Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 47 Peritoneum PPT-Powerpoint Presentations and lecture notes
Peritoneum: Anatomy, functions
Acute Peritonitis
Intraperitoneal abscess
Special types of peritonitis
Peritoneal neoplasms
Dept. of Surgery
Surgical Anatomy
Peritoneum is the largest serous membrane in the body
Surface area: approx. 22,000 cm2.
Divided into parietal and visceral portions
Parietal layer lines the abdominal and pelvic cavities and the
abdominal surface of the diaphragm.
loosely connected with the body wall, separated from it by an
adipose layer, tela subserosa
Visceral layer covers the abdominal and pelvic viscera and
includes the mesenteries.
visceral peritoneum is usually tightly attached to the organs it
covers.
It does not line the entirety of the abdominopelvic cavity.
It is lifted from the body wall, especially posteriorly, by organs
located against the wall during embryologic development.
This chain of events causes the formation of a retroperitoneal
space between the peritoneum and the body wall, with organs
situated within the space.
An organ that is covered only in part by the peritoneum is
referred to as a retroperitoneal organ.
An organ that is covered by peritoneum essentially everywhere
except for the site of entrance of vessels is referred to as an
intraperitoneal organ.
Innervation of peritoneum
Parietal peritoneum is
Visceral peritoneum is sensitive
to stretch & tearing.
sensitive to pain, pressure,
temperature & touch
It is supplied by autonomic
Parietal peritoneum is
afferent nerves which supply the
viscera.
supplied by:
T7-- T12,L1 nerve
NB. Parietal peritoneum of the
pelvis is supplied by Obturator
phrenic nerve.
nerve.
Functions of peritoneum
It suspend the organs within the peritoneal cavity.
It fixes some organs within the abdominal cavity.
Storage of large amount of fat in the peritoneal ligaments (e.g..
Greater omentum)
Peritoneal covering of intestine tends to stick together in infection
Greater omentum is cal ed the policeman of abdomen to prevent
spread of infection
It secretes the peritoneal fluid
Peritoneal fluid
Peritoneal fluid is pale yellow fluid rich in leukocytes
Mobile viscera glide easily on one another.
Peritoneal fluid moves upward towards subphrenic spaces-
whatever the position of the body by:
Movements of diaphragm.
Movements of abdominal muscles
Peristaltic movements.
Peritoneum is extensive in the region of diaphragm.
Peritonitis
Peritonitis ? inflammation of the peritoneum which
maybe localised or generalised
Peritonism ? refers to specific features found on
abdominal examination in those with peritonitis
Characterised by tenderness with guarding
Rebound /percussion tenderness on examination
Eased by lying still and exacerbated by any movement
Maybe localised or generalised
Generalised peritonitis is a surgical emergency ?
requires resuscitation and immediate surgery
Types
Primary:
Not related to intraabdominal abnormality
Also cal ed spontaneous bacterial peritonitis
Secondary:
Due to spil age of GI or GU organisms into peritoneal
space due to breach of mucosal barrier
Tertiary:
clinical peritonitis and systemic signs of peritonitis persist
after treatment of secondary peritonitis
No/low virulence organism isolated
Causes
Infective ?
bacteria cause peritonitis
most common cause of peritonitis
Non-infective ?
leakage of certain sterile body fluids into the peritoneum
can cause peritonitis.
