The structure of the peritoneum. Abdominal cavity

The peritoneum, peritoneum, a thin serous membrane of the abdominal cavity, has a smooth, shiny, uniform surface. The peritoneum covers the walls of the abdominal cavity and small pelvis and, to one degree or another, the organs enclosed in it on their free surfaces facing the abdominal or pelvic cavity. The surface of the peritoneum is 20400 cm2 and is equal to the area of \u200b\u200bthe skin. The peritoneum has a complex microscopic structure.

Its main elements are the connective tissue base, which consists of many strictly oriented layers of a certain structure, and the layer of mesothelial cells covering it. The peritoneum lining the walls of the abdomen is called the parietal peritoneum, peritoneum parietale, or parietal leaf; the peritoneum covering the organs is the visceral peritoneum, peritoneum viscerale, or the viscera; the part of the peritoneum between the parietal peritoneum and the serous cover of organs or between individual organs is called a ligament, ligamenlum. fold, plica, mesentery, mesentcrium. The visceral peritoneum of any organ is connected with the parietal peritoneum, as a result of which all organs are to one degree or another fixed by the peritoneum to the walls of the abdominal cavity. Most organs are associated with the back wall of the abdominal cavity. The organ, covered on all sides by the peritoneum, is located intraperitoneally, or intraperitoneally; an organ covered by the peritoneum on three sides and not covered by the peritoneum on one side is located mesoperitoneally; an organ covered with only one, external, surface is located retro-peritoneally (or extraperitoneally).

Organs located intraperitoneally may have a mesentery that connects them to the parietal peritoneum. The mesentery is a plate consisting of two connected sheets of the peritoneum - duplication; one, free, edge of the mesentery covers the organ (intestine), as it were, suspends it, and the other edge goes to the abdominal wall, where its leaves diverge in different directions in the form of the parietal peritoneum. Usually, between the sheets of the mesentery (or ligament), blood vessels, lymph vessels and nerves approach the organ. The line of attachment (beginning) of the mesentery on the abdominal wall is called the mesentery root, radix mesenterii; Approaching the organ (for example, the intestine), its leaves diverge on both sides, leaving a narrow strip at the site of attachment - the extramesenteric field, area nuda.

The serous cover, or serous membrane, tunica serosa, does not directly adjoin the organ or abdominal wall, but is separated from them by a layer of connective tissue sub-serous base. tela suhserosa, which, depending on the location, has a different degree of development. For example, it is poorly developed under the serous membrane of the liver, diaphragm, upper part of the anterior abdominal wall and, conversely, is highly developed under the parietal peritoneum lining the posterior wall of the abdominal cavity (subperitoneal tissue), for example, in the region of the kidneys, etc., where the peritoneum it is very movably connected with the underlying organs or with their parts by means of a loose sub-serous base. The organs located intraperitoneally, intraperitoneally include: stomach, small intestines (except for the duodenum), transverse colon and sigmoid colon, proximal rectum, appendix, spleen, uterus, fallopian tubes; to the mesoperitoneally located organs include: liver, gallbladder, ascending and descending colon, middle (ampullar) part of the rectum; to retro. peritoneal organs include: the duodenum (except for its initial section), pancreas (except for the tail), kidneys, adrenal glands, ureters. The space of the abdominal cavity limited by the peritoneum is called the peritoneal, or peritoneal cavity, cavum peritonei.

The parietal peritoneum of the posterior wall of the abdominal cavity delimits the peritoneal cavity from the retroperitoneal space, spatium retroperitorieale: both of these spaces form the abdominal cavity, cavum abdominale. Since the peritoneum is a continuous cover both on the walls and on the organs, the peritoneal cavity is completely closed. The only exception is communication through the fallopian tubes in women; one end of the fallopian tubes opens into the peritoneal cavity, the other leads out through the uterine cavity. The abdominal organs are adjacent to one another, and the space between them and the walls of the abdominal cavity, as well as between the organs themselves, is slit-like and contains a very small amount of serous fluid (liquor peritonei). The peritoneal cover and peritoneal folds. The parietal peritoneum of the anterior abdominal wall forms a series of folds. Below the navel in the midline is the median umbilical fold, plica umhilicalis mediana, which stretches from the navel to the apex of the bladder; in this fold, a connective tissue cord is laid, which is an obliterated urinary duct, urachus. From the navel to the lateral walls of the bladder, there are medial umbilical folds, plicae umbilicales mediates, in which the cords of the neglected anterior sections of the umbilical arteries are laid. Outside of these folds are the lateral umbilical folds, plicae umbilicales laterales, stretching from the middle of the inguinal ligament obliquely upward and inwardly to the back wall of the sheath of the rectus abdominis muscles. These folds enclose the lower epigastric arteries, aa .. epigastricae inferiores, which feed the rectus abdominis muscles. Pits are formed at the base of these folds. On both sides of the median fold, between it and the medial, above the upper edge of the bladder, there are supravesical fossae, fossae supravesicales; between the medial and lateral folds are the medial inguinal fossa, fossae inguinales mediates: lateral inguinal fossa, fossae inguinales laterales lie outward from the lateral folds; these pits are located opposite the deep inguinal rings.

The parietal peritoneum of the anterior abdominal wall above the level of the navel forms a falciform (hanging) ligament of the liver, lig. falciforme hepatis. It is a protrusion of the peritoneum of the anterior wall of the abdominal cavity at the lower surface of the diaphragm, located in the form of a median sagittal fold; from the abdominal wall and diaphragm, the sickle ligament follows down to the diaphragmatic surface of the liver, where both leaves pass into the visceral peritoneum of the diaphragmatic surface of the liver. In the free lower edge of the crescent ligament passes the round ligament cord, lig. teres hepatis, which is an obliterated umbilical vein. The round ligament goes along the visceral surface of the liver, in the fissura lig. teretis, to the gate of the liver.

The leaves of the crescent ligament pass back into the coronary ligament of the liver, lig. consonarium hepatis. The coronary ligament is the transition of the visceral peritoneum of the diaphragmatic surface of the liver to the parietal peritoneum of the posterior abdominal wall. The leaves of the coronary ligament along the edges of the liver form the right and left triangular ligaments, lig. triangulare dextrum and lig. triangulare sinistrum. The visceral peritoneum of the facies visceralis of the liver covers the gallbladder from the underside. From the visceral peritoneum of the facies visceralis of the liver, the peritoneal ligament is directed to the lesser curvature of the stomach and the upper part of the twelve duodenum; it is a duplication of the peritoneal leaf, starting from the edges of the hilum (transverse groove) and from the edges of the venous ligament gap. The left side of this ligament (from the venous ligament gap) goes to the lesser curvature of the stomach and is called the hepato-gastric ligament, lig. hepalogastricum; it is a thin, cobweb-like plate. Between the sheets of the hepato-gastric ligament, along the lesser curvature, there are arteries and veins of the stomach, arteriae et venae gastricae dextra et sinistra, and nerves, as well as regional lymph nodes.

The right part of the ligament, more dense, goes from the gate of the liver to the upper edge of the pylorus and duodenum; its last section is called the hepato-duodenal ligament, lig. hepatoduodenale, and includes the common bile duct, the common hepatic artery and its branches, the portal vein, lymphatic vessels, nodes and nerves. On the right, the hepato-duodenal ligament forms the anterior edge of the omental foramen, foramen epiploicum. Approaching the edge of the stomach and duodenum, the ligament leaves diverge and lie on the anterior and posterior walls of these organs. Both bundles are lig. hepatogastricum and lig. hepatoduodenale, as well as a small ligament from the diaphragm to the lesser curvature of the stomach, gastrophrenic ligament, lig. gaslrophrenicum, make up a small omentum, amentum minus.

The crescent ligament and the lesser omentum are ontogenetically the anterior, ventral, mesentery of the stomach, mesogastrium ventrale. Between the lower edge of the right lobe of the liver and the adjacent upper end of the right kidney, the peritoneum forms a transitional fold, the hepatic-renal ligament, lig. hepatorenale. The sheets of the visceral peritoneum of the anterior and posterior surfaces of the stomach pass into the lig along the greater curvature of the stomach. gastrocolicum, continue downward in the form of a large omentum, omentum majus. A large omentum in the form of a wide plate ("apron") follows down to the level of the upper aperture of the small pelvis. Here, the two leaves forming it return, heading upward behind the descending two leaves. These returnable two leaves are spliced \u200b\u200bwith the front leaves.

At the level of the transverse colon, all four leaves of the greater omentum grow to tenia omentalis, located on the anterior surface of the intestine. Here, the posterior (recurrent) omentum leaves depart from the anterior ones, connect to the mesentery of the transverse colon, mesocolon transrersum, and go together dorsally to the line of attachment of the mesentery along the posterior abdominal wall to the margo anterior pancreatis. Thus, a pocket is formed between the anterior and posterior omentum at the level of the transverse colon (see below). Approaching the margo anterior pancreatis, the two posterior omentum leaves diverge: the upper leaf passes into the posterior wall of the omental bursa (on the surface of the pancreas) in the form of a parietal peritoneal leaf, the lower one passes into the upper leaf of the mesentery of the transverse colon. The area of \u200b\u200bthe greater omentum between the greater curvature of the stomach and the transverse colon is called the gastro-colon ligament, lig. gastrocolicum; this ligament fixes the transverse colon to the greater curvature of the stomach. Between the leaves of the gastro-colonic ligament along the greater curvature, the right and left gastroepiploic arteries and veins run, and regional lymph nodes lie.

The gastro-colon ligament covers the front of the transverse colon; in order to see the intestine when the abdominal cavity is opened, it is necessary to pull the large omentum upward. The large omentum covers the small and large intestines in front; it lies behind the anterior abdominal wall. A narrow gap forms between the omentum and the anterior abdominal wall - the pre-omentum space. The greater omentum is a distended mesentery of the stomach, mesogastrium. Its continuation to the left is the gastro-splenic ligament, lig. gastrolienale, and splenic-phrenic ligament, lig. phrenicolienale, which merge into one another. Of the two sheets of the peritoneum of the gastro-splenic ligament, the anterior one passes to the spleen, surrounds it on all sides, returns back to the gate of the organ and then continues in the form of a sheet of the splenic-phrenic ligament. The posterior leaflet of the gastro-splenic ligament, reaching the gate of the spleen, turns directly to the posterior abdominal wall in the form of a second leaflet of the splenic-phrenic ligament.

As a result of these ratios, the spleen is, as it were, included from the side in the ligament connecting the greater curvature of the stomach with the diaphragm. The mesentery of the transverse colon begins on the posterior abdominal wall at the level of the descending part of the duodenum, the head and body of the pancreas, the left kidney; Approaching the intestine in tenia mesocolica, two sheets of the mesentery diverge and cover the intestine in a circle (see "Colon"). The width of the mesentery from the root to attachment to the intestine at its widest point is 15 cm and decreases towards the edges. On the sides, the mesentery of the transverse colon begins from the bends of the colon, flexurae colicae, located in the hypochondria, and extends over the entire width of the abdominal cavity. The transverse colon with the mesentery lies horizontally, at the level of the ends of the X ribs, and divides the abdominal cavity into two floors: the upper floor, where the stomach, liver, spleen, pancreas, upper duodenum are located, and the lower floor, where the small intestines are located with the lower half of the duodenum and colon. The left bend of the colon is connected to the diaphragm by a horizontally located peritoneal fold, phrenic-colonic ligament, lig. phrenicocolicum.

