Lesser Omentum Project: Penny Fleming Kimberly Burnham

Lesser Omentum Project
Penny Fleming
Kimberly Burnham
The Question
Describe the anatomical, physiological, neurological, vascular, and
embryological relationships of the lesser omentum. As well as the
corresponding vertebral and somite (embryological segment) levels
and level of nerve segmentation.
Describe its contents.
Evaluation test.
Two normalization techniques.
Canadian College of Osteopathy
Toronto, Ontario May, 2000

4th Year
Lesser Omentum Presentation May 2000 1 4th Year CCO Penny Fleming / Kim Burnham
Table of Contents
2 Table of Contents
3 Introduction - Penny
Naming of the Lesser Omentum
Embryologic Development of the Lesser Omentum and the Gastrointestinal Tract
Central Chain and the Lesser Omentum
Anatomy - Penny
Relationship with Liver - Penny
Lesser Omentum Relationship with Esophagus, Stomach, Duodenum
Relationship with Pancreas - Penny
Functions of the Lesser Omentum -Kim
Portal Triad and The Lesser Omentum - Kim

Relationship with Lymphatics - Kim
Chapman Reflexes - Kim
Lesser Omentum Lesions - Kim
Metholdology
Tests and Techniques - Penny
References
Introduction
The lesser omentum is a double layered sheet of peritoneum that is typically

divided into two parts: the hepatogastric and the hepatoduodenal ligaments. As their
names imply, these mesenteric structures are stretched from the inferior surface of the
liver to the lesser curvature of the stomach, the abdominal portion of the esophagus
and the first 2cm of the duodenum. The lesser omentum lies posterior to the left lobe of
the liver, forms the anterior lip to the foramen of Winslow and the anterior border of the
Omental bursa or lesser sac of the peritoneum. Its embryological origin, from ventral
mesentery, implies the lesser omentums significance with respect to the central chain
and influence over surrounding and connecting viscera. Of primary importance,
however, are its contents: the hepatic artery, portal vein and common bile duct. Given
its location and its attachments, osteopathicly, anatomically and functionally the lesser
omentum is a significant structure within the abdomen.
Naming of the Lesser Omentum
Naming of the Lesser Omentum is defined in relation to the Greater Omentum

as the lesser or smaller of the two abdominal omentums. The word omentum comes
from the Latin OMENT which means the fat skin, membrane. It is made up of two major
ligaments: the hepatogastric ligament, the hepatodudodenal ligament and some
authors include a thrid part as the hepatoesophageal ligament. These ligaments derive
their names from the Greek names for the structure they connect. HEPAT (Gr.) for
pertaining to or affecting the liver. ESOPHAG (Gr.) for the gullet and OISO (Gr.) for I
shall carry and PHAGET (Gr.) for food. GASTROS (Gr.) for the belly or stomach.
DUODENI is Latin for twelve each. The duodenum is so name because it is
approximately twelve finger breaths long. The embryological layer that the lessero
omentum derives from , the mesenchyme come from the Greek for MESOS middle, the
half, intermediate and CHYM to pour, an infusion, something poured in.
Embryologic Development of the Lesser Omentum and the Gastrointestinal Tract
The body cavities and their mesenteries, including the lesser omentum are
complex and clinically important. The three main body cavities are the pleural cavity,
the pericardial cavity and the peritoneal cavity. The peritoneal cavity is the space left
between the visceral and parietal layers of the mesoblast and the serous membrane is
developed from these.
The mesoderm lying near the gut is called splanchnic and diferentiates into the
visceral peritoneum. This visceral mesoderm produces the smooth muscle and
connective tissue of the gut. This layer is not innervated and are not directly sensitive to
pain. Abscesses in the visceral layers may be experienced as referred pain in the
innervated parietal layer.
The layer ling the body wall is the somatic or parietal peritoneum, which
produces the connective tissue and adipose tissue and is innervated by somatic
efferent nerves growing out from the neural tube.
The lesser omentum is made up visceral peritoneum. It is formed by a thining of
the mesoblast or anterior primitive mesentery, which attaches the lesser curvature of
the stomach to the anterior abdominal wall. By subsequent growth of the liver, this leaf
of mesoblast is divided into two parts: the lesser omentum between the stomach and
the liver and the falciform ligament between the liver and the abdominal wall and
diaphragm.
In embryologic development the gut is suspended from a dorsal mesentery and
in the fore and hindgut region is attached in the anterior body structures by a ventral
mesentery, which gives rise to the lesser omentum and the falciform ligament. The
dorsal mesentery runs along the entire length of the gut below the diaphragm. Regional
names are used locally to describe various parts of the dorsal mesentery as
appropriate: dorsal mesogastrum, dorsal mesoduodenum, mesentery proper and the
dorsal mesocolon. The lienorenal ligament lies between the spleen and the urogenital
ridge. The ventral mesentery gives rise to the lesser omentum and the falciform
ligament.
The folding of the embryo in the thrid and fourth weeks converts the flat
trilaminar germ disc into an elongated cylinder consisting of three concentric nested
tubes. The outer tube is ectoderm. The central tube is the endodermal primary gut tube.
Between the ectodermal and endodermal layers is the mesoderm.
The emdodermal gut tube created by embryonic folding during the fourth week
consits of a blind ended cranial foregut, a blind - ended caudal hindgut and a mid gut
open to the yolk sac through the vitelline duct.
The arterial supply to the gut develops throug consolidation and reduction of the
ventral branches of the dorsal aorta that anastomose with the vessel plexuses that
originally supply blood to the yolk sac. Three of these vitelline artery derivaties
vascularize the abdominal gut.
The primitive abdominal gut is initially a straight tube suspended in the peritoneal
cavity by a dorsal mesentery. In the stomach region the gut tube remains connected to
the ventral body wall by the thick septum transversum (ventral mesentery), which thins
to for the ventral mesentery connecting the stomach and the developing liver to the
ventral body wall. The abdominal esophagus, stomach and superior part of the
duodenum are suspended by dorsal and ventral mesenteries. The rest of the abdominal
gut tube excluding the rectum is suspended in the abdominal cavity by a dorsal
mesentery only. The mesodermal coating of the primitive gut tube gives rise to the
submucosal connective tissue and the smooth muscle layers of the definitive
gastrointestinal tract.
The rotation of the stomach and the secondary fusion of the duodenum to the
dorsal bdoy wall create the lesser sac of the peritoneal cavity, wiich includes the greater
omentum. The rest of the peritoneal cavity is call the greater sac.When the stomach
rotates to the left and the liver shifts into the right side of the peritoneal cavity, the
lesser omentum rotates from a sagittal into a coronal (frontal) plane. The
mesogastrium, being attached to the greater curvature, must necessarily follow its
movements, and hence it becomes greatly elongated and drawn outward from the
vertebral column and like the stomach, what was originally its right surface is now
directed backward and its left side faces forward. This repositioning reduces the
communication between the greater and lesser sacs of the peritoneal cavity to a narrow
canal lying just posterior to the lesser omentum. This canal is the epiploic foramen of
Winslow.
On about day 22, a small endodermal thickening, the hepatic plate, appears on
the ventral side of the duodenum. This becomes the liver, which is a major early
hematopoietic organ of the embryo. At the fourth week after fertilization, before the
stomach and duodenum have begun to rotate, the liver bud or hepatic diverticulum
starts to grow ventrally from the caudal part of the foregut. This bud will also give rise to
the primordium of the gallbladder. The bud pushes ventrally and cranially into the
mesoderm ventral to the gut. Mostly covered by visceral peritoneum, the liver has one
area when it makes direct contact with the developing central tendon of the diaphragm,
called the bare area of the liver. This bare area results in the formation of anastomoses
between hepatic portal vessels and the systemic veins of the dipahrgm.
In development the liver tends to control the growth and location of the other
organs. This is significant to the lesser omentum, in that the falciform ligament of the
liver and the lesser omentum develop from the ventral mesentery and the lesser
omentum connects the liver and the stomach. As embryological growth occurs the liver
pushes the stomach over to the left side and stomach turns to the right due to stretch
on the fascia. The stomach makes the mesogastrium pulls and causes little
tears/vacuoles to form the omental bursa. The medial mesogastrium becomes greater
omentum as the different layers fuse and include fatty tissue. Part of the mesogastium
between stomach and liver becomes the lesser omentum.
The develomental movement continues as the stomach turns right the
duodenum turns. The duodenum is attached to ventral pancreas. The ventral bud of
pancreas and dorsal bud go together and fuse with the ventral bud becoming the head.
The tail is already placed and the head moves back behind the duodenum to meet it.
Once together the buds of the pancreas are tossed back by stomach, spleen and
duodenum and pushed back and mesoduodenum of pancreas fuses with posterior
parietal wall.
In the fifth week of embryologic development the spleen shows up. The stomach
pushes left. The spleen gets pushed with it so it is posterior lateral. The dorsal
mesogastrium becomes the greater omentum and the duodenum goes posterior as
stomach rotates. The spleen, a vascular lymphatic organ, is derived from the dorsal
mesogastrium, not from the gut tube endoderm.. The spleen begins as a mesenchymal
condensation in the dorsal mesogastrium of the lesser sac. The spleen initially
functions as a hematopoietic organ and later acquires a definitive lymphoid character.
Embryologically the lesser omentum is derived from the septum transversum and
is therefore connected to several other important structures (see chart below). The
septum transversum lies at the level of the third, fourth and fifth cervical somites. In an
oblique transverse section through the embryo it has the apperance of a wall of
mesoderm running across the axis. It lies obliquely across the body axis, then after the
descent of the diaphragm it will lie much more transversely across the axis. The
mesoderm of the septum transversum is innervated by motor and sensory nerves from
cervical roots 3, 4, 5, the phrenic nerve. They run to the septum transversum via the
pleuropericardial folds.
Derivatives of the Septum Transversum
# Cranial region
Central tendon of the diaphragm
Myocytes of the pleuroperitoneal membranes
# Central Mesenchyme
Hematopoietic cells of liver
Falciform Ligament, which carries the umbilical vein from the body wall to the liver.
# Caudal Region (Ventral mesentery)
Visceral peritoneum of the liver, including the coronary ligament. It is a a Serous
coverings of the liver.
Visceral peritoneum of the gallbladder
Lesser omentum, including the hepatoduodenal and hepatogastric ligaments.
It is a translucent membrane that attach the liver to the stomach and to the
ventral body wall.
The hepatoduodenal ligament connects the liver and duodenum and contains
the portal vein, the proper hepatic artery and branches; the hepatic cystic
and common bile ducts.
The hepatogastric ligament connects the liver and the stomach.
In regards to health, the mesodermal origin of the gut membranes is a mixed

