DOCSLIB.ORG

Laparoscopic Splenectomy in Hematological Disorders

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Laparoscopic Splenectomy in Hematological Disorders LAPAROSCOPIC SPLENECTOMY IN HEMATOLOGICAL DISORDERS Thesis Submitted in Partial Fulfillment of The M.D. degree in General Surgery By Ahmad Abdalaziz Mohammad Abdalaziz [M.B., B.Ch.; M.Sc., (Cairo University)] Supervised by: Prof. Dr. Safwat Abdalkader Salem Professor of General Surgery, Faculty of Medicine, Cairo University Prof. Dr. Mervat Mohammad Wageh Mattar Professor of Internal Medicine and Hematology, Faculty of Medicine, Cairo University Prof. Dr. Ayman Essawy Professor of General Surgery, Faculty of Medicine, Alfayoum University Dr. Tamer Nabil Lecturer of General Surgery Faculty of Medicine, Bani Swef University Faculty of Medicine Cairo University 2011 ﺒﺴم اﷲ اﻝرﺤﻤن اﻝرﺤﻴم ii Acknowledgement ACKNOWLEDGEMENT First and foremost, I thank Allah,, who gave me the strength to accomplish this work. Words cannot express my sincere gratitude and appreciation to Prof. Dr. Safwat Abd Al KaderKader, Professor of General and Plastic Surgery, Faculty of Medicine, Cairo University, for his generous guidance, Keen interest and precious time he offered me throughout this study. His scientific advices were kindly given to me and are beyond acknowledgement. I would like to express my sincere indebtedness to, Prof. Dr. Ayman EssawyEssawy. Professor of General Surgery, Faculty of Medicine, Alfayuom University, for his continuous guidance, valuable suggestions and keen supervision throughout work. I wish also to express my deep gratitude to Prof. Dr. Mervat MatterMatter, Professor of Hematology, Faculty of Medicine, Cairo University, Dr. Tamer NabilNabil, Lecturer of General Surgery, Faculty of Medicine, Beni Swef University and DrDrDr.Dr Wael NaeemNaeem, Lecturer of General Surgery, Faculty of Medicine Cairo University, for their continuous support, valuable remarks meticulous supervision and for offering me much of their time and effort throughout this study. iii Contents CONTENTS Page ° Introduction …………………………………..………… 1 ° Aim of the work ……………………………………….. 4 ° Review of Literature ……………………………….. 5 o Anatomy of the Spleen …………………………. 5 O Physiology of the Spleen ……………………. 37 o Haematological Disorders for which Splenectomy is Indicated as a Line of Treatment ………………. 42 o Laparoscopic Splenectomy …………………….... 56 o Surgical Technique ……………………………65 ° Patients and Methods ……………………………….. 107 ° Results ………………………………………………. 115 ° Discussion ……………………………………………. .131 ° Conclusion …………………………………………….139 ° Summary …………………………………………….. 140 ° References …………………………………………… 142 ° Arabic Summary ……………….……………………. 157 iv List of Tables LIST OF TABLES No. Title Page 1 Segmental origin of splenic arterial branches. 22 2 Biologic Substances Removed by the Spleen. 40 3 Causes of thrombocytopenia. 50 4 Thrombocytopenia as a result of drugs or toxins. 51 5 Classification of splenomegaly according to spleen length. 62 6 Age distribution of patients. 115 7 Sex distribution. 116 8 Distribution of patients according to the type of their 117 presentation. 9 Laboratory findings. 118 10 Splenic size. 120 11 Results of bone marrow picture. 121 12 Distribution of induction methods for pneumoperitoneium 122 13 Distribution of technique for ligation of splenic vessels. 123 14 Pecentage of complications. 124 15 Intraoperative blood loss. 125 16 Distribution of accessory splenules. 126 17 Methods of splenic extractions. 127 18 Operative time. 128 19 Distribution of postoperative discharge. 129 20 Distribution of postoperative improvement among the 130 studied cases. v List of Figures LIST OF FIGURES No. Title Page 1 Shapes of the spleen. 6 2 Location of the spleen. 7 3 Borders of the spleen. 7 4 Close relations of the spleen. 9 5 Sagittal view of peritoneum covering the spleen. 