The lower leaf of the mesentery of the transverse colon from the top down from the root passes into the parietal leaf of the peritoneum, lining the posterior wall of the mesenteric sinuses of the abdomen. The peritoneum, lining the back wall of the abdominal cavity in the lower floor, passes in the middle into the mesentery of the small intestine, mesenterium. The parietal peritoneum of the right and left sinuses, passing to the mesentery of the small intestine, forms the right and left leaves of its duplication. The mesenteric root, radix mesenterii, stretches from above from the posterior wall of the abdominal cavity in the region of the II lumbar vertebra on the left (end part of the upper duodenal fold, plica duodenojejunalis) down and to the right to the sacroiliac joint (the place where the ileum flows into the blind). The length of the root reaches 17 cm, the width of the mesentery is 15 cm, but the latter increases in the areas of the small intestine most distant from the posterior abdominal wall. In its course, the mesentery root crosses the ascending part of the duodenum at the top, then the abdominal aorta at the level of the IV lumbar vertebra, the inferior vena cava and the right ureter. The superior mesenteric vessels go along the root of the mesentery, following from top left to bottom and to the right; the mesenteric vessels give the intestinal branches between the mesenteric leaves to the intestinal wall. In addition, lymphatic vessels, nerves and regional lymph nodes are located between the mesenteric sheets. All this largely determines the fact that the duplication plate of the mesentery of the small intestine becomes dense, thickened. Thus, through the mesentery of the small intestine, the peritoneum of the posterior wall of the abdominal cavity is divided into two sections: the right and left mesenteric sinuses, sinus mesenterici dexter el sinister.

The parietal peritoneum of the right sinus passes to the right into the visceral peritoneum of the ascending colon, to the left and downward - into the right leaf of the mesentery of the small intestine, upward - into the mesocolon transversum. The parietal peritoneum of the left mesenteric sinus passes to the left into the visceral peritoneum of the descending colon, upwards into the mesocolon transversum; below, bending over the promontory, into the pelvic peritoneum, and down and to the left, in the iliac fossa, into the mesentery of the sigmoid colon. The peritoneum covers the ascending colon on the right from three sides, lines the posterior and lateral walls of the abdomen to the right of it, forming the right lateral canal, canalis lateralis dexter, passes forward into the parietal peritoneum of the anterior abdominal wall, upward - into the peritoneum of the right half of the diaphragm; below it passes into the peritoneum of the right iliac fossa and below the cecum, in the region of the inguinal fold, on the anterior abdominal wall; in the medial direction, it bends over the border line into the small pelvis. To the right of the ascending colon, it forms transverse folds connecting at the top of the flexura colica dextra with the lateral wall of the abdomen, and the right phrenic-colonic ligament, usually weakly expressed, sometimes completely absent.

Below, at the confluence of the ileum into the blind, an ileocecal fold, plica ileocecalis, is formed. It is located between the medial wall of the cecum, the anterior wall of the ileum and the parietal peritoneum, and also connects the medial wall of the cecum with the lower wall of the ileum - above and with the base appendix - down below. Between the upper edge of the appendix, the ileum and the wall of the medial section of the bottom of the cecum is the mesentery of the appendix, mesoappendix. The feeding vessels pass in the mesentery, a. et v. appendiculares, and regional lymph nodes and nerves are laid. Between the lateral part of the bottom of the cecum and the parietal peritoneum of the iliac fossa, there are plentiful folds, plica cecales. The parietal peritoneum of the left mesenteric sinus passes to the right into the left mesentery leaf of the small intestine. In the flexura duodenojejunalis area, the parietal peritoneum forms a fold around the initial loop of the jejunum, bordering the intestine from above and on the left, - the upper duodenal fold (duodenojejunal fold), plica duodenalis superior (plica duodenojejunalis). To the left of the descending colon there is a fold of the peritoneum connecting the left bend of the colon with the diaphragm, the phrenic-colon ligament, lig. phrenicocolicwn; in contrast to the right ligament of the same name, the left one is constant and well expressed.

To the left, the parietal peritoneum passes into the visceral peritoneum, covering the descending colon on three sides (except for the posterior). To the left of the descending colon, forming the left lateral canal, canalis lateralis sinister, the peritoneum lines the back and side walls of the abdominal cavity and goes to its front wall; down the peritoneum passes into the parietal peritoneum of the iliac fossa, the anterior abdominal wall and the small pelvis. In the left iliac fossa, the peritoneum forms the mesentery of the sigmoid colon, mesocolon sigmoideum. The root of this mesentery goes from top to bottom and to the right to the borderline and reaches the anterior surface of the III sacral vertebra; here a short mesentery is formed for the uppermost part of the rectum. The feeding vessels enter the mesentery of the sigmoid colon, a. et vv. sigmoideae; it also contains lymphatic vessels, nodes and nerves. The peritoneal folds, ligaments, mesentery and organs create in the peritoneal cavity, relatively isolated from each other and from the general cavity of the peritoneal cavity, cracks, pockets, sinuses, bags. As shown above, the peritoneal cavity is subdivided into three main areas: the upper floor, the lower floor, and the pelvic cavity. The upper floor is separated from the lower at the level of the II lumbar vertebra by the horizontally located mesentery of the transverse colon. The lower floor is separated from the small pelvis by a boundary line (the upper edge of the pelvic ring).

The border of the upper floor at the top is the diaphragm, at the bottom - the transverse colon with its mesentery; the lower border of the pelvic cavity is the peritoneal fold of its bottom (rectal-cystic in men, rectal-uterine, plica rectouterina, in women). In the upper floor of the peritoneal cavity, there are three peritoneal bags: hepatic, bursa hepatica, located mainly in the right half of the upper floor , pregastric, bursa pregastrica, located mainly in the left half of the upper floor, and the most pronounced omental bursa, bursa omentalis, lying behind the stomach. Hepatic bag, bursa hepatica, a slit-like space that covers the free part of the liver. It distinguishes between the suprahepatic fissure and the subhepatic fissure (in practical medicine, the terms subphrenic space and subhepatic space are adopted). The suprahepatic fissure on the left is separated from the adjacent pregastric sac by the falciform ligament; behind it is limited by a leaf of the coronary ligament. It communicates with the underlying peritoneal spaces: in front of the free lower edge of the liver - with the subhepatic fissure, the pre-omental fissure (see below); through the free edge of the right lobe of the liver - with the right lateral canal, then with the iliac fossa, and through it - with the small pelvis. The subhepatic fissure is formed from above by the visceral surface of the liver, from behind by the parietal peritoneum and the hepato-renal ligament, lig. hepatorenale.

Laterally, the subhepatic fissure communicates with the right lateral canal, anteriorly - with the pre-omental space, deeply through the omental opening with the omental bursa, to the left - with the pregastric bursa. located under the left dome of the diaphragm, surrounds the left lobe of the liver on the right, and the spleen on the left. The pregastric sac is bounded from above by the diaphragm, on the right by the falciform ligament, on the left by the phrenic-colonic ligament, behind by the small omentum (all three of its parts) and the gastro-splenic ligament. In front, the pre-gastric bag communicates with the pre-omentum fissure, on the right - with the subhepatic and omental bags; to the left, it communicates with the left side channel. The omental bursa, bursa omentalis, is located behind the stomach. To the right, it extends to the omental opening, to the left - to the gate of the spleen. The front wall of the omentum, if you go from top to bottom, are: the lesser omentum, the posterior wall of the stomach, the gastrocolic ligament, and sometimes the upper part of the greater omentum, if the descending and ascending leaves of the greater omentum are not fused and there is a gap between them, which is considered as continuation of the stuffing box down.

The posterior wall of the omental bursa is the organs covered by the parietal peritoneum located on the posterior wall of the abdominal cavity, on the right is the inferior vena cava, the abdominal aorta with the celiac trunk extending here from it, the left adrenal gland, the upper end of the left kidney, splenic vessels and below - the body of the pancreas, occupying the largest space in the rear wall of the stuffing box. The caudate lobe of the liver serves as the upper wall of the omental bursa; the transverse colon and its mesentery can be considered the lower wall. Thus, the omental bursa is a peritoneal slit closed on all sides except one; the outlet or, rather, the entrance to it is the omental opening, foramen epiploicum, located on the right side of the bag behind the hepato-duodenal ligament. This hole allows 1-2 fingers. Its anterior wall is the hepato-duodenal ligament with the vessels and the common bile duct located in it. The posterior wall is the hepato-renal peritoneal ligament, behind which the inferior vena cava and the upper end of the right kidney are located. The lower wall is the upper edge of the upper part of the duodenum. The narrow section of the bag closest to the opening is called the vestibule of the omental bursa, vestibulum bursae omentalis; it is limited to the caudate lobe of the liver from above and the head of the pancreas from below.

Behind the caudate lobe of the liver, between it and the medial pedicle of the diaphragm covered with the parietal peritoneum, there is a pocket, an upper omental cavity, recessus superior omentalis. which below is open towards the vestibule. Downward from the vestibule, between the posterior wall of the stomach - in front and the pancreas covered with the parietal peritoneum and the mesocolon transversum - in the back, there is the lower omental cavity of the recessus inferior omentalis. To the left of the vestibule, the cavity of the omental bursa is narrowed by the gastropancreatic fold of the peritoneum, plica gastropancreatica, extending from the upper edge of the omental tubercle of the pancreas upward and to the left, to the lesser curvature of the stomach (it contains the left gastric artery, a gastrica sinistra). The continuation of the lower recess to the left is the sinus located between the lig. gastrolienale and lig. phrenicolienale, which is called the splenic cavity, recessus lienalis. In the lower floor of the abdominal cavity, on the posterior wall, there are two large mesenteric sinuses and two lateral canals. The mesenteric sinuses are located on either side of the mesentery of the small intestines: on the right is the right mesenteric sinus, on the left is the left mesenteric sinus.

The right mesenteric sinus is limited: above - by the mesentery of the transverse colon, on the right - by the ascending colon, on the left and below - by the mesentery of the small intestine. Thus, the right mesenteric sinus has a triangular shape and is closed on all sides. Through the parietal peritoneum lining it, the lower end of the right kidney (to the right) is contoured and translucent above the mesocolon; adjacent to it is the lower part of the duodenum and the lower part of the pancreas head bordered by it. Below in the right sinus, the descending right ureter and the iliocolic artery with a vein are visible. The left mesenteric sinus is limited: from above - by the mesentery of the transverse colon, on the left - by the descending colon, on the right - by the mesentery of the small intestine. Downward, the left mesenteric sinus communicates through the cape region with the peritoneal cavity of the small pelvis. The left mesenteric sinus has an irregular quadrangular shape and is open downward. Through the parietal peritoneum of the left mesenteric sinus, they are translucent and contoured: at the top - the lower half of the left kidney, below and medially - in front of the spine - the abdominal aorta and to the right - the inferior vena cava with their bifurcation and the initial segments of the common iliac vessels. Below the bifurcation is a cape.

To the left of the spine, the left testicular artery (ovary), the left ureter and branches of the inferior mesenteric artery and vein are visible. At the top of the left mesenteric sinus, around the beginning of the jejunum, between the flexura duodenojejunalis and the plica duodenalis superior (plica duodenojejunalis) bordering it, there is a narrow gap in which the superior and inferior duodenal grooves are distinguished, the recessus duodenodenales are located superior and inferior pockets under the ileum: upper and lower ileocecal grooves, recessus ileocecalis superior, recessus ileoce-calis inferior. Sometimes under the bottom of the cecum lies behind the digestive depression, recessus retrocecalis. To the right of the ascending colon is the right lateral canal; it is bounded outside by the parietal peritoneum of the lateral abdominal wall, on the left by the ascending colon; downward, the canal communicates with the iliac fossa and the peritoneal cavity of the small pelvis. Above, the right canal communicates with the subhepatic and suprahepatic slit-like spaces of the hepatic bursa. To the left of the descending colon is the left lateral canal; it is limited to the left (lateral) by the parietal peritoneum, which lines the lateral abdominal wall. Downward, the canal is open into the iliac fossa and further into the pelvic cavity. Upward, at the level of the left colic bend, the canal is crossed by the already described phrenic-colic ligament; up and to the left, it communicates with the pregastric sac. Below between the knees of the mesentery of the sigmoid colon there is a peritoneal intersigmoid depression, recessus intersigmoideus. Throughout the ascending and descending colon from the outside, the lateral canals are sometimes blocked by more or less pronounced peritoneal folds and near-colonic grooves around them, suici paracolici. The topography of the peritoneum in the pelvic cavity in men and women, see "Urogenital apparatus" in the same volume.

Abdominal cavity ( cavitas abdominis) - the space bounded at the top by the diaphragm, at the bottom - by the pelvic cavity, behind - by the lumbar spine with adjacent square muscles of the lower back, iliopsoas muscles, in front and from the sides - by the abdominal muscles.

