193 Questions
What is the location of the spermatic cord or round ligament of the uterus?
Inguinal ring
What is the function of the internal oblique muscle?
To radiate upward and forward
What is the shape of the defect in the external oblique aponeurosis?
Triangular
Where does the lowest part of the internal oblique muscle attach?
Pectineal line
What is the function of the lacunar ligament?
To extend from the inguinal ligament
What is the purpose of the inguinal ligament?
To fold back on itself
What is the relationship between the internal oblique muscle and the transversus abdominis?
They merge to form the conjoint tendon
What is the location of the posterior free border of the internal oblique muscle?
Behind the spermatic cord
Which structure lies between the external oblique aponeurosis and the internal oblique aponeurosis?
Posterior layer of internal oblique aponeurosis
What is the name of the structure formed by the aponeuroses of the abdominal muscles?
Rectus sheath
Which muscle is not involved in the formation of the rectus sheath?
Pectoralis major muscle
What is the name of the structure that connects the rectus abdominis muscle to the pubis?
Conjoint tendon
Which layer of the rectus sheath is in contact with the rectus abdominis muscle?
Posterior layer of internal oblique aponeurosis
What is the name of the layer of fascia that lies deep to the rectus abdominis muscle?
Fascia transversalis
Which structure passes through the spermatic cord?
Femoral artery
What is the name of the structure that forms the anterior wall of the rectus sheath?
External oblique aponeurosis
What is the likely consequence of a rupture of the penile urethra?
Extravasation of urine into the scrotum, perineum, and parts of the abdominal wall
What is the purpose of a surgeon's continuous suture in closing abdominal wounds?
To strengthen the healing wound and prevent stretching of the skin scar
What is the function of the aponeuroses of the three sheets in the rectus abdominis muscle?
To form the rectus sheath
What is the small muscle that may be present in the lower part of the rectus sheath?
Pyramidalis
What is the anatomical landmark that marks the edge of the arcuate line?
Anterior superior iliac spine
What is the purpose of the rectus abdominis muscle?
To support the abdominal wall
What is the relationship between the fascia and the thigh in a rupture of the penile urethra?
The fascia attaches to the thigh, preventing urine from entering the thigh
What is the function of the anterior abdominal wall muscles?
To support the abdominal wall and compress the abdominal contents
What is the term for the condition where the lower part of the anterior abdominal wall protrudes forward?
Abdominal hernia
What is the term for the layer of fat that can accumulate in the superficial fascia?
Fatty layer
What is the term for the group of muscles that include the external and internal obliques?
Lateral abdominal muscles
What is the location of the dermatome of T7?
Over the xiphoid process
What fascia is deep to the muscles?
Transversalis fascia
What is the skin loosely attached to, except at the umbilicus?
Underlying structures
What are the natural lines of cleavage in the skin?
Downward and forward, almost horizontally around the trunk
What is the umbilicus?
A scar representing the site of attachment of the umbilical cord
Which arteries supply the skin near the midline?
Branches of the superior and inferior epigastric arteries
What is the cutaneous nerve supply to the anterolateral abdominal wall derived from?
The anterior rami of the lower six thoracic and the first lumbar nerves
Where does venous drainage from the upper abdominal wall mainly pass into?
The axillary vein via the lateral thoracic vein
What is the function of the vas deferens?
To transport spermatozoa from the epididymis to the urethra
Which structure is located in the posterior aspect of the spermatic cord?
Vas deferens
What is the origin of the testicular artery?
Abdominal aorta, at the level of the second lumbar vertebra
What is the function of the testicular veins?
To drain blood from the testes to the heart
What forms the superficial inguinal ring?
The aponeurosis of the external oblique
What is the name of the plexus formed by the testicular veins?
Pampiniform plexus
Which nerve is responsible for the autonomic innervation of the testes?
Genital branch of the genitofemoral nerve
What is the function of testosterone in fetal development?
It stimulates the descent of the testis
What is the name of the muscle formed from the lowest fibers of the internal oblique muscle?
Cremaster muscle
What is the function of the remains of the processus vaginalis?
