1
17
2 3
16 4 5 15 6
14 7
13 12
8
9 11
10
Fig. 4.6 Diaphragm and structures passing through it. Inferior surface 1 – sternum, 2 – superior epigastric vessels. 3 – ribs, 4 – left phrenic nerve, 5 – oesophageal hiatus (oesophagus and vagi), 6 – splanchnic nerves, 7 – lumbocostal trigone, 8 – m. quadratus lumborum, 9 – m. psoas major, 10 – vertebra L1, 11 – aorta in aortic hiatus, 12 – thoracic duct (cisterna chyli), 13 – arcuate ligaments, 14 – median arcuate ligament, 15 – right phrenic nerve, 16 – caval opening, 17 – sternocostal triangle 1
22
2
3
4 5
ef 21
6
20
7
19
8
18
9
17 16 10
15 p
11 14 13
12
Fig. 4.7 Greater and lesser sac of the peritoneal cavity. Sagittal section 1 – liver, 2 – diaphragm, 3 – lesser sac, 4 – aorta, 5 – pancreas, 6 – duodenum, 7 – root of mesentery, 8 – retroperitoneal space, 9 – sigmoid mesocolon, 10 – rectum, 11 – uterus, 12 – vagina, 13 – urinary bladder, 14 – pubic symphysis, 15 – greater sac, 16 – loop of small intestine, 17 – greater omentum, 18 – umbilicus, 19 – transverse colon, 20 – transverse mesocolon, 21 – stomach, 22 – lesser omentum, ef – arrow in epiploic foramen, p – peritonenum
98
Ukázka elektronické knihy, UID: KOS195739
1
2 3
10
4 9
5
6
8
7 apd
pd
Fig. 4.7 B Relationship of the gallbladder to colon and duodenum. Parasagittal section viewed from the left side 1 – liver (cut surface), 2 – hepatic portal, 3 – common hepatic duct, 4 – right kidney, 5 – common bile duct, 6 – duodenum (descending part), 7 – inferior vena cava, 8 – ascending colon, 9 – right colic flexure, 10 – gallbladder, apd – opening of accessory pancreatic duct (cut), pd – pancreatic duct (cut)
The supramesocolic (supracolic) compartment (Fig. 4.9) of the peritoneal cavity contains three large organs – the liver with the gallblader and the biliary ways, the stomach and the spleen. The liver, located mainly under the right dome of the diaphragm, is for the greater part hidden by the lower ribs, only the left lobe crosses the epigastrium so that its lower margin projects approximately alongside the line connecting the cartilage of the right 9th rib with the cartilage of the left 8th rib. Under the liver are the gallbladder and the hepatic ducts which continue to the duodenum as the common bile duct, the proper hepatic artery and the portal vein go to the hilum of the liver (Fig. 4.7 B). These structures are enclosed in a fascial sheath and form the hepatoduodenal ligament, in which the common bile duct is on the right side, the hepatic artery to the left of it and the portal vein is located posteriorly, behind these two structures. The posterior surface of the liver is attached to the diaphragm by the bare area. From the edges of this area continue the right and the left coronary ligament ending as the triangular ligaments (Fig. 4.8) From the superior surface of the liver to the diaphragm and to the anterior abdominal wall goes the falciform ligament. In the lower margin of this ligament runs the round ligament (remnants of the umbilical vein) from the umbilicus to the hilum of the liver. The stomach, together with the abdominal part of the oesophagus and the first portion of the duodenum (duodenal bulb), is also intraperitoneal (Figs. 4.10, 4.11). From the lesser curvature to the visceral surface of the liver goes the hepatogastric ligament which, together with the hepatoduodenal ligament, forms the lesser omentum. Under the left dome of the diaphragm, hidden behind the 9th–11th ribs, is the spleen. Between the hepatoduodenal and hepatorenal ligaments (extension of the coronary ligament to the right kidney) is the (gastro‑)epiploic foramen of Winslow leading into the omental bursa (the lesser omental 99
Ukázka elektronické knihy, UID: KOS195739
sac). The omental bursa is a space behind the hepatogastric ligament and the posterior wall of the stomach, under the visceral surface of the liver and above the transverse colon and mesocolon, the posterior wall is formed by the parietal peritoneum. Behind this posterior wall in the retroperitoneal space is the pancreas, upper pole of the left kidney, and the left suprarenal gland (Fig. 4.9). The omental bursa has the superior recess behind the liver, the splenic recess, and the lower omental recess between the anterior and posterior layer of the greater omentum (often obliterated). The arterial supply of all the supramesocolic organs is from the celiac trunk, the venous blood flows into the portal vein, the lymphatics drain finally mainly into the celiac lymph nodes. The inframesocolic (infracolic) compartment of the peritoneal cavity is covered by the greater omentum and contains the small intestine, the colon (Fig. 4.12) and the upper portion of the rectum. It is further subdivided by the mesentery, whose root goes obliquely from the body of L2 to the right iliac fossa, into the right and the left infracolic space. The supracolic and the infracolic compartments communicate by the paracolic gutters alongside the ascending and the descending colon. (Alternatively, the infracolic compartment is 23
1
2
3
4
5
6
7
22 8 9
21
10
20
11 12
19
13
18
14
17
16
15
Fig. 4.8 Peritonenum of the posterior abdominal wall after removal of the abdominal organs (stomach, liver, spleen and intestines) 1 – parietal peritoneum, 2 – falciform ligament, 3 – hepatic veins and inferior vena cava, 4 – stomach (cardia), 5 – left triangular ligament, 6 – lienorenal ligament, 7 – lienal vessels, 8 – phrenicocolic ligament, 9 – left kidney, 10 – duodenojejunal flexure, 11 – attachment of descending colon, 12 – left ureter, 13 – abdominal aorta, 14 – root of mesentery, 15 – sigmoid mesocolon, 16 – urinary bladder, 17 – rectum, 18 – right ureter, 19 – attachment of ascending colon, 20 – superior mesenteric vessels, 21 – duodenum, 22 – hepatoduodenal ligament, 23 – coronary ligament of liver
100
Ukázka elektronické knihy, UID: KOS195739