Download MBBS Surgery Presentations 47 Peritoneum Lecture Notes

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