loops in the abdominal cavity are located in several layers, some - superficially, in contact with the greater omentum and the anterior abdominal wall, others - deeply, adjacent to the posterior wall. The edge of the small intestine, attached to the mesentery, is called mesenteric, the opposite - free. Along the mesenteric edge between the mesenteric leaves there is a narrow strip not covered by the peritoneum. The sutures when imposing intestinal anastomoses in the area devoid of the peritoneum are fragile, which is taken into account when conducting peritonizationof this site. Front projection abdominal wall corresponds to the celiac and hypogastric regions. The duodenal bend is usually well defined. To find flex. duodenojejunalis they use Gubarev's technique - the large omentum with the transverse colon is taken up; go along the mesentery to the spine and slide off it to the left, capturing the first, fixed, loop of the small intestine. To determine the leading and withdrawing loops, the Wilms-Gubarev method is used - the intestinal loop is installed along the mesentery root, that is, from top to bottom, from left to right. In this case, the leading end will be located on the left and above, and the abducting end of the intestine on the right and below.Developmental anomalies small intestine - atresia, stenosis, congenital enlargement of the small intestine, bowel rotation disorders, etc. Meckel's diverticulum - protrusion of the small intestine as a result of pathology of the reverse development of the yolk-intestinal duct. The extraorganic arterial system is represented by the superior mesenteric artery system, its branches, arcades and straight vessels. Superior mesenteric artery departs from abdominal aorta at level I of the lumbar vertebra. In some cases, the superior mesenteric artery can compress the duodenum, causing arteriomesenteric obstruction. From it at the lower edge of the pancreas, the lower anterior and posterior pancreatoduodenal arteries... The small intestinal branches are subdivided into the jejunal arteries and the ileal arteries. Each of them divides and supplies blood to a limited section of the intestine - ascending and descending, which anastomose with each other, forming arcs (arcades) of the first order. New branches extend from them distally, which form second-order arcades, etc.
The last row of arcades forms a parallel or marginal vessel, from which there are straight vessels that supply blood to the intestine. The veins of the small intestine begin to form from the straight veins into the system of venous arcades. All veins, merging, form superior mesenteric vein.
2. Large intestine (topography) Colon - the final section of the digestive tract. It starts from the ileocecal junction and ends with the rectum with the anus. It is divided into three parts - blind, colon and rectum... The colon is subdivided into ascending, transverse, descending and sigmoid... The place of transition of the ascending to the transverse is the right rim bend ( hepatic curvature), and the place of transition of the transverse to the descending one is the left bend ( splenic curvature). The ileocecal section is located in the right iliac fossa and represents the place of transition of the small intestine to the large intestine, includes the cecum with a vermiform appendix and the ileocecal junction with the Bauginia valve. It provides insulation for the small and large intestines.
Cecum - the area of \u200b\u200bthe large intestine located below the upper edge of the ileum. The appendix, or appendix, is a rudimentary continuation of the blind. At its base, all three muscle bands of the cecum converge. It is covered with a peritoneum on all sides. When the cecum does not have a complete peritoneal cover, its posterior wall is tightly fixed to the retroperitoneal tissue and ileal fascia.
Appendix covered with peritoneum on all sides, vessels and nerves pass through the mesentery .
Ascending colon intestine - the right lateral region of the abdomen, the continuation of the cecum to the right hypochondrium, where it passes into the right bend - the transition of the ascending colon to the transverse colon. The ascending colon is located mesoperitoneally. The right bend touches the bottom surface right lobe the liver, the bottom of the gallbladder, is located intraperitoneally or mesoperitoneally. The transverse colon is located intraperitoneally, begins in the right hypochondrium, passes into the actual epigastric and umbilical regions, and then reaches the left hypochondrium, where it passes into the left bend. The left flexure of the colon is located intraperitoneally .
Transverse colon the intestine is bordered at the top by the liver, gallbladder, greater curvature of the stomach and spleen, below by the loops of the small intestine, at the front by the anterior abdominal wall, at the back by the duodenum, pancreas and left kidney, which are separated from it by the mesentery and parietal peritoneum. The descending colon is the left lateral region of the abdomen. It is separated from the anterior abdominal wall by loops of the small intestine and a large omentum, behind it are the muscles of the posterior abdominal wall, located mesoperitoneally.
Sigmoid colon intestine - left ileal and pubic region, located intraperitoneally, has significant mobility. The line of attachment of the mesentery root to the posterior abdominal wall has two sections - the first is directed from left to right, the second - down. The colon is supplied with blood from two vascular highways - superior and inferior mesenteric artery... The blood supply to the ileocecal region is carried out by the ilio-colonic artery.
Tags:
Description for the announcement:
Start of activity (date): 06/25/2013 06:35:00
Created by (ID): 1
Like other operations, it can be conditionally divided into three stages: online access, prompt reception and exit from the operation. When performing these stages, it is necessary to observe the principles of separation and connection of tissues, namely: layering, hemostaticity, relative atraumaticity and asepticity. For example, when conducting operational access the parietal peritoneum should be dissected after creating a "dome", which prevents damage to the internal organs of the abdominal cavity. For this, the peritoneal fold is grasped with two surgical or gripping forceps and pulled anteriorly. With the help of palpation, make sure that the contents of the abdominal cavity did not get into the "dome" of the peritoneum and cut the peritoneum between the tweezers (at the top of the "dome"). Then two fingers (or a grooved probe) are inserted into the hole formed and, continuing to pull the peritoneum forward, dissect it with a scalpel or scissors over the entire length of the surgical wound.
Observance of "asepticity" acquires special relevance during all stages of an abdominal operation, so the infection can get into the surgical wound not only from the outside, but also from the inside (the contents of the gastrointestinal tract are always infected). In order to protect the layers of the anterolateral abdominal wall dissected during the operative access from infection, wet wipes are fixed to the edges of the dissected peritoneum using Mikulich clamps. After releasing the clamps along the edges of the wound, these napkins provide isolation of the layers of the surgical wound from the contents of the abdominal cavity.