10 6 Different ligaments of the spleen. 11 7 Types of splenic pedicle. 13 8 Major ligaments of the spleen. 15 9 Splenomental criminal fold of Morgenstern. 16 10 Suspensory ligaments of the spleen. 17 11 Types of splenic vasculature. 21 12 General scheme of levels of division of splenic artery 23 branches. 13 Anatomy of splenic vein. 24 14 Relation of splenic artery and vein. 25 15 Segmental anatomy of the spleen. 27 16 Microstructure of the spleen. 31 17 Development of splenic primordium. 33 18 Development of peritoneal reflections of the spleen. 33 19 Development of the splenic ligaments. 34 20 Structure of the spleen in relation to open and closed 38 blood flow routes. 21 Orientation of the spleen in the lateral approach. 65 22 Operating room arrangement with positions of surgeon 67 and Assistant. 23 Patient’s position for LS. 68 24 Port position for anterolateral approach. 70 25 A more medial port position for anterolateral approach. 71 26 Locations of accessory spleens. 72 27 Intraoperative picture of an accessory spleen. 72 28 Diagram of Inferolateral dissection. 73 29 Intraoperative picture of Inferolateral dissection. 73 30 Intraoperative pictures of dissection of lateral splenic 74 attachments. vi List of Figures No. Title Page 31 Intraoperative picture of the splenic tent after opening 74 the lesser sac. 32 Diagram of the medial dissection. 75 33 Intraoperative pictures of dissecting the short gastric 75 vessels. 34 Diagram for dealing with the hilum. 76 35 Intraoperative picture for hilar division with a linear 77 stapler. 36 Showing intraoperative picture of a completely detached 78 spleen. 37 Showing intraoperative picture of bagging and 79 morcellation of the spleen. 38 Port placement for posterolateral approach. 82 39 Diagram of inferolateral dissection. 83 40 Intraoperative picture of dissection of the posterolateral 83 splenic attachments. 41 Different steps of medial dissection. 84 42 Intraoperative picture of dissection of gastrosplenic 84 vessels. 43 Diagram of division of the hilum. 85 44 Intraoperative picture of hilar division. 85 45 Patient and port position in supine approach. 87 46 Intraoperative picture of dissecting the gastrocolic 88 ligament. 47 Intraoperative picture of stapled division of the hilum in 89 supine approach. 48 Age distribution of patients 115 49 Sex distribution 116 50 Distribution of patients according to the type of their 117 presentation. 51 Splenic size. 120 52 Results of bone marrow picture of the studied cases. 121 53 Distribution of induction methods for 122 pneumoperitoneum. 54 Distribution of technique for ligation of splenic vessels. 123 55 Percentage of complications. 124 56 Intraoperative blood loss. 125 57 Distribution of accessory splenules. 126 vii List of Figures No. Title Page 58 Methods of splenic extractions. 127 59 Operative time. 128 60 Distribution of post operative discharge. 129 61 Distribution of post operative improvement among the 130 studied cases. 62 Division of phrenico-colic ligament. 133 63 Division of lower pole attachments. 133 64 Division of lienorenal ligament . 134 65 Division of short gastric vessls. 134 66 Division of the hilar vessls using stapler . 135 67 Shows a splenul in the omentum. 136 viii Abstract ABSTRACT What's already known, that splenectomy may be indicated as a line of treatment in some hematological disorders. But the study showed that, laparoscopic splenectomy is safe, efficient and with better compliance to the patients of some hematological disorders in whom splenectomy is indicated. Keywords: Spleen Blood diseases Laparoscopy Treatment Complications ix Introduction INTRODUCTION The spleen is a hematopoietic organ which is capable of supporting elements of erythroid, myeloid, megakaryocytic, lymphoid, and monocyte-macrophage (i.e., reticuloendothelial) systems (John et al., 2002) . Accordingly, the spleen participates in cellular and humoral immunity through its lymphoid elements and is involved with the removal of senescent red blood cells, bacteria, and other particulates from the circulation (monocyte-macrophage system). An increase in this function (i.e. hypersplenism) may be associated with varying degrees of cytopenia, while removal of the spleen may render the patient susceptible to bacterial sepsis, especially with encapsulated organisms (John et al., 2002) . Since splenectomy was initially described for hereditary spherocytosis (HS) by Sutherland and Burghard in 1910 and for idiopathic thrombocytopenic purpura (ITP) by Kaznelson in 1916, it has been well recognized as an effective cure for some hematological disorders (Greene et al., 2002) . Since the first laparoscopic splenectomy was reported in 1991, laparoscopic splenectomy has been performed and recommended for a wide variety of indication of benign splenic diseases when the spleen largest diameter does not exceed 20-22 cm, including immune thrombocytopenia, hemolytic anaemia and splenic artery aneurysm (Cuschieri et al., 1992) . Laparoscopic splenectomy (LS) has rapidly become the surgical approach of choice for patients that require elective splenectomy in the treatment of hematologic disorders (Brodsky et al., 2002) . 1 Introduction That is primarily because patients undergoing LS have less postoperative pain, a shorter length of hospital stay, and faster recovery when compared with patients who undergo open splenectomy (Kercher et al., 2002) . The most common indication for elective splenectomy is idiopathic thrombocytopenic purpura (ITP) (Heniford et al., 2001) . Patients with this benign hematologic disorder typically have normal to slightly enlarged spleens and benefit the most from LS (Torelli et al., 2002) . The outcomes of LS in patients with other forms of benign hematologic disorders are typically not as good as those described for ITP (Rosen et al., 2002) . These patients often have splenomegaly, which has been associated
Load more

Recommended publications
  • The Subperitoneal Space and Peritoneal Cavity: Basic Concepts Harpreet K
    ª The Author(s) 2015. This article is published with Abdom Imaging (2015) 40:2710–2722 Abdominal open access at Springerlink.com DOI: 10.1007/s00261-015-0429-5 Published online: 26 May 2015 Imaging The subperitoneal space and peritoneal cavity: basic concepts Harpreet K. Pannu,1 Michael Oliphant2 1Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA 2Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA Abstract The peritoneum is analogous to the pleura which has a visceral layer covering lung and a parietal layer lining the The subperitoneal space and peritoneal cavity are two thoracic cavity. Similar to the pleural cavity, the peri- mutually exclusive spaces that are separated by the toneal cavity is visualized on imaging if it is abnormally peritoneum. Each is a single continuous space with in- distended by fluid, gas, or masses. terconnected regions. Disease can spread either within the subperitoneal space or within the peritoneal cavity to Location of the abdominal and pelvic organs distant sites in the abdomen and pelvis via these inter- connecting pathways. Disease can also cross the peri- There are two spaces in the abdomen and pelvis, the toneum to spread from the subperitoneal space to the peritoneal cavity (a potential space) and the subperi- peritoneal cavity or vice versa. toneal space, and these are separated by the peritoneum (Fig. 1). Regardless of the complexity of development in Key words: Subperitoneal space—Peritoneal the embryo, the subperitoneal space and the peritoneal cavity—Anatomy cavity remain separated from each other, and each re- mains a single continuous space (Figs.
