Anatomy, Abdomen and Pelvis, Peritoneum


Article Author:
Arjun Kalra


Article Editor:
Faiz Tuma



Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
11/26/2018 9:44:12 PM

Introduction

The peritoneum is the serous membrane that lines the abdominal cavity that is embryologically derived from mesoderm. It is composed of mesothelial cells that are supported by a thin layer of fibrous tissue. The peritoneum serves to support the organs of the abdomen and acts as a conduit for passage of nerves, blood vessels, and lymphatics. Although the peritoneum is thin, it is made of 2 layers with a potential space between them. The potential space between the 2 layers contains about 50 to 100 ml of serous fluid that prevents friction and allows the layers and organs to glide freely.[0] The outer layer also known as the parietal peritoneum attaches to the abdominal and pelvic walls. The inner or visceral layer wraps around the internal organs located inside the intraperitoneal space. The structures bound by the peritoneal cavity may be intraperitoneal or retroperitoneal.

Structure and Function

The boundaries of the peritoneal cavity include:

  • Anterior abdominal muscles
  • Vertebrae
  • Pelvic floor
  • Diaphragm

The structure itself is 2 layers, comprising a superficial parietal layer and the deep visceral layer. The peritoneal cavity contains omentum, ligaments, and mesentery. These structures connect the abdominal organs or the abdominal wall or to each other. Knowing an organ's relationship to the peritoneum has surgical significance. Organs that are considered intraperitoneal are the stomach, spleen, liver, the first and fourth parts of the duodenum, jejunum, ileum, transverse and sigmoid colon. The list of retroperitoneal organs includes the aorta, esophagus, second and third parts of the duodenum, ascending and descending colon, pancreas, kidneys, ureters, and adrenal glands.

A key space in the peritoneal cavity is the epiploic foramen, also known as the foramen of Winslow. This foramen allows communication between the greater and lesser sacs. It is bordered by the hepatoduodenal ligament anteriorly, the inferior vena cava (IVC) posteriorly, duodenum inferiorly, and caudate lobe of the liver superiorly. The foramen provides access to a surgeon, should they need to clamp the hepatoduodenal ligament to stop a hemorrhage or gain anatomical access to the lesser sac. The foramen can also serve as a location for a lesser sac hernia.

The greater omentum loosely hangs from the greater curvature of the stomach and folds over the anterior of the intestine before curving back superiority to attach to the transverse colon. It acts as a protective or insulating layer. The mesentery helps attach the abdominal organs to the abdominal wall and contains many blood vessels, nerves, and lymphatics. Abdominal organs that are intraperitoneal are usually mobile while those in the retroperitoneum are usually fixed to the posterior abdominal wall. The dorsal mesentery also gives off the transverse and sigmoid mesocolons, which are important due to them containing the blood, nerve, and lymphatic supply for related structures.

Embryology

The peritoneum is derived from mesoderm and helps suspend the primitive gut tube during development. Specifically, the parietal peritoneum is derived from the somatic mesoderm, and visceral peritoneum is derived from the splanchnic mesoderm. It helps suspend the gut tube via ventral and dorsal mesenteries. The mesenteries are extensions of the peritoneum that anchor the anterior and posterior abdominal walls. The ventral mesentery eventually develops into the lesser omentum, which can be further described as the gastrohepatic and hepatoduodenal ligaments, which contains the portal triad and plays a clinical role in potential hemorrhage control in trauma situations. The dorsal mesentery remains as a mesentery, and gives off the gastrosplenic ligament, greater omentum, and helps keep midgut and foregut organs anchored to the posterior abdominal wall.[2]

Nerves

A thorough understanding of the innervation of the peritoneum is important as it has clinical implications. The peritoneum has both somatic and autonomic innervations that help explain why various abdominal pathologies, such as peritonitis or appendicitis present the way they do. The parietal peritoneum receives its innervation from spinal nerves T10 through L1. This innervation is somatic and allows for the sensation of pain and temperature that can be localized. The visceral peritoneum receives autonomic innervation from the Vagus nerve and sympathetic innervation that result in the difficult to localize abdominal sensations triggered by organ distension.[2][3]

Surgical Considerations

Inguinal Hernia Repair

The peritoneum plays a significant role in surgical planning for inguinal hernia repairs. The peritoneum is significant enough that the laparoscopic approaches refer to the relationship to the peritoneum with options of a transabdominal pre-peritoneal (TAPP) or total extra pre-peritoneal (TEPP) repairs. In a TAPP, the peritoneum is penetrated, and the surgeon works to repair a hernia from an iatrogenic hole dissected to access the hernia sac that is then primarily closed. A TEPP avoids the peritoneum altogether by staying superficial to it to access the hernia sac and repair it.[4]

Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

A new way to manage malignancies that have originated or widely metastasized to the peritoneum is being investigated.[5] The concept behind HIPEC is to directly administer chemotherapy to the peritoneal surface in the hopes of widely reducing tumor burden. Prior to the advent of HIPEC, surgery was utilized to resect involved areas but was not feasible when widely disseminated, conferring a poor prognosis for the patient. While still requiring extensive research, there is hope that HIPEC will be a new tool for surgeons to use in the battle against cancer.