The digestive organs (stomach, small and large intestines, liver, pancreas), spleen, kidneys, adrenal glands and ureters, vessels and nerves are located in the abdominal cavity.

The inner surface of the abdominal cavity is lined inside the abdominal fascia ( fascia endoabdominalis), inward from which the peritoneum is located.

Diagram of the relationship of organs to the peritoneum (cross section)

Peritoneum ( peritoneum) - the serous membrane lining the walls of the abdominal cavity (parietal sheet of the peritoneum) and internal organs (visceral sheet of the peritoneum). Between the visceral and parietal sheets of the peritoneum is the peritoneal cavity ( cavitas peritonei). The peritoneum secretes serous fluid, which moisturizes it and allows the organs covered by the peritoneum to slide freely:

1- peritoneum parietale - parietal peritoneum - covers the walls of the abdominal cavity;

2 - peritoneum viscerale - the visceral peritoneum, which covers the organ in different ways;

3 - mesoperitoneal position. The organ is covered by the peritoneum on three sides (eg, the ascending and descending colon, liver);

4 - extraperitoneal position. The organ is covered by the peritoneum on one side (for example, the pancreas and partly the duodenum) or not at all (for example, the kidney), which is called the retroperitoneal position;

5 - intraperitoneal position. The organ is covered by the peritoneum from all sides (eg, stomach, mesenteric part of the small intestine);

6 - mesenterium - the mesentery of the small intestine;

7 -cavitas peritonei - peritoneal cavity.

Diagram of the course of the peritoneum on a sagittal section (in men)

The peritoneum, passing from the walls of the abdominal cavity to organs and when passing from organ to organ, forms ligaments, which are a duplicate of the peritoneum (two sheets):

1 - lig. coronarium hepatis - the coronary ligament of the liver, which is formed when the peritoneum passes from the diaphragm to the liver;

2 - hepar - liver - covered by the peritoneum mesoperitoneally. The peritoneum from the visceral surface of the liver passes to the duodenum ( lig. hepatoduodenale) and the lesser curvature of the stomach ( lig. hepatogastricum);

3 - lig. hepatogastricum - hepato-gastric ligament, which, together with lig. hepatoduodenale forms a small oil seal ( omentum minus). The omental bursa is located behind the lesser omentum and stomach;

4 - bursa omentalis - omental bursa - limited: at the top by the caudate lobe of the liver, at the bottom by the posterior plate of the greater omentum, or, if taken as a whole, by the mesentery of the transverse colon, in front by the stomach and small omentum, at the back by the parietal peritoneum and the organs that it covers ( v. cava inferior, aorta, corpus pancreatis);

5 - gaster - stomach - covered by the peritoneum intraperitoneally. At the transition point lig. hepatoduodenale on the stomach, between the two sheets of the peritoneum and the lesser curvature of the stomach, there is an area not covered by the peritoneum, or a bare place;

6 - pars nuda (curvatura ventriculi minor) - a bare place (small curvature of the stomach);

7- pars nuda (curvatura ventriculi major) - a bare place (greater curvature of the stomach). Along the greater curvature of the stomach, two sheets of the peritoneum join and descend in front of the transverse colon and loops of the small intestine (the anterior plate of the greater omentum). Then these two sheets of the peritoneum are tucked posteriorly and rise up (the posterior plate of the greater omentum). Thus, a large omentum is formed from the four sheets of the peritoneum.

8 - omentum majus - large oil seal. The posterior plate of the greater omentum (two posterior sheets of the peritoneum) is directed to the posterior abdominal wall and splits. One sheet passes to the posterior wall of the peritoneal cavity, the other - to the transverse colon, connecting with one more peritoneal sheet - the mesentery of the transverse colon is formed, which, therefore, will consist of four peritoneal sheets;

9 - mesocolon transversum - the mesentery of the transverse colon;

10 - colon transversum - the transverse colon - covered by the peritoneum intraperitoneally. The lower leaf of the mesentery of the transverse colon passes to the posterior wall of the peritoneal cavity. The pancreas and most of the duodenum are located retroperitoneally (extraperitoneally);

11 - pancreas - pancreas;

12 - duodenum - the duodenum - the parietal peritoneum, covering the front of the duodenum; goes to the small intestine. Its two leaves form the mesentery of the small intestine;

13 - mesenterium - the mesentery of the small intestine;

14 - jejunum - the jejunum - located in relation to the peritoneum intraperitoneally; has one bare place ( pars nuda) in the area of \u200b\u200bmesentery attachment;

15 - rectum - rectum;

16 - vesica urinaria - bladder;

17 - spatium retroperitoneale - retroperitoneal space - filled with fatty tissue. It contains the kidneys and ureters;

18 - excavatio rectovesicale - rectal-vesicular depression;

19 - os pubis - the pubic bone.

The peritoneum, covering the organs of the abdominal and pelvic cavities, has a different relationship to the organs: some of these organs (duodenum, pancreas, kidneys) are covered with the peritoneum only from the front surface, other organs (ascending, descending parts of the large intestine) are covered by the peritoneum on three sides, finally , stomach, small intestine, completely surrounded by the peritoneum, excluding their hilyus. The peritoneum adjacent to the abdominal walls is called parietal (parietal); covering the organs - visceral.

The anatomy of the peritoneum forms a series of protrusions, folds, ligaments and mesenteries, which is why a number of cracks form in the peritoneal cavity. These gaps are only part of the common cavity, they are more or less widely communicated with each other. Among the bags of the abdominal cavity, the omental bursa is of great surgical interest.

The bursa is the slit around the right hepatic lobe. The left part of the hepatic bursa is separated from the pregastric bursa by the falciform ligament.

The middle section of the peritoneum becomes visible if the large omentum is pulled upward. Here, at the place of transition of the duodenum into the jejunum, a duodenal fold is formed. Below the fold and to the left is a depression, which is differently expressed in different people. This is the so-called duodenal skin eversion. In order to see the root of the mesentery, for example, to anesthetize it, it is necessary to pull the small intestine down and to the left. The mesenteric root delimits two distinctively shaped sections, the upper right is called the "right mesenteric sinus", and the lower and left - the "left mesenteric sinus".

The right mesenteric sinus is isolated from the adjacent anatomical sections, only in front of the intestine, this sinus communicates with them. The left mesenteric sinus is wider and communicates with the small pelvis. In the place of the anatomical transition of the small intestine to the large intestine, there are two small pockets of the peritoneum, of which the upper one is called the upper ileal-blind pocket of the peritoneum and the same lower pocket.

The border between the lower and upper ileal-blind pockets is the end of the ileum. There are blind pockets of the peritoneum, which go posterior to the cecum - peritoneal eversion behind the cecum (recessus retrocaecalis sinistra - fossae caecalis).

On the sides of the middle section, the ascending colon is located on the right and the descending colon on the left. The slit of the peritoneum outward from the ascending intestine, delimited by the postero-lateral part of the abdominal wall - the right lateral canal. Downward, this canal passes into the right iliac region, and below - into the small pelvis. Outward from the descending colon, there is, similarly to the right, left lateral canal. Downward, it continues into the small pelvis, expanding, passes into the peritoneum of the S-shaped curvature. The lower part of the peritoneum, descending into the pelvic cavity, covers the organs genitourinary systemss.

In men, the peritoneum, walking along the posterior wall of the pelvis, passes to the rectum, forming its mesentery, and, having passed about 8 cm, the peritoneum from the rectum covers the posterior wall of the bladder. Then the peritoneal leaf goes to the apex of the bladder and goes to the anterior wall, goes to the inner surface of the anterior abdominal wall. The localization of the transition of the anatomy of the peritoneum from the bladder to the abdominal wall changes depending on its filling. The depression between the bladder and rectum is called the vesico-rectal depression. On the sides of its peritoneum covers the ureters and vas deferens.

In women, the anatomy of the peritoneum from the rectum goes to the fornix of the vagina, goes up, covers the supravaginal part of the uterine cervix and the body of the uterus, goes to the bottom of it, then descends to the front of the body of the uterus. In front, it does not reach the cervix, but goes to the bladder.

The uterus with a broad ligament forms two indentations of the peritoneum: the anterior vesicouterine depression is less than the posterior recto-uterine cavity (posterior Douglas). The holes in the fallopian tubes open into the posterior recess.

Thus, the peritoneal cavity in men is a completely closed formation, and in women it has a message through the fallopian tubes, uterus, vagina with outside world, which can serve as a gateway for the penetration of inflammatory pathogens.

The anatomical features of the abdominal cavity and the serous membrane lining it contribute to the development of severe complications as soon as the peritoneum is involved in the process. These complications depend on the following reasons:

The abdominal cavity has an abundance of folds and pockets. Examination of these pockets is extremely difficult, and a systematic examination of all organs is usually not possible due to the serious condition of the patient. Therefore, during the time it is easy to see any damage or disease of both the peritoneum itself and the organ located in it, and with perforations and injuries, it is difficult to completely clean the peritoneum from the pus accumulating in it, food and feces.

The organs located inside the abdominal cavity, especially the small, large intestine, constantly move depending on respiration, intestinal filling and peristalsis. Therefore, foreign bodies, pus, food masses trapped in the abdominal cavity are easily carried throughout the peritoneum.

Since the peritoneum is richly equipped with a receptor apparatus and reflexes from it continuously go to the central nervous system, reflex disorders of the activity of not only the intestines, but also the respiratory and circulatory organs can occur.

Especially dangerous is irritation, even if only mechanical, in the mesentery, pancreas and solar plexus (reflexogenic zones). Any gross mechanical irritation is completely unacceptable, even with complete anesthesia of the nerve trunks and plexuses in the area of \u200b\u200bthe listed zones.

The article was prepared and edited by: surgeon

Abdominal cavity, cavitas abdominalis , Is the space bounded from above by the diaphragm, in front and from the sides - by the anterior abdominal wall, behind - by the spine and back muscles, from below - by the diaphragm of the perineum. In the abdominal cavity are the organs of the digestive and genitourinary systems. The walls of the abdominal cavity and internal organs located in it are covered with a serous membrane - peritoneum, peritoneum ... The peritoneum is divided into two sheets: parietal, peritone u m parietale covering the walls of the abdominal cavity, and visceral, peritoneum visceral e covering the abdominal organs.

Peritoneal cavity, cavitas peritonei , Is a space bounded by two visceral sheets or visceral and parietal sheets of the peritoneum, containing a minimum amount of serous fluid.

The relationship of the peritoneum to the internal organs is not the same. Some organs are covered with the peritoneum on only one side, i.e. located extraperitoneally (pancreas, duodenum, kidneys, adrenal glands, ureters, bladder in an unfilled state and the lower part of the rectum). Organs such as the liver, the descending and ascending colon, the filled bladder, and the mid-rectum are covered on three sides by the peritoneum, i.e. occupy a mesoperitoneal position. The third group of organs is covered by the peritoneum on all sides and these organs (stomach, mesenteric part of the small intestine, transverse and sigmoid colon, cecum with appendix, upper part of the rectum and uterus) occupy an intraperitoneal position.

The parietal peritoneum covers the inside of the anterior and lateral walls of the abdomen and then continues to the diaphragm and the posterior abdominal wall. Here the parietal peritoneum passes into the visceral. The transition of the peritoneum to the organ is carried out either in the form ligaments, ligamentum , or in the form mesentery, mesenterium , mesocolon . The mesentery consists of two sheets of the peritoneum, between which are vessels, nerves, lymph nodes and adipose tissue.

The parietal peritoneum on the inner surface forms five folds:

median umbilical fold, plica umbilicale mediana, unpaired fold, goes from the apex of the bladder to the umbilicus, contains the median umbilical ligament - an overgrown embryonic urinary duct, urachus ;

medial umbilical fold , plica umbilicalis medialis , paired fold - runs along the sides of the median fold, contains the medial umbilical ligament - the overgrown umbilical artery of the fetus;

lateral umbilical fold, plica umbilicalis lateralis , also steam room - contains the lower epigastric artery. The umbilical folds delimit the fossa associated with the inguinal canal.

The parietal peritoneum passes to the liver in the form of liver ligaments.