    [Show full text]
  • Greater Omentum Connects the Greater Curvature of the Stomach to the Transverse Colon
    Dr. ALSHIKH YOUSSEF Haiyan General features The peritoneum is a thin serous membrane Consisting of: 1- Parietal peritoneum －lines the ant. Abdominal wall and the pelvis 2- Visceral peritoneum - covers the viscera 3- Peritoneal cavity - the potential space between the parietal and visceral layer of peritoneum - in male, is a closed sac - but in the female, there is a communication with the exterior through the uterine tubes, the uterus, and the vagina ▪ Peritoneum cavity divided into Greater sac Lesser sac Communication between them by the epiploic foramen The peritoneum The peritoneal cavity is the largest one in the body. Divided into tow sac : .Greater sac; extends from diaphragm down to the pelvis. Lesser Sac .Lesser sac or omental bursa; lies behind the stomach. .Both cavities are interconnected through the epiploic foramen(winslow ). .In male : the peritoneum is a closed sac . .In female : the sac is not completely closed because it Greater Sac communicates with the exterior through the uterine tubes, uterus and vagina. Peritoneum in transverse section The relationship between viscera and peritoneum Intraperitoneal viscera viscera is almost totally covered with visceral peritoneum example, stomach, 1st & last inch of duodenum, jejunum, ileum, cecum, vermiform appendix, transverse and sigmoid colons, spleen and ovary Intraperitoneal viscera Interperitoneal viscera Retroperitoneal viscera Interperitoneal viscera Such organs are not completely wrapped by peritoneum one surface attached to the abdominal walls or other organs. Example liver, gallbladder, urinary bladder and uterus Upper part of the rectum, Ascending and Descending colon Retroperitoneal viscera some organs lie on the posterior abdominal wall Behind the peritoneum they are partially covered by peritoneum on their anterior surfaces only Example kidney, suprarenal gland, pancreas, upper 3rd of rectum duodenum, and ureter, aorta and I.V.C The Peritoneal Reflection The peritoneal reflection include: omentum, mesenteries, ligaments, folds, recesses, pouches and fossae.
    [Show full text]
  • ABDOMINOPELVIC CAVITY and PERITONEUM Dr
    ABDOMINOPELVIC CAVITY AND PERITONEUM Dr. Milton M. Sholley SUGGESTED READING: Essential Clinical Anatomy 3 rd ed. (ECA): pp. 118 and 135­141 Grant's Atlas Figures listed at the end of this syllabus. OBJECTIVES:Today's lectures are designed to explain the orientation of the abdominopelvic viscera, the peritoneal cavity, and the mesenteries. LECTURE OUTLINE ­ PART 1 I. The abdominopelvic cavity contains the organs of the digestive system, except for the oral cavity, salivary glands, pharynx, and thoracic portion of the esophagus. It also contains major systemic blood vessels (aorta and inferior vena cava), parts of the urinary system, and parts of the reproductive system. A. The space within the abdominopelvic cavity is divided into two contiguous portions: 1. Abdominal portion ­ that portion between the thoracic diaphragm and the pelvic brim a. The lower part of the abdominal portion is also known as the false pelvis, which is the part of the pelvis between the two iliac wings and above the pelvic brim. Sagittal section drawing Frontal section drawing 2. Pelvic portion ­ that portion between the pelvic brim and the pelvic diaphragm a. The pelvic portion of the abdominopelvic cavity is also known as the true pelvis. B. Walls of the abdominopelvic cavity include: 1. The thoracic diaphragm (or just “diaphragm”) ­ located superiorly and posterosuperiorly (recall the dome­shape of the diaphragm) 2. The lower ribs ­ located anterolaterally and posterolaterally 3. The posterior abdominal wall ­ located posteriorly below the ribs and above the false pelvis and formed by the lumbar vertebrae along the posterior midline and by the quadratus lumborum and psoas major muscles on either side 4.