Note: although sterile at first these fluids often become
infected within 24-48 hrs of leakage from the affected
organ resulting in a bacterial peritonitis
Clinical features
Pain
Constant and severe
Worse on movement
Eased by lying stil
Signs of ileus (generalised peritonitis > localised
peritonitis)
Distension
Vomiting
Tympanic abdomen with reduced bowel sounds
Signs of systemic shock
Tachycardia, tachypnoea, hypotension, low urine output
More prominent with generalised than localised peritonitis
Investigations
Diagnosis most often made on history and examination
If localised peritonitis
Bloods tests
Chest X Ray
ECG
Complex investigations are requested depending on suspected
diagnosis
If generalised peritonitis
Surgical emergency ? wil require emergency operation
Following investigations should be performed:
Bloods: FBC, U&E, LFT, Amylase!! CRP, clotting, G&S, ABG
Chest X ray
CT scan
Management
ABC
Oxygen
Fluid resuscitation
IV antibiotics
Analgesia
Surgery
Pelvic Abscess
? Rare but the most serious late postop complication
? Involve one or both residual adnexa (tubo-ovarian
abscess)
? occur almost exclusively in premenopausal women
occur despite prophylactic AB
? often have a latent period of many between surgery
and onset of symptoms
Clinical features
? fever (high spike late in the afternoon or
early evening)
? palpable mass high in the pelvis
? WBC: around 20,000/mm
? ESR
Ultrasonography and CT scan
? confirm the presence of a mass
? help to determine whether it is
Loculated
related to an intraperitoneal structure
drainable percutaneously
? Immediate drainage is not mandatory if it is
inaccessible AB therapy alone may be successful
? isolation of -lactamase?producing Prevotella
species use of clindamycin, metronidazole, or
other agents against gram-negative anaerobes
Clindamycin + gentamicin fails to respond
drainage
Necrosis+infections surgical exploration in some
cases
Aerobic and anaerobic culture of purulent material
or tissue
Primary peritoneal tumours
Defined As Tumors With Primary Manifestation In
The Peritoneum In The Absence Of A Visceral Site
Of Origin
Arise From Mesothelial Cel s, Sub Mesothelial
Mesenchymal cel s, and uncommitted stem cells
Classification
Differential diagnosis
Peritoneal Malignant Mesothelioma
Uncommon Malignant Neoplasm
Arises From Mesothelial Cells Or Multipotential Subserosal
Mesenchymal Cells
Account for 6%?10% of malignant mesotheliomas
Diffuse: highly aggressive, are incurable
Localized: good prognosis following complete surgical
excision
Etiology
Exposure To Higher Levels Of Asbestos, Erionite
Therapeutic Irradiation
Exposure To Simian Virus 40
Chronic pleural or peritoneal irritation
Majority in males
Median age: 60 years
Clinical presentation
Abdominal Pain Or Discomfort
Abdominal Distension
Increasing Abdominal Girth
Nausea, Anorexia
Weight Loss
Bowel Obstruction
Palpable Abdominal or pelvic mass
A:innumerable tumor nodules
B: macrolobulated mass with foci of
(arrows) scattered over the
intratumoral degeneration and
omental surfaces
hemorrhage
Imaging Features
Nodular Thickening Of The Peritoneum
Omental Caking: Fine, Nodular, Soft-tissue
Studding
Ascites: diffuse to focal,small, loculated collections
Barium examination shows separation of small bowel segments
and irregular fold thickening of small bowel segments
A: Axial CT scans: show ascites
B: large, heterogeneously enhancing
and omental nodule
mass in the greater omentum
Treatment
The most effective treatment for peritoneal
mesothelioma is:
Cytoreductive Surgery
Hyper thermic Intraperitoneal
Chemotherapy (HIPEC)
Primary Peritoneal Serous Carcinoma
Epithelial tumor that arises from the peritoneum
Almost always occurs in women (mean age, 56?62 years)
Clinical features:
abdominal distension
Pain, nausea and vomiting
Increasing abdominal girth
ascites
elevated serum levels of cancer antigen CA-125
Multiple nodules on omentum
Omental caking
Psammoma bodies are commonly present
So reffered as psammomacarcinoma
The fol owing criteria have been established to make
the diagnosis of primary peritoneal serous carcinoma:
Both ovaries are normal
Involvement of extra ovarian sites must be greater than the
involvement on the surface of either ovary
Ovarian involvement is limited to ovarian surface epithelium,
either without stromal invasion or involving the cortical
stroma with tumor size less than 5 x5 mm
Imaging Features
Ascites
Peritoneal nodules and thickening
Omental nodules and masses
CT scan: showing calcified nodules and soft-tissue caking of the
greater omentum (arrowheads)
Treatment
Cytoreductive Surgery
(optimal < 1 cm residual disease)
Chemotherapy
(Cisplatin,Taxol based)
Primary Peritoneal Serous Borderline Tumor
Rare lesion of low malignant potential
Tumor cells do not invade into the submesothelial layers of
the peritoneum or omental fat
Female patients,16- 67 years of age (mean:33 years)
Treated by surgical resection (omentectomy,
hysterectomy, and oophorectomy)
Have a good long-term prognosis
Leiomyomatosis Peritonealis Disseminata
(diffuse peritoneal leiomyomatosis)
Rare, benign entity
Innumerable smooth muscle nodules throughout the
peritoneal cavity
Associated with high estrogen states, caused by pregnancy
and oral contraceptive use
Spontaneous regression of the leiomyomas or regression
following withdrawal of ovarian hormones or oophorectomy
This post was last modified on 08 April 2022