Before the start of the operational reception and after its completion, it is necessary to carry out revision , that is, examination of the contents of the abdominal cavity. For revision of the lower floor of the abdominal cavity, use gubarev's reception... The purpose of this technique is to find the duodenal-lean (duodeno-jejunal) bend. Reception Gubarev begins with the fact that the large omentum and the transverse colon fused with it are thrown upwards, thereby isolating the upper floor of the abdominal cavity from the lower floor. After this, the loops of the small intestine are displaced to the right, partially freeing the left mesenteric sinus. Then the surgeon, with his right hand with the thumb retracted, slides along the root of the mesentery of the small intestine from bottom to top, from right to left, continuing to displace the movable part of the small intestine. The surgeon's hand will stop when a fixed part of the small intestine is between his thumb and forefinger - it will correspond to the transition of the duodenum into the jejunum. After finding the duodeno-jejunal bend, you can examine the pocket of the same name (depression), representing the transition of the parietal peritoneum to the visceral. In this pocket, most often (in comparison with the other four pockets), an infringement of the loop of the small intestine can occur - the formation of an internal hernia (infringement in the duodeno-jejunal pocket is called Treitz's hernia). In addition, the detection of the duodeno-jejunal flexure makes it possible to consistently examine the loops of the jejunum and ileum up to the ileo-cecal (ileocecal) angle. In this case, parts of the small intestine are examined by a surgeon and transferred from one hand to another. Sequentially going over the parts of the small intestine and thus reaching from the duodeno-jejunal flexure to the ileocecal angle, the surgeon will be sure that all the loops of the jejunum and ileum have been examined by him. Such an examination is mandatory for penetrating wounds of the anterolateral abdominal wall, since the damaged part of the small intestine can move from the place of its injury due to its mobility. Penetrating wounds of the anterolateral abdominal wall are those wounds that are accompanied by damage to the parietal peritoneum, which can be confirmed by probing the wound. With such injuries, it is imperative to perform a midline laparotomy (even if there are no symptoms of damage to internal organs) in order to revise the abdominal cavity and sanitize it.
When examining the contents of the abdominal cavity, one should consider criteria for distinguishing the small intestine from the large intestine... Diameter is not an effective criterion for distinguishing these parts of the intestine (!). Reliable criteria of distinction include: color, presence or absence of muscle bands, haustra, omental processes (fatty suspensions). The pathologically unchanged small intestine is pink, and the large intestine is grayish-bluish. The small intestine lacks muscle bands, haustra, and omental processes. In the large intestine, muscle bands and gaustra are present throughout, over a greater extent there are also omental processes (they are usually absent in the cecum). On cadaveric material, the large intestine reliably differs from the small intestine only by the features of its muscle layer (by the presence of paler muscle bands).
Color is one of gut vitality criteria... The pathologically unchanged small intestine has a pink, shiny color, and the large intestine is grayish-bluish in color and also has a gloss. Normally, all abdominal organs covered with a peritoneum have luster. Loss of gloss during the operation indicates drying of the serous surface of the organ. In this case, fibrin effusion occurs, and as soon as two damaged serous surfaces touch, they quickly enough (during the first day) stick together, forming adhesions. For the prevention of adhesive disease, one should monitor the color and shine of the serous surfaces of the organs and from time to time water them with warm saline. Other criteria for intestinal vitality are pulsation of the mesenteric arteries, and the presence of peristalsis in response to touch.
In preparation for performing an operative technique on the abdominal organs, isolation the body on which the intervention is performed (or parts of it). Isolation is aimed at keeping infected contents out of the abdominal cavity. The most optimal way to isolate is to remove the organ (or part of it) into the wound (on the anterolateral abdominal wall) and cover it with wet wipes. This method can be used only if the organ has sufficient mobility. The mobility of organs depends on how they are covered by the peritoneum (intra-, meso- or extraperitoneally). The organs covered by the peritoneum intraperitoneally (intraperitoneally) have the maximum mobility. These organs usually include the stomach, spleen, jejunum and ileum, most of the cecum, and appendix, transverse colon, sigmoid colon. If the organ is covered by the peritoneum over a greater extent, but not on all sides, then it is covered by the peritoneum mesoperitoneally (these organs usually include: the liver, gallbladder, ascending and descending colon). The mobility of these organs is limited. The organs located extraperitoneally (extraperitoneally) have minimal mobility: most of the duodenum and pancreas. When describing the coverage of these organs by the peritoneum, the term "retroperitoneally" can be used, that is, posteriorly peritoneally. In addition, the mobility of the organ is limited by its ligamentous apparatus and the mesentery (if any). The mesentery is usually present in the small intestine, transverse colon, and sigmoid colon. The mesentery and ligaments of the internal organs of the abdominal cavity are sheets of the peritoneum adjacent to each other, between which are the vessels, nerves and lymphatic formations. Usually the vessels are visible (translucent) through the thickness of the peritoneal layer. If the mobility of an organ (or part of it) is insufficient to bring it to the anterolateral abdominal wall, another isolation option should be used: put napkins over this organ directly in the wound. The wipes must be moist, otherwise their contact with the serous coating of nearby organs will lead to mechanical damage sheets of the peritoneum and will contribute to the occurrence of adhesive disease.
To give additional mobility to an organ (or part of it), as well as to prepare a hollow organ for resection, use mobilization (exsanguination, skeletonization). The essence of mobilization is to dissect the mesentery or ligamentous apparatus of the organ with simultaneous ligation of the vessels located between the sheets of the peritoneum (see Fig. 2). Exsanguination (mobilization, skeletonization) of intraperitoneally located organs is carried out as follows: through the avascular part of the mesentery (ligament) of the jaws of the open hemostatic clamp, an injection is made and, at some distance - an injection, the clamp is closed. The second clamp is passed through the formed holes towards the first clamp, it also closes. Then the peritoneum and the vessels located between its sheets are dissected with a scalpel or scissors between the clamps. A preliminary turn of a simple assembly is tightened under the first clamp; in the process of tightening it, the clamp opens. A locking turn is formed, a knot under the second clamp is formed in the same way, the ends of the threads are cut to a minimum length.
Fig 2. Exsanguination (mobilization) of hollow organs:
- temporary;
- final.