blessing. The mesothelium layers of the visceral and parietal peritoneum will readily
fuse to each other, unlike true epithelium. This means that adhesions can readily form
due to trauma or surgery. The mesothelium also heals well. If left alone the peritoneal
layers will heal in 7-8 days. Perhaps as a result of these extensive healings (ie) cell
division capabilities, tumors of the mesothelium or mesotheliomas are highly malignant.
Also see the section on lesions of the lesser omentum.
Central Chain and the Lesser Omentum
The lesser omentum is also one of several connective tissue structures that
make up the central chain (see chart below). The central chain is a midline deep
connective tissue chain that significantly affects physiological function and structural
integrity of the visceral system. A lesion or disturbance of one of the elements of the
central chain can affect every other component of the central chain and therefore
significantly alter metabolism and structural function of the body.
Central Chain Elements Netters ! Relationship with neighbouring or attached structures ! All points of
pages central chain are related embryologically; ! Runs down the middle of
the 5 spheres
Vertex N.100
Third Ventricle N.102 ! Related to Pineal gland, Thalamus, Hypophysis

! for effect on immune system: thalamus, thyroid, pancreas
Sphenobasilar Junction N.57 ! Sphenoid and Occiput related to whole cranium; ! Relationship to
pituitary
Tongue's attachment to N.66, ! Cervical spine, attachments to C1, hyoid bone, cricoid cartilage;
the pharyngiobasilar 223 occiput via fascia
fascia ! Pharangiobasilar fascia attaches on sphenoid, occiput, temporal
Relation to esophagus petrous part; what eventually becomes the tongue starts at the
and trachea pharangiobasilar fascia;
! Tensor palatini & levator palatini for raising / lowering tongue
Middle Cervical N.61 ! Related to Esophagus, Trachea, Thyroid gland; Connections with
Aponeurosis Grays pulmonary fissures
Infra hyoid fascias ! Ligament from thyroid to pericardium --> ligaments from pericardium
to diaphragm --> falx of the liver --> umbilicus to urachus
Pericardium N.200 ! Parts of pericardium attach to xiphoid and diaphragm; central to all the
thorax; heart and islets of the lungs (close to mediastinum where
arteries and veins come)
Thoracic Diaphragm N.218 ! Middle leaflet of the diaphragm cardia; stomach, liver, spleen
Tissue around Cardia
Falciform Ligament of N.270, ! Center phrenic joins with falciform of liver

Liver 182
Lesser Curvature of N. 258 ! Relationship with lesser omentum attachment; ! Lesser omentum is
Stomach also related embryologically with the Falx of the liver and Falx cerebrum.
Head of the pancreas N.257, ! There is a convergence of fascia at the head of the pancreas;!
279 Pancreas is like the headlight of the abdominal fascia; ! Relation with
Fascia of Toldt; Ligament / Muscle of Treitz and Transverse Mesocolon
! Relation with Solar plexus
Root of the Mesentery N.333 ! Root of the Mesentery is the great giver of energy
Urachus N.236 ! Urachus is the ligament between the bladder and umbilicus
Isthmus of Uterus / N.350 ! Problems here can lead to difficult births

