TOPIC: “The lower floor of the abdominal cavity. Organs ".
Relevance of the topic: Knowledge of the topographic anatomy, blood supply and innervation of the organs of the lower floor of the abdominal cavity, the formations of the peritoneum (lateral canals, sinuses, pockets), is the basis for the diagnosis of diseases of these organs, the anatomical substantiation of surgical approaches and the choice of the method of surgical reception.
Duration of the lesson: 2 academic hours.
General purpose: To study the structure, blood supply, innervation of the organs of the lower floor of the abdominal cavity, for topographic and anatomical substantiation of surgical interventions on the small and large intestines.
Specific goals (know, be able to):
1. Know the skeletotopy and syntopy of the intestines.
2. Know the peculiarities of the blood supply to the small intestine, the topography of the mesentery root of the small intestine.
3. Know the sections of the large and small intestines, their relationship with the peritoneum.
4. Know the possible options for the positions of the appendix.
Material and technical support of the lesson
2. Tables and dummies on the topic of the lesson
3. A set of general surgical instruments
Technological map of the practical lesson.
| P / p. | Stages | Time (min.) | Tutorials | Location |
| 1. | Checking workbooks and the level of preparation of students for the topic of the practical lesson | Workbook | Study room | |
| 2. | Correction of students' knowledge and skills by solving the clinical situation | Clinical situation | Study room | |
| 3. | Analysis and study of material on dummies, a corpse, watching demonstration videos | Dummies, cadaveric material | Study room | |
| 4. | Test control, solving situational problems | Tests, situational tasks | Study room | |
| 5. | Summing up the results of the lesson | - | Study room |
Clinical situation
A patient with signs of acute appendicitis was admitted to the surgical department. During the production of the operation - appendectomy, the surgeon did not find the appendix in the right iliac fossa.
Tasks:
1. Name the possible positions of the appendix in relation to the cecum and peritoneum.
The solution of the problem:
1. The appendix is most often located intraperitoneally and relative to the cecum can occupy a medial position, and also has its own mesentery. However, the appendix can occupy, in relation to the cecum, the following positions: ascending, descending, lateral and retrocecal.
The appendix may not have a mesentery and may be located mesoperitoneally, and with the mesoperitoneal position of the cecum and the retrocecal position of the cecum, the latter may be located in the retroperitoneal space.
Lateral canals and mesenteric sinuses of the lower abdominal floor
In the lower floor of the abdominal cavity, four sections are distinguished: two external and two internal. The outer sections are called lateral canals. They are spaces enclosed between the fixed sections of the large intestine (colon asdendens and descendens) and the lateral walls of the abdomen. Each of the lateral canals - canalis lateralis dexter and sinister - communicates at the top with the upper floor of the abdominal cavity, and the communication is more complete on the right than on the left. This is due to the fact that on the left there is a ligament - lig.phrenicocolicum, stretched between the diaphragm and the splenic curvature of the colon; usually it is significantly pronounced. A similar ligament on the right side is usually absent. Lig.phrenicocolicum is located in the horizontal plane, and if the fingers inserted into the left lateral canal are moved up, they will encounter an obstacle from the phrenic-colonic ligament; on the right, this obstacle is absent. Below, each lateral canal passes into the iliac fossa, from there into the small pelvis.
Mesenteric sinuses (sinuses)
Between the fixed sections of the large intestine, on the one hand, and the mesentery root of the small intestines, on the other, there are two depressions called the mesenteric sinuses - sinus mesentericus dexter and sinister . The right sinus is bounded on the right by the ascending colon, on the left and below by the root of the mesentery of the small intestines, from above by the mesentery of the transverse colon. The left mesenteric sinus is bounded on the right by the mesentery root of the small intestine, from above by the mesentery of the transverse colon, on the left by the descending colon and the mesentery root of the sigmoid colon. Above, both sinuses communicate with each other through a narrow slit, limited by the initial segment of the small intestine and the mesentery of the transverse colon hanging over it (Fig. 1).
Rice. 1. Sinuses and canals of the lower floor
1 - right lateral canal (canalis lateralis dexter), 2 - right mesenteric sinus (sinus mesentericus dexter), 3 - ascending colon (colon ascendens), 4 - duodenum (duodenum), 5 - right hepatic bursa, 6 - transverse colon intestine (colon transversum), 7 - left mesenteric sinus (sinus mesentericus sinister), 8 - descending colon (colon descendens), 9 - left lateral canal (canalis lateralis sinister), 10 - mesenteric root (radix mesenterii), 11 - rectal - uterine cavity, 12 - vesicouterine cavity. (From: Netter F.H. Atlas of human anatomy. - Basle, 1989.)
Below, the left mesenteric sinus leads directly into the pelvic cavity, to the right of the rectum. The right mesenteric sinus is open only in front, except for the already mentioned communication with the left sinus at the root of the mesentery of the transverse colon. Therefore, the accumulations of pathological fluids formed in the right sinus are initially limited to the boundaries of this sinus (Fig. 2).
Rice. 2. Parietal peritoneum of the posterior abdominal wall
1 - transition of the peritoneum to the ascending colon, 2 - right triangular ligament (ID triangulare dextrum), 3 - coronary ligament (lig.coronarum), 4 - left triangular ligament (ID triangulare sinistrum), 5 - phrenic-colonic ligament ( lig.phrenicocolicum), 6 - the mesentery of the transverse colon (mesocolon transversum), 7 - the transition of the peritoneum to the descending colon, 8 - the mesentery of the small intestine (mesenterium), 9 - the mesentery of the sigmoid colon (mesocolon slgmoideum). (From: Sinelnikov R.D. Atlas of human anatomy. - M., 1972. - T. II.)
The significance of the lateral canals and mesenteric sinuses lies in the fact that encapsulated peritonitis can develop in them and hematomas can spread. Through the lateral canals, pus or blood can pass into the pelvic cavity or the upper abdominal cavity, especially on the right, where the message is better expressed. So, purulent exudate formed with purulent appendicitis can penetrate through the right lateral canal into the upper floor of the abdominal cavity, which sometimes leads to the formation of a subphrenic abscess.
In cases of perforation of the duodenal ulcer, the contents poured into the abdominal cavity are directed through the right lateral canal into the right iliac fossa and from there into the pelvic cavity.
Small intestine
The jejunum and ileum occupy most of the lower abdominal floor. The jejunal loops lie mainly to the left of the midline, the ileal loops mainly to the right of the midline. Part of the loops of the small intestine fit into the pelvis.