    [Show full text]
  • Unusual Causes of Large Bowel Obstruction
    Current Problems in Surgery 56 (2019) 49–90 Contents lists available at ScienceDirect Current Problems in Surgery journal homepage: www.elsevier.com/locate/cpsurg Unusual causes of large bowel obstruction ∗ Nicholas G. Farkas, MBBS, MRCS , Ted Joseph P. Welman, BSc, MBBS, MRCS, Talisa Ross, MBChB, BSc, Sarah Brown, MB, BCH, BAO, BSc, Jason J. Smith, MD, DMI, FRCS (General Surgery), Nikhil Pawa, MD, LLM, MSc, FRCS Introduction Large bowel obstruction (LBO) is defined as a surgical emergency where a mechanical inter- ruption (either complete or partial) occludes the flow of intestinal contents. 1 Understanding the varying etiologic causes of LBO is important for clinicians and surgeons when tailoring manage- ment to each patient. Knowledge of large bowel anatomy, embryology, and pathophysiology is vital when investigating and treating LBO. Many clinicians will have encountered patients with LBO on a ward or in the operating room and will appreciate the challenges posed by such presentations. Although less common than small bowel obstruction (25% of all intestinal obstructions 2 ) LBO poses more immediate risks in the form of perforation and subsequent peritonitis. Establishing the cause of an obstruction is paramount, given the high associated morbidity and mortality, 3 in order to facilitate the guid- ance of treatment. Recent studies highlight high morbidity and mortality rates of 42% to 46% and 13% to 19%, respectively, following operation. 3,4 LBO accounts for nearly 2% to 4% of all surgical admissions. 5 Colonic malignancy remains the most common cause of LBO, representing approximately 60% of cases. 3,6 Other prevalent etiolo- gies relate to adhesions, diverticulosis, hernia, inflammatory bowel disease (IBD), and volvulus.
    [Show full text]
  • Peritoneum by MUHAMMAD RAMZAN UL REHMAN
    MUHAMMAD RAMZAN UL REHMAN ..... STUDYLOVERS.COM 1 The peritoneum BY MUHAMMAD RAMZAN UL REHMAN MUHAMMAD RAMZAN UL REHMAN ..... STUDYLOVERS.COM 2 General features The peritoneum is a thin serous membrane that line the walls of the abdominal and pelvic cavities and cover the organs within these cavities Parietal peritoneum －lines the walls of the abdominal and pelvic cavities Visceral peritoneum －covers the organs Peritoneal cavity －the potential space between the parietal and visceral layer of peritoneum, in the mail, is a closed sac, but in the female, there is a communication with the exterior through the uterine tubes, the uterus, and the vagina MUHAMMAD RAMZAN UL REHMAN ..... STUDYLOVERS.COM 3 Function Secretes a lubricating serous fluid that continuously moistens the associated organs Absorb Support viscera MUHAMMAD RAMZAN UL REHMAN ..... STUDYLOVERS.COM 4 The relationship between viscera and peritoneum Intraperitoneal viscera －viscera completely surrounded by peritoneum, example, stomach, superior part of duodenum, jejunum, ileum, cecum, vermiform appendix, transverse and sigmoid colons, spleen and ovary Interperitoneal viscera －most part of viscera surrounded by peritoneum, example, liver, gallbladder, ascending and descending colon, upper part of rectum, urinary bladder and uterus Retroperitoneal viscera －some organs lie on the posterior abdominal wall and are covered by peritoneum on their anterior surfaces only, example, kidney, suprarenal gland, pancreas, descending and horizontal parts of duodenum, middle and lower parts of rectum, and ureter Intraperitoneal viscera Interperitoneal viscera Retroperitoneal viscera MUHAMMAD RAMZAN UL REHMAN ..... STUDYLOVERS.COM 5 Interperitoneal viscera MUHAMMAD RAMZAN UL REHMAN ..... STUDYLOVERS.COM 6 Structures which are formed by peritoneum Omentum －two-layered fold of peritoneum that extends from stomach to adjacent organs MUHAMMAD RAMZAN UL REHMAN ....
