GOOD AFTERNOON!

PERITONEAL CAVITY

Peritoneal cavity
fluid filled GAP b/n the wall of the abdomen and the organs contained w/in the abdomen Contains small amount of fluid that serves as a lubricant & has antiinflammatory properties

Males: completely closed Females: communicates with exterior of body via uterine tubes, uterus and vagina

PERITONEUM

Serosal membrane Single layer of flat mesothelial cells supported by submesothelial CT

2 layers a.visceral b.parietal

VISCERAL/ PARIETAL PERITONEUM

Inner layer of the membrane which wraps around the internal organs

Outer layer attached to the abdominal wall

INTRAPERITONEAL ORGANS RETROPERITONEAL ORGANS Nearly totally covered by A. PRIMARY: KIDNEYS visceral peritoneum -develop & remain beneath Projects into the peritoneal the parietal peritoneum cavity Attached to body wall by B. SECONDARY: ADRENAL mesenteries and ligaments GLANDS, PANCREAS, 2ND4TH PART OF DUODENUM, LIVER, SPLEEN, STOMACH, 1ST PART OF DUODENUM, ASC & DESC COLON JEJUNUM, ILEUM, -developed w/ short TRANSVERSE & SIGMOID mesentery COLON, SUPERIOR -fusion fascia RECTUM

MESENTERIES
TRUE MESENTERIES:
connect to the posterior peritoneal wall

SPECIALIZED MESENTERIES: do not

connect to the posterior peritoneal wall

Small Bowel Mesentery Transverse Mesocolon Sigmoid Mesentery or Mesosigmoid

Greater Omentum Lesser Omentum Mesoappendix

OMENTUM

GREATER Double layer of peritoneum Hangs fr the greater curvature of the stomach & descends infront of the abdominal viscera separating bowel fr the ant abdl wall Encloses fat and a few BV Serves as s fertile ground for implantation of peritoneal metastases and assists in loculation of inflammatory processes of the peritoneal cavity

LESSER Suspends the lesser curve of the stomach & the duodenal bulb from the inferior surface of the liver Separates the gastrohepatic recess of the left subphrenic space fr the lesser sac Tansmits the coronary vein and contains LN

OMENTUM

GREATER OMENTUM Gastrocolic Ligament Gastrosplenic Ligament Gastrophrenic Ligament LESSER OMENTUM Gastrohepatic Ligament Hepatoduodenal Ligament

LIGAMENT
A.LIVER 1. Falciform - liver-ant abdl wall 2. Gastrohepatic - lesser curvature of the stomachliver 3. Hepatoduodenal - liver1st part of duodenum B. SPLEEN 1. Gastrosplenicstomach to hilum of spleen 2. Splenorenal (lienorenal)-spleen-left kidney

C. STOMACH 1. Gastrophrenic-stomachinf diaphragmatic surface 2. Gastroplenic-stomachhilum of spleen 3. Gastrocolic-stomach as the greater omentumtransverse colon D.PHRENICOCOLIC LIGAMENT/ SUSTENTACULUM LIENIS -left hepatic flexuretransverse colon-diaphragm -supports the spleen

GASTROHEPATIC LIGAMENT ON UTZ

SUBDIVISIONS OF THE PERITONEAL CAVITY

GREATER SAC Main compartment

LESSER SAC/ OMENTAL BURSA

Smaller

Extends from the diaphragm into the pelvis

Lies behind the stomach

A. Superior Recess A. Supramesocolic Compartment B. Inferior Recess B. Inframescolic Compartment

Foramen of winslow
3-cm potential opening anterior to the IVC and posterior to the hepatoduodenal ligament communication between the lesser sac and the greater peritoneal cavity Bowel may herniate through it

SUBPHRENIC SPACE
RIGHT:
ANT SUBHEPATIC POST SUBHEPATIC/ MORISON POUCH/ RIGHT HEPATORENAL FOSSA

LEFT/PERISPLENIC:

LEFT SUBHEPATIC SPACE / GASTROHEPATIC RECESS

Space affected by disease of the duodenal bulb, lesser curvature of the stomach, GB, left lobe of the liver

PERITONEAL CIRCULATION

Watershed Regions: 1. Ileocolic region 2. Root of the Sigmoid Mesentery 3. Pouch of Douglas