When resecting the small intestine for its malignant tumor, it is advisable to mobilize a wedge-shaped (segmental) method - with the removal of a part of the mesentery together with regional lymph nodes... When resection of the small intestine for necrotic damage (for example, with strangulated hernia) usually carry out marginal mobilization - at the level of rectal intestinal arteries or distal arcades. When determining the level of resection from the apparently damaged area, one should step back towards the adductor and towards the discharge section 10-15 cm (in order to be sure that undamaged areas of the intestine will be used to form the anastomosis). Mobilization of the stomach along the greater curvature involves dissection of the gastrocolic ligament (the upper part of the greater omentum). Mobilization of the stomach along the lesser curvature involves dissection of the hepato-gastric ligament (part of the lesser omentum). The hepato-duodenal ligament can only be incised (to isolate its contents), but this ligament cannot be dissected so as not to damage the formations located between its sheets (bile ducts, portal vein and own hepatic artery with its branches). In order to temporarily stop bleeding from the liver, you can briefly squeeze the hepato-duodenal ligament with your fingers (after inserting the index finger into the omental opening located behind this ligament). In this case, the clamping of both the own hepatic artery and the portal vein, which supplies about 75% of the blood to the liver, occurs.
The most frequently performed stages of abdominal surgery are:
Tomia (dissection);
Stomy (fistula or fistula formation);
Raffia (suturing);
Pexia (hemming, fixation);
Ectomy ( complete removal) and
resection (removal of a part).
The name of the operation is determined by the name of its most important stage. So, gastrotomy (dissection of the stomach) can be an independent operation (which can be used to remove foreign body from the stomach), and may be the stage of gastrostomy (fistula imposition on the stomach) or gastric resection.
Before dissecting the organs of the gastrointestinal tract, they should be prepared for dissection. After examination and determination of the level of resection, the contents are squeezed out of the resected part of the organ and intestinal pulp is applied along its edges. Part of the organ must be mobilized between the pulp. It is possible to dissect the organs of the gastrointestinal tract only between two adjacent pulp, above the napkin (so that the infected contents do not get into the abdominal cavity). For dissection of the organs of the gastrointestinal tract, a scalpel or a blade taken on a clamp is usually used, since they are less traumatic instruments compared to scissors. However, the mucous membrane on the front wall of the organ can be dissected with scissors, which reduces the likelihood of damage to the back wall of the organ. After removing a part of the organ, the patency of the gastrointestinal tract is restored by forming an anastomosis. The use of special staplers in this case can significantly reduce the time of the operation. In most cases, the most physiological anastomosis is an end-to-end anastomosis. After formation, the anastomosis should be checked for tightness and patency. Then the mesentery defect is sutured and, if possible, the formed anastomosis is isolated from the anterolateral abdominal wall, since the contact of the damaged peritoneal sheets leads to their soldering. A large omentum can be used as a natural spacer between damaged serous surfaces (the damaged serous surface, in contact with the intact surface, does not solder to it).
An obligatory step in performing operations on the abdominal organs is peritonization , that is, to restore the integrity of the serous coating. Peritonization prevents pathological contents from entering the abdominal cavity. Usually it is provided by the imposition of gray-serous sutures. If it is impossible to match the edges of the peritoneum (for example, due to the significant size of the gallbladder bed during cholecystectomy), a flap of the greater omentum on the pedicle can be used for peritonization. At the end of the operative reception, control for hemostasis is carried out (there should be no traces of blood on a clean, damp napkin after blotting the operating field with it), examination of the nearby contents, napkins and instruments are recounted and proceeds to exit the operation.
The exit from the operation should be carried out in layers. The first row of sutures is applied to the peritoneum. Since it is easy to pierce, only piercing needles are used to pierce the peritoneum. When suturing the peritoneum, it is advisable to use absorbable suture material, since the edges of the peritoneum quickly stick together. The use of a continuous suture on the peritoneum (simple continuous or Multanovsky suture) saves time and suture material. Then the elements of the middle layer are sutured with a pickup of the intra-abdominal fascia and preperitoneal tissue. If you need to suture the muscles, then it is rational to use a piercing needle, tweezers - anatomical or clawed, suture material - absorbable. In this case, you can use a continuous seam. If the white line of the abdomen is sutured as an element of the middle layer, then it is more advisable to use a non-absorbable material (due to a relatively long healing process) and U-shaped stitches, which make it possible to strengthen this weak spot. After that, a suture is applied to the elements of the surface layer: skin, subcutaneous tissue and superficial fascia. At the same time, a cutting needle is used (capable of overcoming significant tissue resistance), tweezers - surgical or gripping. A simple interrupted suture is usually used as a skin suture, and a fairly thick silk is often used as a suture material. If the subcutaneous tissue at the suture site is thick enough, then it is advisable to suture it separately (with the capture of the superficial fascia), and put an intradermal suture on the skin. In addition, a Donati suture can be used on the anterolateral abdominal wall.
INTESTINAL SUTTING TECHNIQUE. PRINCIPLES OF THE FORMATION OF ANASTOMOSIS
Intestinal sutures - these are the sutures that are used to suture the walls of hollow organs (not only the intestine, but also the esophagus, stomach, bladder, urethra, renal pelvis, etc.). These seams constitute a special group and demands to intestinal sutures special ones are presented, namely:
asepticity ("Cleanliness", non-infection);
hemostaticity ;
tightness ;
preservation of passability organ at the suture site.
gray-serous (adventitia-adventitia);
serous (or adventitiously -) - muscular ;
serous (or adventitiously -) - muscle with a submucosa ;
cross-cutting .
Figure: 3. Diagram of intestinal sutures: 1 - gray-serous suture; 2 - serous-muscular suture; 3 - serous-muscular suture with a grasp of the submucosa; 4 - through seam. The structure of the wall of hollow organs: A - serous membrane; B - muscle layer; C - submucosa; D - mucous.
Through seams have the highest hemostatic properties, but are "dirty". The first three varieties of the intestinal suture are "clean", but only those that are accompanied by a grasp of the submucosa are relatively hemostatic. Thus, it becomes necessary to combine the advantages of various seams and level their disadvantages. For this, were proposed multi-row seams
(usually two-, sometimes three-row are used). However, multi-row seams also have disadvantages compared to single row
... So, they are applied longer, require a greater consumption of suture material, more injure the wall of a hollow organ and, which is especially important, may be accompanied by obstruction of a hollow organ at the site of its imposition, since the imposition of each subsequent row is accompanied by immersion in the lumen of the organ of the previous row (it that's what it's called - submersible
row). In addition, like the rest of the sutures, the intestinal can be interrupted and continuous. Intestinal sutures are often used, which are usually called by the author:
- lambert seam (single row, nodular, gray-serous);
Furrier schmiden's seam (single row, continuous, through,
screwing in);
- joly seam (single row, simple continuous, through);
- seam Pirogov (Bira or Pirogova-Bira) (single row, nodal,
serous-muscular with a grasp of the submucosa);
- seam Mateshuk (single row, nodular, serous-muscular with
grabbing the submucosa and nodules inside);
- cherni seam (Cherni-Pirogova) (two-row, the first row is represented by the Pirogov seam, and the second - by the Lambert seam);
- albert's seam (two-row, in which the immersion row is represented
a through seam (most often - Joly), and the other row with a Lambert seam).