The visceral peritoneum from the liver passes to the stomach and duodenum in the form of two ligaments: hepato-gastric, lig. hepatogastrium , and hepato-duodenal, lig. hepatoduodenale ... In the latter, the common bile duct, portal vein and own hepatic artery pass.

Hepato-gastric and hepato-duodenal ligaments make up small stuffing box, omentum minus .

Big gland, omentum majus , consists of four sheets of the peritoneum, between which there are vessels, nerves and adipose tissue. The greater omentum begins with two sheets of the peritoneum from the greater curvature of the stomach, which go down in front of the small intestine, then rise up and attach to the transverse colon.

The peritoneal cavity is divided into three levels: upper, middle and lower:

the upper floor is bounded from above by the diaphragm, from below by the mesentery of the transverse colon. In the upper floor there are three bags: hepatic, pregastric and omental. Hepatic bag, bursa hepatica , is separated from pregastric bag, bursa pregastrica , crescent ligament. The hepatic bag is limited by the diaphragm and the right lobe of the liver, the preventricular bag is located between the diaphragm and the diaphragmatic surface of the left lobe of the liver and between the visceral surface of the left lobe of the liver and the stomach. Packing bag, bursa omentalis , is located behind the stomach and lesser omentum and communicates with the peritoneal cavity through stuffing box, foramen epiploicum ... In children, the omental bursa communicates with the cavity of the greater omentum; adults do not have this cavity, since the four sheets of the peritoneum grow together;

the middle floor of the peritoneal cavity is located between the mesentery of the transverse colon and the entrance to the small pelvis. The middle floor is divided by the mesentery root of the small intestine, which runs from the left side of the XI lumbar vertebra to the right sacroiliac joint on right and left mesenteric sinuses, sinus mesentericus dex. et sin ... Between the ascending colon and the lateral wall of the abdominal cavity - left lateral channel, canalis lateralis sin ;

The parietal peritoneum forms several depressions (pockets), which are the site of the formation of retroperitoneal hernias. When the duodenum passes into the jejunum, upper and lower duodenal pockets, recessus duodenalis sup . et inf ... When the small intestine passes into the colon, there are upper and lower iliocecal pockets, recessus ileocecalis sup. et inf ... Behind the cecum is retrocecal fossa, recessus retrocecalis ... On the lower surface of the mesentery of the sigmoid colon there is intersigmoid cavity, recessus intersigmoideus;

the lower floor of the peritoneal cavity is located in the small pelvis. The peritoneum covers its walls and organs. In men, the peritoneum passes from the rectum to the bladder, forming rectal vesicular depression, excavatio rectovesicalis ... In women, the uterus is located between the rectum and the bladder, so the peritoneum forms two depressions: a) rectal uterine, excavatio rectouterina , - between the rectum and the uterus; b) vesicouterine, excavatio vesicouterina , - between the bladder and the uterus.

Age features.Peritoneum of a newborn thin, transparent. Through it, the blood vessels and lymph nodes are visible, since the subperitoneal fatty tissue is poorly developed. The large gland is very short and thin. The depressions, folds and pits formed by the peritoneum are present in the newborn, but they are weakly expressed.

Abdominal cavity subdivided into peritoneal cavity and retroperitoneal space. Peritoneal cavity limits the parietal leaf of the peritoneum. The retroperitoneal space is the part of the abdominal cavity that lies between the parietal fascia of the abdomen at its posterior wall and the parietal peritoneum.

bursa pregastrica

bursa omentalis

BURSA OMENTALIS

Has 6 walls:

6. Front wall

VINSL HOLE WALLS

INursa hepatica

Contains the right lobe of the liver.

It communicates with the omental bursa and with the right lateral canal (located in the middle floor of the abdominal cavity)

Bursapregatrica

Covers the left lobe of the liver.

MIDDLE FLOOR the abdominal cavity is limited

above mesocolon transversum

In the middle floor, between the mesentery and the intestine itself, there are two mesenteric sinuses: right and left.

Two bags of the upper floor communicate with the right lateral canal: b.omentalis, b. hepatica; and it ends in the right iliac fossa.

LOWER FLOOR.

In women, excavation rectouterina is of practical importance, from the side of the vagina it corresponds to its posterior fornix. When puncture of the posterior fornix of the vagina, they fall into the excavatio rectouterina - with pathological processes in the abdominal cavity (for example, an ectopic pregnancy), blood accumulates there.

MINISTRY OF HEALTH OF THE REPUBLIC OF BELARUS

INSTITUTION OF EDUCATION

"GOMEL STATE MEDICAL UNIVERSITY"

Department of Human Anatomy

With the course of operative surgery and topographic anatomy

E. Y. DOROSHKEVICH, S. V. DOROSHKEVICH,

I. I. LEMESHEVA

SELECTED QUESTIONS

TOPOGRAPHIC ANATOMY

AND OPERATIONAL SURGERY

Study guide

TO practical training in topographic anatomy

And operative surgery for 4th year medical students,

Medical and diagnostic faculties and faculty for training

Specialists for foreign countries studying in their specialty

"General Medicine" and "Medical Diagnostic Business"

Gomel

GomGMU

CHAPTER 1

SURGICAL ANATOMY OF THE ABDOMINAL CAVITY

TOPOGRAPHY OF THE UPPER FLOOR BODIES

ABDOMINAL CAVITY

1.1 Abdominal cavity (cavitas abdominis)and its floors (boundaries, content)

The boundaries of the abdominal cavity.

The upper wall of the abdominal cavity is formed by the diaphragm, the posterior wall is formed by the lumbar vertebrae and muscles of the lumbar region, the anterolateral wall is formed by the abdominal muscles, the lower boundary is the terminal line. All of these muscles are covered with a circular fascia - the fascia of the abdomen, which is called the intra-abdominal fascia (fascia endoabdominalis); it directly limits the space that is called the abdominal cavity (or abdominal cavity).

The abdominal cavity is divided into 2 sections:

􀀹 peritoneal cavity (cavitas peritonei)- a slit space located between the sheets of the parietal and visceral peritoneum and containing intraperitoneal and mesoperitoneal organs;

􀀹 retroperitoneal space (spatium retroperitoneale)- located between the parietal leaf of the peritoneum covering the posterior abdominal wall and the intra-abdominal fascia; it contains extra-peritoneal organs.

The transverse colon and its mesentery form a septum that divides the abdominal cavity into 2 floors - upper and lower.

In the upper floor of the abdominal cavity there are: liver, stomach, spleen-zenka, pancreas, upper half of the duodenum. The subgastric gland is located behind the peritoneum; nevertheless, it is considered as an organ of the abdominal cavity, since the operative access to it is usually carried out by means of celiac disease. The lower floor contains: loops of the small intestine (with the lower half of the duodenum) and the large intestine.

Peritoneal topography: course, canals, sinuses, bursae, ligaments, folds, pockets

Peritoneum (peritoneum)- a thin serous membrane with a smooth, shiny, uniform surface. Consists of the parietal peritoneum (peri-toneum parietale)lining the abdominal wall, and the visceral peritoneum (peritoneum viscerale)covering the abdominal organs. Between the leaves there is a slit-like space called the peritoneal cavity and containing a small amount of serous fluid, which moisturizes the surface of the organs and facilitates peristalsis. The parietal peritoneum lines the inside of the anterior and lateral walls of the abdomen, at the top it passes to the diaphragm, at the bottom - in the region of the large and small pelvis, behind it does not reach the spine a little, limiting the retroperitoneal space.

The relationship of the visceral peritoneum to the organs is not the same in all cases. Some organs are covered with it from all sides and are located intraperitoneally: stomach, spleen, small, blind, transverse and sigmoid colon, sometimes gallbladder. They are completely covered by the peritoneum. Some of the organs are covered with a visceral peritoneum from 3 sides, i.e., they are located mesoperitoneally: liver, gallbladder, ascending and descending colon, initial and final parts of the duodenum.

Some organs are covered with the peritoneum on only one side - extraperitoneally: duodenum, pancreas, kidneys, adrenal glands, bladder.

Peritoneal stroke

The visceral peritoneum, covering the diaphragmatic surface of the liver, passes to its lower surface. The leaves of the peritoneum, going one from the front of the lower surface of the liver, the other from the back, at the gate meet and go down towards the lesser curvature of the stomach and the initial part of the duodenum, participating in the formation of ligaments of the lesser omentum. The leaves of the lesser omentum at the lesser curvature of the stomach diverge, cover the stomach in front and behind, and, again joining at the greater curvature of the stomach, descend downward, forming the anterior plate of the greater omentum (omentum majus).Going down, sometimes to the pubic symphysis, the leaves are wrapped and directed upward, forming the posterior plate of the greater omentum. Having reached the transverse colon, the sheets of the peritoneum bend around its anteroposterior surface and go to the posterior wall of the abdominal cavity. At this point, they diverge, and one of them rises upward, covering the pancreas, the posterior wall of the abdominal cavity, partly the diaphragm, and, reaching the posterior lower edge of the liver, passes to its lower surface. Another sheet of the peritoneum is wrapped and goes in the opposite direction, that is, from the back wall of the abdomen to the transverse colon, which covers, and again returns to the back wall of the abdomen. This is how the mesentery of the transverse colon is formed. (mesocolon transversum), consisting of 4 sheets of the peritoneum. From the root of the mesentery of the transverse colon, the sheet of the peritoneum goes down and already as the parietal peritoneum lines the back wall of the abdomen, then covers the ascending (right) and descending (left) colon from 3 sides. Inwardly from the ascending and descending colon, the parietal sheet of the peritoneum covers the organs of the retroperitoneal space and, approaching the small intestine, forms its mesentery, enveloping the intestine from all sides.

From the back wall of the abdomen, the parietal leaf of the peritoneum descends into the pelvic cavity, where it covers the initial sections of the rectum, then lines the walls of the small pelvis and passes to the bladder (in women, it first covers the uterus), covering it from behind, from the sides and from above. From the apex of the bladder, the peritoneum passes to the anterior abdominal wall, closing the peritoneal cavity. For a more detailed course of the peritoneum in the pelvic cavity, see the topic Topographic anatomy of the pelvis and perineum.

Channels

On the sides of the ascending and descending colon are the right and left canals of the abdominal cavity (canalis lateralis dexter et sinis-ter),formed as a result of the transition of the peritoneum from the lateral wall of the abdomen to the colon. The right channel has a communication between the upper floor and the lower one. On the left channel, there is no connection between the upper floor and the lower one due to the presence of the phrenic-colonic ligament (lig. phrenicocolicum).

Sinuses of the abdominal cavity(sinus mesentericus dexter et sinus mesentericus sinister)

The right sinus is limited: on the right - by the ascending colon; from above - the transverse colon, on the left - the mesentery of the small intestine. Left sinus: on the left - the descending colon, from below - the entrance to the pelvic cavity, on the right - the mesentery of the small intestine.

Handbags

Packing bag(bursa omentalis)limited: in front - by the lesser omentum, the posterior wall of the stomach and the gastro-colon ligament; behind - the parietal peritoneum covering the pancreas, part abdominal aorta and inferior vena cava; on top - the liver and diaphragm; from below - the transverse colon and its mesentery; on the left - the gastro-splenic and phrenic-splenic ligaments, the gate of the spleen-spleen. Communicates with the peritoneal cavity through stuffing box hole(foramen epiploicum, Winslow's hole),bounded in front by the hepato-duodenal ligament, from below by the duodenal-renal ligament and the upper horizontal part of the duodenum, behind by the hepato-renal ligament and parietal peritoneum covering the inferior venous vein, above by the caudate lobe of the liver.

Right hepatic bag(bursa hepatica dextra)from above it is bounded by the tendon center of the diaphragm, from below - by the diaphragmatic surface of the right lobe of the liver, from behind - by the right coronary ligament, on the left - by the crescent ligament. It is the site of subphrenic abscesses.

Left hepatic bag(bursa hepatica sinistra)from above it is bounded by the diaphragm, from behind - by the left coronary ligament of the liver, on the right - by the falciform ligament, on the left - by the left triangular ligament of the liver, below - by the diaphragmatic surface of the left lobe of the liver.