Women
Vertical Fascia of N.342, ! Fascia of Denonvillier is the central tendon behind the prostrate; In
Denonvillier / 367 relation with arteries of prostate ! With age this vertical fascia behind
Aponeurosis Prostatic prostate changes lead to problems if central chain goes thru prostate
Peritoneal in Men instead of behind
Central Tendon of the N.355 ! Connections with fascia of extremities ! Perineum central tendon is a
Perineum is the end thickening in the centre of the pelvic floor; Central Perineal Raphe; !
The zone of fusion between the urorectal septum and the cloacal
membrane becomes the perineum.
Anatomy
The peritoneum is the largest serous membrane in the body. In the abdomen, it is an
empty and intricately folded sac lining and reflected over the viscera. In males it represents a
closed sac but in females, due to the extensions of the fallopian tubes, it is open. Two layers
exist within the abdomen cavity: peritoneal, which lines the abdominal wall and visceral, which
covers the viscera. Between these layers is a serous fluid that facilitates gliding of the viscera
on itself and on others. In the stomach, the serous fluid is derived from the peritoneum and
covers its entire surface except along the greater and lesser curves at the points of attachment
of their respective omenta. Along the lesser curvature, for example, the two layers of
peritoneum leave a small triangular space for blood vessels, nerves, and lymphatics.
Numerous peritoneal folds extend between various organs or connect organs to
abdominal and pelvic walls, enclose vessels and nerves proceeding viscera, and though clearly
not designed to sustain much weight, they may help to retain certain viscera in contact with
each other. The folds of peritoneum may be ligaments, mesentery or omenta. Ligaments have
primarily a suspensory role, mesentery connects certain parts of the intestine to the abdominal
wall and omenta (a cover) join two or more elements of the digestive tract. For example, the
lesser omentum plays a role in the suspensory, transport and connective function between the
stomach, esophagus, liver and duodenum (D1).
Waligora refers to the lesser omentum as a mesos or meso tendu stretching from the liver to
the stomach. Its two peritoneal layers, anterior and posterior, are continuous over and behind
the anterior and posterior surfaces of the stomach where they then come into contact again and
continue downward in front of the transverse colon forming the anterior two layers of the greater
omentum. Reaching the free edge, they then bend upwards to form the two posterior layers of
the greater omentum which separate to enclose the transverse colon and then again come into
contact and pass backwards to the abdominal wall as the transverse mesocolon.
The peritoneum covering the upper and anterior surfaces of the liver is reflected around and
underneath where it covers the lower aspect of the quadrate lobe and the lateral aspect of the
gallbladder. At the transverse fissure it is continuous with the anterior layer of the lesser
omentum. The posterior layer of the lesser omentum is reflected onto the caudate and
Spigelian lobes and is continued from the upper extremity of the Spigelian lobe to the thoracic
diaphragm forming the upper limit of the lesser sac of the peritoneum or omental bursa. Thus,
the visceral peritoneum plunges into the transverse fissure between the caudate and left
hepatic lobes in two layers, anterior and posterior. At the upper end of the transverse or portal
fissure, its anterior layer merges with the posterior layer of the left triangular ligament and its
posterior layer with the line of reflexion of the peritoneum from the upper end of the right
caudate lobe (and indirectly with the coronary ligaments).
The lesser omentums position is anatomically determined by that of the liver, stomach and
duodenum. The liver occupies the right upper quadrant of the abdomen anteriorly from the level
of the right 5th intercostal space at the midclavicular line to the diaphragm. It ends on the left
between the 5th and 6th intercostal spaces just medial to the left midclavicular line. Posteriorly is
appears between T8-9 to T12. The stomach typically occupies the left upper quadrant
suspended from the esophagus at the vertebral level of T10-11 slightly left of the aorta. This
corresponds tot he 7th costocartilage anteriorly and it descends to the pylorus near the midline
at the body of L1. The inferior border of the stomach can descend to the level of L2-3. The
duodenum or D1 extends to the right and slightly superior tot he level of T11 until in turns
inferiorly into D2.
Thus, the lesser omentum begins at the right border of the abdominal esophagus at the
vertebral level of T10. It is attached along the lesser curvature or right border of the stomach
between the cardiac and pyloric sphincters or from the level of the 7th costal cartilage to L1. The
lesser curvature itself descends in front of the left crus of the thoracic diaphragm along the left
side of T11 & 12 and turning to the right crosses L1 and ascends to the pylorus. The lesser
omentum, however, continues along the first 2 cm of the duodenum or D1. Superiorly, the
lesser omentum continues and separates at the livers transverse fissure. This portal fissure is
short (2 inches) and deep separating the quadrate lobe in front from the caudate and Spigelian
lobe behind. This is considered the gateway to the liver (hence porta hepatis) transmitting the
hepatic artery, nerves, hepatic duct, portal vein and lymphatics. The right border or free edge of
the lesser omentum forms the anterior border of the foramen of Winslow (epiploic foramen).
Hence the right vertical border extends from the hilus of the liver to D1 and forms the
anterior border of the epiploic foramen. The left border is gastric and fixed to the D1, small
curvature of the stomach and the right border of the esophagus. The superior aspect is hepatic
and fixed to the portal fissure of the liver. The posterior aspect of the lesser omentum forms the
anterior aspect of the omental bursa.
It is interesting to note at this point; that the lesser omentum begins at the cardiac sphincter
which is one of the most fixed points of the stomach at the level of T11 and then ends at D1,
which is the most mobile part of the duodenum. The pyloric sphincter must remain extremely
mobile in order to adjust to stomach filling and emptying. This also applies to the stomach and
thus, the lesser omentum. Fixation or restriction of any or all of the structures will decrease
emptying and hence function of the stomach.
Moore describes the lesser omentum as having two parts: the hepatogastric and the
hepatoduodenal ligaments. The hepatogastric portion runs between the transverse fissure of
the liver to the lesser curvature where its two layers separate and house the right and left
gastric vessels, the rami of the gastric (vagus) nerves and some of the left gastric lymph nodes
and their lymph vessels. It is a thin avascular structure according to Waligora, thin and
perforated states Moore, but can be thinner on the left and fenestrated according to Grays.
Barral describes this ligament as furled like a sail. The hepatogastric ligament ascends and
attaches to the bottom of the fissure for the ligamentum venosum (remnant of the fetal ductus
venosus) along which it is carried to the thoracic diaphragm where the two layers separate to
embrace the end of the esophagus. Waligora refers to this portion as the pars condensa or
superior part that contains the hepatic branch of the left gastric artery and pneumogastric
nerves.
The pars vasculosa (Waligora) or hepatoduodenal ligament (Moore) is thick, vascular, relatively
strong and corresponds to the free border and the porta hepatis. This portion of the lesser
omentum runs between the hilus of the liver to the pyloric part of the stomach and the
duodenum at D1. Between the two layers close to the free margin are contained the hepatic
artery, portal vein, common bile duct, lymphatic nodes and vessels and the hepatic plexus of
nerves. These structures are enclosed within loose areolar tissue known as the Glissons
capsule. It is this thickened free edge of the hepatoduodenal ligament that forms the anterior lip
of the epiploic foramen.
The porta hepatis (situated between quadrate lobe in front and caudate process behind) is
found in a deep transverse fissure between the upper ends of the fissure for the ligamentus
teres and the fossa for the gallbladder. At the porta hepatis the portal vein, hepatic artery and
hepatic nervous plexus enter and the right and left hepatic ducts and some lymph vessels
emerge. The right and left hepatic ducts merge to form the hepatic duct and pass downwards
and to the right for 1.5 inches within the lesser omentum where it is joined by the cystic duct
from the gallbladder forming the common bile duct. Positionally, the common bile duct lies to
the right, the hepatic artery lies to the left and the portal vein lies behind and between the other
two structures. The portal vein and hepatic artery ascend in the lesser omentum to the porta
hepatis where each divides to enter the right and left lobes.
According to Moore, the gastroduodenal artery passes between layers of the lesser omentum
as the hepatic artery proper which ascends in the free margin, as mentioned above, anterior to
the portal vein and to the left of the bile duct. Near the porta hepatis the hepatic artery proper
divides into the right and left terminal branches or the right and left hepatic arteries. Moore
notes in 11% of the cases the left hepatic artery arises from the left gastric artery in vicinity of
the gastroesophageal junction and passes between the layers of the superior part or pars
condensa of the lesser omentum to the left lobe of the liver.
Also located within the lesser omentum along the lesser curvature of the stomach is the
anastomosis of the gastric arteries. The left gastric branches directly off the celiac trunk,
passes upwards and to the left behind the omental bursa to the cardiac orifice of the stomach. It
gives off branches to the esophagus, anastomoses with splenic branches and passes along the
lesser curvature to the pylorus lying in the lesser omentum. It gives branches to both surfaces
of the stomach and at it termination anastomoses with the pyloric or right gastric artery of the
hepatic branch. An accessory left gastric artery may arise off the left branch of the hepatic that
also reaches the lesser curvature through the lesser omentum. It is critical to note this
anastomoses of the right and left gastric arteries and differing sources of blood supply to the
stomach.
The common hepatic artery passes forward and to the right (accompanied by the
hepatic autonomic plexus) to the pyloric end of the stomach forming the lower boundary of the
foramen of Winslow. It then passes upwards between the lesser omentum, in front of the
foramen, to the porta hepatis where it divides into the right and left branches. Branches of this
artery include the right gastric, gastroduodenal and the cystic artery. The right gastric artery
arises above the pylorus, descends to the pyloric end of the stomach passing to the left along
the lesser curvature. It supplies both surfaces of the stomach and the lesser omentum. The
gastroduodenal artery is a short large branch, which descends near the pylorus (giving off small
branches to the pyloric end of the stomach and lesser omentum) and divides into the right
gastroepiploic and pancreatico-duodenal superior arteries. The right and left gastroepiploic
arteries, also from different sources, anastomose within the greater curvature of the stomach
and give rise to branches supplying the greater omentum. The cystic artery, usually a branch of
the right hepatic artery, passes downward and along the neck of the gallbladder and divides
into two branches to the gallbladder and liver.
The final branch of the celiac trunk is the splenic artery. It is large, accompanied by the
splenic vein and nerve plexus, and passes to the left horizontally along the upper border of the
pancreas. It crosses in front of the left kidney and adrenal and divides into branches near the
spleen. Several, the short gastrics, posterior gastric and left gastroepiploic return to supply the
fundus, posterior surface and greater omentum of the stomach respectively.
With respect to the venous supply of the stomach in relation to the lesser omentum, the
right and left gastric veins are of importance. The right gastric vein is small and runs to the right
along the pyloric section of the lesser curvature within the lesser omentum ending in the portal
vein. The left gastric vein drains both gastric surfaces, ascends in the lesser curvature to the
left within the lesser omentum to the esophageal opening. It then curves and joins the portal
vein.
The lymphatics of the stomach are numerous and both superficial and deep. Lymphatic
glands are found along the two curvatures of the stomach within the omenta. Their valves direct
lymph from the right part of the stomach to the lesser curvature and from the left part to the
greater curvature. It is primarily the inferior left gastric nodes that descend along the cardiac
half of the lesser curvature within the lesser omentum. Clemente notes that lymphatic vessels
of the stomach follow the course of the right and left gastroepiploic vessels along the greater
curvature and the right and left gastric vessels along the lesser curvature.
Lymphatics to the liver follow the course of the hepatic artery and portal vein. Hepatic
nodes extend within the lesser omentum along the hepatic artery and bile duct and if enlarged
can press on and obstruct the portal vein. The lymphatic system of the liver itself can be divided
into two systems. The superficial lymphatic vessels course through the subserous areolar tissue
over the surface of the liver. Deep vessels follow either the hepatic veins upward or the porta
hepatis inferiorly ending in the hepatic lymph nodes.
The parasympathetic supply for the stomach is from the vagus nerve. The left supplies
the anterior surface of the stomach and the right the posterior. This orientation is related to the
rotation of the esophagus and stomach during fetal development. The anterior vagus divides
into gastric branches of which the largest, the greater anterior gastric nerve, lies within the
lesser omentum. Smaller branches include the two pylorics, one of which transverses the lesser
omentum horizontally to the right towards the free edge and then turns down the left side of the
hepatic artery to reach the pylorus. The posterior vagus branches into the gastric (greater
posterior gastric nerve) and celiac which both pass within the lesser omentum giving branches
to the celiac plexus.
Sympathetic supply of the stomach (T5-9) is mainly from the celiac plexus via its
extensions around the gastric and gastroepiploic arteries. Some rami from the hepatic plexus
reach the lesser curvature between the hepatogastric ligament layers. Rami of the left phrenic
plexus pass to the cardiac end of the stomach.
Innervation of the liver is derived from the hepatic plexus containing sympathetic fibres
of the greater splanchnic nerve (T5-9) and parasympathetic or vagal fibres. These enter the
liver via the porta hepatis and the lesser omentum. Also from this plexus, branches pass to the
pyloric portion of the stomach, sphincter and D1. Branches of the phrenic nerve (C3-5) also
innervate the liver via the hepatic plexus.
Peritoneum and Other Abdominal Connective Tissues