Usually, the Albert suture refers to the suture used to form the posterior wall of the anastomosis. At the same time, first, a Lambert suture is applied to the posterior (inner) lips of the anastomosis, and only then - the Joly suture. This seam has the hemostaticity of the immersion row and the "purity" of the Lambert seam.
Figure: 4. A - a diagram of a two-row seam of Cherni (Cherni-Pirogov), where 1 is an immersion row of a seam of Pirogov (Bir or Pirogov-Bir), and 2 is a seam of Lambert.
B - Mateshuk seam diagram.
Figure: 5. Schmiden's furrier's screw-in seam. 
Figure: 6. Scheme of a two-row Albert stitch, where 1 is a knotted stitch of a Lambert stitch, 2 is a through stitch.
In order to impose any intestinal suture, it is necessary to have an intestinal needle (all intestinal needles are stabbing), more often curved needles are used, therefore, a needle holder, anatomical tweezers, scissors (for cutting off the ends of the threads) and thin suture material (for immersion sutures - you can use absorbable material, for Lambert sutures - non-absorbable). For greater accuracy of manipulations, it is rational to keep the needle holder "in a fist" (index finger near the needle itself), and tweezers (anatomical) - in the "writing pen" position, periodically transferring it to a non-working position. Like others, they try to impose intestinal sutures in the direction "towards themselves" (from the far corner of the wound to the near one).
When overlapping stitches lambert suture (see Fig. 3) from the edge of the wound closest to the hand with a needle holder, 2-3 mm recede from its far corner and, carrying out an injection and an injection, they grab this edge by the serosa and, partially, the muscle layer. It is imperative to grab the muscle, otherwise the seam will not be strong enough. Then, if possible, without intercepting the needle with a needle holder, the opposite edge of the wound is picked up in the same way. In total, two punctures and two punctures are carried out, which should be on a line perpendicular to the axis of the wound. The distance between the stitches when applying any intestinal suture should be 4-5 mm (!). If the suture pitch is more than 5 mm, then the suture will not be airtight (i.e., infected contents from the intestinal lumen through the suture line can enter the abdominal cavity, which will cause peritonitis). However, stitches should also not be applied too often, as this will be accompanied by additional tissue trauma (can lead to deserosis, i.e. to detachment of the serous covering from the muscle layer), unnecessary waste of time and suture material. After the thread is passed through the tissue of the intestinal wall, its ends are tied together. In this case, you can use a simple (female) knot, and they try to form the knot at the near edge of the wound. When tying a knot in the Lambert suture, the edges of the wound touch their serous surfaces, therefore the suture is gray-serous. The ends of the threads are cut with scissors (they should be held in such a way that they do not obscure the knot and allow the formation of "antennae" 2-3 mm long). The Lambert suture has "purity", tightness (if the distance between the stitches is correctly observed), the patency of the organ at the site of this suture should be assessed individually for each case, but this suture is not hemostatic.
Schmiden seam (see Fig. 5) is a "hemostatic" suture and is relatively aseptic due to the fact that when this suture is tightened, the edges of the wound are screwed into the lumen of the hollow organ and stick together due to fibrin effusion (the infected part is immersed inward). To apply such a suture, it is necessary to sequentially pick up the edges of the wound from the inside out, i.e. from the side of the mucous membrane. As the only row, the Schmiden suture can only be used by experienced surgeons, while the use of an atraumatic needle is mandatory.
Seam Pirogov (Bira) (see Fig. 4) has aseptic and relative hemostatic properties, its tightness is ensured by observing the optimal pitch between stitches of 4-5 mm. The advantage of this suture is that its imposition is not accompanied by screwing in the edges of the wound and narrowing the lumen of the hollow organ. To sew a stitch on this seam,
the edge of the wound closest to the hand with a needle holder, and the puncture is made through the submucosa. Then the opposite edge of the wound at the same level is picked up through the submucosa, and the injection is carried out through the serosa. The ends of the thread are tied together to form a knot, shifted to one edge of the wound. However, it turned out that in the process of wound healing, the nodule rotates inward and leaves behind a wound canal through which the infection can spread outside the organ cavity (if the layers are not accurately matched to each other). Therefore, a series of Lambert seams is usually applied over the seam of Pirogov (the result is a two-row cherni seam , which is more reliable in terms of asepticity, but is accompanied by a narrowing of the lumen of the hollow organ, more time and suture material). In addition, it was proposed to initially form nodules facing the lumen of a hollow organ ( seam Mateshuk ). For this, the first injection should be carried out through the submucosa, the injection through the serosa, and then: the injection through the serosa of the opposite edge of the wound, the injection through the submucosa. This seam has all the advantages of the Pirogov seam, except for some difficulties in tying the last knots.
Seam Joly is a typical "hemostatic" suture, the advantages of which are the speed of application and economy of suture material. The main disadvantage of this seam is that it is "dirty". Therefore, it can only be used as an immersion row.
Albert's seam
(see Fig. 6) has the hemostaticity of the immersion row and the "purity" of the Lambert seam. Its tightness is ensured by observing the optimal distance between the stitches and the presence of two rows of seams. The disadvantages of this suture in comparison with single-row sutures are in the additional consumption of time and suture material, as well as in the narrowing of the lumen of the hollow organ.
Figure: 7. A - purse string suture; B - Z-shaped seam.
In addition to the already described intestinal sutures, purse-string and Z-shaped sutures are quite widely used (see Fig. 7). If you pick up the serous and muscle layers with a needle, then these seams will have asepticity.
With the help of intestinal sutures, you can form anastomoses (anastomosis) between the hollow organs. There are three types of anastomoses:
1) "end to end" (in Latin - anastomosis terminoterminalis, in English - "end to end");
2) "side to side" (anast. Laterolateralis, "sait to sait");
3) "end to side" (anast. Terminolateralis, "end to sait").
The most physiological is the end-to-end anastomosis (with the exception of resection of the ileocecal angle). However, a significant discrepancy between the diameters of the adducting and efferent sections, as well as the threat of obstruction of the anastomosis (especially when using a two-row suture) limit its use.