Pregastric bag(bursa pregastrica)from above it is limited by the left lobe of the liver, in front - by the parietal peritoneum of the anterior abdominal wall, behind - by the small omentum and the anterior surface of the stomach, on the right - by the falciform ligament.

Pre-omentum gap(spatium preepiploicum)- a long slit located between the anterior surface of the greater omentum and the inner surface of the anterior abdominal wall. Through this gap, the upper and lower floors communicate with each other.

Peritoneal ligaments

In places where the peritoneum passes from the abdominal wall to the organ or from organ to organ, ligaments are formed (ligg.peritonei).

Hepatic duodenal ligament(lig. hepatoduodenale)stretched between the gate of the liver and the upper part of the duodenum. On the left, it passes into the hepato-gastric ligament, and on the right it ends with a free edge. The ligaments pass between the leaves: on the right - the common bile duct and the common hepatic and cystic ducts, on the left - the own hepatic artery and its branches, between them and behind - the portal vein ("TWO"- ductus, vein, artery from right to left), as well as lymphatic vessels and nodes, nerve plexuses.

Hepato-gastric ligament(lig. hepatogastricum)is a duplication of the peritoneum, stretched between the gate of the liver and the lesser curvature of the stomach; on the left, it passes to the abdominal esophagus, on the right, it continues into the hepato-duodenal ligament.

In the upper part of the ligament, the hepatic branches of the anterior vagus trunk pass. At the base of this ligament, in some cases, the left gastric artery is located, accompanied by the vein of the same name, but more often these vessels lie on the stomach wall along the lesser curvature. In addition, quite often (in 16.5%) in the tense part of the ligament there is an accessory hepatic artery, coming from the left gastric artery. In rare cases, the main trunk of the left gastric vein or its tributaries passes here.

When mobilizing the stomach along the lesser curvature, especially if the ligament is dissected near the gate of the liver (in case of stomach cancer), it is necessary to take into account the possibility of the left accessory hepatic artery passing here, since its intersection can lead to necrosis of the left lobe of the liver or part of it.

On the right, at the base of the hepato-gastric ligament, the right gastric artery passes, accompanied by the vein of the same name.

Hepato-renal ligament(lig. hepatorenale)is formed at the place of transition of the peritoneum from the lower surface of the right lobe of the liver to the right kidney. In the medial part of this ligament, the inferior vena cava passes.

Gastrophrenic ligament(lig. gastrophrenicum)is located to the left of the esophagus, between the fundus of the stomach and the diaphragm. The ligament has the shape of a triangular plate and consists of one sheet of the peritoneum, at the base of which there is a loose connective tissue. On the left, the ligament passes into the superficial layer of the gastro-splenic ligament, and on the right, into the anterior semicircle of the esophagus.

The transition of the peritoneum from the gastrophrenic ligament to the anterior wall of the esophagus and to the hepato-gastric ligament is called diaphragm-esophageal ligament(lig. phrenicooesophageum).

Phreno-esophageal ligament (lig.phrenicoesophageum)represents the transition of the parietal peritoneum from the diaphragm to the esophagus and the cardiac part of the stomach. At its base in loose fiber along the front surface of the esophagus there are r. esophageusof a. gastrica sinistraand the trunk of the left vagus nerve.

Gastro-splenic ligament (lig.gastrolienale), stretched between the bottom of the stomach and the upper part of the greater curvature and the hilum of the spleen, is located below the gastrophrenic ligament. It consists of 2 sheets of the peritoneum, between which there are short gastric arteries, accompanied by the veins of the same name. Continuing downward, it passes into the gastro-colon ligament.

Gastrocolic ligament (lig.gastrocolicum)consists of 2 sheets of the peritoneum. It is the initial part of the greater omentum and is located between the greater curvature of the stomach and the transverse colon. It is the broadest ligament that runs from the lower pole of the spleen to the pylorus in a strip. The ligament is loosely connected to the anterior semi-circle of the transverse colon, as well as to tenia omentalis.The right and left gastroepiploic arteries pass through it.

Gastro-pancreas ligament (lig.gastropancreaticum)is located between the upper edge of the pancreas and the cardiac part, as well as the fundus of the stomach. It is quite clearly defined if the gastrocolic ligament is cut and the stomach is pulled anteriorly and upward.

In the free edge of the gastro-pancreatic ligament is the initial section of the left gastric artery and the vein of the same name, as well as lymphatic vessels and gastro-pancreatic lymph nodes. In addition, pancreatic-splenic lymph nodes are located at the base of the ligament along the upper edge of the pancreas.

Pyloric-pancreas ligament (lig.pyloropancreaticum)in the form of a duplication of the peritoneum stretched between the pylorus and the right side of the pancreas. It has the shape of a triangle, one side of which is fixed to the posterior surface of the pylorus, and the other to the anteroinferior surface of the body of the gland; the free edge of the ligament is directed to the left. Sometimes the ligament is not pronounced.

In the pyloric-pancreatic ligament, small lymph nodes are concentrated, which can be affected in cancer of the pyloric stomach. Therefore, when resecting the stomach, it is necessary to completely remove this ligament together with the lymph nodes.

Between the gastro-pancreatic and pyloric-pancreatic ligaments, there is a slit-like gastro-pancreatic opening. The shape and size of this hole depends on the degree of development of the mentioned ligaments. Sometimes the ligaments are developed so much that they overlap or grow together, closing the gastro-pancreas opening.

This leads to the fact that the cavity of the stuffing box is divided by ligaments into 2 separate spaces. In such cases, in the presence of pathological contents in the cavity of the omental bursa (effusion, blood, gastric contents, etc.), it will be in one or another space.

Phrenic-splenic ligament (lig.phrenicolienale)located deep in the posterior part of the left hypochondrium, between the costal part of the diaphragm and the hilum of the spleen.

Stretched between the ribs of the diaphragm and the left flexure of the colon phrenic-colonic ligament (lig.phrenicocolicum)... This ligament, together with the transverse colon, forms a deep pocket in which the anterior pole of the spleen is located.

Duodenal-renal ligament (lig.duodenorenale)located between the posterior superior edge of the duodenum and the right kidney, limits the omental opening from below.

Supportive ligament of the duodenum or treitz's ligament (lig. suspensorium duodeni s. lig. Treitz)formed by a fold of the peritoneum covering the muscle that suspends the duodenum (m. suspensorius duo-deni)... Muscle bundles of the latter arise from the circular muscle layer of the intestine at the site of its inflection. A narrow and strong muscle is directed from flexura duodenojejunalisup, behind the pancreas, it expands in a fan-like manner and is woven into the muscle bundles of the legs of the diaphragm.

Pancreas-splenic ligament (lig. Pancreaticolienale)is a continuation of the phrenic-splenic ligament and is a fold of the peritoneum that extends from the tail of the gland to the hilum of the spleen.

1. Around the beginning of the jejunum, the parietal peritoneum forms a fold bordering the intestine from above and to the left, this is the superior duodenal fold (plica duodenalis superior).In this area, the superior duodenal cavity is localized (recessus duodenalis superior),on the right, bounded by a 12-duodenal bend, above and on the left - by the superior duodenal fold, in which the inferior mesenteric vein passes.

2. To the left of the ascending part of the duodenum is the para-duodenal fold (plica paraduodenalis).This fold limits the inconsistent paraduodenal depression in front (recessus paraduodenalis), the back wall of which is the parietal peritoneum.

3. To the left and below from the ascending part of the duodenum 12 passes the lower duodenal fold (plica duodenalis inferior),which limits the lower duodenal cavity (recessus duodenalis inferior).

4. To the left of the mesentery root of the small intestine, behind the ascending part of the duodenum, there is a retroduodenal depression (recessus retroduodenalis).

5. At the confluence of the ileum into the blind, an ileocecal fold is formed (plica ileocecalis).It is located between the medial wall of the cecum, the anterior wall of the ileum, and also connects the medial wall of the cecum with the lower wall of the ileum above and with the base of the appendix below. Under the ileocecal fold, there are pockets located above and below the ileum: the upper and lower ileocecal depressions (recessus ileocecalis supe-rior et recessus ileocecalis inferior).The upper ileocecal depression is upwardly limited by the ileo-colon fold, below - by the end of the ileum and outside by the initial part of the ascending colon. The lower ileocecal depression at the top is bounded by the terminal ileum, behind by the mesentery of the vermiform process and in front by the ileocintestinal fold of the peritoneum.

6. Behind the digestive cavity (recessus retrocecalis)bounded in front by the cecum, behind by the parietal peritoneum and outside by the blind-intestinal folds of the peritoneum (plicae cecales)stretched between the lateral edge of the caecum floor and the parietal peritoneum of the iliac fossa.

7. Intersigmoid groove (recessus intersigmoideus)located on the left at the root of the mesentery of the sigmoid colon.

The abdominal cavity is the part of the abdominal cavity covered by the parietal peritoneum. In men, it is closed, and in women it communicates with the uterine cavity through the openings of the fallopian tubes.

The visceral layer of the peritoneum covers the organs located in the abdominal cavity. Organs can be covered by the peritoneum from all sides (intraperitoneal), from three sides (mesoperitoneal) and extraperitoneal (from one side or extraperitoneal). The organs covered by the peritoneum intraperitoneally have significant mobility, which is increased by the mesentery or ligaments. The displacement of the mesoperitoneal organs is insignificant (Fig. 123).

The peculiarity of the peritoneum is that the mesothelium (the first layer of the peritoneum) forms a smooth surface, which ensures the sliding of organs during their peristalsis and changes in volume. In the peritoneal cavity, under normal conditions, there is a minimum amount of clear serous fluid, which moisturizes the surface of the peritoneum and fills the gaps between organs and walls. Movements of organs in relation to each other and to the abdominal wall are carried out easily and without friction, due to the fact that all contacting surfaces are smooth and moist. There is an oil seal between the front wall of the abdomen and the internal organs. "

In the area of \u200b\u200bthe diaphragm, the peritoneum becomes thinner at the site of the "suction hatches". The clearance of the hatches changes during the respiratory movements of the diaphragm, which ensures their suction effect. "Suction hatches" are also found in the peritoneum of the rectal-cystic cavity in men and in the rectal-uterine cavity in women.

Distinguish transudatory, suction and indifferent to the cavity fluid areas of the peritoneum. Transudating sites - small intestine and wide ligaments of the uterus. The suction parts of the parietal peritoneum are the diaphragm and iliac fossa.

The abdominal cavity by the mesentery of the transverse colon is divided into two floors: upper and lower, which communicate with each other from the front through the pre-omental fissure and from the sides through the right and left lateral canals. In addition, the peritoneal floor of the small pelvis is isolated

The upper floor of the abdominal cavity is located between the diaphragm and the mesentery of the transverse colon. In it, the stomach, spleen and mesoperitoneally - the liver, gallbladder and the upper part of the duodenum - lie intraperitoneally covered. The pancreas belongs to the upper floor of the abdominal cavity, although it lies retroperitoneally, and part of the head is located below the mesentery root of the transverse colon. The listed organs, their ligaments and the mesentery of the transverse colon limit isolated spaces, cracks and bags in the upper floor of the abdominal cavity.

Top floor bags. The space between the diaphragm and the liver is divided by the falciform ligament into two sections: left and right.

The right hepatic bag, or bursa hepatica dextra, is the gap between the right lobe of the liver and the diaphragm. From above it is bounded by the diaphragm, from below - by the right lobe of the liver, behind - by the right part of the coronary ligament and on the left - by the falciform ligament of the liver. In it, the right subphrenic space and the subhepatic space are distinguished.

The right subphrenic space is located most deeply between the posterior surface of the right lobe of the liver, the diaphragm and the coronary ligament. It is in the subphrenic space, as in the deepest place of the hepatic bursa, that fluid that has poured into the abdominal cavity can be retained. The subphrenic space in most cases passes directly into the right lateral canal of the lower floor of the abdominal cavity. Therefore, the inflammatory exudate from the right iliac fossa can freely move towards the subphrenic space and lead to the formation of an enclosed abscess, called a subphrenic abscess. It most often develops as a complication of perforated gastric and duodenal ulcers, destructive appendicitis, cholecystitis.