The peritoneum is a complex invaginated, serous membrane that invests many
of the abdominal viscera, blood vessels and nerves. The peritoneum is divided into
parietal and visceral layers. The two layers of the peritoneum are separated by a
potential space, the peritoneal cavity, which is a closed sac containing a small layer of
fluid that allows the viscera to move freely over each other without friction.
The parietal layer lines the abdominal wall, pelvic wall and inferior surface of the
diaphragm. The parietal peritoneum reflects from the body wall onto the surfaces of
many viscera as a visceral layer that covers and is fused to the surface of te organ.
Viscera with such peritoneal coverings on several surfaces are referred to as
peritonealized or intraperitoneal organs. Many of the visceral peritoneal reflections from
the body wall form named mesnteries and ligaments that provide considerable mobility
for the viscera. It is important to note that most of the vascular and nerve supply to the
peritonealized viscera is distributed through these visceral reflections. The relationships
between the vascular and nerve supply and the visceral peritoneum is of primary
importance.
The retroperitoneal viscera are the organs located posterior to the parietal
peritoneum and thus are usually covered on only one surface by the peritoneum. The
aorta, most of the pancreas and duodenum, ascending and descending colon, kidneys
and inferior vena cava are examples of retroperitoneal structures on the posterior
abdominal wall.
The greater omentum which attaches to the inferior, left border (greater
curvature) of the stomach is a peritoneal apron divided into three parts: the gastrolienal
(gastrosplenic) ligament, the gastrophrenic ligament and the gastrocolic ligament.
From the superior, right border (lesser curvature) of the stomach is the lesser
omentum. It extends from the visceral surface of the liver to the stomach and first part
of the duodenum. The lesser omentum is formed by two ligaments, the hepatogastric
ligament, which is thin and transparent and connects the liver and the lesser curvature
of the stomach and the hepatoduodenal ligament, which extends from the liver to the
first part of the duodenum. This latter ligament is thick because it contains a number of
vasculare structure.
In addition to the attachments of the lesser omentum to the visceral surface of
the liver , the liver is attached to the anterior body wall and diaphragm by the falciform
ligament containing the ligamentum teres. The continuation of the falciform ligament
from the liver to the diaphragm and posterior body wall forms the coronary ligaments.
The gallbladder projects from the inferior border of the liver and is attached to
the visceral surface of the liver and is covered by peritoneum
The first part of the duodenum (D1) near the right side of L1 is mostly
intraperitoneal (hepatoduodenal ligament) and is relted superiorly to the gallbladder and
quadrate lobe of the liver. Posterior to D1 is the gastroduodenal artery, common bile
duct and hepatic portal vein. Just inferior to it is the head of the pancreas.
The peritoneal cavity is divided into two compartments, the greater and lesser
peritoneal sacs. The anterior boundary of the lesser peritoneal sac (also called the
omental bursa) is formed by the posterior surface of the stomach, gastrocolic ligament
and the lesser omentum. The inferior boundary of the lesser sac is formed by the
transverse colon and transverse mesocolon. The superior boundary of the omental
bursa is the left lobe of the liver and the posterior lamina of the coronary ligament.
The greater peritoneal sac occupies the remainder of the peritoneal cavity. The
omental bursa communicates with the greater peritoneal sac via the epiploic foramen of
Winslow. This foramen is posterior to the right free margin of the lesser omentum. The
boundaries of the epiploic foramen are as follows: inferiorly, the first part of the
duodenum, superiorly, the liver (caudate lobe); posteriorly, the retroperitoneal inferior
vena cava; and anteriorly, the right free margin of the lesser omentum (hepatoduodenal
ligament).
The liver is the largest gland of the body and is located mainly in the upper right
quadrant of the abdomen, inferior to the diaphragm and deep to the right costal margin.
It is covered by visceral peritoneum, except for the bare area adjacent to the diaphragm
and posterior wall. From the anterior body wall, the falciform ligament extends from the
umbilicus to the visceral surface of the liver. In its inferior free border is ligamentum
teres. The right and left divergence of the falciform ligament travel onto the
diaphragmatic surface of the liver to form the right and left anterior layers of the
coronary ligament. The anterior layers extend to the right and left onto the
diaphragmatic surface of the right and left lobes of the liver and make a sharp, medial
reflection to form the right and left triangular ligaments. The posterior layers of the
coronary ligament continue from the triangular ligaments and reach the visceral surface
of the liver, where they encircle the prta hepatis and then continue to the stomach and
first part of the duodenum as the lesser omentum (hepatogastric and hepatoduodenal
ligaments. The bare are of the liver is devoid of a peritoneal covering and is located
primarily posterior to the right aspect of the coronary ligament.
There are several structures that pass in and out of the liver through the right
free margin of the lesser omentum: the proper hepatic artery, hepatic portal vein and
common bile duct. The proper hepatic artery and the common bile duct are anterior and
the hepatic portal vein is posterior. They enter or leave the visceral surface of the liver
at the porta hepatis.
The proper hepatic artery divides into the right and left hepatic arteries near the
porta hepatis. The cystic artery branches from the right hepatic artery. The proper
hepatic artery also gives origin to the right gastric artery in the lesser omentum.
The hepatic portal vein, which drains most of the gastrointestinal system,
pancreas and spleen and branches into right and left branches similar to the arteries.
The origin of the hepatic portal vein is deep to the neck of the pancreas .by the junction
of the superior mesenteric and splenic veins. If portal obstruction, which could be due
to a lesion of the lesser omentum, venous returns to the right atrium via an alternate
route (ie) via esophageal, rectal, paraumbilical and retroperitoneal routes.
At the porta hepatis the right and left hepatic ducts unite to form the common
hepatic duct. Inferior to the formation of the common hepatic duct, the cystic duct joins
in to for the common bile duct. It descends in the lesser omentum and posterior to the
duodenum to reach the pancreas and second part of the duodenum.
The peritoneum is like a big bag in the abdomen. It is fascia with two layers.
The visceral peritoneum covers the viscera. It contains the embryonic cells for
the organs and it grows and folds around the viscera. The visceral peritoneum changes
names and is called ligaments, mesos, omentums, or fascias.
The parietal layer lines the whole abdominal cavity.
Organs are divided into those that are intra - peritoneal and retroperitoneal.
Intra-peritoneal where the organ is completely covered by peritoneum such as the liver,
spleen, stomach, tail of pancreas, gallbladder, small intestine, transverse colon, sigmoid
colon. Those that are retroperitoneal or in other words only one aspect of the viscera
and organ is covered by peritoneum, includes most of digestive tube, most of
duodenum, pancreas, ascending colon and descending colon, kidneys..
Mesos are named parts of the peritoneum which unite parts of the digestive tube
to the abdominal wall. Anything with a meso, has a lot more mobility and is more
anterior
Omenumts are the name of layers of peritoneum, which attach tow organs or
viscera together. Omental Bursa...... The coronary ligament is superior part of omental bursa.
The omentum migrates towards any site of inflammation.
Abdominal fascia, also known as sticking fascia are transition areas between the
where visceral peritoneum sticks to the parietal peritoneum when organ becomes a
retro peritoneal organs. The duodenum and the and pancreas are attached to the
Fascia of Treitz. The Fascia of Toldt is attached to the ascending and descending
colon. Anything with a fascia, is more posterior and more bound down.
Peritoneum
Most of the abdominal organs are covered by a membrane known as the peritoneum. It
is a large membrane folded back on itself and forming 2 layers. The layer attached to the organ
is known as the Visceral Peritoneum. The layer attached to abdominal wall or other tissue is
known as the Parietal Peritoneum. Between the two layers is a thin film of serous fluid which
keeps the two layers in contact but allows for friction-free gliding of one layer on the other.
These layers include the pleura, cardium, peritoneum, meninges (arachnoid and dura). The
peritoneum has loose connective tissue which attaches it to other structures. The adipose
makes it loose. If it is connected to the abdominal wall it is known as Mesentery. If like the
lesser omentum and greater omentum it attaches it to another organ is known as Omentum.
Some structures in the post abdomen are not covered by peritoneum and are said to be
Retroperitoneal Structures (ie) behind. This includes the kidneys, ureters, pancreas and some
parts of the liver and colon. Inferiorly the peritoneum rests on the bladder in males and bladder
and uterus in females.
The lesser omentume attaches to the lesser curvature, meets with falciform
ligament and contains the portal vein
Grays pg 899-902
Muscle and Ligament of Treitz

In embryology when the ligament of Treitz is forming there is migration of the
muscular tissue of the pillars of the diaphragm and the fascial tissue of the omentum. A
diaphragm spasm will make the angle more acute or more closed. Up to right crux of
diaphragm. Part of the cross connective tissue chains
Baral
Lesser Omentum
- pg 83: The liver is closely connected via the hepatic vein to the inferior vena cava, which in
turn adheres strongly to the diaphragm. The lesser omentum is a peritoneal fold uniting the liver
to the esophagus, stomach and superior duodenum. It is covered by the liver and its anterior
aspect faces left. Its gastroduodenal edge begins at the right side of the abdominal esophagus,
follow along the lesser curvature of the stomach and ends at the superior duodenum. The
lesser omentum comprises the hepatogastric ligament (which is furled like a sail) and the
hepatoduodelan ligament (which is fixed to the descending duodenum, hepatic flxure of the
colon and greater omentum.) The hepatoduodenal ligament is relatively strong for an omentum.
All of these connections have an important influence on the livers motion.
- pg 85 picture of Topographical Anatomy of the Liver.
- pg 115: Picture of Visceral Articulations of the Stomach
- pg 116: The lesser omentum joins the lesser curvature of the stomach to the liver. It is found
far posteriorly and faces right and superiorly. The greater omentum is a peritoneal fold which
joins the stomach to the transvers colon. It is joined to the diaphragm by the phrenicoloic
ligaments at the level of the colonic flexures. The gastrosplenic omentum connects the stomach
to the spleen but does not appear to have a supporting role.
- pg 116 To summarize, the stomach is interdependent with the diaphragm by means of the
gastrophrenic ligament and greater omentum, it also have a very close connection with the liver
and lesser omentum.
Pocket Atlas of Human Anatomy Heinz Fenesis Thieme Publisher:

Hepatocolic ligament is an inconstant continuation of the hepatoduodenal
liagment. It continues towards the right at the right colic flexure or at the transverse
colon.
Lesser Omentum Relationship with the Liver - Penny
In addition to the attachments of the lesser omentum to the visceral surface of

the liver, the liver is attached to the anterior body wall and diaphragm by the falciform
ligament containing the ligamentum teres. The continuation of the falciform ligament
from the liver to the diaphragm and posterior body wall forms the coronary ligaments.
The gallbladder projects from the inferior border of the liver and is attached to
the visceral surface of the liver and is covered by peritoneum
Peritoneal relations of the liver