When forming the anastomosis, it is customary to distinguish the following elements: the inner (back) lips are those edges of the wound, after stitching which the back wall of the anastomosis is formed, and the outer (front) lips, after which the front wall is formed. The formation of any type of anastomosis always begins from the back wall. The rows of seams should follow from back to front. If the surgeon uses double-row sutures to form both walls of the anastomosis, then a series of aseptic sutures (most often Lambert's suture) is applied between the holding sutures first on the posterior lips of the anastomosis. Then the same lips (already matched) are sutured with a suture, which should ensure hemostaticity (most often with a Joly suture). After that, the front lips of the anastomosis are stitched with a Schmiden suture or another suture that ensures hemostaticity along the anastomosis anterior wall. And in conclusion, after processing the line of the previous seam with an antiseptic solution, changing gloves and tools, they begin to apply the last row - an aseptic seam (most often - Lambert). After the formation of the anastomosis, it must be checked for patency and tightness. Checking for patency is carried out by palpation (due to invagination of the walls of the adducting and efferent bowel sections). The tightness test is carried out by forcing the liquid contents from the leading to the outlet section. During such operations, it is imperative to carry out the prevention of adhesive disease. To do this, you need to periodically water the intestine with warm saline, preventing loss of gloss. Otherwise, fibrin effusion occurs, and if two such surfaces come into contact, a spike will form between them. 
Figure: 8. Diagram of different types of intestinal anastomoses: A - "end to end", B - "side to side", C - "end to side", where 1 - the inner (back) lips of the anastomosis, and 2 - the outer (front) lips anastomosis.
Revision is an important stage of the operation, which has not only diagnostic
Figure: 12-14. Various types of thoracolaparotomy. a - thoracotomy + laparotomy, b - laparotomy + thoracotomy, c - thoracolaparotomy, d-laparothoracotomy. (Of: Littmann I.Abdominal surgery. - Budapest, 1970.)
something, but also a tactical value. It is produced in order to detect damaged organs in case of abdominal injuries, to find out the source inflammatory process in case of acute abdomen syndrome, solving the issue of operability in malignant tumors of the abdominal organs, which makes it possible to make a final decision on the nature of the intervention.
A necessary element of the revision of the abdominal organs is an examination of the liver (signs of cirrhosis), spleen (increase in size), vessels of the portal system, small intestine (bleeding tumors), pancreas (signs of chronic pancreatitis, adenoma in the syndrome Zollschger-Ellison).
After a midline laparotomy, the examination is first performed in situinserted into the abdominal cavity with the right hand, without removing organs.
Revision of parenchymal organs
If there is blood in the abdominal cavity, parenchymal
organs: liver, spleen, pancreas.
During the revision of the liver, its anterior edge and lower surface are available for inspection, and the lower surface becomes clearly visible after the transverse colon is retracted downward. The diaphragmatic surface of the liver is examined with a hand inserted into the right hypochondrium under the dome of the diaphragm. In doubtful cases for better view the crescent ligament of the liver should be dissected. Visually determine the state of the gallbladder and hepatic-duodenal ligament.
To examine the spleen, the stomach is pulled
to the right, and the left bend of the colon - downward. This allows the detection of damage to the lower pole of the spleen. With a hand inserted into the left hypochondrium, palpation determines the presence of damage to its other parts.
Of the parenchymal organs, the least dosage
the pancreas is dull for examination
leza. Access to the pancreas when
its revisions are possible through the small gland
after dissection of the gastro-colonic
ligaments (lig. gastrocolicum)and mesentery of the pope
river colon. The head is tighter
the breast is examined from the side as
stuffing box and descending hour
ty the duodenum, which
mobilized by dissecting the parietal
the peritoneum along its outer edge.
Hollow organs revision
Inspection of hollow organs is primarily carried out when the contents of the stomach or intestines are found in the abdominal cavity and in strict sequence.
1. The anterior wall of the stomach, its pyloric section and the upper horizontal part of the duodenum.
2. The posterior wall of the stomach after dissection of the gastro-colonic ligament.
3. The posterior wall of the descending duodenum. To examine it, you need to use the technique Petrova-Khun-dadze(dissection of the parietal layer of the peritoneum along the outer edge of the ascending colon). Mobilization of the intestine should be carried out with great care so as not to damage the underlying
her wall of the portal vein (v. portae)and the end sections of the common bile duct and pancreatic ducts.
Revision of the duodenum and stomach is performed after dilution of the wound with a retractor and displacement of the left lobe of the liver. Lowering the stomach makes it possible to examine the lesser and greater curvature, the area of \u200b\u200bthe fundus of the stomach. After weakening the traction for the stomach, the abdominal esophagus and the entire anterior wall of the stomach are examined by palpation. A perforation located in a typical place, as well as a duodenal ulcer, is usually easily detected if there is gastric contents in the abdominal cavity or if the inflammatory infiltrate is pronounced and passes to the serous cover of the organ. It should be remembered that in unclear cases for ulcerative infiltration can be taken pylorus, the localization of which is easy to determine visually along the pyloric vein running across the pylorus (v. prepylorica);careful palpation helps to avoid mistakes. A detailed examination of the posterior wall of the stomach is possible after dissection of the gastrocolic ligament. Thorough revision of the stomach, duodenum and adjacent organs is an important stage of the operation, which has not only diagnostic, but also tactical significance, as it allows you to make a final decision on the nature of the intervention.
Inspection of the small intestine is carried out in strict sequence from the level of the duodenal-jejunal flexure (flexura duodenojejunalis)(reception Gubarev)with a thorough alternate examination of each intestinal loop along its free and mesenteric edges. Until the end of the revision, it is not recommended to suture the damaged areas of the intestinal wall, since in the future it may be necessary to resect the damaged area.
Colon examination begins with revision
ileocecal angle. The right and left curves of the colon should be examined especially carefully. If the posterior wall of the ascending or descending colon is damaged, the resulting hematoma is opened through the corresponding
lumbar divisions, bringing drainage to the damaged intestine. The revision of the abdominal organs ends with an examination upper divisions rectum, the bottom of the bladder, the uterus with the appendages, the contours of both kidneys.