Jejunum and ileum come in contact with the following organs and formations. The small intestine is separated from the anterior abdominal wall by a large omentum. Behind are the organs that are located on the posterior abdominal wall and are separated from the small intestine by the parietal peritoneum: kidneys (partially), the lower part of the duodenum, large blood vessels (inferior vena cava, abdominal aorta and their branches). From above, the small intestine is in contact with the transverse colon and its mesentery. From the bottom of the intestinal loop, descending into the pelvic cavity, lie in men between the large intestine (sigmoid and rectum) in the back and the bladder in front; in women, the uterus and bladder are located anterior to the loops of the small intestine. On the sides, the small intestine is in contact with the blind and ascending colon on the right side, with the descending and sigmoid colon on the left.
The small intestine is anchored to the mesentery; from flexura duodenojejunalis to the transition to the large intestine, it is covered by the peritoneum on all sides, with the exception of a narrow strip where the mesenteric sheets are attached. Due to the presence of the mesentery, the mobility of the small intestine is very significant, however, the length (height) of the mesentery throughout the intestine is different, and therefore its mobility is not the same everywhere. The small intestine is least mobile in two places: near the beginning of the jejunum, at flexura duodenojejunalis, and at the end of the ileum, in the ileocecal (ileocecal) angle. The root of the mesentery of the small intestine (radix mesenterii) has an oblique direction, going from top left to bottom and to the right: from the left half of the body of the II lumbar vertebra to the right sacroiliac joint. The length of the mesentery root is 15-18cm.
The blood supply to the small intestine is carried out by the superior mesenteric artery, which gives numerous branches (up to 20 or more) - aa.jejunales and aa.ilei - to the small intestine, as well as a number of branches to the right half of the colon. Passing between the leaves of the mesentery, the arteries are soon divided into branches, forming arcs, or arcades (Fig. 3).
From the latter, vessels arise, dividing again and forming arcs (Fig. 4). The result is arterial mesenteric arches of the first, second, third (and even fourth, fifth) order. In the very initial parts of the jejunum, there are only arcs of the first order, and as one approaches the ileocecal angle, the structure of the vascular arcades becomes more complicated and their number increases. The veins of the small intestine are tributaries of the superior mesenteric vein.
The nerves of the small intestine accompany the branches of the superior mesenteric artery; they are branches of the superior mesenteric plexus.
The diverting lymphatic vessels of the jejunum and ileum (milk vessels) converge at the root of their mesentery, but along the way are interrupted by numerous mesenteric lymph nodes (nodi lymphatici mesenterici), the number of which reaches 180-200. They are located, according to D.A. Zhdanov, in 4 rows.
Rice. 3. Blood supply to the intestines
1 - ileum, 2 - appendix, 3 - cecum, 4 - artery and vein of the appendix, 5 - ileal arteries and veins, 6 - ascending colon, 7 - ileo-colon artery and vein, 8 - duodenal intestine, 9 - right colon arthria, 10 - pancreas, 11 - middle colon arthria, 12 - superior mesenteric vein, 13 - superior mesenteric artery, 14 - transverse colon, 15 - jejunum, 17 - jejunal arteries and veins. (From: Sinelnikov R.D. Atlas of Human Anatomy. - M., 1972. - T. II.)
Rice. 4. Features of blood supply to the jejunum (a) and ileum (b) intestines
1 - jejunum, 2 - rectal vessels, 3 - arcades, 4 - ileum. (From: Moore K.L. Clinically oriented Anatomy, 1992.)
The central nodes through which lymph passes from the entire small intestine (with the exception of the duodenum) are 2-3 lymph nodes lying on the trunks of the superior mesenteric vessels in the place where they are covered by the pancreas. The outflowing vessels of these nodes partly flow into the roots of the thoracic duct, partly into the nodes located on the anterior and lateral surfaces of the abdominal aorta (nodi lymphatici lumbales).
Colon
To distinguish the large intestine from the small intestine, the following 4 features of the large intestine should be remembered.
1. On the large intestine, the longitudinal musculature is located not in the form of a continuous layer, as on a thin one, but in the form of three stripes (ribbons) - teniae coli, clearly visible through the peritoneum. Teniae are absent on the small intestine and rectum.
2. There are swellings on the large intestine - haustra. In the intervals between the swellings on the walls of the intestine, there are circular grooves, where the annular muscles are more pronounced, and the mucous membrane forms folds that protrude into the lumen of the intestine. On the small intestine, haustra are absent.
3. The walls of the colon are supplied with fatty appendages - appendices epiploicae. They are not present in the small intestine.
4. In normal condition, the large intestine has a grayish-blue tint, and the small intestine has a light pink color.
The cecum and the appendix
The cecum (caecum) with the appendix (appendix) is located in the right ilio-inguinal region, which corresponds to the right iliac fossa. The base of the appendix is usually projected at the McBourney point, corresponding to the border between the outer and middle third linea spinoumbilicalis. However, this projection corresponds to the position of the process base only in rare cases. A more accurate projection for the base of the appendix is the Lanza point, which lies on the linea bispinalis, on the border between its outer and middle third. But this projection also corresponds to the position of the appendix base only in 20% of cases. Any of the projections proposed for the appendix is applicable only to people of a certain age, since the cecum moves downward with age (Fig. 5).
The cecum is usually covered by the peritoneum on all sides, however, the presence of a well-defined mesentery is not so common. In rare cases, there is a common mesentery for the cecum, the terminal ileum and the initial part of the ascending intestine. Then this whole section of the mesentery is called mesenterium ileocaecale; at the same time, the caecum has abnormal mobility, which can create conditions for its volvulus. Finally, in exceptional cases, the posterior wall of the cecum is devoid of the peritoneal cover and adjoins, together with the appendix, directly to the retroperitoneal tissue.
The process has its own mesentery, heading to the cecum and the terminal ileum.
At moderate filling, the cecum is adjacent to the m.iliopsoas; the intestine is separated from this muscle by the parietal peritoneum, a layer of retroperitoneal tissue and the iliac fascia. A heavily distended intestine can fill the entire iliac fossa. With a weak filling, the caecum is covered in front with loops of the small intestine.
Rice. 5. The cecum and the appendix
1 - ileocecal valve (valva ileocaecalis), 2 - ileum (ileum), 3 - appendix vermiformis, 4 - cecum (caecum), 5 - ostium appendicis vermiformis. (From: Moore K.L. Clinically oriented Anatomy, 1992.)
With its inner edge, the cecum can adjoin the right ureter, separated from it by the parietal peritoneum, and often the intestine covers the ureter in the place where it approaches the common iliac vessels.
It is almost impossible to feel the unchanged vermiform appendix through the anterior abdominal wall, because in 96% of cases it is covered with other parts of the intestine and only in 4% of cases it is located directly behind the anterior abdominal wall, in front of the intestine. The pathologically thickened process is sometimes palpable.
