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The peritoneum is the serous membrane that lines the abdominal muscle cavity. That is composed of mesothelial cell that are supported by a thin layer that fibrous tissue and is embryologically derived from the mesoderm. The peritoneum offer to assistance the guts of the abdomen and acts as a conduit for the i of nerves, blood vessels, and also lymphatics. Although the peritoneum is thin, it is made of 2 layers through a potential space between them. The potential space between the 2 great contains about 50 come 100 ml of serous fluid that stays clear of friction and permits the layers and also organs come glide freely.<1> The outer layer is the parietal peritoneum, i m sorry attaches come the abdominal and pelvic walls. The within visceral great wraps roughly the interior organs situated inside the intraperitoneal space. The frameworks bound by the peritoneal cavity may be intraperitoneal or retroperitoneal.
Structure and Function
The borders of the peritoneal cavity include:
Anterior ab muscles
The peritoneum is made up of 2 layers: the superficial parietal layer and the deep visceral layer. The peritoneal cavity contains the omentum, ligaments, and also mesentery. Intraperitoneal organs incorporate the stomach, spleen, liver, an initial and 4th parts of the duodenum, jejunum, ileum, transverse, and also sigmoid colon. Retroperitoneal offal lie behind the posterior sheath the the peritoneum and also include the aorta, esophagus, second and 3rd parts that the duodenum, ascending and also descending colon, pancreas, kidneys, ureters, and adrenal glands.
An important an are in the peritoneal cavity is the epiploic foramen, likewise known together the foramen that Winslow. This foramen permits communication in between the greater and also lesser sacs. That is bordered by the hepatoduodenal ligament anteriorly, the inferior vena cava (IVC) posteriorly, duodenum inferiorly, and also the caudate lobe the the liver superiorly. The foramen provides accessibility to a surgeon, need to they must clamp the hepatoduodenal ligament to prevent a hemorrhage or get anatomical access to the lesser sac. The foramen can additionally serve together a place for a lesser sac hernia.
The greater omentum loose hangs native the better curvature of the stomach and also folds end the anterior the the intestine prior to curving back superiority to connect to the transverse colon. That acts together a protective or insulating layer. The mesentery helps connect the abdominal muscle organs come the abdominal wall and contains many blood vessels, nerves, and lymphatics. Intraperitoneal organs are usually mobile while those in the retroperitoneum room usually fixed to the posterior abdominal muscle wall. The dorsal mesentery likewise gives off the transverse and sigmoid mesocolons, which are important because of them comprise the blood, nerve, and lymphatic it is provided for related structures.
The peritoneum is obtained from mesoderm and helps suspend the primitive gut tube throughout development. Specifics the parietal peritoneum is obtained from the somatic mesoderm, and also visceral peritoneum is derived from the splanchnic mesoderm. It help suspend the gut pipe via ventral and also dorsal mesenteries. The mesenteries are expansions of the peritoneum that anchor the anterior and posterior abdominal walls. The ventral mesentery eventually creates into the lesser omentum, which can be further explained as the gastrohepatic and hepatoduodenal ligaments, which contains the portal triad and plays a clinical function in potential hemorrhage manage in trauma situations. The dorsal mesentery continues to be as a mesentery, and also gives turn off the gastrosplenic ligament, greater omentum, and also helps keep midgut and also foregut guts anchored to the posterior abdominal wall.<2>
Blood Supply and Lymphatics
The parietal peritoneum receives blood from the abdominal wall vasculature, including the iliac, lumbar, epigastric, and intercostal arteries. The visceral peritoneum receives supply from the superior and inferior mesenteric arteries. The two parts of the peritoneum additionally differ in their venous drainage: the parietal peritoneum drains right into the inferior vena cava when the visceral peritoneum drains right into the portal vein.<3>
A thorough understanding of the innervation the the peritoneum is important as it has actually clinical implications. The peritoneum has actually both somatic and autonomic innervations that help explain why various abdominal pathologies, such together peritonitis or appendicitis present the way they do. The parietal peritoneum receive its innervation native spinal nerves T10 through L1. This innervation is somatic and permits for the emotion of pain and temperature that have the right to be localized. The visceral peritoneum receive autonomic innervation from the Vagus nerve and also sympathetic innervation that result in the difficult to localize abdominal muscle sensations triggered by organ distension.<2><4>
Inguinal Hernia Repair
The peritoneum theatre a far-reaching role in operation planning for inguinal hernia repairs. The peritoneum is significant enough the the laparoscopic philosophies refer to the connection to the peritoneum with options of a transabdominal pre-peritoneal (TAPP) or complete extra pre-peritoneal (TEPP) repairs. In a TAPP, the peritoneum is penetrated, and the surgeon works to fix a hernia native an iatrogenic feet dissected to accessibility the hernia sac that is then primarily closed. A TEPP stays clear of the peritoneum altogether by staying superficial come it to access the hernia sac and also repair it.<5>
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
A new means to manage malignancies that have actually originated or widely metastasized to the peritoneum is being investigated.<6> The principle behind HIPEC is to directly administer chemotherapy to the peritoneal surface in the really hopes of widely reducing tumor burden. Prior to the arrival of HIPEC, surgical procedure was made use of to resect involved areas but was no feasible as soon as widely disseminated, conferring a bad prognosis because that the patient. While tho requiring considerable research, over there is hope the HIPEC will be a brand-new tool because that surgeons to use in the battle versus cancer.