To provide a pathway for the testicular vessels and nerves
What structure passes through the layers of the lower part of the anterior abdominal wall?
Processus vaginalis
What is the location of the vas deferens in the scrotum?
In the upper part of the scrotum
What is the name of the structure that forms the third tubular covering of the testis?
Internal spermatic fascia
During what months of fetal life does the testis descend through the pelvis and inguinal canal?
7th and 8th months
What is the name of the band of mesenchyme that extends from the developing gonad to the labioscrotal swelling?
Gubernaculum
What is the name of the diverticulum that forms before the descent of the testis and ovary from their site of origin?
ProceMUa vaglnalis
What is the purpose of the pampiniform plexus?
To form a venous plexus that drains into the renal vein
Where do the afferent sensory nerves that accompany the testicular artery originate from?
The renal or aortic sympathetic plexuses
What is the fate of the processus vaginalis in both sexes?
It remains as a vestigial structure
Where does the testicular vein drain into on the left side?
The left renal vein
What is the course of the autonomic nerves that supply the testis?
They run with the testicular artery
What is the purpose of the genitofemoral nerve?
To supply the genital branch to the testis
What is the destination of the testicular vein on the right side?
The inferior vena cava
What is the primary function of the nerve that supplies the cremaster muscle?
Regulating the contraction of the cremaster muscle
What is the fate of the round ligament of the uterus?
It remains as a vestigial structure
Through which canal do the testicular lymph vessels ascend?
Inguinal canal
Where do the testicular lymph vessels ultimately drain?
Para-aortic lymph nodes
What is the level of the first lumbar vertebra in relation to the testicular lymph vessels?
At the level
What is the relationship between the spermatic cord and the testis?
The spermatic cord and testis are separate structures
How many layers of fascia cover the spermatic cord?
Three concentric layers
What is the name of the artery that supplies the testis?
Testicular artery
What is the name of the nerve that accompanies the testicular artery?
Genitofemoral nerve
During which process does the covering of the spermatic cord acquire its layers?
As it descends into the scrotum through the abdominal wall
What is the significance of the presence of spermatozoa in the first few postoperative ejaculations after vasectomy?
It is an emptying process of the spermatozoa present in the vas deferens
Which structure is attached to the margins of the deep inguinal ring?
Transversalis fascia
What is the purpose of ligating the vas deferens during vasectomy?
To produce infertility
What is the composition of the seminal fluid after vasectomy?
Only seminal vesicle secretions and prostate secretions
What is the location of the incision made during vasectomy?
In the upper part of the scrotal wall
What is the origin of the external spermatic fascia?
External oblique aponeurosis
What is the attachment of the cremasteric fascia?
To the margins of the superficial inguinal ring
What is the term for the layer of muscle that fuses to form large sheets?
Mesenchyme
What is the significance of the tendinous intersections in the rectus abdominis?
They indicate the segmental origin of the muscle
What is the embryonic structure that gives rise to the abdominal wall and peritoneal cavity?
Lateral plate mesoderm
What is the fate of the segmental arrangement in the thorax?
It is lost due to the absence of ribs
What is the term for the layer of mesoderm associated with ectoderm?
Somatopleuric layer
What is the term for the layer of mesoderm associated with entoderm?
Splanchnopleuric layer
What is the structure that forms the boundary between the abdominal wall and the peritoneal cavity?
Peritoneum
What is the term for the cavity that forms from the extra-embryonic coelom?
Amniotic cavity
What is the result of the lateral folds of the embryo fusing in the midline?
The closing off of the intraembryonic coelom
What is the direction of the fibers of the psoas muscle?
Upward and medially
What is the function of the umbilical arteries?
To carry deoxygenated blood from the fetus to the chorion
What is the structure that covers the anterior surface of the psoas muscle?
Lumbar fascia
What is the result of the ventral mesentery breaking down?
The formation of the peritoneal cavity
What is the location of the swelling in a psoas abscess?
Upper part of the thigh below the inguinal ligament
What is the function of Wharton's Jelly?
To form the loose connective tissue in the umbilical cord
What is the result of the anterior body wall closing in the midline?