The lesser omentum,enclosing the portal triad (portal vein, bile duct, and hepatic
artery) at the porta hepatis, passes to the lesser curvature of the stomach and the first 2
cm of the superior part of the duodenum. The part of the lesser omentum extending
between the liver and stomach is called the hepatogastric ligament and the part
between the liver and the duodenum is called the hepatodeodenal ligament. The free
edge of the lesser omentum enclosed the portal triad, a few lymph nodes and lymphatic
vessels and the hepatic plexus of nerves
Spatial Relationships of the Liver with Other Organs

Directly above the liver are the lungs, the heart, pericardium and mediastinum.
Attached under the liver to the right lobe are the hepatic flexure of the colon (anterior)
and the right kidney (posterior). These leave impressions in the liver itself. More medial
is the gallbladder, which leaves a deep indentation in the liver. In the same vicinity,
usually just medial to the gall bladder, is the first part of the duodenum.
Under the left lobe of the liver and somewhat posterior, sits the upper surface of
the stomach and a small portion of the esophagus. These two structures leave
impression under the left lobe. Above the left lobe of the liver sits the heart,
pericardium, mediastinum and part of the left lung. The lesser curvature of the stomach
is attached to the liver via the lesser omentum, which is in reality a posterior inferior
continuation of the falciform ligament.
The relationship between the lesser omentum and the liver is important because the
liver has many key functions and will not move and function well if restricted by the lesser
omentum.. Among some of the important features of the liver is that it is the thoraco-abdominal
pivot point. The left lobe in on the left side of body with the Falciform ligament dividing the two
parts is very central (just to the right of midline). The liver is in the right upper quadrant,
between 5-8th rib on the right. It is in an oblique position (oblique towards the left). The left lobe
is smaller. It is under right diaphragmatic surface. The liver has many ligamentous and
connective tissue attachments.
Another important aspect of the relationship between the lesser omentum and the liver
is tha the lesser omentum, the falciform ligament and the falx cerebrum come from the same
embryologic tissue. The falciform ligament also known as the falx of the liver is part of the part
of central chain and folds into each lobe. It comes anterior on anterior abdominal wall, goes
along the anterior parietal peritoneum. It is part of original visceral peritoneum and attaches to
the septum and the anterior abdominal wall.
The coronary ligaments attache the whole superior aspect of the liver to the
diaphragm. On the right lobe it comes down on the posterior aspect and is part of the
visceral peritoneum. At the extremities they are called the triangular ligament. The left
and right triangular ligament attached to diaphragm. The inside the posterior aspect of
the coronary ligament is called the bare area (defined by the coronary ligament). The
bare area is the only area of the liver that has no peritoneum. At this place it is held up
by suction to the diaphragm (there is space). The coronary on posterior aspect comes
towards the stomach. The falciform is anterior. It is called the lesser omentum and
attaches to the lesser curvature of the stomach
Relationship with Gallbladder

Gallbladder goes through the hepatogastric ligament and constriction can cause
congestion in gallbladder, liver, D1, D2, and pancreas.
Lesser Omentum Presentation 17 4th Year CCO Penny Fleming / Kim Burnham
Osteopathic Relevance and Relations The Lesser Omentum and the Liver
Barral states that normal extrinsic motions provide healthy adaptations to

