PERITONEAL SPACES
AND RECESSES
BY
DR. A.PERVEZ
MS (GEN.SURGERY)
CONTENTS
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INTRODUCTION
PERITONEAL FOLDS
PERITONEAL COMPARTMENTS
SUPRACOLIC COMPARTNENT
LESSER SAC
INFRACOLIC COMPARTMENT
RETROPERITONEAL SPACE
PERITONEAL RECESSES
APPLIED ANATOMY
INTRODUCTION
• Serous membrane lining the abdominal cavity
• Comprises of 2 layers i.e parietal peritoneum
and visceral peritoneum.
• Consists of a single layer of flattened cells with
phagocytic properties,overlying areolar tissue
which varies in thickness and density.
• Various peritoneal reflections connect viscera to
the abdominal walls or to one another( a.k.a
folds,mesentery,ligament or omentum).
PERITONEAL FOLDS OF
ANTERIOR ABDOMINAL WALL
• On the posterior surface of the anterior abdominal
wall,the peritoneum is raised into 6 folds.
1.Falciform ligament
2.Median umbilical fold containing median umbilical
ligament centrally.
3.Medial umbilical fold containing medial umbilical
ligament on each side.
4.Lateral umbilical fold containing inferior epigastric
vessels on each side.
PERITONEAL COMPARTMENTS
• Peritoneal cavity is descriptively divide into
supracolic,infracolic & pelvic compartments.
• Dividing line between supra & infracolic
compartments is the transverse mesocolon.
• Attachments of liver to diaphragm & abdominal
wall define the subdivisions of the supracolic
compartment.
• The infracolic compartment is divided further
by the root of the mesentery.
• On either side of the median umbilical fold (i.e
between median & medial folds) there are
depressions called SUPRAVESICAL FOSSAE.
• Between the medial & the lateral umbilical folds
are depressions called MEDIAL INGUINAL
FOSSAE.
• Lateral to the lateral folds are the LATERAL
INGUINAL FOSSAE.
• On either side of the urinary bladder are the
PARAVESICAL FOSSAE.
SUPRACOLIC COMPARTMENT
• To the right & left of the falciform ligament are
the RIGHT & LEFT
SUBPHRENIC(subdiaphragmatic) spaces.
• They are closed above by superior layer of
coronary ligament & anterior layer of left
triangular ligament.
• Behind the right lobe of liver & in front of the
right kidney is the RIGHT SUBHEPATIC
space or Morrison’s hepatorenal pouch.
• This space is closed above by the inferior layer of
coronary ligament & right triangular ligament.
• To its right is the diaphragm & on the left the space
communicates with the lesser sac or LEFT
SUBHEPATIC through the epiploic foramen.
• Below it’s continuous with the right paracolic gutter.
• On lying supine the hepatorenal pouch is the lowest
part of the peritoneal cavity and is a likely area of
intraperitoneal fluid accumulation.
LESSER SAC
• It’s a large recess of the peritoneal cavity that
communicates with the main cavity or greater sac
through foramen epiploicum.
• Upper part of the posterior wall of the lesser sac
is formed by peritoneum lining structures on the
posterior abdominal wall.
• Lower part of the posterior wall is formed by
posterior 2 layers of the greater omentum.
• Lower border of the lesser sac is formed by the
anterior 2 layers of the greater omentum
• The right side of its upper border is formed by
peritoneal reflection from upper end of caudate
lobe of liver.
• To the left of the caudate lobe the lesser sac is
formed by reflection of peritoneum from upper
part of fundus of stomach.
• The left border is formed by the gastrosplenic and
leinorenal ligaments.
• Left border is formed by the continuity of
anterior&posterior layers of greater omentum.
INFRACOLIC COMPARTMENT
• To the right of the root of mesentery is the triangular
RIGHT INFRACOLIC space.
• Its apex lies at the ileocaecal junction. It’s right side is
the ascending colon & it’s base is the attachment of
transverse mesocolon.
• Lateral to ascending colon is the RIGHT PARACOLIC
gutter which can be traced upwards into the
hepatorenal pouch and downwards into the pelvis.
• The LEFT INFRACOLIC is larger than its right
counterpart.
• Its quadrilateral shaped & widens below where its continuous
across the pelvic brim. It’s upper border is the transverse
mesocolon attachment & to its left is the descending colon.
• Lateral to the descending colon is the LEFT PARACOLIC
gutter. It’s limited above by the phrenico-colic ligament. Traced
downwards this gutter leads to attachment of lateral limb of
sigmoid mesocolon.
• There is a midline extraperitoneal space called as the BARE
AREA OF LIVER. It’s present between both layers of the
coronary ligament and the IVC lies to it’s left
RETROPERITONEAL SPACE
Major structures lie on the posterior abdominal
wall behind the peritoneum.
These include aorta,IVC,cysterna chyli,urogenital
system,ascending&descending colon to name a
few.
All the above are said to lie in the
RETROPERITONEAL space. Any hemorrhage
or pus can get confined here.
PERITONEAL RECESSES
• The largest recess is the lesser sac but there are
other such recesses in the peritoneum.
• SUPERIOR DUODENAL RECESS
• INFERIOR DUODENAL RECESS
• PARADUODENAL RECESS
• RETRODUODENAL RECESS
• DUODENUJEJUNAL RECESS
• MESENTEROPARIETAL RECESS
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SUPERIOR ILEOCAECAL RECESS
INFERIOR ILEOCAECAL RECESS
RETROCAECAL RECESS
Sometimes a recess may be present deep to the
apex of the sigmoid mesocolon and its related to
left ureter & left common iliac artery.
CLINICAL CORRELATIONS
OF THE PERITONEUM
• Peritoneal fluid is not static but circulates
through the peritoneal cavity and gets replaced.
The flow is upward towards the diaphragm.
• This principle is used to for peritoneal dialysis.
• Under certain conditions there is increase in the
quantity of peritoneal fluid called ascitis. This
ascitic fluid can be drained by placing a cannula
in the peritoneum through the abdominal wall by
a procedure called paracentesis.
• The large absorptive area of the peritoneum
poses a serious danger when infection develops
in the peritoneum (peritonitis).
• The parietal peritoneum has a rich supply of
somatic nerves so inflammation makes it very
sensitive to stretching.This forms the basis for a
clinical test called rebound tenderness.
• Infection can occur in any of the subphrenic
spaces described earlier.
• The right subhepatic space which is the most
dependent part of the peritoneal cavity is the
most commonest site of a subphrenic abscess
and infection can spread to gallbladder or
appendix from here.
• Pain arising from a subdiaphragmatic infection
can radiate to the shoulder (phrenic N c3,4,5).
• Accumulation of fluid in the lesser sac is a
complication of pancreatitis & leads to formation
of pseudocyst.
• Peritoneum on the front of rectum reflected on
to the uppermost part of the vagina is called
rectouterine pouch(pouch of douglas) which
becomes the most dependent part of the
peritoneal cavity. This area is accessible either
through rectum or posterior fornix of vagina.
• In the male it is replaced by the rectovesical
pouch.
• The procedure through which the peritoneal
cavity is opened is called a laparotomy.
• This procedure is done as preliminary to
abdominal surgery or used to inspect the interior
of the abdominal cavity where diagnosis is
difficult. The above may also be carried out via a
minimal access procedure called laparoscopy.
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