The completion of the anterior body wall
What is the term for the swelling that occurs in the right groin above and below the right inguinal ligament?
Psoas abscess
What is the purpose of the yolk sac?
To provide nutrients to the embryo
What is the result of the mesenchymal core of the cord forming?
The formation of Wharton's Jelly
What is the muscle that forms the posterior abdominal wall?
All of the above
What is the structure that is thickened above to form the lateral arcuate ligament?
Lumbar fascia
What is the function of the umbilical veins?
To carry oxygenated blood from the placenta to the fetus
What is the condition that results in the swelling of the upper part of the thigh below the inguinal ligament?
Psoas abscess
What is the origin of the iliacus muscle?
Upper part of the iliac fossa
What is the function of the quadratus lumborum muscle?
Fixes the 12th rib during inspiration
What is the innervation of the abdominal wall muscles?
Anterior rami of the spinal nerves
What is the combined muscle formed by the iliacus and psoas major muscles?
Iliopsoas
What is the function of the iliopsoas muscle?
Flexes the trunk on the thigh
What is the origin of the psoas major muscle?
Lumbar vertebrae and intervertebral discs
What forms the posterior abdominal wall?
Lumbar vertebrae and intervertebral discs
What is the nerve supply of the iliacus muscle?
Femoral nerve
What is the embryological origin of the abdominal wall muscles?
Mesoderm
What is the approximate length of the umbilical cord at the end of pregnancy?
20 in.
What is the result of the amnion and chorion fusing?
The amnion encloses the body
What is the purpose of the ligature applied to the umbilical cord after birth?
To constrict the umbilical vessels
What may be present as an umbilical hernia in the remains of the extraembryonic coelom?
A piece of intestine
What is the result of a congenital urethral obstruction in newborns?
The cavity of the allantois persists
What is the significance of the expansion of the amniotic cavity?
It causes the cord to become covered with amnion
What is the fate of the umbilical vessels after the application of the ligature?
They constrict and thrombose
What is the location of the allantois in relation to the umbilical cord?
It is located near the umbilicus
What is the order of anatomic structures penetrated to reach the parietal peritoneum?
Skin, fatty layer, linea alba, inferior epigastric artery
What is the purpose of peritoneal lavage?
To confirm the diagnosis of non-traumatic situations
What structure is located between the skin and the fatty layer?
Superficial fascia
What is the name of the artery located inferior to the fatty layer?
Inferior epigastric artery
What is the purpose of the catheter in peritoneal lavage?
To inject fluid into the peritoneum
What is the name of the layer that is penetrated first during peritoneal lavage?
Skin
What is the primary disadvantage of the incision described in the text?
It can lead to excessivecollection of peritoneal fluid
What structure is pushed away by the cannula during paracentesis?
Coils of small intestine
What is the primary advantage of endoscopic surgery on the gallbladder, bile ducts, and appendix?
Minimal disruption to surrounding tissues
What is the usual entry point of the cannula during paracentesis?
Midline
Which anatomical structure is traversed during endoscopic surgery on the gallbladder, bile ducts, and appendix?
Parietal peritoneum
What is the purpose of paracentesis?
To drain fluid from the abdominal cavity
What is the primary concern during endoscopic surgery on the gallbladder, bile ducts, and appendix?
Damage to the segmental nerves
What is the likely consequence of damaging multiple segmental nerves during an incision?
Severe postoperative abdominal weakness
What is the potential consequence of bleeding into the peritoneal cavity during surgery?
False-positive result
Which structure is not damaged during paracentesis?
Underlying coils of intestine
What is the significance of securing superficial fascia during surgery?
To minimize bleeding into the peritoneal cavity
Which blood vessels are encountered during endoscopic surgery on the gallbladder, bile ducts, and appendix?
Terminal branches of the superficial epigastric arteries and veins
What is the usual location of the incision mentioned in the text?
Laterally through the oblique and transversus abdominis muscles
What is the purpose of the cannula sheath during paracentesis?