Clinical correlation

ASCITES

at least 500 mL to be present. Plain film findings of ascites include: diffusely increased density of the abdomen poor definition of the the soft tissue shadows, such as the psoas muscles, liver and spleen medial displacement of bowel and solid viscera (away from properitoneal fat stripe) bulging of the flanks increased separation of small bowel loops

ASCITES

Ultrasound May detect smaller volumes especially if its adjacent diaphragm or the anterior margin of the liver 3. Assessment of fluid type: Simple ascites = anechoic Exudative, haemorrhagic or neoplastic ascites contains floating debris Septations suggest inflammatory or neoplastic cause

ASCITES

Transudative ascites density (-10 to +10HU). Exudative ascites density > 15 HU. Haemoperitoneum density is higher still (~ 45HU).

PNEUMOPERITONEUM
1. Riglers or double wall

sign visualization of serosal and mucosal surface of one or more dilated gaseous small bowel loops ( seen as thin white line ), but many of the times it would be misleading 2. Football sign or air dome sign Lot of free air in the parietal peritoneal cavity. 3. Cupola sign Free air under right diaphragm near midline in supine position 4. Falciform ligament sign Visualisation of falciform ligment due to air around it

PNEUMOPERITONEUM

5. Morrisons pouch sign Air in hepato-renal pouch due to pneumoperitoneum 6. Telltale triangle or Triangular air sign 7. Right upper quadrant sign air below or around part ( sub or perihepatic ) of the liver surface 8. Umbilical inverted V sign 9. Scrotal air sign ( in children )

PNEUMOPERITONEUM

PNEUMOPERITONEUM

free (extraluminal) air between the Liver and the inner surface of the anterior abdominal wall on either side of the Falciform ligament.

SPLENIC TRAUMA

a subcapsular hematoma with a splenic laceration extending from the capsule to the hilum with an intraparenchymal hematoma (blue arrow). Within the intraparenchymal and subcapsular hematomas are areas of hyperdensity that represent active extravasation (red arrow).

HERNIA THROUGH THE FORAMEN OF WINSLOW

Abscess formation on ultrasound and CT. (a) Ultrasound shows a heterogeneous fluid collection with dirty shadowing (arrows) consistent with intraluminal gas, a thickened wall and multiple septations in a 13-year-old boy. (b) CT demonstrates a rim enhancing, hypodense, and well-defined bilobed fluid collection in a 15-year-old boy.

SUB-PHRENIC ABSCESSS two large abscesses (arrows) situated below the right side of the diaphragm. (CT image shows a cross-section through the abdomen, looking from below). The abscesses have welldefined margins of connective tissue with semi-dense pus in the cavity. These abscesses are most likely secondary to gall bladder perforation.

Tumor seeding in the peritoneal cavity after RF ablation of a metastatic liver nodule. (a) Follow-up CT scan obtained 1 day after RF ablation shows the ablated area with peritumoral hyperemia (arrow) in the left lateral segment of the liver. (b) Follow-up CT scan obtained 6 months later shows multiple extrahepatic and intraperitoneal tumor nodules (arrows) just below the site of ablation.

Sonographic features. Hepatocellular carcinoma in 59-year-old man. Unenhanced gray-scale sonogram shows peripheral halo sign (arrow).

Spontaneous rupture of a hepatoma The CT scan of the abdomen and pelvis at 2 levels reveals a heterogenous 4-cm mass within the dome of the right lobe of the liver (blue arrow), with active bleeding. High-density material around the liver and under the right hemidiaphragm (yellow arrows) that extends down along the right pericolic gutter into the pelvis is consistent with blood based on Hounsfield unit measurement. The liver has a shrunken, nodular contour suggestive of cirrhosis.

Incisional Hernia. A hernia through a surgical wound created during cholecystectomy is well visualized in a patient with ascites (a). The ascites clearly defines the layer of parietal peritoneum (arrow) lining the peritoneal cavity. Omentum containing fluid between its layers herniates (arrowheads) into the abdominal wall. Ascites fluid (f) has also dissected into the hernia sac. The size of the hernia defect is measured by a cursor (+). Omentum is differentiated from bowel by absence of peristalsis and lack of continuity with bowel in the peritoneal cavity.