    [Show full text]
  • Ta2, Part Iii
    TERMINOLOGIA ANATOMICA Second Edition (2.06) International Anatomical Terminology FIPAT The Federative International Programme for Anatomical Terminology A programme of the International Federation of Associations of Anatomists (IFAA) TA2, PART III Contents: Systemata visceralia Visceral systems Caput V: Systema digestorium Chapter 5: Digestive system Caput VI: Systema respiratorium Chapter 6: Respiratory system Caput VII: Cavitas thoracis Chapter 7: Thoracic cavity Caput VIII: Systema urinarium Chapter 8: Urinary system Caput IX: Systemata genitalia Chapter 9: Genital systems Caput X: Cavitas abdominopelvica Chapter 10: Abdominopelvic cavity Bibliographic Reference Citation: FIPAT. Terminologia Anatomica. 2nd ed. FIPAT.library.dal.ca. Federative International Programme for Anatomical Terminology, 2019 Published pending approval by the General Assembly at the next Congress of IFAA (2019) Creative Commons License: The publication of Terminologia Anatomica is under a Creative Commons Attribution-NoDerivatives 4.0 International (CC BY-ND 4.0) license The individual terms in this terminology are within the public domain. Statements about terms being part of this international standard terminology should use the above bibliographic reference to cite this terminology. The unaltered PDF files of this terminology may be freely copied and distributed by users. IFAA member societies are authorized to publish translations of this terminology. Authors of other works that might be considered derivative should write to the Chair of FIPAT for permission to publish a derivative work. Caput V: SYSTEMA DIGESTORIUM Chapter 5: DIGESTIVE SYSTEM Latin term Latin synonym UK English US English English synonym Other 2772 Systemata visceralia Visceral systems Visceral systems Splanchnologia 2773 Systema digestorium Systema alimentarium Digestive system Digestive system Alimentary system Apparatus digestorius; Gastrointestinal system 2774 Stoma Ostium orale; Os Mouth Mouth 2775 Labia oris Lips Lips See Anatomia generalis (Ch.
    [Show full text]
  • Peritoneal and Retro Peritoneal Anatomy and Its Relevance For
    Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights. GASTROINTESTINAL IMAGING 437 Peritoneal and Retro­ peritoneal Anatomy and Its Relevance for Cross- Sectional Imaging1 Temel Tirkes, MD • Kumaresan Sandrasegaran, MD • Aashish A. Patel, ONLINE-ONLY CME MD • Margaret A. Hollar, DO • Juan G. Tejada, MD • Mark Tann, MD See www.rsna Fatih M. Akisik, MD • John C. Lappas, MD .org/education /rg_cme.html It is difficult to identify normal peritoneal folds and ligaments at imag- ing. However, infectious, inflammatory, neoplastic, and traumatic pro- LEARNING cesses frequently involve the peritoneal cavity and its reflections; thus, OBJECTIVES it is important to identify the affected peritoneal ligaments and spaces. After completing this Knowledge of these structures is important for accurate reporting and journal-based CME activity, participants helps elucidate the sites of involvement to the surgeon. The potential will be able to: peritoneal spaces; the peritoneal reflections that form the peritoneal ■■Discuss the impor- ligaments, mesenteries, and omenta; and the natural flow of peritoneal tance of identifying peritoneal anatomy fluid determine the route of spread of intraperitoneal fluid and disease in assessing extent processes within the abdominal cavity. The peritoneal ligaments, mes- of disease. ■■Describe the path- enteries, and omenta also serve as boundaries for disease processes way for the spread and as conduits for the spread of disease. of disease across the peritoneal spaces to ©RSNA, 2012 • radiographics.rsna.org several contiguous organs. ■■Explain inter- fascial spread of disease across the midline in the ret- roperitoneum and from the abdomen to the pelvis.