To protect the underlying structures
What is the benefit of minimal disruption to the anatomic features of the anterior abdominal wall during endoscopic surgery?
Quicker recovery time for the patient
What is the primary layer of fascia encountered during endoscopic surgery on the gallbladder, bile ducts, and appendix?
Thin layer of deep fascia
What is the main disadvantage of the McBurney's incision?
It requires dividing one or more segmental nerves to the rectus abdominis muscle.
What is the purpose of incising the transversalis fascia and the peritoneum?
To open the abdominal cavity.
Why is an infraumbilical right paramedian incision used instead of the McBurney's incision?
If there is a doubt about the diagnosis.
What is the significance of the anatomic structures penetrated during peritoneal lavage?
They can cause bleeding, leading to a false-positive result.
What is the result of dividing one or more segmental nerves to the rectus abdominis muscle?
Postoperative rectus muscle weakness.
What is the location of the inferior epigastric artery?
In the rectus sheath
What is the purpose of the peritoneal lavage procedure?
To diagnose and treat peritonitis
What is the advantage of using the paramedian incision?
It does not require dividing one or more segmental nerves to the rectus abdominis muscle.
What is the purpose of retracting the rectus muscle medially?
To expose the segmental nerves entering the posterior surface of the rectus muscle.
What is the layer of fascia that lies deep to the rectus abdominis muscle?
Transversalis fascia
What is the consequence of not suturing the cut ends of the rectus muscles?
No consequence, as it is unnecessary to suture the cut ends.
What is the consequence of perforating the gut during peritoneal lavage?
Perforation of a full bladder
What is the significance of the lines alba in peritoneal lavage?
It is not a significant structure in peritoneal lavage
What is the purpose of incising the posterior wall of the rectus sheath?
To open the abdominal cavity.
What is the purpose of the paraumbilical incision technique?
To facilitate peritoneal lavage
What is the consequence of bleeding from the epigastric vessels during peritoneal lavage?
False-positive result
What is the likely route of infection spread from the peritoneum to the pleura?
Diaphragmatic lymph vessels
Why is it common to find local pus in a pleural space in a patient with a subphrenic abscess?
Due to the close proximity of the pleura and peritoneum
What is the purpose of sitting a patient up in bed at an angle of 45 degrees?
To delay the absorption of toxins from intraperitoneal infections
What is the role of the greater omentum in surgery?
All of the above
What is the term for the twisting of the greater omentum?
Torsion
What is the ligament that connects the stomach to the hilum of the spleen?
Gastrosplenic omentum
Which structure lies inferior to the liver?
First part of the duodenum
What nerves supply the parietal peritoneum lining the anterior abdominal wall?
Lower six thoracic nerves and the first lumbar nerve
What is the name of the pocket-like pouches of peritoneum close to the duodenojejunal junction?
Duodenal recesses
Why does a patient with a subphrenic abscess often complain of pain over the shoulder?
Due to the skin of the shoulder being supplied by the same nerves as the peritoneum
What is the term for the lower six thoracic nerves and the first lumbar nerve?
Abdominal policeman
What lies anteriorly to the right lobe of the liver?
Free border of the lesser omentum
What is the name of the ligament that connects the liver to the anterior abdominal wall?
Falciform ligament
What lies superiorly to the liver?
Caudate process of the caudate lobe of the liver
What is the name of the folds of peritoneum close to the cecum?
Cecal recesses
What is the name of the peritoneal reflection that connects the liver to the anterior abdominal wall?
Falciform ligament
What is the location of the cecum in the abdominal cavity?
Right iliac region
Which part of the large intestine is located at the periphery of the abdominal cavity?
All of the above
What is the relationship between the large intestine and the small intestine in the abdominal cavity?
The large intestine arches around the small intestine
What is the function of the peritoneal fluid?
To facilitate the movement of the mobile viscera
What is the location of the pancreas in the abdominal cavity?
Posterior abdominal wall
What is the shape of the appendix?
Worm-shaped tube
What is the effect of infection on the peritoneal coverings of the intestine?
They stick together
What is the characteristic of the peritoneal fluid?