Most often, the appendix begins from the posterior-inner segment of the cecum, slightly above its bottom. The base of the appendix is located at the convergence of the three longitudinal ribbons of the colon (teniae); however, when looking for a process, it is enough to determine one anterior (free) tape of the cecum (tenia libera) - a direct continuation of this tape is the appendix. It then descends downward and medially, passing through the terminalis line into the small pelvis. The lower end of the process crosses the vasa testicularia (in women - ovarica) and vasa iliaca externa, lying retroperitoneally, and in the small pelvis it can come into contact with the bladder or rectum (depending on its length); in women, it can reach the ovary and fallopian tube. In about 9% of cases, there is a retrocecal position of the process, in which it often has an ascending direction, reaching the kidney (its front surface) and even the liver. In very rare cases, the process lies not only behind the cecum, but also behind the peritoneum, immersed in the thickness of the retroperitoneal tissue (retroperitoneal position of the process) (Fig. 6).
Rice. 6. Variants of the position of the appendix
1 - descending, 2 - lateral, 3 - retrocecal, 4 - in the lower ileocecal cavity, 5 - medial. (From: Moore K.L. Clinically oriented Anatomy, 1992.)
To find the appendix, you must first determine the cecum. In this case, they are guided by the fact that the cecum occupies the extreme right position in relation to the entire intestine and it should be looked for by moving the fingers from the right lateral abdominal wall inward (to the left). Next, you need to be able to distinguish the cecum from the transverse colon and sigmoid colon, tk. the latter can sometimes, with a long mesentery, move into the right iliac fossa: the transverse colon is determined by the sign that it has a mesentery and well-defined fatty appendages that are absent or poorly expressed on the caecum.
The most correct technique for finding the appendix is to find the ileocecal angle formed by the final segment of the ileum and the cecum. The second method is to find the place of convergence of three longitudinal bands of the cecum or one anterior band.
Great difficulties in finding the appendix can be encountered in its retrocecal or retroperitoneal position. The following fact, established on a large clinical material, can render service here. If the final segment of the ileum is pulled up by means of a special fold of the peritoneum to the entrance to the small pelvis and the right iliac fossa, then in 9 out of 10 such cases the appendix is located behind the cecum. And then, to detect it, one should dissect the peritoneum outward from the caecum, and then rotate the cecum so that its posterior surface faces anteriorly. This will reveal the appendix.
Above and below the confluence of the ileum into the colon, there are pockets of the peritoneum. One of them is located above the ileum, the other below it (recessus ileocaecalis superior and inferior). The third pocket is located behind the cecum, between it and the posterior abdominal wall (recessus retrocaecalis).
The blood supply to the cecum and the appendix is carried out by the ilio-colonic artery (a.ileocolica), a branch of the superior mesenteric artery. The trunk of a.ileocolica passes through the retroperitoneal tissue and reaches the ileocecal angle, where it divides into 4-5 branches. One of them is the artery of the appendix (a.appendicularis), which runs in the thickness of the mesentery of the appendix, along its free edge, to the end of the appendix. The veins of the cecum and the appendix are tributaries of v.ileocolica, which flows into the superior mesenteric vein.
The innervation of the cecum and the appendix is carried out by the branches of the superior mesenteric plexus.
Regional nodes of the first stage for the discharge lymphatic vessels of the cecum and the appendix are the nodes located in the area of the ileocecal angle, along the branches of a.ileocolica. They are located in front and behind of the cecum and ascending colon and at the base of the appendix. The lymph nodes of the appendix are unstable; more often there is one nodus lymphaticus appendicularis (in the mesentery of the appendix). The carrying vessels of the lymph nodes of the ileocecal angle flow into the nodes located along the trunk of a.ileocolica.
Ascending colon
The ascending colon (colon ascendens) lies in the right lateral region of the abdomen, and somewhat closer to the midline than the descending colon.
Behind the ascending colon are the muscles of the posterior abdominal wall and the lower part of the right kidney, separated from the intestine by cellulose and fascia. In front and from the sides, the intestine is in contact with the anterolateral abdominal wall or is partially covered by a large omentum and loops of the small intestines.
The right (hepatic) curvature (flexura coli dextra) lies in the right hypochondrium. In front and above it is covered by the right lobe of the liver, and immediately inwardly, the right curvature is in contact with the bottom of the gallbladder.
Transverse colon
The transverse colon (colon transversum), starting in the right hypochondrium, passes into its own epigastric and umbilical regions and then reaches the left hypochondrium. Since the left curvature of the colon is higher than the right, colon transversum is usually located somewhat obliquely.
The transverse colon is bordered at the top by the liver, gallbladder, greater curvature of the stomach and spleen; below - with loops of the small intestine; in front - with a large omentum and with the anterior abdominal wall; behind - with the duodenum and pancreas, which are separated from the transverse colon by its mesentery and parietal peritoneum.
The left (splenic) curvature (flexura coli sinistra) is located in the left hypochondrium. Above, the splenic curvature approaches the lower pole of the spleen, and behind it partially adjoins the left kidney, being separated from it by the peritoneum and retroperitoneal tissues.
Descending colon
The descending colon (colon descendens) lies in the left lateral region of the abdomen, and somewhat farther from the midline than the ascending colon. It is located in front of the muscles of the posterior abdominal wall and the outer edge of the left kidney. In front, the colon descendens are usually covered with loops of the small intestine.
Sigmoid colon
The sigmoid colon (colon sigmoideum) is projected in the left ilio-inguinal and suprapubic regions. Its initial section is located in the left iliac fossa, the final one - in the small pelvis. In cases where the intestine is distended, it can go significantly to the right of the midline.
In the iliac fossa behind the intestine, peritoneum and retroperitoneal tissue is m. iliopsoas, and at the level of the border line - common iliac vessels: in front of the sigmoid colon is covered with loops of the small intestine, if empty, and adjacent to the anterior abdominal wall, if stretched.
The mesentery of the sigmoid colon (mesocolon sigmoideus) has a line of attachment starting at the iliac crest and ending in the pelvis at the border between II and III sacral vertebra. This line forms two knees, the angle between which approaches a straight line, its apex corresponds to the boundary line and the iliac vessels. Here, the parietal peritoneum forms a fold over the passing ureter, and between this fold and the mesentery of the sigmoid colon there is a slit-like pocket - recessus intersigmoideus, where hernias sometimes form. The recessus is where the left ureter is most easily found behind the peritoneum.
Colon blood supply, innervation, lymph outflow
Blood supply is carried out by branches of two systems - the superior and inferior mesenteric arteries (Fig. 7).