Adhesions

Anything that injures the peritoneum, such as infection, trauma, or surgery can cause scar formation. This scar formation is referred to as adhesions and has this name because the formation can lead to pathologic attachments between structures. This can be problematic as it can lead to small or large bowel obstructions and serve as a nidus for volvulus.[6]

FAST Exam

In trauma situations, it is important to assess free intraperitoneal fluid in the abdomen in a time-efficient manner to help determine if the patient will need emergent surgery. Spaces in the peritoneum can often house large amounts of blood and are therefore important to critically assess. A noninvasive way to accomplish this is the Focused Assessment with Sonographic Trauma (FAST) scan, which is the utilization of ultrasound to assess for fluid in four windows where fluid can accumulate.[7] The four locations are the: hepatorenal recess (also known as Morrison's pouch), splenorenal recess, the pelvis, and pericardium. A positive result as signified by an anechoic region representing fluid in any of these areas in the setting of hemodynamic instability suggests that the patient undergo emergency surgery to localize and stop the bleed and repair any other injury.

Clinical Significance

Peritonitis

The peritoneum is of significant clinical importance. The peritoneum can develop inflammation that can present as peritonitis. The condition is often associated with perforation of the intestinal viscera and florid infection. Other causes of peritonitis include free blood, gastric and pancreatic juices, medications and chemicals in the peritoneal cavity. Peritonitis may be localized or diffuse and often presents with signs of an acute abdomen, such as rigidity, rebound tenderness, or guarding. Treatment depends on the cause. All perforations need surgical treatment. Infections need to be treated with antibiotics. Mortality is highest in elderly patients.

Ascites

Normally, the peritoneal space only contains up to 100 mL of serous fluid. In various situations, such as cirrhosis or chyle leaks, there can be a pathologic increase in peritoneal fluid volume. Cirrhotic ascites is believed to be due to portal hypertension, leading to increased permeability in blood vessels, allowing for altered oncotic and hydrostatic pressures that result in an imbalance of protein and electrolytes, thus altering the fluid flow.[8] In chylous ascites, there is an increase in lymphatic fluid in the peritoneal cavity, that can be secondary to a chyle leak, which can occur from surgery or trauma.[9] Treatment is primarily medical but can be surgical on occasion.

Peritoneal Dialysis Infusion of a hypertonic fluid in the peritoneal cavity performs peritoneal dialysis. Once the waste products are absorbed, the fluid is then drained out. Several cycles are performed each time. The most common complication of peritoneal dialysis is the risk of infection. Another complication that is not rare is a perforation of bowel when the dialysis catheter is inserted inside the peritoneal cavity.

Malignancy

The peritoneal cavity is sometimes affected by malignancy of which the most common 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 believed to be a cancer of appendiceal or colon origin. Treatment is primarily surgical to resect involved areas.

Hydrocephalus

The peritoneum is also utilized in therapeutic approaches for hydrocephalus. Patients who want definitive treatment for their hydrocephalus or are refractory to medical management can pursue surgical management via a ventriculoperitoneal shunt where the excess cerebrospinal fluid is shunted to the peritoneum, where it is then reabsorbed by the body more appropriately.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Anatomy, Abdomen and Pelvis, Peritoneum - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following is false about the peritoneum?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 20-year-old otherwise healthy male presents to the emergency department with a 1-day history of abdominal pain that started diffusely throughout his abdomen and has since become right sided. He endorses a complete loss of appetite. His vital signs reveal a temperature of 101.0F. The physical exam reveals a male in distress with rebound tenderness and guarding. What best explains this patient's presentation?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true about the peritoneum?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following best describes the innervation of the peritoneum?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following best describes organs and their relationship to the peritoneum?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Anatomy, Abdomen and Pelvis, Peritoneum - References

References

Blackburn SC,Stanton MP, Anatomy and physiology of the peritoneum. Seminars in pediatric surgery. 2014 Dec     [PubMed]
Sheehan D, The Afferent Nerve Supply of the Mesentery and its Significance in the Causation of Abdominal Pain. Journal of anatomy. 1933 Jan     [PubMed]
Yang XF,Liu JL, Anatomy essentials for laparoscopic inguinal hernia repair. Annals of translational medicine. 2016 Oct     [PubMed]
Salti GI,Naffouje SA, Feasibility of hand-assisted laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancy. Surgical endoscopy. 2018 Jun 20     [PubMed]
Loftus TJ,Morrow ML,Lottenberg L,Rosenthal MD,Croft CA,Smith RS,Moore FA,Brakenridge SC,Borrego R,Efron PA,Mohr AM, The Impact of Prior Laparotomy and Intra-abdominal Adhesions on Bowel and Mesenteric Injury Following Blunt Abdominal Trauma. World journal of surgery. 2018 Sep 17     [PubMed]
Bloom BA,Gibbons RC, Focused Assessment with Sonography for Trauma (FAST) . 2018 Jan     [PubMed]
Pericleous M,Sarnowski A,Moore A,Fijten R,Zaman M, The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and recommendations. European journal of gastroenterology & hepatology. 2016 Mar     [PubMed]
Mandavdhare HS,Sharma V,Singh H,Dutta U, Underlying etiology determines the outcome in atraumatic chylous ascites. Intractable & rare diseases research. 2018 Aug     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of your specialty. When it is time for the board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study.