constraints imposed by motor and autonomic activities. For example, it is key to the
digestive process that the pylorus, pyloric sphincter and D1 remain mobile so to
accommodate for increases in size of the stomach when filling. Thus, lesser omentum
mobility is a significant factor in maintaining this capacity. Barral continues that intrinsic
motility is the manifestation of good health of an organ and the ability to function at its
best. Obstacles to visceral motion such as restriction of the lesser omentum will
predispose the organ to an abnormal physiology, which translated to functional
difficulty. For example, adhesions of the lesser omentum can be caused by infections
(peritonitis or gastritis), scar tissue (MVA or trauma), surgical intervention of the thorax
or abdomen (pancreatic surgery access site in through foramen of Winslow),
inflammation (caused by secretion of peritoneal fluid) or tumors (benign or malignant).
The lesser omentum lies in close relation to the liver via its attachment
surrounding the porta hepatis and the fissure for the ligamentum venosum. With this in
mind, we should consider all the visceral relations of the liver. Superiorly (and laterally),
the liver is in direct contact with the thoracic diaphragm, and thus indirectly with the
pleura, pulmonary bases of the R & L lobes, pericardium, ventricular part of the heart
and the endothoracic fascias. Posteriorly, the liver provides a groove and hence,
contacts with the inferior vena cava. On the inferior or visceral surface of the liver
imprints for various organs delineate their articulations. These include the R superior
portion of the stomach, the hepatic flexure of the colon, the duodenum (primarily D1 &
D2), the R kidney and R suprarenal capsule, and the gallbladder. More precisely, the
quadrate lobe of the liver is in close relation with the pyloric end of the stomach and D1
of the duodenum. Given that the lesser omentum directly contacts the caudate lobe and
the porta hepatis lies between the quadrate and caudate lobes, tension via the lesser
omentum on the liver would primarily effect these lobes initially.
The liver is also considered the command organ of the abdomen. . Any reduction
in the mobility or motility of the liver would impact significantly on these articulating
structures and their relationship with the liver. Thus, influences on the gastrointestinal
tract, the craniovertebral system (T5-9, C3-5, OM), the musculoskeletal system (R
shoulder), the vascular system and the acid-base balance of the body are multiple and
diverse.
Normal mobility of the liver (R SF + L Rot + anteflexion) and stomach (L SF + R
Rot) provides a system of autoregulation for the abdomen by facilitating pumping of the
abdominal organs. This visceral pump crosses through the lesser omentum and
facilitates regulation of abdominal pressures. Thus, any restriction of the lesser
omentum or decreased mobility of these two organs will reduce pumping action and
further effect organ mobility, abdominal pressures, and the flow of fluids.
It is the coordinated movement of the liver and all abdominal organs that allows
for normal peristalsis and mechanical processing through segmentation. Any
disturbance to the coordinated movement, such as tension of the lesser omentum
restricting the stomachs ability to SF + Rot will slow the digestive process and impair
function of the subsequent viscera.
Compression of the lesser omentum, its contents and the surrounding structures
can occur via a ptosis or inferior shear, a L SF and lateral shear, or hepatomegaly of
the liver. Consider compression of the hepatic artery, its effects and the role of the
artery is absolute. Restriction of blood flow to the liver results in decreased function of
the liver but also of other organs supplied by branches of the hepatic artery such as the
gallbladder, stomach, spleen, duodenum, greater omentum, pancreas. If the portal vein
were effected increases in portal pressure (known as portal hypertension) would result
in congestion within structures of the portal system (see Netter 297) as well as the
portocaval anastomoses. This may appear as ascites (the accumulation of fluid in the
peritoneal cavity) or as varisose veins, esophageal varices or hemorrhoids as the body
seeks a means of collateral circulation. Since the role of the artery is considered
absolute, a patent hepatic artery and portal vein are critical to the function, mobility and
motility of the liver and other abdominal viscera.
Ptosis of the liver or compaction of the liver on the stomach (or vice versa) will
also decrease the vascular and lymphatic circulation along the lesser curvature of the
stomach. Thus, the R & L gastric arteries and veins and the lymphatic nodes and
vessels of this peritoneal space would be compromised. As a result, decreased blood
and lymphatic flow to and from the stomach (primarily anterior surface) would decrease
leading to decreased functional capacity. Compression of vascular structures within this
area is common due to enlarged lymph nodes.
Compression of the lesser omentum will also effect the passage of bile not only
from the liver to the gallbladder for storage and concentration but also from the
gallbladder to the Ampulla of Vater at D2. Obstruction to the flow of bile can lead to
poor digestion of fats and ultimately, jaundice. This may be seen as an example of
structure governs function. Obstruction or compression certainly reduces the functional
capacity of the liver and gallbladder.
Other examples of structure governs function can be seen in altered positions of
the liver and reduced ability to detoxify portal blood, regulate the systems pH balance
and store glycogen. Barral reports listless, fatigued persons often suffer from some
form of liver dysfunction. An altered mechanical relationship with the thoracic
diaphragm may change the diaphragms functional capacity by decreasing its descent
(thus effecting the mobility of all the abdominal organs and viscera), decreasing
respiratory capacity and eventually respiratory rate.
If the liver loses its axis, it no longer acts as the thoracolumbar pivot which in
turn decreases the dissociation between the pelvis and the thorax, which leads to
increased incidence of shoulder, scapular and upper thoracic problems. This loss of
axis will also alter the neurological output of the greater splanchnic nerve which again
will effect its other recipients including the stomach, spleen, pancreas, omenta,
gallbladder and duodenum. Ptosis of liver or inferior displacement may also place the
gallbladder in contact with D1 and/or D2. This may alter digestive function by
decreasing transit from the stomach or altering the flow of bile and pancreatic enzymes
via the sphincter of Oddi.
Traction on the liver via the lesser omentum can be related to ptosis of the
stomach or the transverse colon. Lesions or restrictions of the stomach such as an L
lateral shear, a R SF + L Rot (PRS L or Expiration) restriction, or a L SF + L Rot lesion
will all place tension on the lesser omentum and thus the liver. Similarly, L rotation of
the esophagus, or inferior displacement of the D1 will place tension on to the lesser
omentum. The primary structures effected would be the hepatic artery, portal vein,
common bile duct, various lymphatic vessels and nodes and the hepatic plexus.
Restricted lymphatic flow can lead to congestion within the liver or liver nodes.
Compression of the hepatic plexus will significantly alter or diminish the functional
capacity of the liver.
The liver and stomach are part of the lateral fascial chains. If one or both of
these organs are restricted due to adhesions within the lesser omentum, other
structures of these pathways may also be effected. Similarly, the lesser omentum, by
way of its attachment to the lesser curvature of the stomach is part of the central chain.
It may be effected by tensions within the chain as a result of superior or inferior
structures in lesion or restriction of the lesser omentum secondary to ptosis of the liver
or stomach will have an impact on the central chain.
Lesser Omentum Relationship with Esophagus, Stomach and Duodenum
Organs are divided into those that are intraperitoneal and retroperitoneal.
Intraperitoneal where the organ is completely covered by peritoneum such as the liver,
spleen, stomach, tail of pancreas, gallbladder, small intestine, transverse colon, sigmoid
colon. Those that are retroperitoneal or in other words only one aspect of the viscera
and organ is covered by peritoneum, includes most of digestive tube, most of
duodenum, pancreas, ascending colon and descending colon, kidneys..The lesser
omentum provides some of the peritoneum and intraperitoneal status for the liver,
stomach, duodenum, esophagus.
The lesser omentum is a peritoneal fold uniting the liver to the inferior esophagus, leeser
curvature of the stomach and superior duodenum.. It is covered by the liver and its anterior
aspect faces left. Its gastroduodenal edge begins at the right side of the abdominal esophagus,
follow along the lesser curvature of the stomach and ends at the superior duodenum. The
lesser omentum comprises the hepatogastric ligament which is thin and transparent
membrane that is furled like a sail and the hepatoduodenal ligament, a thickmembrane which is
fixed to the descending duodenum, hepatic flexure of the colon and the greater omentum. The
hepatoduodenal ligament is relatively strong for an omentum and is thick due to a number of
vascular structures contained within it.. The liver is closely connected via the hepatic vein to the
inferior vena cava, which in turn adheres strongly to the diaphragm. All of these connections
have an important influence on the livers motion.
The peritoneal cavity is divided into two compartments, the greater and lesser
peritoneal sacs. The anterior boundary of the lesser peritoneal sac (also called the
omental bursa) is formed by the posterior surface of the stomach, gastrocolic ligament
and the lesser omentum. The inferior boundary of the lesser sac is formed by the
transverse colon and transverse mesocolon. The superior boundary of the omental
bursa is the left lobe of the liver and the posterior lamina of the coronary ligament. The
pancreas is posterior and the spleen is lateral to the omental bursa. The omental bursa
communicates with the greater peritoneal sac through the omental foramen (epiploic
foramen). This foramen is posterior to the right free margin of the lesser omentum. The
boundaries of the epiploic foramen of Winslow are: the first part of the duodenum,
superiorly, the liver (caudate lobe); posteriorly, the retroperitoneal inferior vena cava;
and anteriorly, the right free margin / posterior leaf of the lesser omentum
(hepatoduodenal ligament).
As mentioned the lesser omentum joins the superior right border of the anterior stomach
at the lesser curvature to the liver. It is found far posteriorly and faces right and superiorly. The
greater omentum is a peritoneal fold which joins the stomach to the transverse colon. It is
joined to the diaphragm by the phrenicoloic ligaments at the level of the colonic flexures. The
gastrosplenic omentum connects the stomach to the spleen but does not appear to have a
supporting role. The stomach is also interdependent with the diaphragm by means of the
gastrophrenic ligament and greater omentum.
The stomach is a musculoglandular sack, which is mobile; contractile,
deformable. It is on the left side under the liver. It starts at the cardia at end of
esophagus. The fundus is also called the tuberosity. The stomach is in the shape of a
J. The more medial aspect is the lesser curvature, where the lesser omentum attaches.
The lateral aspect is the greater curvature. The pylorus at bottom of J as it comes up.
The pyloric sphincter between stomach and duodenum. The stomach is the attachment
between the esophagus and duodenum.
Opposite the lesser omentum on the lesser curvature is the greater omentum,
which attaches the stomach to transverse colon loosely like an apron. The greater
omentum is full of fatty tissue and attaches stomach to spleen called gastrosplenic or
gastrolienal ligament at that point. (lienal is an another word for spleen). The
gastrophrenic ligament attaches stomach to diaphragm.
Epiploic means related to stomach and omentum and there are many arteries
and veins housed in the gastroepiploic area. There are very important anastomosis at
this point between the two layers underneath the stomach. There is another important
anastomosis in lesser omentum between the left and right gastric arteries and veins.
In addition to the liver via the lesser omentum the stomach has other important
relationships. Lateral to stomach is spleen. Behind the stomach tail of pancreas, left
kidney and mesocolon transverse, omental bursa. The omental bursa is a pouch with
liquid to permit sliding between stomach, pancreas, spleen, transverse colon and
between the greater and lesser omentum.
Restriction of the lesser omentum will influence stomach functions, which include
mixing by peristaltic movement; evacuation by the pylorus; alcohol and water are
absorbed but no food and the breakdown of proteins by the hydrochloric acid.
The movements of the stomach on inspiration are sidebending left, rotation right
(opposite to liver). There is a pump happening between stomach and liver sidebend
opposite and rotation towards each other. There is no ante/post flexion of the stomach
since it is limited by the esophagus. The axis for rotation is esophagus (stomach does
mostly rotation). The sidebending axis is the gastrophrenic (small ligament, small
sidebending).
The mechanical churning and mixing functions of the stomach require a good
mobility vertically and laterally for optimal function. The osteopathic manupulations will
focus on regaining motion in all three planes, except at the areas of attachment which
will be encouraged to be supple. This means stretching and loosening adhesions and
viscerospasms. Also, encouraging elasticity and suppleness of surrounding connective
tissues and the local suspensory tissues. Then of course, mobility and motility will be
encouraged to more normal levels.
The first part of the duodenum (D1) near the right side of T12 - L1 is mostly
intraperitoneal (covered by the hepatoduodenal ligament) and horizontal in orientation.
There are two parts of D1. The first part encased in the lesser omentum going up to the
liver. The second part of D1 is retroperitoneal, not mobile, fixed by the fascia of Treitz.
D1 is just below ribs on right side of midline. It is related superiorly to the gallbladder
and quadrate lobe of the liver. Posterior to D1 is the gastroduodenal artery, common
bile duct and hepatic portal vein. Just inferior to it is the head of the pancreas.
In the Atlas of Operative Surgery Esophagus Stomach Duodenum the medial
edge of the hepatogastric ligament is defined as the hepatoesophageal ligament. This
provides an attachment between the liver and the esophagus.
Functions of the Lesser Omentum
The lesser omentum stabilizes the position of the stomach and provides an
access route for blood vessels and other structures entering and leaving the liver. The
lesser omentum helps the falciform ligament to stabilize the position of the liver relative
to the abdominal wall.
Fascia plays an important supportive, stabilizing and anchoring role with respect
to the body viscera, but some of the implications of this role are easy to overlook,
according to Gerald Cooper, DO, FAAO in the Jan 1979 Journal of AOA. He goes on to
say that when the body is in a pronograde position its walls give support to the
suspended viscera and there is little opportunity for visceral displacement. In the
orthograde position of man the viscera of the abdomen are suspended from the
porterior wall of the cavity. They tend to assume a more dependent position than in
other animals, with the result that mesenteric drag and the harmful results of pressure
are more common.
Jean Pierre Baral, DO also notes that abdominal pressures are affected by:
ligamentous structures such as the lesser omentum as well as other serous
membranes (meningies, pleura, pericardium, peritoneum) and serous fluid creates
suctioning from one organ to another. The double layer system of serous membranes
and fluid create suction in pulmonary, cardiac, peritoneal, cerebrospinal and visceral
articulations. The ligamentous structures: maintain the structures in the proper
relationship with one another. The peritoneal fascias also provide a nutritive function by
providing passage ways for vascular and lymphatic sturctures.
The lesser omentum has an influence on the physiologic motion of the liver,
stomach, duodenum, esophagus due to its attachments. An organ/viscera in good
health has physiologic motion. The viscera are affected and affect 4 areas in the body.
The somatic nervous system, abdominal muscle tone, the autonomic nervous system
and cranial rhythmic impulse.
The somatic nervous system controls the voluntary motion from CNS (ie) forward
bending. The liver moves in relation to diaphragm and stomach. One of the reasons for
this movement is the connection via the lesser omentum. The stomach has to move in
relation to diaphragm. Raising an arm moves the lung, gait, movement of trunk. All
viscera contained within the skull, thorax or abdomen.
The autonomic nervous system controls the diaphragm movement (5-18
cycles/minute). It is responsible for the automatic survival response. The diaphragm
contracts anterior and inferior, 24,000 times a day. Diaphragm descends in inhalation
and presses on organs, expansion of thorax. The abdominal cylinder: posterior and
inferiorly skeleton so creates a downward pressure and horizontal force. Organs move
in 3 planes: sagittal, frontal & transverse. The Diaphragm related to viscera (Liver,
Glissons Capsule, Coronary Ligament, Right and Left Triangular Ligament, Falciform
Ligament, Esophagus, Esophageal hiatus, Cardiac Sphincter, Stomach, Gastrophrenic
Ligament, Greater Omentum, Lesser Omentum, Gastro Hepatic Ligament, Hepato
Duodenal Ligament, Ligament of Trietz, Phrenico-colic ligaments, Transverse colon,
Hepatic Flexure, Splenic Flexure)
The heart motion directly affects lungs, esophagus, mediastinum, and
diaphragm. 120,000 beats a day. Inferior vena cava, abdominal aorta and esophagus
pass through the diaphragm. Visceral manipulation can increase circulation to viscera
through palpation.
There are three types of restrictions lead to decreased motion. These are
articular, ligamentous or muscular restrictions. There can be functional or. positional
restrictions. There are several things that can decrease the motility of the abdominal
organs. Food substances can decrease motility. Nervous depression affects liver
motility. Articular restrictions lead to decreased mobility and motility. Ligamentous laxity
can cause a ptosis, which restricts superior movement.. There can also be muscular
restrictions or viscerospasm: Hollow organs like the stomach and intestines are most
affected by a stasis of transit and decreased motility.
Lesser Omentums Relationship with Portal Triad
Arteries, Veins, Bile Duct and Lymphatics
Housed in the lessor omentum are the portal triad consiting of the portal vein;
hepatic artery and the bile duct.
The left and right gastric arteries and veins also have an important anastomosis
in the lesser omentum. The inferior portion of flaccid part of the lesser omentum
contains the right gastric artery.
The arteries supplying the liver include the abdominal aorta which gives rise to
the phrenic arteries right and left; the celiac trunk to liver, duodenum, pancreas,
spleen, pancreas, and the hepatic artery and cystic artery to gallbladder
Treatment of the lesser omentum very important for blood flow in subdiaphragm
The liver is very fluidic, when treating it it is important to focus of the volume and the
fluid flow through the lesser omentum to and from the liver.
The liver is the largest gland of the body and is located mainly in the upper right
quadrant of the abdomen, inferior to the diaphragm and deep to the right costal margin.
It is covered by visceral peritoneum, except for the bare area adjacent to the diaphragm
and posterior wall. From the anterior body wall, the falciform ligament extends from the
umbilicus to the visceral surface of the liver. In its inferior free border is ligamentum
teres. The right and left divergence of the falciform ligament travel onto the
diaphragmatic surface of the liver to form the right and left anterior layers of the
coronary ligament. The anterior layers extend to the right and left onto the
diaphragmatic surface of the right and left lobes of the liver and make a sharp, medial
reflection to form the right and left triangular ligaments. The posterior layers of the
coronary ligament continue from the triangular ligaments and reach the visceral surface
of the liver, where they encircle the prta hepatis and then continue to the stomach and
first part of the duodenum as the lesser omentum (hepatogastric and hepatoduodenal
ligaments. The bare are of the liver is devoid of a peritoneal covering and is located
primarily posterior to the right aspect of the coronary ligament.
There are several structures that pass in and out of the liver through the right
free margin of the lesser omentum: the proper hepatic artery, hepatic portal vein and
common bile duct. The proper hepatic artery and the common bile duct are anterior and
the hepatic portal vein is posterior. They enter or leave the visceral surface of the liver
at the porta hepatis.
The proper hepatic artery divides into the right and left hepatic arteries near the
porta hepatis. The cystic artery branches from the right hepatic artery. The proper
hepatic artery also gives origin to the right gastric artery in the lesser omentum.
The hepatic portal vein, which drains most of the gastrointestinal system,
pancreas and spleen and branches into right and left branches similar to the arteries.
The origin of the hepatic portal vein is deep to the neck of the pancreas .by the junction
of the superior mesenteric and splenic veins. If portal obstruction, which could be due
to a lesion of the lesser omentum, venous returns to the right atrium via an alternate
route (ie) via esophageal, rectal, paraumbilical and retroperitoneal routes.
At the porta hepatis the right and left hepatic ducts unite to form the common
hepatic duct. Inferior to the formation of the common hepatic duct, the cystic duct joins
in to for the common bile duct. It descends in the lesser omentum and posterior to the
duodenum to reach the pancreas and second part of the duodenum.
Within the liver lobes are multiple, smaller anatomic units called liver lobules.
They are formed of cords or plates of hepatocytes, which are the functional cells of the
liver. These cells can regenerate; therfore damaged or resected liver tissue can regrow.
Small capillaries or sinusoids are located between the plates of hepatocytes. They
receive a mixture of venous and arterial blood from branches of the hepatic artery and
portal vein. Blood from the sinusoids drains to a central vein in the middle of each liver
lobule. Venous blood from all the lobules then flows into the hepatic vein, which
empties into the inferior vena cava. Small channels (bile canaliculi) conduct bile, which
is produced by the hepatocytes, outward to bile ducts and eventually drain into the
common bile duct. This duct emties bile into the duodenum through an opeing called
the sphincter of Oddi (major duodenal papilla).
Roughly one-third of the blood supply to the liver is arterial blood from the
hepatic artery. The remainder consists of venous blood from the hepatic portal vein,
which begins in the capillaries of the esophagus, stomach, small intestine, and most of
the large intestine. The distribution and major tributaries of the hepatic portal vein
were... In the liver, the hepatocytes adjust circulating levels of nutrients by selective
absorbtion and secretion. Blood leaving the liver returns to the systemic circuit via the
liver returns to the systemic circuit via the hepatic veins that open into the inferior vena
cava.
Blood enters the liver sinusoids from small brnaches of the portal vein and
hepatic artery. A typical lobule has a hexagonal shape in cross section. There are six
portal areas or hepatic triads, one at each corner of the lobule. A portal area contains
three structures: a branch of the hepatic portal vein, a branch of the hpatic artery and a
small branch of the bile duct.
Liver disease such as the various forms of hepatitis and conditions such as
alcoholism can lead to degenerative changes in the liver tissue and contriction of the
circulatory supply. Any condition that severely damages the liver represents a serious
threat to life. The liver has a limited ability to regenerate after injury, but liver function
will not fully recover unless the normal vascular poattern returns.
When working osteopathically on the abdomen there are several things to
consider. First look for non-physiological lesions, which influence on structures of the
abdomen. It is also very important to keep in mind the osteopathic concept of the role of the
artery. Think of the compression on the arteries, veins, lymphatics, nerve. Then consider pull on
the fascias (lesser omentum) and vessels passing through this area. A ptosis of the stomach is
very common as well as hiatus hernia.
Splenic a gives off the left gastroepiploic. Left gastric branch off the celiac trunk.
Right gastric branch off the hepatic trunk. Right and left meet / anastomose to supply
the lesser curvature of the stomach . The large hepatic trunk off celiac a. The right and
left gastroepiploic arteries anastomoses in the greater omentum. The celiac a.>
hepatic > gastrodueodenal> right gastroepiploic . In addition to a lesser omentum
lesion the pancreas in eversion lesion will compress on these arteries.
The portal vein receives blood from the right and left gastric veins; the superior
mesenteric vein and the splenic vein. The portal vein enters the liver at the hilum or the
porta hepatis (doorway to the liver). Other structures found at the hilum of the liver are
the common hepatic duct, proper hepatic artery and the portal vein. From there
deoxygenated blood travels to the inferior vena cava. Blood in the portal veins can be
very warm at 40 degrees Celcius.
When the liver is congested there will be pressure in veins and back into the
portal vein. The rectal area have an anastomosis that will cause hemmerhoids if liver is
congested. It is important to get the liver mobilizied and functioning better. Other areas
where congestion can cause varicosities is at the esophagus; retroperitoneal and also
paraumbilical.
Lesions Involving the Lesser Omentum
Ptosis, Hiatal Hernia, Acute Abdomen, Cancers, Portal Hypertension,
Peritonitis and Abscesses
Ptosis and Hiatal Hernia