The superior mesenteric artery gives branches:
1) a.ileocolica, which supplies the terminal ileum, vermiform appendix, cecum and lower ascending part;
2) a.colica dextra supplies the upper part of the ascending colon, hepatic curvature and the initial section of the transverse colon;
3) a.colica media passes between the sheets of the mesentery of the transverse colon and supplies most of this intestine (the artery should be spared during operations involving the dissection of the mesentery of the transverse colon or gastro-colon ligament).
In addition, the gastro-colon ligament, as shown by studies on cadavers and observations during operations on patients, is almost always soldered to the mesentery of the transverse colon, mainly at the level of the pyloric part of the stomach. In the zone of adhesion of these elements of the peritoneum, arterial arcades formed by the branches of the middle colic artery are located twice as often as outside this zone. Therefore, the dissection of the gastro-colonic ligament during operations on the stomach should be started 10-12 cm to the left of the pylorus in order to avoid damage to the arcades of the middle colic artery.
Rice. 7. Blood supply to the colon
1 - superior mesenteric artery (a.mesenteries superior), 2 - middle colic artery (a.colica media), 3 - right colic artery (a.colica dextra), 4 - ilio-colon artery (a.ileocolica), 5 - lower mesenteric artery (a. mesenterica inferior), 6 - left colic artery (a. colic sinistra), 7.9 - sigmoid arteries (aa. sigmoidei), 8 - superior rectal artery (a. rectalis superior). (From: Ognev B.V., Frauchi V.Kh. Topographic and clinical anatomy. - M., 1960.)
Branches branch off from the inferior mesenteric artery:
1) a.colica sinistra, supplying part of the transverse colon, splenic curvature of the colon and the descending colon;
2) aa.sigmoideae, going to the sigmoid colon;
3) a.rectalis superior (a.haemorrhoidalis superior - BNA), going to the rectum.
The listed vessels form arcades similar to those found on the small intestines. The arch formed at the confluence of the branches of the middle and left colon arteries passes between the mesenteric sheets of the transverse colon and is usually well pronounced (it was formerly called the Riolan arch - arcus Riolani). It supplies the left end of the transverse colon, the splenic flexure of the colon, and the beginning of the descending colon.
When ligating the superior rectal artery (in connection with the prompt removal of a highly located cancer of the rectum), the nutrition of the initial segment of the rectum can be sharply disrupted. This is possible because an important collateral that connects the last vascular arcade of the sigmoid colon with a.haemorrhoidalis (a.rectalis - PNA) superior is turned off. The confluence of this artery with a.haemorrhoidalis siperior is called the "critical point" and it is suggested to ligate the rectal artery above this point - then the blood supply to the initial section of the rectum is not disturbed.
There are other "critical points" along the bowel vessels. These include, for example, the trunk of a.colica media. Ligation of this artery can cause necrosis of the right half of the transverse colon, since the arterial arcades of a.colica sinistra usually cannot provide blood supply to this part of the intestine.
Veins accompany arteries in the form of unpaired trunks and belong to the portal vein system, with the exception of the middle and lower veins of the rectum, associated with the inferior vena cava system.
The innervation of the large intestine is carried out by the branches of the superior and inferior mesenteric plexuses. Of all parts of the intestine, the most sensitive zone to reflex influences is the ileocecal angle with the appendix.
Colon lymph nodes (nodi lymphatici mesocolici) are located along the arteries that supply the intestines. They can be divided into nodes:
1) the cecum and the appendix;
2) the colon;
3) rectum.
The nodes of the cecum are located, as already mentioned, along the branches of a.ileocolica and its trunk. Colon nodes, like mesenteric ones, are also arranged in several rows. The main nodes of the colon are:
1) on the barrel a. colica media, in the mesocolon transversum, next to the central group of mesenteric nodes;
2) at the beginning of a.colica sinistra and above it;
3) along the trunk of the inferior mesenteric artery.
Theoretical questions for the lesson:
1. Anatomy of the small intestine: syntopy, sections, mesentery and its skeletopia, blood supply and innervation.
2. Topography of the 12-ring-skinny bend.
3. Anatomy of the large intestine: syntopy, skeletotopy, divisions and their relation to the peritoneum, blood supply and innervation.
4. Anatomical differences between the large intestine and the small intestine.
5. Topography of the ileocecal angle and appendix, options for the location of the appendix, its blood supply and innervation.
6. Formation of the peritoneum of the lower floor
7. Ways of spreading purulent infection in the upper and lower levels of the abdominal cavity.
Practical part of the lesson:
1. Determine the sections of the small and large intestines.
2. Master the technique of detecting the appendix.
Questions for self-control of knowledge
1. What is the boundary between the upper and lower levels of the abdominal cavity?
2. What ligament fixes the 12-tip bend to the parietal peritoneum?
3. Name the boundaries of the right and left side channels.
4. How do the upper and lower levels of the abdominal cavity communicate with each other?
5. What is the clinical significance of the pockets and sinuses of the lower floor of the abdominal cavity?
6. What methods of detecting the appendix are known?
7. Topographic anatomy of the ileocecal angle.
8. Variants of the location of the appendix in relation to the cecum and peritoneum.
9. Features of the blood supply to the rectum.
10. How is the Reolan arc formed?
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Delimited forms of purulent peritonitis (abdominal abscesses) occur in 30-70% of patients [V.L. Fedorov, 1974; In D. Savchuk, 1979]. Their occurrence is mainly due to a decrease in the effectiveness of antibiotics, an increase in the proportion of elderly and senile patients, a decrease in the reactivity and defense mechanisms of the body, allergization of the population, an overestimation in some cases of the possibilities of antibacterial therapy, an increase in the number of staphylococcal diseases, the progression of purulent-inflammatory diseases, for which the first operation was performed, insufficient sanitation of the abdominal cavity during the first operation, NSA, the presence in the abdominal cavity of the IT left after the first operation, insufficient complete drainage of the abdominal cavity during the previous intervention, etc.
Abdominal abscesses (ABP) are more often observed after destructive forms of appendicitis, complicated by peritonitis, trauma to the abdominal cavity, perforated stomach and duodenal ulcers, destructive pancreatitis, cholecystitis, etc. ABPs result from the accumulation of inflammatory exudate in one of the abdominal canals and sinus pockets (under the diaphragm, under the liver, between the bowel loops, in the Douglas space) of the abdominal cavity and its delimitation (encapsulation).
We give a brief description of those most likely places of the abdominal cavity, where the accumulation and delimitation (encapsulation) of pathological fluids (infected effusion) occurs, and the ways of their possible spread.
In the upper floor of the abdominal cavity, located above the transverse OC and its mesentery, the hepatic, pancreas and omental bursae are distinguished. The hepatic bursa is divided by the liver into two parts: the suprahepatic (right subphrenic space) and the subhepatic. The suprahepatic space, in turn, is divided by the falciform ligament into two halves: right and left, and the right is divided by the frontally located right coronary ligament of the liver into the anterior and posterior parts.