The subhepatic space is the lower part of the i fava of the hepatic bursa and is located between the lower surface of the right lobe of the liver, the transverse colon and its mesentery, to the right of the hilum of the liver and the hepato-duodenal ligament. In the subhepatic space, the anterior and posterior sections are distinguished. Almost the entire peritoneal surface of the gallbladder, the upper outer surface of the duodenum, faces the anterior part of this space. The posterior section, located at the posterior edge of the liver, is the least accessible part of the subhepatic space - a depression called the renal-hepatic pocket. Abscesses resulting from perforation of a duodenal ulcer or purulent cholecystitis are more often located in the anterior section, while the spread of a periappendicular abscess occurs mainly in the posterior subhepatic space.

The left subphrenic space consists of widely communicated bursae: the left hepatic and pregastric.

The left hepatic bag is a gap between the left lobe of the liver and the diaphragm, bounded on the right by the falciform ligament of the liver, the posterior left part of the coronary ligament and the left triangular ligament of the liver. This bursa is much smaller in width and depth than the right hepatic bursa and usually does not stand out as a special part of the subphrenic space.

The pregastric bag is bounded from behind by the lesser omentum and stomach, from the top to the left lobe of the liver, by the diaphragm, from the front to the anterior abdominal wall, to the right by the crescent and round ligaments of the liver; to the left, the pregastric bag has no pronounced border. In the outer-posterior part of the left subphrenic space is the spleen with the ligaments: gastro-splenic and diaphragmatic-splenic. () t of the left lateral canal, it is separated by the left phrenic-colonic ligament. This ligament is often wide, it covers the lower pole of the spleen and is called the suspension ligament of the spleen. Thus, the bed of the spleen is well demarcated from the left lateral canal, this is a blind pocket (saccus caecus lienalis). The left subphrenic space plays a much lesser role than the right, as the site of abscess formation. Purulent processes that rarely develop in this space tend to spread between the left lobe of the liver and the stomach down to the transverse colon or to the left to the blind sac of the spleen. Communication between the right hepatic and pregastric sacs is carried out through a narrow gap between the liver and the pyloric part of the stomach, in front of the lesser omentum.

The omental bursa (bursa omentalis) is a large closed slit-like space of the abdominal cavity, the most isolated and deepest.

The anterior wall of the omentum is formed by the lesser omentum, the posterior wall of the stomach and the gastro-colic ligament (the initial part of the greater omentum). The lesser omentum is three ligaments, passing one into the other: hepato-duodenal, hepato-gastric and diaphragmatic-gastric. Bottom wall the omental bursa forms the transverse colon and its mesentery. From above, the omental bursa is bounded by the caudate lobe of the liver and the diaphragm, the posterior wall is formed by the parietal peritoneum, which covers the front of the pancreas, aorta, the inferior vena cava, the upper pole of the left kidney with the adrenal gland, on the left it is bounded by the spleen with the gastro-splenic ligament, and the right wall is not expressed.

In the omental bursa, depressions, or twists, are distinguished: the upper one is located behind the caudate lobe of the liver and reaches the diaphragm, the lower one is in the mesentery of the transverse colon and splenic.

The entrance to the omental bursa is possible only through the omental opening, bounded in front by the hepato-duodenal ligament, behind by the hepato-renal ligament, in the thickness of which lies the inferior vena cava, from above by the caudate lobe of the liver, from below by the renal-duodenal ligament.

The stuffing box hole allows one or two fingers to pass through, but in case of adhesion it can be closed and then the stuffing box bag is a completely isolated space. The contents of the stomach can accumulate in the omental bag when an ulcer perforates, on its back wall can develop
nigsya purulent processes as a result of inflammatory diseases of the pancreas.

There are three operative access to the omental bag for examination, revision of organs and operations on them (Fig. 124):

1. Through the gastro-colic ligament, which is most preferred as it can be dissected widely. It is used to examine the posterior wall of the stomach and pancreas during inflammation and trauma.

2. Through a hole in the mesentery of the transverse colon in an avascular place, the cavity of the omental bursa can be examined, and a gastrointestinal anastomosis can be applied.

3. Through the hepato-gastric ligament, access is more convenient for lowering the stomach. Used for operations on the celiac artery.

Channels and sinuses of the lower floor. The lower floor of the abdominal cavity occupies the space between the mesentery of the transverse colon and the small pelvis. The ascending and descending colon, the root of the mesentery of the small intestine divide the lower floor of the abdominal cavity into four sections: the right and left lateral canals and right and left (mesenteric sinuses (Fig. 125).

The right lateral canal is located between the ascending colon and the right lateral wall of the abdomen. At the top, the canal passes into the subchaphragmatic space, at the bottom - into the right iliac fossa, and then into the small pelvis.

The left lateral canal is bounded by the descending colon and the left lateral wall of the abdomen and passes into
left iliac region. The deepest in the horizontal position are the upper parts of the canals.

The right mesenteric sinus on the right is bounded by the ascending colon, above by the mesentery of the transverse colon, on the left and below by the mesentery of the small intestine. This sinus is largely delimited from other parts of the abdominal cavity. In the horizontal position, the deepest is the upper right corner of the sinus.

The left mesenteric sinus is larger than the right one. From above it is bounded by the mesentery of the transverse colon, from the left to the descending colon and the mesentery of the sigmoid, to the right by the mesentery of the small intestine. From below, the sinus is not limited and directly communicates with the pelvic cavity. In the horizontal position, the deepest is the upper sinus angle. Both mesenteric sinuses communicate with each other through the gap between the mesentery of the transverse colon and the initial part of the jejunum. Inflammatory exudate from the mesenteric sinuses can spread into the lateral canals of the abdominal cavity. The left mesenteric sinus is larger than the right one, and due to the absence of anatomical restrictions in its lower parts, suppurative processes developing in the sinus tend to descend into the pelvic cavity much more often than from the right mesenteric sinus.

Along with the tendency for the spread of inflammatory exudates in all the cracks of the abdominal cavity, there are anatomical prerequisites for the formation of enclosed peritonitis both in the lateral canals and in the mesenteric sinuses, especially in the right, as more closed. During operations on the organs of the abdominal cavity, especially with peritonitis, it is important to take the loops of the small intestine first to the left, then to the right and remove pus and blood from the mesenteric sinuses in order to prevent the formation of enclosed abscesses.

Abdominal pockets. The peritoneum, passing from organ to organ, forms ligaments, next to which there are depressions, called pockets (recessus).

Recessus duodenojejunalis is formed at the junction of the duodenum into the jejunum, recessus iliocaecalis superior is formed at the confluence of the ileum into the blind in the region of the superior ileal-caecal angle, recessus iliocaecalis inferior is formed in the region of the lower intestinal recessus ileal angle intersigmoideus is a funnel-shaped depression between the mesentery of the sigmoid colon and the parietal peritoneum, its beginning facing the left lateral canal.

The peritoneal pockets can become the site of internal hernia formation. Peritoneal pockets with internal hernias can be very large. Internal hernias can become pinched and cause intestinal obstruction.

Topographic anatomy of the stomach. The stomach is the laryngeal organ of the digestive system and is a mystical, saccular enlargement of the digestive tract, located between the esophagus and the duodenum.

Holotopy. The stomach is projected onto the anterior abdominal wall in the left hypochondrium and its own epigastric region.

Departments. The inlet of the stomach is called cardiac, and the outlet is pyloric. The perpendicular, lowered from the esophagus to the greater curvature, divides the stomach into the cardiac section, consisting of the fundus and the body, and the pyloric section, consisting of the vestibule and the pyloric canal. In the stomach, the greater and lesser curvatures, the anterior and posterior surfaces are distinguished.

Syntopy. The concept of "syntopic fields of the stomach" is distinguished. These are the places where the stomach touches neighboring organs. Syntopic fields of the stomach should be taken into account in case of concomitant injuries, penetration of ulcers and germination of stomach tumors. Three syntopic fields are distinguished on the anterior wall of the stomach: hepatic, diaphragmatic and free, which is in contact with the anterior wall of the abdomen. This field is also called the gastric triangle. This site is commonly used for gastrootomies and gastrostomies. The dimensions of the gastric triangle depend on the filling of the stomach. On the back wall of the stomach, five syntopic fields are distinguished: splenic, renal, adrenal, pancreas, and intestinal-colon.

Position. In the abdominal cavity, the stomach occupies a central position in the upper floor. Most of the stomach is located in the left subphrenic space, limiting the back of the pregastric sac, and in front - the omental. The position of the stomach corresponds to the degree of inclination of the longitudinal axis of the stomach. Shevkunenko, in accordance with the location of the axis of the stomach, identified three types of positions: vertical (hook shape), horizontal (horn shape), oblique longitudinal. It is believed that the position of the stomach is in direct proportion to the body type.

Attitude to the peritoneum. The stomach is in an intraperitoneal position. In the places of transition of the sheets of the peritoneum on the lesser and greater curvatures, stomach ligaments are formed. The ligaments of the stomach are divided into superficial and deep. Superficial ligaments:

1) gastro-colon (part of the greater omentum);

2) gastro-splenic, short gastric vessels pass through it, splenic vessels are located behind the ligament;

3) gastro-diaphragmatic;

4) diaphragmatic-esophageal, in it the esophageal branch passes from the left gastric artery;

5) hepato-gastric, in it along the lesser curvature there is a left gastric artery and a vein;

6) hepato-pylorus - continuation of the hepatic / xlural ligament. It has the form of a narrow strip stretched between the gate of the liver and the pylorus, it forms the intermediate part between the hepato-gastric and hepato-duodenal gii and dogs and serves as the right border when dissecting the ligaments of the stomach.

Deep ligaments:

1) gastro-pancreas (at the transition of the peritoneum from the top - I micro edge of the pancreas to the back of the stomach);

2) with the pyloric-pancreas (between the pyloric otic otic of the stomach and the right side of the pancreas);

3) lateral diaphragmatic-pico-venous.

Blood supply to the stomach. The stomach is surrounded by a ring

wide-anastomosed vessels, giving off intramural branches and forming a dense network in the submucosa (Fig. 126). The source of blood supply is the celiac trunk, from which the left gastric artery extends directly to the lesser curvature of the stomach. The right gastric artery departs from the common hepatic artery, which anastomoses with the left on the lesser curvature of the stomach, forming an arteral arc of the lesser curvature. The left and right gastroepiploic arteries form an arc of greater curvature, and there are also short gastric arteries.

Innervation of the stomach. The stomach has a complex nervous apparatus. The main sources of innervation are the vagus nerves, celiac plexus and its derivatives: gastric, hepatic, splenic, superior mesenteric plexus. The vagus nerves, branching out at the esophagus, form the esophageal plexus, I de branches of both nerves are mixed and repeatedly connected. Passing from the esophagus to the stomach, the branches of the esophageal splash are concentrated in several trunks: the left one passes to the anterior surface of the stomach, and the right one passes to the posterior surface of the stomach, giving branches to the liver, solar plexus, kidney and other organs. From the left vagus nerve to the pyloric section of the stomach, a long branch of Latarzhe departs. the vagus nerves are a complex conduction system that connects to the stomach and other organs nerve fibers various functional purposes. There is a large number of connections between the left and right nerves in the chest and abdominal cavities, here the exchange of fibers takes place. Therefore, we cannot talk about the exclusive innervation of the anterior wall of the stomach by the left vagus nerve, and the posterior wall by the right one. The right vagus nerve goes more often in the form of a single trunk, and the left forms from one to four branches, more often there are two.

Lymph nodes gh\u003e dka. Regional lymph nodes of the stomach are located along the lesser and greater curvature, as well as along the left gastric, common hepatic, splenic and celiac arteries. According to A. V. Melnikov (1960), lymph drainage from the stomach occurs through four main collectors (basins), each of which includes 4 stages.

The lymph drainage collector I collects lymph from the pyloroan- gral part of the stomach, adjacent to the greater curvature. The first stage is the lymph nodes located in the thickness of the gastrocolic ligament along the greater curvature, in the vicinity of the pyloric, the second stage is the lymph nodes along the edge of the pancreatic head under and behind the pylorus, the third\u003e tap is the lymph nodes located in the thickness of the mesentery of the small intestine and the fourth is the retroperitoneal para-aortic lymph nodes.