Anything the injures the peritoneum, such together infection, trauma, or surgery can reason scar formation. This scar formation is referred to as adhesions and also has this name due to the fact that the development can result in pathologic attachments in between structures. This can be problematic together it can lead to little or huge bowel obstructions and also serve as a nidus because that volvulus.<7>
In trauma situations, that is vital to assess free intraperitoneal fluid in the abdomen in a time-efficient path to help determine if the patient will require emergent surgery. Spaces in the peritoneum can often house huge amounts the blood and are therefore important to critically assess. A noninvasive method to achieve this is the focused Assessment with Sonographic Trauma (FAST) scan, which is the utilization of ultrasound to evaluate for liquid in 4 windows where fluid can accumulate.<8> The 4 locations space the: hepatorenal recess (also recognized as Morrison"s pouch), splenorenal recess, the pelvis, and also pericardium. A positive an outcome as signified by an anechoic an ar representing fluid in any kind of of these locations in the setting of hemodynamic instability says that the patient undergo emergency surgical treatment to localize and also stop the bleed and also repair any type of other injury.
Any significant defect in the peritoneum is classically closed using gradually absorbable monofilament sutures if the closure deserve to be performed. However, current research has indicated the non-closure of the peritoneum may be associated with much better outcomes. Part studies have actually indicated that peritoneal defects in open up appendectomy, caesarian section, gastric bypass, and more may it is in avoided in certain conditions. For example, non-closure the the peritoneum was recommended in c-section patient who have actually renal insufficiency or hypertensive disorders. This is one area of arising research that may guide future practice.<9><10><11><12>
The peritoneum is of far-reaching clinical importance. The peritoneum can construct inflammation that can present as peritonitis. The problem is frequently associated with perforation that the intestinal viscera and also florid infection. Other reasons of peritonitis include totally free blood, gastric and also pancreatic juices, medications, and also chemicals in the peritoneal cavity. Peritonitis might be localized or diffuse and also often presents with indications of an acute abdomen, such together rigidity, fag tenderness, or guarding. Treatment depends on the cause. Every perforations require surgical treatment. Infections require to be treated with antibiotics. Mortality is highest possible in yonsei patients.
Normally, the peritoneal room only contains up to 100 mL of serous fluid. In assorted situations, such together cirrhosis or chyle leaks, there deserve to be a pathologic increase in peritoneal liquid volume. Cirrhotic ascites is believed to be because of portal hypertension, top to raised permeability in blood vessels, permitting for altered oncotic and hydrostatic pressures that result in an imbalance the protein and also electrolytes, thus transforming the fluid flow.<13> In chylous ascites, over there is an increase in lymphatic fluid in the peritoneal cavity, which have the right to be second to a chyle leak or can occur from surgical procedure or trauma.<14> Treatment is generally medical however can be surgical on occasion.
Peritoneal DialysisInfusion of a hypertonic liquid in the peritoneal cavity performs peritoneal dialysis. As soon as the garbage products are absorbed, the fluid is then drained out. Several cycles space performed every time. The most usual complication that peritoneal dialysis is the risk of infection. An additional complication that is no rare is a perforation of bowel when the dialysis catheter is inserted inside the peritoneal cavity.
The peritoneal cavity is sometimes affected by malignancy of which the most typical is mesothelioma. In addition, cancer can metastasize resulting in peritoneal carcinomatosis. A rarer manifestation of cancer presenting in the peritoneum is pseudomyxoma peritonei, which is thought to it is in a cancer that appendiceal or colon origin. Treatment is mostly surgical to resect associated areas.
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The peritoneum is additionally utilized in therapeutic philosophies for hydrocephalus. Patient who want definitive therapy for your hydrocephalus or are refractory to clinical management have the right to pursue surgical management via a ventriculoperitoneal shunt wherein the overabundance cerebrospinal fluid is shunted to the peritoneum, whereby it is climate reabsorbed by the body an ext appropriately.