Most often, abscesses form in the right posterior superior space located above the liver behind the right coronary ligament, but they can also be localized in the right anteroposterior space located above the liver in front of this ligament. In the subhepatic space, pus is encapsulated between the lower surface of the liver, the anterior surface of the right kidney, the right bend of the OC and the round ligament of the liver. The right posterior superior and subhepatic spaces behind the liver easily communicate with each other and with the right lateral canal of the lower floor of the abdominal cavity [OB. Milonov et al, 1990].
The left subphrenic space is located in front of the stomach, which, together with the lesser omentum, forms its posterior and lower walls. In front and above, the left subphrenic space is limited by the liver and diaphragm, and on the right - by the falciform ligament, passing to the anterior abdominal wall, and the round ligament of the liver. In the supine position of the patient, the deepest section of the left subphrenic space is located above the lesser curvature of the stomach and to the left of the hepatic hilum.
The left subphrenic space is not as limited as the right one. Fluids that get here during the operation (blood, stomach contents, peritoneal exudate, etc.) rarely linger under the diaphragm. They flow down between the interchangeable organs located here (the left lobe of the liver, the spleen with its ligaments, the anterolateral surface of the stomach) and linger only at the lower pole of the spleen above the phrenic-colonic ligament. This explains the reason for the significant predominance of right-sided subphrenic abscesses over left-sided ones.
The omental bursa is also part of the upper floor of the abdominal cavity, its most isolated section. The walls of the omental bursa are formed in the front by the lesser omentum, the posterior surface of the stomach and gastrocolic ligament, posteriorly by the mesentery of the transverse OC, the anterior surface of the pancreas and the parietal peritoneum lining the posterior wall of the abdominal cavity.
The upper border of the omental bursa is the caudate lobe of the liver and the posterior portion of the diaphragm and esophagus, the lower border is the portion of the transverse OC. The part of the omental bursa located under the edge of the liver is its deepest section in the horizontal position of the patient. If the patient is given a semi-vertical or vertical position, then the liquid contents of the omental bursa flows into its lower section, where abscesses can form between the adjacent sheets of the gastro-colonic ligament and the mesentery of the transverse OC.
The omental bursa communicates with the free abdominal cavity through a slit opening located behind the right edge of the lesser omentum. The opening in the front is limited by the hepato-duodenal ligament located between the gate of the liver and the posterosuperior edge of the duodenum, behind - by the hepato-renal ligament located between the posterior edge of the liver and the medial edge of the kidney, from above - by the caudate lobe of the liver and from below - by the duodenal ligament in the form of a fold of the peritoneum, stretched between the upper edge of the duodenum and the kidney.
In the lower floor of the abdominal cavity, located between the mesentery of the transverse OC and the plane of the entrance to the small pelvis, there are four spaces that play an important role through which pathological fluids can spread. Residual interloop ulcers are often localized in them. The right lateral canal is located between the right OC and the right lateral wall of the abdominal cavity.
The length of the channel is from the SC to the right bend of the OC. The right lateral canal freely communicates with the lateral part of the right subphrenic space. The deepest part of the canal in the horizontal position of the patient is the area located outside the ascending OK and slightly above the iliac crest.
The left lateral canal is located between the left OC and the left lateral wall of the abdominal cavity. The length of the canal is from the left bend of the OC to the end of the peritoneum of the S-shaped intestine.
Its deepest section is in the upper part, at the level of the XI rib. The canal is fenced off from the upper floor of the abdominal cavity by the diaphragm-colonic ligament and freely opens towards the iliac fossa of the pelvic cavity, just like the right canal. The right and left lateral canals are characteristic pathways for the spread of pus in peritonitis. On the left lateral canal, pus can penetrate into the left subphrenic region.
The right mesenteric sinus is delimited from all sides from the rest of the abdominal cavity. In the horizontal position of the body, the deepest section of the right mesenteric sinus is the upper right angle. The left mesenteric sinus is larger than the right one. The right mesenteric sinus is separated from the left mesentery of the TC. Unlike the right sinus, the left mesenteric is not delimited from below, but directly communicates with the pelvic cavity. In the horizontal position of the trunk, the deepest section is the upper left corner of the sinus. If you raise the upper body, then the fluid from the left sinus flows freely into the pelvic cavity.
The pelvic cavity is the lower part of the abdominal cavity, where the TC loops are located, and in some cases the sigmoid colon, CHO, transverse OC and greater omentum. The parietal peritoneum, when passing from the anterior abdominal wall to the bladder, opens it from above and partially from the sides and in front, forming a transverse vesical fold.
In men, behind the bladder, the peritoneum covers the inner edges of the ampullae of the vas deferens of the apex of the seminal vesicles, passing to the rectum and forming the vesicoprectal cavity.
In women, during the transition from the bladder to the uterus and from the uterus to the rectum, the peritoneum forms a vesicouterine cavity, or anterior Douglas space, and a rectal-uterine cavity, or a posterior Douglas space. In these recesses, a bowl in the back, the so-called pelvic abscesses of the abdominal cavity are formed.
However, it should be remembered that in the adhesive fibrinous process and already formed adhesions, the topographic and anatomical relationships of the spaces and cracks of the abdominal cavity can change significantly [OB. Milonov et al., 1990]. There are areas of the abdominal cavity completely isolated from each other, in which pus can accumulate and an abscess can form (Figure 8-11).
Figure 8. Localization of postoperative intra-abdominal abscesses (front view):
1 - right-sided subphrenic; 2,3 - cured; 4-6 - left-sided lower subphrenic; 7 - interintestinal; 8 - left lateral canal of the abdominal cavity; 9 — right lateral canal of the abdominal cavity; 10 - right iliac region: 11, 12 - left iliac region
Figure 9. Localization of postoperative intra-abdominal abscesses (right-sided sagittal incision):
1.3 - right-sided subphrenic and subheated intramural; 2 - liver: 4 - omental bursa; 5 - interintestinal; 6 - pelvic
Figure 10. Localization of postoperative intra-abdominal abscesses (left-sided sagittal incision):
1,2,4,6 - left-sided upper subphrenic and subhepatic; 5 - liver; 3,7 - omental bursa, or postgastric; B - interintestinal; 9 - periosteal; 10 - pelvic
Figure 11. Localization of postoperative abscesses in the abdominal cavity: a - intraperitoneal (subphrenic and interintestinal); b - retroperitoneal and pelvic
This is especially important to take into account in RL and multiple ABPs, when only a thorough revision of all floors of the abdominal cavity, canals and mesenteric sinuses allows not to miss a single isolated abscess. ABP usually forms within the first 3 weeks. after an operation on the abdominal organs [S. Popkirov, 1974; D.P. Chukhrienko, Y.S. Bereznitsky, 1977]. Most often they occur near the focus of infection or directly in the organ on which the operation was performed. After appendectomy, gynecological surgeries, and bowel surgeries, ABD often occurs in the small pelvis, after surgery on the stomach, biliary tract, pancreas - in the subphrenic space.