It is pale yellow and somewhat viscid
What is the direction of the large intestine as it leaves the pelvis?
Forward
What is the continuity of the large intestine as it leaves the pelvis?
It becomes continuous with the anal canal
What is the location of the inferior mesenteric vein?
In the peritoneal fold
What is the position of the coils of the small intestine in the abdominal cavity?
In the central part of the abdominal cavity
What is the purpose of the peritoneal recesses?
To provide additional space for the intestines
What is the effect of the movements of the diaphragm and abdominal muscles on the peritoneal fluid?
It is circulated
What is the name of the structure that forms the paraduodenal recess?
Peritoneal fold
What is the location of the sigmoid mesocolon?
In the region of the sigmoid colon
What is the purpose of the peritoneal ligaments, omenta, and mesenteries?
To permit blood, lymph vessels, and nerves to reach the viscera
What is the location of the lesser sac?
Behind the stomach and the lesser omentum
What are the mesenteries?
Two-layered folds of the peritoneum
What is the function of the mesentery of the small intestine?
To connect the small intestine to the posterior abdominal wall
What is the relationship between the lesser omentum and the lesser sac?
The lesser omentum suspends the lesser sac
What is the significance of studying the transverse and sagittal sections of the abdomen?
To study the extent of the peritoneum and the peritoneal cavity
What is the location of the ligamentum teres?
In the lesser omentum
What is the relationship between the right lobe and the left lobe of the liver?
The right lobe is connected to the left lobe
Study Notes
Abdominal Wall
- The linea alba is a tendinous raphe that runs down the midline of the abdominal wall
- The external oblique aponeurosis forms the anterior wall of the rectus sheath
- The internal oblique muscle is a broad, thin, muscular sheet that lies deep to the external oblique
- The internal oblique has a lower free border that arches over the spermatic cord (or round ligament of the uterus)
Rectus Sheath
- The rectus sheath is formed by the aponeuroses of the three flat muscles (external oblique, internal oblique, and transversus abdominis)
- The rectus abdominis muscle is enclosed by the rectus sheath
- The lower part of the rectus sheath may contain a small muscle called the pyramidalis
Inguinal Region
- The inguinal ligament is formed by the fibrous fold of the external oblique aponeurosis
- The spermatic cord (or round ligament of the uterus) passes through the superficial inguinal ring and attaches to the pubic crest and pectineal line
- The conjoint tendon is formed by the tendinous fibers of the internal oblique and transversus abdominis muscles
Fascia and Ligaments
- The fascia transversalis is the deep fascia of the thigh
- The iliac fascia is attached to the inferior rounded border of the inguinal ligament
- The pectineal ligament extends from the pubic tubercle to the pectineal line
Muscles
- The rectus abdominis muscle is a paired muscle that forms a wide vertical strap on either side of the midline
- The transversus abdominis muscle is the deepest of the flat muscles
- The internal oblique muscle is a broad, thin, muscular sheet that lies deep to the external oblique
Nerve Supply
- The dermatome of T7 is located in the epigastrium over the xiphoid process
- The dermatome of T10 includes the umbilicus and that of L1 lies just above the inguinal ligament and the symphysis pubis
- The cutaneous nerve supply to the anterolateral abdominal wall is derived from the anterior rami of the lower six thoracic and the first lumbar nerves
Blood Supply
- Branches of the superior and inferior epigastric arteries supply the skin near the midline
- Branches of the intercostal, lumbar, and deep circumflex iliac arteries supply the skin of the flanks
- The superficial epigastric, superficial circumflex iliac, and superficial external pudendal arteries supply the skin in the inguinal region
Structures of the Spermatlc Cord
- The spermatlc cord consists of the vas deferens, testicular artery, testicular veins (pamplnlform plexus), testicular lymph vessels, autonomic nerves, remains of the processus vaginalis, and genital branch of the genitofemoral nerve.
Vas Deferens
- The vas deferens is a cordlike structure located in the posterior aspect of the spermatlc cord.
- It is a thick-walled muscular duct that transports spermatozoa from the epididymis to the urethra.