Revision of the abdominal organs in order to identify the source of bleeding
If there is blood in the abdominal cavity, the first step is to examine the parenchymal organs. In the absence of pathology on their part, the surgeon should proceed to the examination of the hollow organs. In addition, the detection of blood in the abdominal cavity in women may indicate an ectopic pregnancy, which requires examination of the pelvic organs. Very rarely, the presence of blood in the abdominal cavity is due to rupture of an aortic aneurysm or other large vessels. Revision of the lateral canals and mesenteric sinuses of the abdominal cavity can play an important role in identifying the source of bleeding.
Revision of the abdominal organs to locate the source of exudate
If, after opening the abdominal cavity, exudate is found, and the appendix looks unchanged, it is necessary to examine the entire abdominal cavity.
First you need to stretch out 30-50 cm of the final
a section of the small intestine to identify a diverticulum Meckel(and its possible inflammation). You should also pay attention to the appearance of the small intestine, the red color of which often suggests purulent inflammation (ileitis terminalis).If such a study does not give positive results, you need to examine the small intestine starting from the duodenodenal bend. Before the examination, novocaine should be injected into the mesentery, and the removed intestinal loops should be overlaid with napkins soaked in warm isotonic sodium chloride solution. Then the stomach, the duodenum, the pancreas, the liver with the gallbladder and the large intestine are examined in turn.
If there is a cloudy yellow-green or
an opalescent pale yellow liquid
sometimes with food debris in the abdominal cavity, a perforated ulcer of the stomach or duodenum should be suspected. The site of perforation should be sought in the areas where it most often occurs (the anterior wall of the lesser curvature, the prepyloric part of the stomach and the initial segment of the duodenum). Finding the perforation site in a typical location is fairly easy. It is much more difficult to do this if the perforation is low in the duodenum, high in the lesser curvature, in the fornix of the stomach and on the posterior wall of the stomach or pylorus. Sometimes a hand inserted through the incision can palpate a characteristic infiltrate near the perforation. If, after the introduction of gauze napkins into the abdominal cavity and the insertion of spoons, the perforation site cannot be found, then the stomach should be tightened relatively strongly to visualize the pylorus and the upper part of the duodenum. The perforated hole is usually round or oval and has clear ("stamped") edges, most often its diameter is 0.5 cm. Around the hole against the background of the hyperemic surface of the stomach or duodenum, a whitish, fragile infiltrated tissue area of \u200b\u200b1-3 cm is found. identifying a perforated ulcer, it is necessary to suck fluid from the lower abdominal cavity, then carefully sew up the incision and open the abdominal cavity in the epigastric region. Continuation of the incision along the outer edge of the rectus muscle upward for surgical treatment a perforated ulcer usually does not provide good access. If, after opening the abdominal cavity, a characteristic transparent or turbid liquid with an admixture of bile is found, then after the introduction of the tampon, the area of \u200b\u200bthe gallbladder should be palpated. Dropsy and bladder suppuration are clearly defined in the form of a characteristic pear-shaped intense formation. With gall peritonitis without perforation of the bile ducts, the fluid is light yellow, and palpation reveals a more or less tense gallbladder with or without stones. If there is no doubt that the cause of the peritonitis was a disease of the biliary tract and if
continuation of the incision upwards provides good access to gallbladder, produce cholecystotomy or (if possible) cholecystectomy. In other cases, the primary incision should be sutured and the biliary tract should be carefully checked after a new incision in the epigastric region.
If, after opening the abdominal cavity, a cloudy yellow-brown liquid resembling meat slops is found, pancreatic necrosis should be suspected. In this case, the omentum should be carefully examined, paying attention to the foci of tissue necrosis, and the posterior wall of the abdominal cavity in search of a characteristic light green exudate protruding the peritoneum. If acute necrosis of the pancreas is found, a drain is usually inserted into the rectal vesicular cavity (excavatio rectovesicalis)[in women - rectal-uterine cavity (excavacio rectouterina, Douglasspace)] (see Chapter 13) through the old incision and close the wound. From a new incision in the epigastric region, the pancreas is drained.
If the fluid in the abdominal cavity is serous-bloody, one should think about strangulated intestinal obstruction, mesenteric infarction, or streptococcal hematogenous peritonitis (rarely).
Characteristic fecal peritonitis with typical
fetid exudate occurs with traumatic perforation of the small intestine, perforation of specific ulcers, prolonged intestinal obstruction, perforation of a colon tumor or perforation of the sigmoid diverticulum. Depending on the diagnosis, you need to either enlarge the old incision, or make a new one to ensure good access to the diseased organ.
Revision of the abdominal cavity organs for tumor processes
Revision is one of the most important stages of surgery for cancer of the stomach and other abdominal organs and should be carried out in the most careful way, taking into account the operative access.
22005 0
After making sure that temporary hemostasis has been achieved and having collected blood from the abdominal cavity, they begin a thorough revision of the organs. It is better to start with hollow organs, since the detection of their damage will allow, firstly, to isolate the sites of injury, thereby stopping the constant infection of the abdominal cavity, and secondly, to resolve the issue of the admissibility of reinfusion of blood collected from the abdominal cavity.
Before revision of the abdominal cavity, novocaine blockade of the mesentery root of the small intestine, transverse colon and sigmoid colon (200 ml of 0.25% solution of procaine) is necessary. Revision start from the stomach. For any damage to the anterior wall of the stomach, duodenum, or pancreas, the gastro-colon ligament should be widely dissected and the posterior wall of the stomach, pancreas, and duodenum examined.
Damage to the duodenumrecognized by the bile staining of the retroperitoneal space and the presence of gas bubbles in it. Diagnosis of damage to the duodenum can be facilitated by intraoperative administration of methylthioninium chloride solution through a gastric tube. In the presence of damage to the duodenum, its posterior wall should be carefully examined after mobilization according to Kocher: in the vertical direction along the lateral edge of the duodenum, the peritoneum is dissected, the intestine is released from its bed in a blunt way with the help of a tupfer. In this case, care must be taken not to damage the inferior vena cava located directly behind the intestine.
Small intestine revision start with the first loop located at the root of the mesentery of the transverse colon a little to the left of the spine (Treitz ligament area). Then the loops of the small intestine are sequentially removed, examined and immersed in the abdominal cavity. When carrying out the operation at a later date after the injury (after 12-24 hours), even minor damage to the small intestine can be detected by the presence of inflammatory infiltration in these zones. Blood clots on the intestinal wall can cover the wound. Large subserous hematomas should be opened in order to exclude their communication with the intestinal lumen. Particular attention should be paid to the mesenteric edge of the intestine, where the hematoma often masks the site of perforation.