The emergence of abscesses in the first days after the operation is most often due to untimely surgical intervention for a destructive-purulent process, insufficient revision of the abdominal organs and sanitation of its pockets (residual accumulations of exudate).
Figures 12 and 13 show the most frequent localizations of residual abscesses and the spread of infection in them.
Figure 12. Most frequent localizations of residual abscesses
Figure 13. Spread of infection with residual abscesses
Associations of pathogens of aerobic and non-aerobic non-spore-forming (non-clostridial) infection play an important role in the emergence and development of ABP [M.I. Kuzin et al., 1983; IN AND. Struchkova isoaut, 1984; H.H. Malinovsky, DB. Savchuk, 1986, etc.].
Postoperative ABP can cause serious complications, for example, a breakthrough of an abscess into the pleural cavity, into the free abdominal cavity (diffuse peritonitis), arrosive profuse bleeding, metastasis of an abscess, NK, eventrations, etc.
The clinical picture of postoperative ABD differs from the picture of generalized peritonitis. If the clinical picture of RP, in particular in NSA, usually manifests itself clearly, then the formation of ABP is often manifested with less intensity, veiled, hidden due to prolonged use of antibiotics, the presence in patients of a kind of barrier formed from organs fused to each other, fibrin, further and granulation tissue. In this regard, the absorption of bacteria and their toxins occurs more slowly and on a smaller scale.
The body temperature in patients with ABD is usually elevated, often of the hectic type. However, in some cases it is subfebrile and even normal. As a result, they are quite often diagnosed with a delay, as a result of which the time for the necessary operation is missed.
Recognition of ABP, especially in the early stages (stages) of its formation, presents significant difficulties. Clinical symptoms of ABP, as a rule, appear on the 5-7th day of the postoperative period with a worsening of the condition - general weakness, chills, high fever, tachycardia, sweating, impaired appetite, low-grade fever, moderate intestinal paresis, abdominal pain, deterioration of blood counts.
The latter is manifested by an increase in ESR, a neutrophilic shift in the leukocyte formula, and toxic granularity of neutrophils. Formed abscess is characterized by sharp fluctuations in temperature between morning and evening.
The symptoms of postoperative ABD, their various complications are so variable that some authors [A.P. Mintser et al, 1983; Yu.N. Mokhnyuk et al., 1984] for the purpose of diagnostics, they propose to use a specially designed algorithm developed on the basis of a probabilistic assessment of clinical information. Such an algorithm allows to form the clinical thinking of a doctor, to speed up the recognition of postoperative abscesses. The number of correct diagnostic conclusions when using this technique exceeds 80%.
After the formation of ABP, local symptoms appear, depending on the localization of the focus and the phase of abscess formation. Quite often, abdominal pain and local pain on palpation are noted. In the same place, the tension of the muscles of the abdominal wall is usually noted. Often there is also an inflammatory painful infiltrate (inflammatory tumor) and a symptom of irritation of the peritoneum. This occurs when the abscess is presented to the anterior abdominal wall. Perkugorno marked soreness. Bloating and weakened intestinal motility are often noted.
Continuing fever in the postoperative period and changes in the blood in the absence of suppuration in the wound are evidence of the unsuccessful postoperative period and the possibility of the development of purulent-septic processes in the abdominal cavity.
Interintestinal forms of abscess in the initial stages of development, especially if the inflammatory focus does not lie to the peritoneum of the anterior abdominal wall, are more often manifested by small cramping abdominal pains.
Diagnosis of intra-abdominal abscesses is not difficult. The diagnosis is made only when the phenomena of partial NK join the general condition and other symptoms, and in some patients the infiltration begins to be felt.
Plain roentgenography, ultrasound and CT of the abdominal organs help to make the correct diagnosis. When plain X-ray of the abdominal cavity organs in these patients against the background of intestinal pneumatosis, darkening zones are revealed. Plain radiography and tomography of the abdominal cavity should be used in patients with interloop abscesses, especially deeply located and inaccessible to palpation. Clinical manifestations of the formed ABD also do not always allow a correct diagnosis to be made.
Ultrasound (echolocation) greatly reduces the time for diagnosing ABP, which helps to conduct RL in a timely manner. The simplicity of the method, the absence of contraindications to its use, and high information content allow diagnosing the localization of the process, determining the volume and nature of RL, avoiding extensive revisions of the abdominal cavity and significantly shortening the treatment time. A great advantage of the method is its non-invasiveness, the ability to repeat studies many times, observing patients in dynamics.
Intra-abdominal non-clostridial abscesses are characterized by special erased clinical symptoms. The temperature at these abscesses is often subfebrile, there is no high leukocytosis with a shift of the formula to the left, abdominal pains are constantly aching in nature. The infiltrate formed around the abscess is "loose", rarely detected on palpation. The paucity of clinical manifestations of such ABP leads to late diagnosis, sometimes after opening them into the free abdominal cavity [B.K. Shurkalin et al., 1988]. It is relatively easy to diagnose ABP adjacent to the surgical wound, which can be detected during its revision.
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 OPERATIVE 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, 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 gluttony. The lower floor contains: the 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, that is, they are located mesoperitoneally: liver, gallbladder, ascending and descending colon, initial and final parts of the duodenum.
Some organs are covered with the peritoneum only on 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 the 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). Having gone 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 it 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 peritoneal sheet goes down and, already as a parietal peritoneum, lines the back wall of the abdomen, then from 3 sides it covers the ascending (right) and descending (left) colon. 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 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).
Abdominal sinuses(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 of the abdominal aorta and the inferior vena cava; from above - by 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 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 lower venous vein, from 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 limited 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 gap 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
Ligaments are formed in the places where the peritoneum passes from the abdominal wall to the organ or from organ to organ. (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) represents 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 hepatoduodenal 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 wall of the stomach along the lesser curvature. In addition, 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, passes the right gastric artery, 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 the base of it in loose fiber along the front surface of the esophagus there are r. esophageus from a. gastrica sinistra and 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-colonic 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 widest ligament that runs from the inferior pole of the spleen to the pylorus in a stripe. 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) 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 gastro-colonic 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 body 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 costal part 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 muscular layer of the intestine at the site of its inflection. A narrow and strong muscle is directed away from flexura duodenojejunalis up, behind the pancreas, it expands in a fan-like manner and is woven into the muscle bundles of the legs of the diaphragm.