- It can be palpated between the finger and thumb in the upper part of the scrotum.
Testicular Artery
- The testicular artery is a branch of the abdominal aorta (at the level of the second lumbar vertebra).
- It is a long and slender artery that descends on the posterior abdominal wall.
- It traverses the inguinal canal and supplies the testis and the epididymis.
Testicular Veins
- The testicular veins form a plexus that leaves the posterior border of the testis.
- The plexus ascends and becomes reduced in size, forming a single testicular vein at about the level of the deep inguinal ring.
- The testicular vein drains into the left renal vein on the left side and into the inferior vena cava on the right side.
Autonomic Nerves
- The autonomic nerves supply the testis and the epididymis.
- Sympathetic fibers run with the testicular artery from the renal or aortic sympathetic plexuses.
- Afferent sensory nerves accompany the efferent sympathetic fibers.
Testicular Lymph Vessels
- The testicular lymph vessels ascend through the inguinal canal and pass up over the posterior abdominal wall.
- They reach the lumbar (para-aortic) lymph nodes on the side of the aorta at the level of the first lumbar vertebra.
Genital Branch of the Genitofemoral Nerve
- The genital branch of the genitofemoral nerve supplies the cremaster muscle.
- It is responsible for the elevation of the testis.
Spermatlc Cord Coverings
- The coverings of the spermatic cord are three concentric layers of fascia derived from the layers of the anterior abdominal wall.
- The external spermatic fascia is derived from the external oblique aponeurosis.
- The cremasteric fascia is derived from the internal oblique muscle.
- The internal spermatic fascia is derived from the transversalis fascia.
Inguinal Canal Development
- The inguinal canal is formed from the processus vaginalis, a peritoneal diverticulum that passes through the layers of the lower part of the anterior abdominal wall.
- The processus vaginalis acquires a tubular covering from each layer as it passes through the layers of the anterior abdominal wall.
- The testicular artery, testicular veins, and testicular lymph vessels traverse the inguinal canal.
Embryology Notes
- The processus vaginalis forms before the descent of the testis and the ovary from their site of origin high on the posterior abdominal wall.
- The testis descends through the pelvis and inguinal canal during the 7th and 8th months of fetal life.
- The normal stimulus for the descent of the testis is testosterone, which is secreted by the fetal testes.
Posterior Abdominal Wall Muscles
- Psoas major muscle: runs downward following the course of the psoas muscle, appears as a swelling in the upper part of the thigh below the inguinal ligament
- Insertion: lower border of the 12th rib and the transverse processes of the upper four lumbar vertebrae
- Anterior surface: covered by lumbar fascia, thickened above to form the lateral arcuate ligament and below to form the lumbar ligament
Transversus Abdominis Muscle
- Fully described with the muscles of the anterolateral abdominal wall
- Psoas abscess present, with swellings in the right groin above and below the right inguinal ligament
Iliacus Muscle
- Fan-shaped, arises from the upper part of the iliac fossa
- Fibers join the lateral side of the psoas major tendon, and the combined muscles are referred to as the iliopsoas
- Iliopsoas is the major flexor of the thigh, or the major flexor of the trunk against the thigh
Posterior Abdominal Wall
- Quadratus lumborum muscle: fixes the 12th rib during inspiration and depresses the 12th rib during forced expiration, laterally flexes the vertebral column of the same side
Embryology Notes
- Abdominal wall development: lateral plate mesoderm splits into a somatopleuric and splanchnic layer associated with ectoderm and entoderm, respectively
- Muscles of the anterior abdominal wall are derived from the somatopleuric mesoderm
- Rectus abdominis retains indications of its segmental origin, as seen by the presence of tendinous intersections
Umbilical Cord and Umbilicus Development
- The umbilical cord is a twisted, tortuous structure that measures about 0.75 in (2 cm) in diameter
- It increases in length until, at the end of pregnancy, it is about 20 in (50 cm) long, the same length as the child
- The umbilical cord contains two arteries that carry deoxygenated blood from the fetus to the chorion (later the placenta) and two veins that convey oxygenated blood from the placenta to the fetus
Clinical Notes
- At birth, the cord is tied off close to the umbilicus, leaving about 2 in (5 cm) of cord between the umbilicus and the ligature
- Occasionally, the cavity of the allantois persists, and urine passes from the bladder through the umbilicus onto the body surface
Abdominal Incisions
- Anatomic structures penetrated to reach the parietal peritoneum: skin, fatty layer, superficial fascia, deep fascia, linea alba, transversalis fascia, extraperitoneal fat, and parietal peritoneum.