In 7 / the lymph drainage collector, lymph flows from the part of the pyloric antrum, adjacent to the lesser curvature, and partly from the body of the stomach. The first stage is the retropyloric lymph nodes, the second is the lymph nodes in the lesser omentum in the dietary part of the lesser curvature, in the area of \u200b\u200bthe pylorus and duodenum, immediately behind the pylorus, the third stage is the lymph nodes located in the thickness of the liver of the intragastric ligament. The fourth stage A. V. Melnikov considered the lymph nodes in the gate of the liver.

III collector collects lymph from the body of the stomach and lesser curvature, adjacent sections of the anterior and posterior walls, paintings, the medial part of the fornix and the abdominal esophagus. The first stage is the lymph nodes located in a chain along the lesser curvature in the tissue of the lesser omentum. The upper nodes of this chain are called paracardial; in cancer of the cardia, they are affected by metastases in the first place. Lymph nodes along the left gastric vessels, in the thickness of the gastro-pancreatic ligament, are the second stage. Stage I - lymph nodes along the upper edge of the pancreas and in the area of \u200b\u200bits tail. The fourth stage - lymph nodes in the paraesophageal tissue above and below the diaphragm.

In the IV collector, lymph flows from the vertical part of the greater curvature of the stomach, the adjacent anterior and posterior walls and a significant part of the fornix of the stomach. The lymph nodes located in the upper-left gastrocolic ligament are the first stage. The second stage is the lymph nodes along the short arteries of the stomach, the third stage is the lymph nodes at the gate of the spleen. The fourth stage A. V. Melnikov considered the defeat of the spleen.

Knowledge of regional anatomy lymph nodes all collectors is extremely important for the correct operation of the stomach in compliance with oncological principles.

Topographic anatomy of the duodenum. The duodenum (duodenum) is the initial section of the small intestine. In front, it is covered by the right lobe of the liver and the mesentery of the transverse colon, it itself covers the head of the pancreas, thus, the duodenum lies deep and nowhere directly adjacent to the anterior abdominal wall. Four parts are distinguished in the duodenum. It consists of an upper horizontal, descending, lower horizontal and ascending parts. Knowledge of the syntopy of the duodenum helps to explain the direction of ulcer penetration, tumor growth and the spread of phlegmon in retroperitoneal rupture of the organ.

The upper part of the duodenum, 4-5 cm long, is located between the pylorus of the stomach and the upper bend of the duodenum and goes to the right and back along the right surface of the spine, passing into the descending part. This is the most mobile part of the intestine, covered on all sides by the peritoneum. All other parts of the intestine are covered with the peritoneum only in front. In the initial part of the duodenum, an expansion is determined, which is called the duodenal bulb. The upper part of the duodenum from above; it comes into contact with the square lobe of the liver, in front - with the gallbladder, behind - with the portal vein, gastro-duodenal artery, common bile duct. The head of the pancreas is adjacent to the intestine from below and from the inside.

The descending part of the duodenum 10- and 2 cm long is located between the flexura duodeni superior and flexura duodeni inferior. This part of the duodenum is inactive and is covered by the peritoneum only in front. The descending part of the duodenum in front is bordered by the right lobe of the liver, the mesentery of the transverse colon, behind - with the gate of the right kidney, renal leg, inferior vena cava. Outside is the ascending part and the hepatic flexure of the colon, from the inside is the head of the pancreas. The common bile duct and pancreatic duct open into the descending part of the duodenum. They pierce the posterior wall of the descending part of the duodenum in its middle section and open on the large (Vater) papilla of the duodenum. Above it, there may be a non-permanent small duodenal papilla, on which the accessory pancreatic duct opens.

From the lower bend of the duodenum begins - 1 "and its horizontal part 2 to 6 cm long, covered in front by the peritoneum. The horizontal (lower) part lies at the level of III and IV lumbar vertebrae, below the mesentery of the transverse colon, partly behind the mesentery root of the small intestine The first oryuntal part of the duodenum passes into an ascending part of 6-10 cm long. The ascending part ends with a 17-duodenal bend covered with a peritoneum in front and on the sides. The following organs adjoin these parts of the duodenum: from above - the head and body of the pancreatic gland, in the front - the transverse colon, loops of the gon intestines, the root of the mesentery of the small intestines and the superior mesenteric vessels, behind - the right psoas muscle, the lower hollow mute, aorta, left renal vein.

Tie up the duodenum. The hepato-duodenal ligament is located between the hilum of the liver and the initial Hi (fracture of the upper part of the duodenum. It fixes the I initial part of the intestine and limits the omental opening

In the upper part, the duodenum is covered on both sides by the peritoneum. The descending and horizontal parts of the races are southerly retroperitoneal, the ascending part occupies an intraperitoneal position.

The blood supply to the duodenum (see Fig. 126) I a "passes from the system of the celiac trunk and the superior mesenteric irregularis. The superior and inferior pancreatic-duodenal arteries have anterior and posterior branches. As a result of anastomosis between them, anterior and posterior arterial arches are formed, which go between the concave semicircle of the duodenum and the head of the pancreas, which makes it impossible to separate them during surgery and forces them to be removed in a single block - pancreatoduodenal resection, performed, for example, in cancer of the Vater's nipple or a tumor of the pancreatic head.

Large glands of the digestive tract

Topographic anatomy of the liver. The liver belongs to the large glands of the digestive tract. The liver is distinguished by four morphofunctional features: 1) it is the largest organ; 2) has three circulatory systems: arterial, venous and portal; 3) all substances that enter the gastrointestinal tract pass through it; 4) serves as a huge blood depot; 5) participates in all types of metabolism, synthesizes albumins, globulins, factors of the blood coagulation system, plays an important role in carbohydrate and fat metabolism and detoxification of the body, plays an important role in lymph production and lymph circulation.

Gayutopia. The liver of an adult is located in the right hypochondrium, the epigastric region itself, and partially in the left hypochondrium. The projection of the liver onto the anterior abdominal wall has the form of a triangle and can be built at three points: the upper point is on the right at the level of the 5th costal cartilage along the midclavicular line, the lower point is the 10th intercostal space along the midaxillary line, on the left - at the level of 6- th costal cartilage along the parasternal line. The lower border of the liver coincides with the costal arch. Behind, the liver is projected onto the chest wall, to the right of the 10-11th thoracic vertebrae.

Liver position. The liver in relation to the frontal plane can be located: 1) in the dorsopetal position, the diaphragmatic surface of the liver is thrown back and its anterior edge can be located above the costal arch; 2) in the ventropetal position, the diaphragmatic surface is facing forward, and the visceral surface - backward. In the ventropetal position, surgical access to the lower surface of the liver is difficult, and in the dorsopetal position, to the upper one.

The liver can take a right-sided position, then its right lobe is highly developed, and the size of the left lobe is reduced. () the pgan occupies an almost vertical position, sometimes located only in the right half of the abdominal cavity. The left-sided position of the liver is characterized by the location of the organ in the horizontal plane and with a well-developed left lobe, which in some cases may extend beyond the spleen.

Syntopy of the liver. The diaphragmatic surface of the right liver juli is bordered by the pleural cavity, the left lobe - with the pericardium, from which it is separated by the diaphragm. The visceral surface of the liver comes into contact with various organs, from which depressions form on the surface of the liver. The left lobe of the liver is bordered by the lower end of the esophagus and the stomach. The pyloric part of the stomach is adjacent to the square lobe. The right lobe of the liver in the region of adherence of the gallbladder neck is bordered by the upper horizontal part of the duodenum. 11 to the right is in contact with the transverse colon and the hepatic curvature of the colon. Behind this impression, the surface of the right lobe of the liver is bordered by the right kidney and the adrenal gland. Syntopy of the liver must be taken into account when assessing the possible variants of combined injuries of the abdominal and thoracic cavities.

The gate of the liver is an anatomical formation that makes up the transverse and left longitudinal grooves of the visceral surface of the liver. Here, the vessels and nerves enter the liver and the bile ducts and lymphatic vessels exit. At the gate of the liver, the vessels and ducts are accessible for surgical treatment, since they are located superficially, outside the parenchyma of the organ. The shape of the gate is of practical importance: open, closed and intermediate. With the open form of the liver gate, the transverse groove communicates with the left sagittal and accessory grooves, thereby creating favorable conditions for access to the lobar and segmental ducts. With the closed form of the liver gate, there is no communication with the left sagittal groove, there are no additional grooves, the gate size is reduced, therefore, it is impossible to isolate segmental vessels and ducts in the liver gate without dissecting its perchyma.

The gate of the liver can be located in the middle between the edges of the liver or displaced to the back or front of it. If the gate is moved backwards, more difficult conditions are created for operational access to the vessels and ducts of the portal system when performing liver resections and operations on the biliary tract.

The relation to the peritoneum is mesoperitoneal, that is, the liver is covered by the peritoneum on three sides. The posterior surface of the liver is not covered by the peritoneum; it is called the extraperitoneal field of the liver or pars m.ida.

The ligamentous apparatus of the liver is usually divided into true ligaments and peritoneal ligaments. True ligaments: 1) coronary, firmly fixing the posterosuperior surface of the liver to the diaphragm, passing into triangular ligaments along the edges; 2) crescent, located in the sagittal plane on the border of the right and left lobes and passing into the steep ligament, which goes to the navel and contains a partially obliterated umbilical vein. From the visceral surface of the liver down to the organs are directed the peritoneal ligaments: hepato-gastric and hepato-duodenal. The hepato-duodenal ligament (ligament of life) is considered the most important, since the common bile duct (right), the common hepatic artery (left) and the portal vein pass through it, lying between them and posteriorly. Compression of the hepato-duodenal ligament with fingers or a special instrument is used to temporarily stop bleeding from the liver.

Fixation apparatus of the liver. The liver is kept in the correct anatomical position: 1) the extraperitoneal field (the part of the posterior surface of the liver not covered by the peritoneum); 2) the inferior vena cava, lying on the posterior surface of the liver and receiving the hepatic veins. Above the liver, the vein is fixed in the opening of the diaphragm, below it is firmly connected to the spine; 3) intra-abdominal pressure, muscle tone of the anterior abdominal wall and suction action of the diaphragm; 4) ligaments of the liver.

Blood supply to the liver. Two vessels bring blood to the liver: the hepatic artery and the portal vein, respectively 25 and 75%. The arterial supply of the liver comes from the common hepatic artery, which, after the gastro-duodenal artery leaves it, is called its own hepatic artery and is divided into the right and left hepatic arteries.

Portal vein, v. porta, forms behind the head of the pancreas. This is the first section of the vein called pars pancreatica. The second section of the portal vein is located behind the upper horizontal part of the duodenum and is wound by the pars retroduodenalis. The third section of the vein is located in the shaft of the hepatoduodenal ligament above the upper horizontal part of the duodenum and is called pars supraduodenaiis. The portal vein collects blood from the unpaired organs of the abdominal cavity: intestines, spleen, stomach, and is formed from three large trunks: the splenic vein, superior mesenteric and inferior mesenteric veins.

At the gate of the liver, the hepatic artery, portal vein and bile duct form a portal triad - the Glisson triad.

Liver yen, vv. hepatic i, are collected from the central lobular veins and, ultimately, form three large trunks, right, left and middle hepatic veins, which exit from the liver tissue on the posterior surface at the upper edge (caval gates of the liver) and flow into the inferior cavity vein at the level of its transition through the diaphragm.

The structure of the liver, segmental division. The division of the liver into right, left, caudate, and square lobes, accepted in classical anatomy, is unacceptable for surgery, since the external boundaries of the lobes do not correspond to the internal architectonics of the vascular and biliary systems. The modern division of the pechia into segments is based on the principle of coincidence of the course of the branches of the first order of the three liver systems: portal, arterial and bile, as well as the location of the main venous trunks of the liver. The portal vein, hepatic artery and bile ducts are called the portal system (portal triad, Glisson's triad). The course of all elements of the portal system inside the liver is relatively the same. The hepatic veins are called the caval system. The course of the vessels and bile ducts of the portal system of the liver does not coincide with the direction of the vessels of the caval system. Therefore, at the present time, division of the liver along a portal basis is more common. The division of the liver along the portal system is of greater importance for the surgeon, since it is with the isolation and ligation of the vascular-secretory elements in the gate of the liver that the resection of this organ begins. However, when performing a resection based on the division of the liver along the portal system, it is necessary to take into account the course of the hepatic veins (caval system), so as not to disrupt venous outflow... In clinical practice, the scheme of segmental division of the liver according to Kuino, 1957 (Fig. 127) has become widespread. In this scheme, the liver is divided into two lobes, five sectors, and eight segments. The segments are arranged in radii around the gate. A lobe, sector and segment is a section of the liver that has separate blood supply, bile outflow, innervation and lymph circulation. The lobes, sectors and segments of the liver are separated from each other by four main slits.