Getting started colon revision, first examine the ileocecal angle. If there is a suspicion of damage to the retroperitoneal colon, the peritoneum is dissected along the outer edge of the intestine for 15-20 cm. Indications for mobilization of fixed sections of the colon: detection of punctate hemorrhages, hematomas, bruises on the posterior peritoneum, as well as injuries, if the direction of the wound canal says about the possibility of damage to the retroperitoneal part of the colon. Insulating tampons are temporarily brought to the sites of the detected damage.
The revision of the hollow organs ends with an examination of the rectum and bladder. During the audit, organ defects should not be sutured, since it may be necessary to resect any of them.
Liver revision performed visually and palpation. After palpation and localization of the injury to examine the diaphragmatic surface of the liver, it is necessary to mobilize the organ. To mobilize the left lobe of the liver, it is pushed down and to the right, the left triangular ligament and part of the coronary ligament are crossed. Since sometimes small bile ducts pass in the ligaments, they are preliminarily applied with clamps and tied with catgut. In a similar way, but pulling the liver down and to the left behind the right lobe, the right triangular ligament is crossed to mobilize the right lobe of the liver. Technically, it is easier to cross the falciform ligament, but it must be borne in mind that in the case of portal hypertension, large vessels can pass through it. Therefore, ligation of the sickle ligament is mandatory. In case of injury to the lower posterior surface of the liver, it is necessary to cross hepatic-renal a bunch. To do this, the liver is lifted up, the ligament is stretched, it is dissected. It does not contain any vessels.
With severe bleeding from the liver, if clamping of the hepato-duodenal ligament did not give an effect, the inferior vena cava is temporarily clamped in order to completely turn off the liver from the circulation. It is pinched above and below the liver with turnstiles. To cross the vena cava below the liver, the duodenum is mobilized according to Kocher and retracted medially, opening access to the inferior vena cava above the renal vessels. Compression of the inferior vena cava above the liver requires thoracophrenolaparotomy. The edges of the diaphragm taken on the holders are widely spread and, pushing the liver anteriorly, a tourniquet is brought around this short section of the inferior vena cava using a dissector. Complete exclusion of the liver from the circulation is possible for no more than 20 minutes.
Spleen... The abdominal wall is removed with a mirror to the left and while pulling the stomach to the right, the spleen is visually and palpably examined. The presence of clots in the area of \u200b\u200ban organ indicates damage. To expose the vascular pedicle along the gastro-colon ligament (closer to the transverse colon), the distal part of the omental bursa is opened, dissecting the gastro-colon ligament. A tourniquet is brought around the vascular pedicle using a dissector, or a soft vascular clamp is applied to the artery and vein, which stops the blood flow.
Pancreas. For its review, the gastro-colonic ligament is widely dissected, tying up the vessels along its length. To avoid disrupting the blood supply to the stomach, the dissection is performed between the gastroepiploic arteries and the colon. Lifting the stomach up and pushing the transverse colon downwards, the pancreas is exposed along its entire length.
Retroperitoneal hematoma. Retroperitoneal hematoma is subject to revision for any injury (cold or firearms). When closed injury The abdominal retroperitoneal hematoma is not opened if the integrity of the kidneys is not in doubt by palpation, the hematoma does not grow before our eyes and its cause is obvious - a fracture of the pelvic bones or spine.
A rapid increase in hematoma, indicating possible damage to large vessels, bleeding from this hematoma into the free abdominal cavity, suspicion of a rupture of the inferior vena cava or rupture of the kidney are indications for its revision. After upward traction of the ileocecal angle and displacement of the loops of the small intestine over the hematoma, the posterior peritoneum is dissected, and hemostatic clamps are applied to the profusely bleeding (pulsating jet) vessels. Venous and capillary bleeding is temporarily stopped with tight tamponade.
Saveliev V.S.
Surgical diseases
The sequence and extent of the abdominal revision depends on the clinical circumstances. In this case, one should bear in mind two fundamental positions:
· Recognition of a specific pathology that was the reason for laparotomy;
· Routine revision of the abdominal cavity.
It should be noted that there is a significant difference between laparotomy for non-traumatic reasons ( intestinal obstruction, organ inflammation or peritonitis) and laparotomy for intra-abdominal bleeding; the latter is rarely associated with non-traumatic intraperitoneal factors.
So you've opened your peritoneum - what's next? Your actions depend on the urgency of the situation (and the patient's condition), the pathogenesis of the abdominal process (inflammation or trauma) and the initial findings (blood, contamination or pus). But whatever you find, follow the principle the priority of the solution is given.
· Recognize and stop active bleeding.
· Recognize and control the resulting contamination.
In the same time do not renounce banality -metaphorically speaking, do not chase individual red blood cells and bacteria in a patient with life-threatening bleeding. In other words, do not suture small mesenteric tears when bleeding from a damaged inferior vena cava, notdivert your attention from solving the main problem.
90. Topographer of the organs of the lower floor.The lower abdominal floor extends from the POC to the pelvic cavity, and contains the small and large intestines. The lower floor has 2 mesenteric sinuses. 2 side channels. Right mesenteric sinus: bounded by the mesentery of the POC. WOC and mesentery of the small and sigmoid colon. Communicates with the left sinus above the dn-lean bend. Left mesenteric sinus:
limited to the LCM and the mesentery of the POK. sigma and small intestine. It is reported with a small pelvis.
The right lateral canal at the top passes into the right, the subphrenic space, at the bottom, into the right, the iliac fossa. The left lateral canal / Above is delimited from the left subphrenic space of the lig.phrenicocolicum. below it passes into the left iliac fossa, and then into the small tt. Pockets of the lower floor: 1). Recessus duodenojejunalis - nah-sya behind the corresponding bend at level L2-L3. 2). Rec. iliocaecalis superior - m-do the upper edge of the end section of the small intestine and VOK. 3). Rec. iliocaecalis inferior - m-do him and the cecum. four). Rec. retrocaecalis - behind the cecum.
five). Rec. intersigmoideus - between the sigmoid mesentery and the parietal peritoneum, opens into the left lateral canal. Has a funnel shape.
91 - Topography of the organs of the lower floor of the abdominal cavity. Mesenteric sinuses, pockets, pits, lateral canals, their importance in the pathology of the abdominal cavity. Determination of the beginning of the jejunum by the method of A.P. Guboreva. Features of intestinal blood supply. Use of the bowel in plastic and reconstructive surgery.