Given the attachments superiorly on the liver and inferiorly on the stomach the
lesser omentum can cause problems with the location of these two organs. The liver
can be pulled down by lesser omental adhesions and fibrosis. This would be a ptosis of
the liver. The lesser omentum can also disturb the pressure relationship between the
esophagus to which it has a attachments and the stomach to which it is also attached.
This can result in a hiatal hernia or esophageal reflux.
When working with a client with a ptosis of the stomach the osteopath should do
the lesser omentum and the greater omentum techniques first to free up the
ligamentous attachments of the stomach.
The lesser omentum can also be damaged in the case of hiatal hernia surgery.
Since in surgery for Gastroesophageal Reflux Disease; Fundoplasty,
Esophagofundopexy and Posterior Hiatoplasty there is a longitudinal incision through
the dense portion of the lesser omentum above the branches of the anterior vagal trunk
parallel to the right edge of the abdominal esophagus. So the osteopath has to consider
the clients history and symptoms when considering to work on the lesser omentum.
Acute Abdomen
Torsion of the omentums, whether primary or secondary, may present as an
acute abdomen, mimicking acute appendicitis, acute cholecystitis or twisted ovarian
cyst. Depending on the bulk of strangulated omentum involved, a mass may or may not
be palpable. Medically a laparotomy is indicated when the surgeon is confronted with
an acute abdomen. Medically the omental torsion is resected. If the osteopath is
presented with an acute abdomen, that is the time to refer the client to their M.D. to rule
out a medical condition. .
Omental and Stomach Cancers