- Types of incisions:
- Paramedian incision: medial and parallel to the lateral margin of the rectus muscle, exposing the segmental nerves entering its posterior surface.
- Muscle-splitting incision (McBurney's incision): used for cecostomy and appendectomy, gives limited exposure, and may require an infraumbilical right paramedian incision if diagnosis is unclear.
- Transverse incision: can be made above or below the umbilicus, small or large, and extends from flank to flank.
- Complications:
- Damage to segmental nerves, resulting in postoperative rectus muscle weakness.
- Perforation of the gut, mesenteric blood vessels, or vessels on the posterior abdominal wall or pelvic walls.
- Bleeding from the epigastric vessels, producing a false-positive result.
- Perforation of a full bladder.
- Wound infection.
Peritoneal Lavage
- Anatomic structures penetrated to reach the parietal peritoneum: skin, superficial fascia, deep fascia, linea alba, transversalis fascia, extraperitoneal fat, and parietal peritoneum.
- Common sites used: midline and laterally.
- Important to secure small blood vessels in the superficial fascia to prevent bleeding into the peritoneal cavity, which may produce a false-positive result.
Endoscopic Surgery
- Anatomic structures traversed by instruments: similar to those enumerated for peritoneal lavage.
- Important to preserve the integrity of segmental nerves as they course down from the costal margin to supply the abdominal musculature.
- Advantages: minimal disruption of anatomic and physiologic features of the anterior abdominal wall, and brief convalescence.
Subphrenic Abscess and Hernial Plug
- Infection can spread from the peritoneum to the pleura via the diaphragmatic lymph vessels.
- A patient with a subphrenic abscess may complain of pain over the shoulder, which is also true for collections of blood under the peritoneum.
- The skin of the shoulder is supplied by the supraclavicular nerves (C3 and 4), which have the same segmental origin as the phrenic nerve, which supplies the peritoneum.
Greater Omentum
- The greater omentum is referred to as the "abdominal policeman" by surgeons.
- It can plug the neck of a hernial sac and prevent the entrance of coils of small intestine.
- The greater omentum can be used to buttress an intestinal anastomosis or in the closure of a perforated gastric or duodenal ulcer.
- It can undergo torsion, which may cause necrosis if the blood supply is cut off.
Peritoneal Space and Intestines
- The peritoneum is a space between the parietal peritoneum (lining the abdominal wall) and the visceral peritoneum (covering the abdominal organs).
- The lower six thoracic nerves and the first lumbar nerve supply the parietal peritoneum lining the anterior abdominal wall.
- The large intestine arches around and encloses the coils of the small intestine, and tends to be more fixed than the small intestine.
- The cecum is a blind-ended sac that projects downward in the right iliac region below the ileocecal junction.
- The appendix (vermiform appendix) is a worm-shaped tube that arises from the medial side of the cecum.
Mesenteries and Peritoneal Ligaments
- Mesenteries are two-layered folds of the peritoneum connecting parts of the intestines to the posterior abdominal wall.
- The peritoneal ligaments, omenta, and mesenteries serve as bridges that permit blood, lymph vessels, and nerves to reach the viscera.
- The lesser sac lies behind the stomach and the lesser omentum.
Peritoneal Functions
- The peritoneal fluid is pale yellow and somewhat viscid, and contains leukocytes.
- It ensures that the mobile viscera glide easily on one another due to the movements of the diaphragm and the abdominal muscles, together with the peristaltic movements of the intestinal tract.
- The peritoneal fluid is not static.
- The peritoneal coverings of the intestine tend to stick together (adhere) in the presence of infection.
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