    [Show full text]
  • The Peritoneum General Features • General Features • the Peritoneum Is a Thin Serous Membrane Consisting Of: • 1- Parietal Peritoneum －Lines the Ant
    The Peritoneum General features • General features • The peritoneum is a thin serous membrane Consisting of: • 1- Parietal peritoneum －lines the ant. Abdominal wall. • 2- Visceral peritoneum - covers the viscera - Peritoneum is continuous below with parietal peritoneum lining the pelvis. • 3- Peritoneal cavity - the potential space between the parietal and visceral layer of peritoneum - in male, is a closed sac - but in the female, there is a communication with the exterior through the uterine tubes, the uterus, and the vagina Peritoneum cavity divided into Greater sac Lesser sac Communication between them by the epiploic foramen Deep to lesser omentum Behind the stomach Between two layers of greater omentum Under the diaphragm and liver Deep to lesser opening (Epiploic opening) Walls： Superior－peritoneum which covers the caudate lobe of liver and diaphragm Anterior－lesser omentum, peritoneum of posterior wall of stomach, and anterior two layers of greater omentum Inferior－conjunctive area of anterior and posterior two layers of greater omentum Posterior－posterior two layers of greater omentum, transverse colon and transverse mesocolon, peritoneum covering posterior abdominal wall. Omental bursa……cont Left－ spleen, gastrosplenic ligament splenorenal ligament Right－omental foramen Deep to ant. Abdominal wall Below the diaphragm Above pelvic viscera Out to: Liver surround all the liver except bare area Stomach completely surrounded by peritoneum Transverscolon Greater omentum two layers of peritoneum from greater curvature
    [Show full text]
  • The Peritoneum 腹膜
    General features The peritoneum is a thin serous membrane Consisting of: 1- Parietal peritoneum －lines the ant. Abdominal wall 2- Visceral peritoneum - covers the viscera - Peritoneum is continuous below with parietal peritoneum lining the pelvis 3- Peritoneal cavity - the potential space between the parietal and visceral layer of peritoneum - in male, is a closed sac - but in the female, there is a communication with the exterior through the uterine tubes, the uterus, and the vagina ▪ Peritoneum cavity divided into Greater sac Lesser sac Communication between them by the epiploic foramen Deep to lesser omentum Behind the stomach Between two layers of greater omentum Under the diaphragm and liver Deep to lesser opening (Epiploic opening) Walls： Superior－peritoneum which covers the caudate lobe of liver and diaphragm Anterior－lesser omentum, peritoneum of posterior wall of stomach, and anterior two layers of greater omentum Inferior－conjunctive area of anterior and posterior two layers of greater omentum Posterior－posterior two layers of greater omentum, transverse colon and transverse mesocolon, peritoneum covering posterior abdominal wall. Omental bursa……cont Left－ spleen, gastrosplenic ligament splenorenal ligament Right－omental foramen Deep to ant. Abdominal wall Below the diaphragm Above pelvic viscera Out to: Liver surround all the liver except bare area Stomach completely surrounded by peritoneum Transverscolon Greater omentum two layers of peritoneum from greater curvature of stomach Duodenum just the anterior
    [Show full text]
  • Diseases of the Peritoneum and Retroperitoneum
    gastrointestinal tract and abdomen 2 DISEASES OF THE PERITONEUM AND RETROPERITONEUM Amanda K. Arrington, MD, and Joseph Kim, MD Anatomy and Physiology: Peritoneum transverse mesocolon, on the other hand, is the mesentery of the transverse colon and suspends this structure from anatomy the posterior abdominal wall. The root of the transverse The word peritoneum is derived from the Greek terms peri mesocolon extends across the descending duodenum and (“around”) and tonos (“stretching”). The peritoneum, which the head of the pancreas and continues along the inferior lines the innermost surface of the abdominal wall and the border of the body and tail of the pancreas. The transverse majority of the abdominal organs, consists of a layer of mesocolon is continuous with the duodenocolic ligament on dense stroma covered on its inner surface by a single sheet the right and with the phrenicocolic and splenorenal liga- of mesothelial cells. In men, the peritoneum is completely ments on the left. Finally, the sigmoid mesocolon attaches enclosed, whereas in women, the peritoneum is open to the the sigmoid colon to the posterior pelvic wall. This mesen- exterior only at the ostia of the fallopian tubes. The perito- tery, which has an inverted V-shape confi guration, with its neum is divided into two components: the parietal and the apex lying anterior to the bifurcation of the left common ilia c visceral peritoneum [see Figure 1]. The parietal peritoneum artery, contains both sigmoid and hemorrhoidal vessels, covers the innermost surface of the abdominal walls, the lymph nodes, nerves, and abundant fat tissue.3 inferior surface of the diaphragm, and the pelvis.