Lecture on the topic:

"TOPOGRAPHY OF BRYUSHINA"

LECTURE PLAN:

1. Embryogenesis of the peritoneum.

2. The functional significance of the peritoneum.

3. Features of the structure of the peritoneum.

4. Topography of the peritoneum:

4.1 Upper floor.

4.2 Middle floor.

4.3 Lower floor.

Embryogenesis of the peritoneum

As a result of embryonic development, the secondary body cavity is generally divided into a number of isolated closed serous cavities: this is how 2 pleural cavities and 1 pericardial cavity are formed in the chest cavity; in the abdominal cavity - the peritoneal cavity.

In men, there is another serous cavity between the testicular membranes.

All these cavities are hermetically closed, with the exception of women - with the help of the fallopian tubes during ovulation and menstruation, the abdominal cavity communicates with the environment.

In this lecture, we will touch on the structure of such a serous membrane as the peritoneum.

The abdomen (peritoneum) is a serous membrane, which is divided into parietal and visceral sheets that cover the walls and internal organs of the abdominal cavity.

The visceral layer of the peritoneum covers the internal organs located in the abdominal cavity. There are several types of organ-to-peritoneal relationship or organ peritoneal coverage.

If the organ is covered by the peritoneum on all sides, then one speaks of the intraperitoneal position (for example, the small intestine, stomach, spleen, etc.). If the organ is covered by the peritoneum on three sides, then the mesoperitoneal position is meant (for example, liver, ascending and descending colon). If the organ is covered by the peritoneum on one side, then this is an extraperitoneal or retroperitoneal position (for example, kidneys, lower third of the rectum, etc.).

The parietal layer of the peritoneum lines the walls of the abdominal cavity. In this case, it is necessary to give a definition of the abdominal cavity.

The ABDOMINAL CAVITY is the space of the body located below the diaphragm and filled with internal organs, mainly the digestive and genitourinary systems.

The abdominal cavity has walls:

the upper is the diaphragm

lower - pelvic diaphragm

posterior - the vertebral column and the posterior abdominal wall.

anterolateral - these are the muscles of the abdomen: straight, external and internal oblique and transverse.

The parietal sheet lines these walls of the abdominal cavity, and the visceral sheet covers the internal organs located in it, and a narrow gap is formed between the visceral and parietal sheets of the peritoneum - the PERITAL CAVITY.

Thus, summarizing what has been said, to note that a person has several isolated serous cavities, including the peritoneal cavity, lined with serous membranes.

Speaking of serous membranes, one cannot but touch upon their functional significance.

FUNCTIONAL VALUE OF THE ABDOMINAL

1. Serous membranes reduce friction against each other internal organs, since they emit a liquid that lubricates the contact surfaces.

2. The serous membrane has a transudatory and exudating function. The peritoneum secretes up to 70 liters of fluid per day, and all this fluid is absorbed by the peritoneum itself during the day. Different parts of the peritoneum can perform one of the above functions. So, the diaphragmatic peritoneum has a predominantly absorbing function, the serous cover of the small intestine has a transudating ability, the serous cover of the anterolateral wall of the abdominal cavity, the serous cover of the stomach are referred to as neutral areas.

3. For serous membranes, the performance of a protective function is characteristic, because they are a kind of barriers in the body: serous-hemolymphatic barrier (for example, peritoneum, pleura, pericardium), serous-hematological barrier (for example, greater omentum). A large number of phagocytes are localized in the serous membranes.

4 The peritoneum has great regenerative abilities: the damaged area of \u200b\u200bthe serous membrane is first covered with a thin layer of fibrin, and then simultaneously along the entire length of the damaged area - with mesothelium.

5. Under the influence of external stimuli, not only the functions, but also the morphology of the serous cover change: adhesions appear - so. for serous membranes, delimiting abilities are characteristic; but at the same time adhesions can lead to a number of pathological conditions that require repeated surgical interventions. And, despite the high level of development of surgical techniques, intraperitoneal adhesions are frequent complications, which made this disease stand out as a separate nosological unit - adhesive disease.

6. Serous membranes are the basis in which the vascular bed, lymphatic vessels and a huge number of nerve elements lie.

Thus, the serous membrane is a powerful receptor field: the maximum concentration of nerve elements, and in particular receptors, per unit area of \u200b\u200bthe serous membrane is called the REFLEXOGENIC ZONE. These areas include the umbilical region, the ileocecal angle with the appendix.

7. The total area of \u200b\u200bthe peritoneum is about 2 square meters. meters and is equal to the area of \u200b\u200bthe skin.

8. The peritoneum performs a fixing function (attaches organs and fixes them, returns to their original position after displacement).

T. about. serous membranes perform several functions:

protective,

trophic,

fixation,

delimiting, etc.

HISTOLOGICAL STRUCTURE OF THE PADDER

The histological structure of the peritoneum deserves attention: let us consider it using the example of the parietal leaf.

Based on the new nomenclature, three main morphologically expressed layers are distinguished in the peritoneum:

Mesothelium

Border basement membrane

Own record.

According to the old nomenclature, six layers are distinguished in the peritoneum.

1. Mesothelium - is part of the serous integument. There are two views on the nature of the mesothelium: some attribute the mesothelium to epithelial tissues, others consider the mesothelium to be a type of connective tissue. (This is a single-layered row of cells that allows serous fluid to pass through itself; the mesothelium can slough off, has a high degree of reactivity).

2. Adjacent to the mesothelium is a layer of fibrillar fibers - the basement membrane - it looks like either a continuous layer or a fenestrated structure. The basement membrane prevents the formation of folds on the surface of the mesothelium.

3. The superficial fibrous collagen layer consists of unidirectional bundles of collagen fibers. This layer helps to stretch the peritoneum.

4. The superficial non-oriented elastic network consists of thin and thick elastic fibers without a specific orientation. This network promotes the gradual opening of folds when the peritoneum is pulled.

5. Deep oriented elastic network is built from parallel oriented bundles. This network is adapted to stretch the peritoneum in only one direction.

6. The deep lattice collagen elastic layer reaches a thickness of 50-60 microns. Collagen and elastic fibers form the basis of the layer. This layer of the peritoneum contains blood and lymph vessels, as well as nerve elements.

In some areas of the parietal peritoneum, a layer of loose retroperitoneal tissue may adjoin this layer.

Thus, the peritoneum has a complex structure and consists of 6 morphologically pronounced layers, the histological features of which determine the function of this integument.

As already noted, the peritoneum covers the walls and organs of the abdominal cavity. When passing from the wall to parts of the intestinal tube, serous folds are formed, which are called mesenteriums (mesenterium), and when passing from the wall to organ, or organ to organ (parenchymal), ligaments.

Ligaments of the peritoneum are PRIMARY and SECONDARY.

PRIMARY originated from the ventral and dorsal mesentery and consist of two leaves: lig. hepatoduodenale, lig. falciforme hepatis

SECONDARY ligaments are formed during the transition of the peritoneum from organ to organ: lig. coronarium hepatis, lig. hepatorenale.

For the convenience of studying and assimilating topography, syntopy, holotopy of the abdominal organs, features of the course of the peritoneum, the abdominal cavity is divided into floors:

UPPER FLOOR - it contains the liver, spleen, stomach, kidneys, adrenal glands, pancreas.

MIDDLE FLOOR - there are loops of the small and large intestines, kidneys, large vessels.

LOWER FLOOR - organs of the urinary system (bladder), the end of the digestive tube (rectum), internal genital organs.

TOP FLOOR limited:

at the top is the diaphragm,

in front - parietal peritoneum of the anterior abdominal wall,

behind - the posterior abdominal wall,

below - colon transversum and its mesentery.

There are three bags on the upper floor of the abdominal cavity:

bursa pregastrica

bursa omentalis

BURSA OMENTALIS

Has 6 walls:

1. The upper wall is the caudate lobe of the liver.

2. The lower wall is the mesentery of the transverse colon.

3. Left wall - lig. gastrolienale, lig. phrenicolienale.

4. Right - foramen epiploicum (Winslow hole).

5. Posterior - parietal peritoneum, covering the pancreas, inferior vena cava, aorta.

6. Front wall

upper third - omentum minus: lig. hepatoduodenale, lig. hepatogastricum.

middle third - the posterior wall of the stomach

lower third - lig. gastrocolicum

The foramen epiploicum is located on the right wall of the stuffing box. With the help of this hole, the omental bursa communicates with the general cavity of the peritoneum; during revision of the abdominal organs, surgeons through this hole perform a finger examination of the omental bursa.

VINSL HOLE WALLS

In front - limitedly lig.hepatoduodenales in this bundle from right to left lies ductus choledochus, v. portae, a. hepatica propria.

Behind - the parietal peritoneum covering v.cava inferior., Lig hepatorenale.

Above - the caudate lobe of the liver.

Below - pars superior duodeni.

INursa hepatica

Above - aperture, lig. coronarium, lig triangulare.

Left - crescent ligament of the liver.

In front and on the right - the parietal peritoneum of the anterior wall.

Behind - the right kidney and adrenal gland.

Contains the right lobe of the liver.

It communicates with the omental bursa and with the right lateral canal (located in the middle floor of the abdominal cavity)

Bursapregatrica

Covers the left lobe of the liver.

Above - limited by the diaphragm;

In front - the parietal peritoneum covering the anterior abdominal wall;

Left- lig. gastrolienale, lig. phrenicolienale;

Behind - the stomach, its front wall.

This bag communicates with the peritoneal cavity. In the upper floor, the great omentum originates, consists of 4 sheets of the peritoneum and sometimes reaches the pubic bones.

MIDDLE FLOOR the abdominal cavity is limited

above mesocolon transversum

on the sides and in front of the parietal peritoneum to linea bispinata (outside) or linea terminalis (inside).

It contains loops of the small and large intestines, covered with an omentum.

In the middle floor, between the mesentery and the intestine itself, there are two mesenteric sinuses: right and left.

The right mesenteric sinus is limited:

on the right - the ascending colon;

left and below - the mesentery of the small intestine;

above - the mesentery of the transverse colon.

It is closed and abscesses do not spread.

The left mesenteric sinus is limited:

on the right and above - the mesentery of the small intestine;

on the left - the descending colon;

from below - passes into the pelvic cavity.

In addition to the sinuses, there are also two lateral canals in the middle floor.

The RIGHT SIDE CANAL is located between the ascending colon (left) and the parietal peritoneum of the anterolateral abdominal walls (right).

The LEFT SIDE CANAL is located between the descending colon (right) and parietal peritoneum (left), respectively.

Two bags of the upper floor communicate with the right lateral canal: b.omentalis, b. hepatica; and it ends in the right iliac fossa.

The left canal starts blindly: at the top is the lig bundle. phrenicocolicum, and below it opens into the pelvic cavity.

In addition to the sinuses and canals, a number of peritoneal depressions are noted on the posterior parietal leaf of the peritoneum:

They are of practical importance: sometimes they serve as the exit site of a retroperitoneal hernia.

LOWER FLOOR.

Descending to the lower floor of the abdominal cavity, the peritoneum covers the pelvic organs: the bladder and rectum; in women, the uterus and fallopian tubes. When passing from organ to organ, the peritoneum forms depressions or pockets:

In women, excavation rectouterina is of practical importance, from the side of the vagina it corresponds to its posterior fornix. When puncture of the posterior fornix of the vagina, they fall into the excavatio rectouterina - with pathological processes in the abdominal cavity (for example, an ectopic pregnancy), blood accumulates there.