Pancreatic-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, limited by a 12-duodenal bend, above and on the left - by the upper 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 delimits an 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 end of the ileum, behind by the mesentery of the vermiform process and in front by the ileo-cecal fold of the peritoneum.
6. Behind the intestinal 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.
In the lower floor of the abdominal cavity. there are two lateral peritoneal canals (right and left) and two mesenteric - mesenteric sinuses (right and left).
Right subphrenic space, or right hepatic bag, bursa hepatica dextra,
bounded above and in front by the diaphragm, below - by the upper-posterior surface of the right lobe
liver, behind - the right coronary and right triangular ligaments of the liver, on the left - crescent
ligament of the liver. Within its limits, so-called subphrenic abscesses are often formed, developing as complications of purulent appendicitis, cholecystitis, perforated stomach ulcers, duodenal ulcers, etc. The inflammatory exudate rises here most often along the right lateral canal from the right iliac fossa or from the subhepatic space along the outer edge of the liver.
The left subphrenic space consists of two departments widely communicating with each other: the pre-gastric bursa, the left hepatic bursa,
The space between the left lobe of the liver from below and the diaphragm above and in front, bursa hepatica sinistra, on the right is bounded by the falciform ligament, behind - by the left part of the coronary ligament and the left triangular ligament of the liver.
Pregastric bag, bursa pregastrica,
bounded behind by the lesser omentum and the stomach, in front and above by the diaphragm, the left lobe of the liver and the anterior abdominal wall, on the right by the crescent and round ligaments of the liver.
The lateral section of the bursa pregastrica, located outside the greater curvature of the stomach and enclosing the spleen, should be emphasized. This section is bounded on the left and back of the lig. phrenicolienale, above - lig. Gastrolien a l and a diaphragm, below - lig. phrenicocolicum.
This space is located around the spleen, is called the blind sac of the spleen, saccus caecus lienis, and during inflammatory processes can be delimited from the medial bursa pregastrica.
The left subphrenic space is separated from the left lateral canal by a well-defined left phrenic-colic ligament, lig. phrenicocolicum sinistrum, and has no free communication with him. The abscesses arising in the left subphrenic space as a result of complications of perforated gastric ulcers, purulent liver diseases, etc. can spread to the left into the blind sac of the spleen, and from the front they descend between the anterior wall of the stomach and the upper surface of the left lobe of the liver to the transverse colon and below.
The subhepatic space, bursa subhepatica, is located between the lower surface of the right lobe of the liver and the mesocolon with the transverse colon, to the right of the hilum of the liver and the omental foramen. Although this space is uniform from a morphological point of view, pathomorphologically it can be divided into
front and back sections. Almost the entire peritoneal surface of the gallbladder and the upper outer surface of the duodenum are facing the anterior part of this space. The posterior section, located at the posterior edge of the liver, to the right of the spine, is the least accessible area under the hepatic space - a depression called the hepatic_renal pocket. Abscess
Syses arising from perforation of duodenal ulcers or purulent cholecystitis are more often located in the anterior section; periappendicular abscess extends mainly into the posterior subhepatic space.
The omental bursa, bursa omentalis, is located behind the stomach, looks like a gap and is the most isolated space of the upper abdominal floor. Free entry into the omental bursa is possible only through the omental opening located near the gate of the liver, foramen epiploicum. It is bounded in front by the hepato-duodenal ligament, lig. hepatoduodenale, behind - the parietal peritoneum covering v. cava inferior, and hepatic-renal ligament, lig. hepatorenale; above - the caudate lobe of the liver and below - renal duodenal, ligament, lig. duodenorenale, and pars superior duodeni. The stuffing box is available in various sizes. In inflammatory processes, it can be closed
spikes, as a result of which the stuffing box bag is completely isolated.
The shape of the stuffing box is very complex and varies from person to person. In it, you can distinguish the front, back, upper, lower and left walls, and on the right - the vestibule of the stuffing box.
The vestibule of the omental bursa, vestibulum bursae omentalis, its rightmost part, is located behind the hepato-duodenal ligament and is bounded from above by the caudate lobe of the liver and the peritoneum covering it, from below by the duodenum, behind by the parietal peritoneum covering the inferior vena cava.
The front wall of the omental bursa is the small omentum (lig.hepatogastricum and lig.hepatoduodenale), the posterior wall of the stomach and lig. gastrocolicum; posterior - the parietal sheet of the peritoneum, covering the pancreas, the aorta, the inferior vena cava and the nerve plexuses of the upper abdominal cavity;
upper - caudate lobe of the liver and partly the diaphragm; lower - transverse mesentery
colon; left - the spleen and its ligaments - lig. gastrolienal et phrenicolienale.
The omental bursa can also be the site of the formation of purulent processes due to perforated stomach ulcers, purulent diseases of the pancreas, etc. In such cases, the inflammatory process is limited to the omental bursa, and when the omental opening becomes infected with adhesions, it remains isolated from the rest of the abdominal cavity.
Surgical access to the omental bag is more often carried out by dissecting the lig. gastrocolicum closer to the left bend of the colon, through the mesocolon transversum.
The right mesenteric sinus (sinus mesentericus dexter) is located to the right of the mesenteric root; medially and from below it is limited by the mesentery of the small intestine, from above - by the mesentery of the transverse colon, on the right - by the ascending colon. The parietal peritoneum lining this sinus grows to the posterior abdominal wall; behind it lie the right kidney, ureter, blood vessels for the blind and ascending colon.
The left mesenteric sinus (sinus mesentericus sinister) is slightly longer than the right. Its borders: from above - the mesentery of the transverse colon (level II of the lumbar vertebra), laterally - the descending part of the colon and the mesentery of the sigmoid colon, medially - the mesentery of the small intestine. The left sinus has no lower border and continues into the pelvic cavity. The aorta, veins and arteries pass under the parietal peritoneum to the rectum, sigmoid and descending colon; the left ureter and the lower pole of the kidney are also located there.
In the middle floor of the peritoneal cavity, right and left lateral canals are distinguished.
The right lateral canal (canalis lateralis dexter) is a narrow gap that is bounded by the lateral wall of the abdomen and the ascending part of the colon. From above, the canal continues into the hepatic bursa (bursa hepatica), and from below through the iliac fossa communicates with the lower floor of the abdominal cavity (pelvic cavity).
The left lateral canal (canalis lateralis sinister) is located between the lateral wall and the descending colon. Above it is limited by the phrenic-colon-intestinal ligament (lig.phrenicocolicum dextrum), from below the canal opens into the iliac fossa.