    [Show full text]
  • Clinical Anatomy and Physiology
    1 Core Surgical Sciences course for the Severn Deanery Surgical Anatomy: Abdomen and pelvis – detailed learning objectives/stations The session will be taught in small groups, with examination of prosections, and three rotating stations: anterior and posterior abdominal wall; abdominal cavity and viscera; pelvis and perineum. Anterior and Posterior Abdominal Wall 1. Anterior abdominal wall and inguinal region You should be able to describe: the boundaries of the abdominal cavity: the diaphragm superiorly; the pelvic diaphragm (pelvic floor) inferiorly; the anterior abdominal wall and the posterior abdominal wall; bony landmarks around the boundaries of the anterior abdominal wall the division of the anterior abdominal wall into 9 regions, in relation to anatomical landmarks (transpyloric plane joins the tips of the 9th costal cartilages bilaterally, level with L1 vertebra; intertubercular plane passes through iliac tubercles, level with L5 vertebra; midclavicular lines pass down through mid-inguinal point) the cutaneous innervation of the anterior abdominal wall the layers of the anterolateral abdominal wall (NB. No deep fascia over thorax or abdomen) the attachments of the inguinal ligament (the inferior free edge of the external oblique aponeurosis), from ASIS to the pubic tubercle Peritoneal folds on the anterior abdominal wall (median umbilical fold – over urachus; medial umbilical folds – over obliterated umbilical arteries; lateral umbilical folds – over inferior epigastric vessels) the inguinal canal, running from the the deep inguinal ring (opening in transversalis fascia just lateral to the inferior epigastric vessels) to the superficial inguinal ring (a deficiency in the external oblique muscle tendon, above and medial to the pubic tubercle), and the tendons/fascia which form its floor, roof, and walls; contents in male and female 2.
    [Show full text]
  • Operative Surgery & Topographical Anatomy of the Abdomen. Surgical
    Operative surgery & topographical anatomy of the abdomen. Surgical anatomy of the inguinal canal and spermatic cord. Surgical anatomy of the inguinal canal and spermatic cord. Topographical peculiarities of the inguinal hernias.The descendense of the testicle, formation of scrotal layers. Boundaries: Superior boundary is formed by the margins of the costal arches (arcus costae) and xyphoid process Inferior boundary is formed by the inguinal folds, which are coincide with inguinal ligaments and pubic symphysis The lateral boundaries are the middle axillary (Lesgaft’s) lines. By two horizontal lines the anterior wall is divided into 3 regions: 1. Epigastrium 2. Mesogastrium 3. Hypogastrium The first horizontal line is between the lower points of the 10th pair of ribs and is called bicostal line (linea bicostarum) The second horizontal line is between spinae iliacae anteriores superiores and is called bispinal line (linea bispinarum) By two vertical lines which pass from the lower points of the 10th pair of ribs to the pubic tubercles the mesogastrium and hypogastrium are divided into three regions . The mesogastrium – into umbilical, right and left abdominal lateral regions, the hypogastrium – into pubic, right and left inguinal regions. So there are formed seven regions. If there will be drawn two vertical lines which coincide with the midclavicular lines to the pubic tubercles the epigastrium also can divided into three regions – the epigastric, right and left hypochondric regions. So nine regions are formed. Layers of anterior abdominal wall: 1. Skin is thin, elastic, moveable, except umbilical region, is covered by hair only in the pubic and inguinal parts, with sebaceous and sweat glands.
    [Show full text]