The transverse colon and its mesentery form a septum, which conventionally divides the abdominal cavity into two floors - the upper and lower.
The lower floor contains: the loops of the small intestine (with the lower half of the duodenum) and the large intestine.
In the lower floor of the abdominal cavity, four sections are distinguished: two external and two internal. The outer sections are called lateral canals. These are the spaces between the fixed sections of the large intestine (colon asdendebs and descendebs) and the lateral walls of the abdomen. The channels at the top communicate with the upper floor of the abdominal cavity (on the right it is better than on the left because of the phrenic-colonic ligament), below the channels pass into the iliac fossa, from there into the small pelvis.
Between the fixed sections of the large intestine and the root of the mesentery of the small intestines, there are two depressions - the mesenteric sinuses. The right one is bounded on the right by the ascending colon, on the left and below by the root of the mesentery of the small intestines, above the mesentery of the transverse colon. The left mesenteric sinus is bounded on the right by the root of the mesentery of the small intestines, from above by the mesentery of the transverse colon, on the left by the descending colon and by the root of the mesentery of the sigmoid colon. Above, both sinuses communicate with each other through a narrow slit bounded by the initial segment of the small intestine and the mesentery of the transverse colon hanging over it.
Below, the left mesenteric sinus leads to the pelvic cavity, to the right of the rectum. The right mesenteric sinus is open only in front, except for the already mentioned communication with its left sinus at the root of the mesentery of the transverse colon.
The significance of the lateral canals and mesenteric sinuses lies in the fact that encapsulated peritonitis can develop in them and hematomas can spread both into the pelvic cavity and into the upper floor of the abdominal cavity (subphrenic abscess).
To determine the initial part of the jejunum, the Gubarev method is used. The large omentum with the colon transversum is grasped with the left hand and folded up so that the mesentery of the transverse colon is stretched. With the right hand, feel the spine at the base of the mesacolon transversum. Sliding the index finger along the left side of the spine, they find an intestinal loop, it lies between the 2 lumbar vertebra and the index finger. Only if this loop is fixed to the spine should it be recognized as the initial loop of the jejunum.
The blood supply to the intestine is carried out by the superior and inferior mesenteric arteries. The superior mesenteric artery departs from the abdominal aorta at the level of the XII thoracic to III lumbar vertebra and gives off branches to the pancreas, duodenum, small and right half of the large intestine. The intestinal branches anastomose among themselves, forming arcades, from which the straight vessels depart, giving off thin branches to the serous membranes. These branches penetrate into the submucosal layer, where they form the vascular plexus.
Surgical anatomy of the superior and inferior mesenteric arteries. Violation of the blood supply to the abdominal organs with thrombosis. Topographic and anatomical substantiation of acute arterio-mesenteric intestinal obstruction.
Superior mesenteric artery (a.mesenterica superior) - a large vessel that supplies blood most intestines and pancreas. The place of origin of the artery varies within the XII thoracic - II lumbar vertebrae. The distance between the orifices of the celiac trunk and the superior mesenteric artery varies from 0.2 to 2 cm.
Coming out from under the lower edge of the pancreas, the artery goes down and to the right and, together with the superior mesenteric vein (to the left of the latter), lies on the anterior surface of the ascending part of the duodenum. Descending along the root of the mesentery of the small intestine towards the ileocecal angle, the artery gives off numerous jejunal and ileal-intestinal arteries, passing into the free mesentery. The two right branches of the superior mesenteric artery (ileo-colonic and right colonic), heading to the right colon, together with the veins of the same name, lie retroperitoneally, directly under the peritoneal leaflet of the right sinus floor (between the parietal peritoneum and Toldt's fascia). Regarding the syntopy of various parts of the trunk of the superior mesenteric artery, it is divided into three sections: I - pancreas, II - pancreatic duodenal artery, III - mesenteric.
The lower mesenteric artery (a.mesenterica inferior). A. mesenterica inferior, the lower mesenteric artery, departs at the level of the lower edge of the III lumbar vertebra (one vertebra above the division of the aorta) and goes down and somewhat to the left, located behind the peritoneum on the anterior surface of the left lumbar muscle.
The duodenum represents the initial section of the small intestine between the stomach and the jejunum. In the duodenum, four sections are distinguished: upper part, descending, horizontal (lower), and ascending. Top part the duodenum is located between the pylorus of the stomach and the upper bend of the intestine, located at the free edge of the lig. hepatoduodenale. Pars superior is 3/4 of the circumference covered with a peritoneum. The peritoneum does not cover the area at the site of attachment to the intestine lig. hepatoduode hepatoduodenale and the right side of the lig. gastrocolicum, as well as the lower-posterior portion of the intestinal surface adjacent to the head of the pancreas.
The descending part of the duodenum starts from the flexura duodeni superior in the form of an arc directed by the bulge to the right, goes down, forms a lower bend (to the left), flexura duodeni inferior, and passes into the horizontal (lower) part of the duodenum, pars horizontalis (inferior). The upper section of the descending part of the intestine is located above the mesocolon, i.e. in the upper floor of the abdominal cavity.
The horizontal (lower) and ascending parts of the duodenum run horizontally in the form of a gentle arc from flexura duodeni inferior to the duodenal bend, flexura duodenojejunalis. Bottom part the duodenum is located below the mesocolon and is covered with the peritoneum in front, except for the ascending section located behind the mesentery root of the small intestine. The posterior surface of the intestine, adjacent to the fascia endoabdominalis, and the superior medial, adjacent to the head of the pancreas, are deprived of the peritoneal cover.
Pars ascendens duoseni is directed to the left and upward and at the lower edge of the pancreatic body at the level of the left edge of the II lumbar vertebra it bends anteriorly, forming duodenal-jejunal flexure... This is where the jejunum begins. Its beginning can be located at the lower edge of the mesentery of the transverse colon or under the mesentery. Treitz Support Ligament keeps flexura duodenojejunalis in a normal position. It is formed by a fold of the peritoneum covering the muscle that suspends the duodenum, m. suspensorius duodeni.
Rationale:
In front, most often at the border of the transition of the horizontal part into the ascending one, the duodenum is crossed by the superior mesenteric artery, which emerges from under the lower edge of the pancreas. In some cases, the superior mesenteric artery can compress the duodenum, causing high arteriomesenteric intestinal obstruction.