In the middle floor of the peritoneal cavity there are numerous depressions formed by the folds of the peritoneum and organs. The deepest of them are located near the beginning of the jejunum, the end of the ileum, cecum and in the mesentery of the sigmoid colon. Here we describe only those pockets that are consistently and clearly defined.
The duodenal-lean cavity (recessus duodenojejunalis) is limited by the peritoneal fold of the mesentery root and flexura duodenojejunalis. The depth of the depression ranges from 1 to 4 cm. It is characteristic that the fold of the peritoneum, which limits this depression, contains smooth muscle bundles.
The upper ileocecal cavity (recessus ileocecalis superior) is located in the upper corner formed by the cecum and the end of the jejunum. This deepening is markedly expressed in 75% of cases.
The lower ileocecal cavity (recessus ileocecalis inferior) is located in the lower corner between the jejunum and the cecum. On the lateral side, it is also limited by the appendix together with its mesentery. The depth of the deepening is 3-8 cm.
The posterior digestive cavity (recessus retrocecalis) is unstable, formed due to folds during the transition of the parietal peritoneum to the visceral and is located behind the cecum. The depth of the depression ranges from 1 to 11 cm, depending on the length of the cecum.
The intersigmoid cavity (recessus intersigmoideus) is located in the mesentery of the sigmoid colon on the left.
TOPOGRAPHIC ANATOMY OF THE LOWER ABDOMINAL FLOOR
TOPOGRAPHIC ANATOMY OF THE LOWER FLOOR OF THE ABDOMINAL CAVITY. SURGERY ON THE SMALL AND COLOR COLUMN
Duodenal malformations
Features of the duodenum in newborns and children
The duodenum in newborns is more often ring-shaped and less often U-shaped. In children of the first years of life, the upper and lower bends of the duodenum are almost completely absent.
The upper horizontal part of the intestine in newborns is above the usual level, and only by the age of 7-9 it descends to the body of the I lumbar vertebra. The ligaments between the duodenum and adjacent organs in young children are very delicate, and the almost complete absence of fatty tissue in the retroperitoneal space creates the possibility of significant mobility of this part of the intestine and the formation of additional kinks.
Atresia- complete absence of lumen (characterized by strong expansion and thinning of the walls of those parts of the intestine that are above the atresia).
Stenosis– due to localized hypertrophy of the wall, the presence of a valve, membrane in the lumen of the intestine, compression of the intestine by embryonic strands, annular subgastric gland, superior mesenteric artery, high cecum.
With atresia and stenosis of the jejunum and ileum, the atresia or narrowed intestine is resected along with a stretched, functionally defective area for 20-25 cm.In the presence of an unrecoverable obstacle above the confluence of the common bile and pancreatic ducts, the posterior gastroenteroanastomosis is superimposed. In case of obstruction in the distal part of the intestine, duodenojejunostomy is used.
Diverticula.
Incorrect position of the duodenum -
mobile duodenum.
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Lecture number 7
Channels
Right lateral canal bounded on the right by the lateral wall of the abdomen, on the left - by the ascending colon. It communicates above with the subhepatic and right hepatic bags, below - with the right iliac fossa and the pelvic cavity.
Left side channel bounded on the left by the lateral wall of the abdomen, on the right - by the descending colon and sigmoid colon. It is communicated below with the left iliac fossa and the pelvic cavity, at the top, the canal is closed by the phrenic-colonic ligament.
Sinuses
Right mesenteric sinus has a triangular shape,
closed, bounded on the right by the ascending colon, from above by the transverse colon, on the left by the root of the mesentery of the small intestine. The mesentery root of the small intestine goes from top to bottom and from left to right from the left side of the 2nd lumbar vertebra to the right sacroiliac joint. On its way, the root crosses the horizontal part of the duodenum, the abdominal aorta, the inferior vena cava and the right ureter.
Left mesenteric sinus bounded on the left by the descending colon, on the right by the mesentery root of the small intestine, from below by the sigmoid colon. Since the sigmoid colon only partially covers the lower border, this sinus freely communicates with the pelvic cavity.
Pockets
Upper duodenal pocket located above the superior duodenal fold.
Lower duodenal pocket lies below the lower duode-
nal fold.
Superior ileal cecum pocket is the place where the small intestine flows into the large intestine, above the ileum.
Lower ileal cecum pocket is the place where the small intestine flows into the large intestine, below the ileum.
Behind the intestinal pocket located behind the blind spot.
Intersigmoid pocket located at the place of attachment of the mesentery of the sigmoid colon along its left edge.
Topographic anatomy of the small intestine Divisions of the small intestine:
duodenum- considered above; jejunum; ileum.
Holotopy: mesogastric and hypogastric regions.
Peritoneal coverage: Between the leaves of the peritoneum along the mesenteric edge, the so-called extraperitoneal field (area nuda) is isolated, along which straight arteries enter the intestinal wall, and direct veins and extraorganic lymphatic vessels exit from it.
Skeletotopy: the mesentery root of the small intestine starts from the L2 vertebra and descends from left to right to the sacroiliac joint, crossing the horizontal part of the duodenum, the aorta, the inferior vena cava, and the right urinary tract.
Syntopy: in front — the great omentum, on the right — the ascending colon, on the left — the descending and sigmoid colon, behind — the parietal peritoneum, below — the bladder, rectum, uterus and its appendages.
Approximately in 1.5-2% of cases, at a distance of 1 m from the confluence of the ileum into the colon, on the edge opposite to the mesentery, a process is found - a Mekkel diverticulum (the remainder of the embryonic yolk duct), which can become inflamed and require surgical intervention.
Blood supply is carried out due to the superior mesenteric artery, from which 10-16 to-cheek and ilio-intestinal arteries, located in the mesentery of the small intestine, sequentially depart.
Features of blood supply:
arcade type - branches of arteries are dichotomously divided and form arterial arches (up to 5 orders of magnitude);
segmental type - i.e. functionally inadequate intraorgan anastomoses between straight branches (move away from the marginal vessel formed by distally located arterial arches) entering the wall of the small intestine;
2 intestinal arteries have 1 vein.
Straight veins emerge from the intestinal wall, which form
jejunal and ileo-intestinal veins forming the superior mesenteric vein are formed. At the root of the mesentery, it is located to the right of the artery of the same name and goes behind the head of the pancreas, where it participates in the formation of the portal vein.
Lymphatic drainage carried out in the lymph nodes located in the mesentery in 3-4 rows. The central regional lymph nodes for the mesenteric part of the small intestine are the nodes that lie along the superior mesenteric vessels behind the head of the pancreas. The outflowing lymphatic vessels form the intestinal trunks, which flow into the thoracic duct.
Innervation the small intestine is provided with nerve conductors extending from the superior mesenteric plexus.