Omental cysts are rare, usually an incidental finding at laparotomy, and are
typically small. Occasionally they may be large and if palpable are usually smooth,
ballottable, nontender midabdominal masses. Diagnosis is made at laparotomy and
tretment is complete excision. Omental tumors are usually metastatic and typically of
gastric, colon, or ovarian origin. If palpable, they are firm, ballottable, and nontender.
Multiple masses may be palpated that are the result of metastatic disease. Definition of
the primary site is essential.
Generally with gastric carcinoma the lesser and greater omentum is excised as
part of a partial or full gastrectomy. Cancer of the stomach. All types below are
adenocarcinomas (cancer of glandular tissues). About 10 percent of all U.S. Cancer
deaths result from gastric carcinoma. It is one of the most common lethal cancers,
responsible for roughly 15,000 deaths in the United States each year and rising.
Treatment involves the surgical removeal of part or all of the stomach. Even a total
gastrectomy can be survived, because the only absolutely vital function of the stomach
is the secretion of intrinsic factor. Protein breakdown can still be performed by the small
intestine, although at reduced efficiency, and the loss of gastric functions such as food
storage and acid production is not life-threatening.
Stomach cancer spread to the liver, lungs, brain and bone. The pathway of the spread
of the cancer can be via the portal vein (travelling through the lesser omentum) which carries
blood from the digestive system to the liver and back to the heart. Early symptoms are rare.
Usually there is no pain. The pain comes later when it enters the bones. The person slowly
becomes anorexic. Indigestion; weight loss and abdominal masses can be signs. After
metastasis the person often experiences pain in the abdomen and becomes anemic. Medical
treatment often is not very successful and includes surgery, radiation and chemotherapy. The
best treatment is preventative with osteopathic treatments to ensure that the lesser omentum,
stomach and liver are functioning well and that the digestive system is free of any irritants that
could cause adhesions, toxicity or loss of function.
Liver Cancers and Dysfunctions

Primary liver cancers are often related to exposure to mycotoxins, chronic liver
disease, especially cirrhosis and infection. Preventatively the osteopath can help
ensure good functioning of the liver with treatment. The liver that functions optimally is
less susceptible to cancers. Any condition that severely damages the liver represents a
serious threat to life. The liver has a limited ability to regenerate after injury, but liver
function will not fully recover unless the normal vascular pattern returns.
The metabolic function of the liver require a large amount of blood. The liver
receives blood from both arterial and venous sources. Both travel through the lesser
omentum. The hepatic artery branches from the abdominal aorta and provides
oxygenated blood at the rate of 400 to 500 ml per minute (about 25 percent of the
cardiac output). The hepatic portal vein, which receives deoxygenated blood from the
inferior and superior mesenteric veins and the splenic vein, delivers about 1000 to 1200
ml per minute to the liver. Portal venous blood constitutes 70 percent of the blood
supply to the liver. This blood carries some oxygen and is rich in nutrients that have
been absorbed from the digestive tract. A lesion of the lesser omentum can negatively
affect all of the blood supply to the liver.
Portal Hypertension
Pressures in the hepatic portal system are usually low, averaging 10 mm Hg or
less. This pressure can increase markedly if blood flow through the liver becomes
restricted as a result of liver damage, a blood clot or a lesion of the lesser omentum
through which the portal vein and hepatic arteries pass. A rise in portal pressure is
called portal hypertension. As pressures rise, small peripheral veins and capillaries in
the portal system become distended and are likely to rupture and intestinal bledding
becomes a problem. Under these conditions, esophageal varices may develop, and
there may also be leakage of fluid into the peritoneal cavity across the serousal
surfaces of the liver and viscera producing acites.
Peritonitis
Peritonitis is an inflammation of the peritoneum. There are two types. The can be
a localise peritonitis where there is a localized or contained in the area of inflamed
organ or tissue (gallbladder, bowel, appendix, etc.). The other type is generalized and is
more serious. It often occurs as a result of rupture of part of the GI tract. Causes of
peritonitis include chemical irritation, enteric bacteria, gangrenous bowel or gallbladder,
pelvic inflammatory disease. It may result from a perforation of peptic ulcer and may be
from perforated diverticula. There can also be a peritonitis in response to a perforated
from abdominal trauma, wound or surgery. Complications include septicemia, abscess
formation, serious adhesions and paralytic ileus: a reflex paralysis of intestines due to
sympathetic response. Symptoms include: severe pain and tenderness over the
inflamed area, pain aggravated by movement / pressure (ie) breathing, rebound
tenderness; absence of bowel sounds, abdominal muscle spasm, tachycardia, high
fever, vomiting, shock if untreated. It represents a medical emergency, so the
osteopathy should refer out to MD if the client presents with any of these symptoms.
Medical treatment includes surgical intervention; fluid and electrolyte replacement;
medications (narcotics, antibiotics).
Abdominal Abscesses
Abscesses may form below the diaphragm, in the middle of the abdomen, in the
pelvis or behind the abdominal cavity. Abscesses also may form in or around any
abdominal organs, such as the kidneys, spleen, pancreas, liver or prostate. Often,
abdominal abscesses are caused by injury, infection or perforation of the
gastrointestinal tract or another abdominal organ.
Liver abscesses may be caused by bacteria or by amebas. Amebas from an
intestinal infection reach the liver through the lymphatic vessels. Bacteria infections can
reach the liver from an abdominal infection or wound. The infections are often carried
by the bloodstream from elsewhere in the body. Remember that the vasculature for the
liver travels through the lesser omentum. Symptoms of a liver abscess include loss of
appetite, nausea, and a fever. There may or may not be pain.
References
4h Year Liver Course
4Th Year Stomach Course
4th Year Intestine Course
Chapman Reflexes
Baral Visceral Manipulation Book 1, Manual Thermal Diagnosis
Medical Embryology John McLachlan pg 264 - 269, 308, 310
Frist Principles of Gastroenterology
Basic Surgery 4th Edition, pg 516
Sobotta
Netters
Dissection Manual 3rd Ed. Jack L. Wilson, Ph.D.. Igaku-Shoin Medical Publishers, Inc..
New York. NY. 1993
Atlas of Operative Surgery for Esophagus, Stomach, Duodenum. Ed. K. Kramer, W.

Lierse, W. Platzer, H.W. Schreiber, S. Weller and F.M. Steichen. George Thieme
Verlag Publishers, Stuttgart, Germany. 1989.
Understanding Pathophysiology. Sue E. Huether and kathryn L. McCance. Mosby. St.

Louis, MO. 1994
Essential Clinical Anatomy Keith L. Moore / Anne M. R. Agur pg 95, 96, 97, 118 , 119
Grays pg 899-902
Pocket Atlas of Human Anatomy Heinz Fenesis Thieme Publisher
Clinically Oriented Anatomy 4th Ed., Keith L. Moore and Arthur F. Dailley.
Fundamentals of Anatomy and Physiology 3rd Ed. Frederic H. Martini. Prentice hall.
Englewood Cliffs, NJ.
Merick Manual Home Edition
Barral, JP, Mercier, P: Visceral Manipulation. Seattle: Eastland Press (1988)
Barral, JP, Mercier, P: Visceral Manipulation II. Seattle: Eastland Press (1995)
Bullock, BL, Philbrook Rosendahl, P: Pathophysiology. Boston: Little, Brown & Co.
(1984)
Netter, FH: Atlas of Human Anatomy. Summit: Ciba-Geigy Corp. (1989)
Carlson, BM: Pattens Foundations of Embryology. New York: McGraw-Hill. (1981)
Waligora, J, Perlmuter, L: Anatomie: Abdomen. Paris: Masson et Cie. (1975)
Gray, H: Grays Anatomy. London: Senate. (1994)
Gray, H: Grays Anatomy.
Moore, KL: Clinically Oriented Anatomy, 2nd Ed. Baltimore: Williams & Wilkins. (1985)
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Lesser Omentum Project

Canadian College of Osteopathy

Toronto, Ontario May, 2000

Embryologic Development of the Lesser Omentum and the Gastrointestinal Tract

Central Chain and the Lesser Omentum

Relationship with Liver - Penny

Lesser Omentum Relationship with Esophagus, Stomach, Duodenum

Relationship with Pancreas - Penny

Functions of the Lesser Omentum -Kim

Portal Triad and The Lesser Omentum - Kim

Lesser Omentum Lesions - Kim

The lesser omentum is a double layered sheet of peritoneum that is typically

Naming of the Lesser Omentum

Naming of the Lesser Omentum is defined in relation to the Greater Omentum

In regards to health, the mesodermal origin of the gut membranes is a mixed

Central Chain and the Lesser Omentum

Third Ventricle N.102 ! Related to Pineal gland, Thalamus, Hypophysis

Falciform Ligament of N.270, ! Center phrenic joins with falciform of liver

Isthmus of Uterus / N.350 ! Problems here can lead to difficult births

Peritoneum and Other Abdominal Connective Tissues

Muscle and Ligament of Treitz

- pg 85 picture of Topographical Anatomy of the Liver.

- pg 115: Picture of Visceral Articulations of the Stomach

Pocket Atlas of Human Anatomy Heinz Fenesis Thieme Publisher:

Lesser Omentum Relationship with the Liver - Penny

In addition to the attachments of the lesser omentum to the visceral surface of

Peritoneal relations of the liver

Spatial Relationships of the Liver with Other Organs

Relationship with Gallbladder

Barral states that normal extrinsic motions provide healthy adaptations to

Ptosis and Hiatal Hernia

Omental and Stomach Cancers

Liver Cancers and Dysfunctions

Baral Visceral Manipulation Book 1, Manual Thermal Diagnosis

Medical Embryology John McLachlan pg 264 - 269, 308, 310

Frist Principles of Gastroenterology

Basic Surgery 4th Edition, pg 516

Atlas of Operative Surgery for Esophagus, Stomach, Duodenum. Ed. K. Kramer, W.

Understanding Pathophysiology. Sue E. Huether and kathryn L. McCance. Mosby. St.

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