That upper floor of the abdominal cavity is the abdominal cavity. Derivatives of the peritoneum in the upper floor of the abdominal cavity. Upper floor of the abdominal cavity Floors of the abdominal cavity diagram

Peritoneum- part of the abdominal cavity limited by the parietal layer of the peritoneum. It is a serous membrane that covers the inner surface of the walls of the abdomen and the organs located in it, forming a closed cavity. Normally, it has the character of a gap filled with serous fluid. Consists of two layers - parietal and visceral. Organs covered with visceral peritoneum on all sides are located intraperitoneally or intraperitoneally, mesoperitoneally on three sides and extraperitoneally on one side. In topographic anatomy, it is traditionally accepted that intra- and mesoperitoneally lying organs belong to the organs of the abdominal cavity, and organs occupying a retroperitoneal, retroperitoneal position (a special case of extraperitoneal) belong to the organs of the retroperitoneal space.

Lig. Hepatoduodenal- hepatic-duodenal ligament is one of the three ligaments of the lesser omentum and is of greatest importance. This ligament contains: the bile duct, ductus choledochus, portal vein, v. portae and proper hepatic artery, a. hepatica propria. On the left it passes into the hepatopyloric ligament, lig. hepatopyloricum.

Lig. suspensorium duodeni - suspensory ligament of the duodenum (ligament of Treitz) goes from the left leg of the lumbar diaphragm to the duodenojejunal bend, flexura duodenojejunalis. In the thickness of this peritoneal duplication lies the smooth muscle of the same name, m. duodenojejunalis, supporting the duodenum.

Omentum majus(large seal) - a duplication of the peritoneum descending from the greater curvature of the stomach, covering the loops of the small intestine and fused with the transverse colon. The cavity of the greater omentum has the following boundaries: in front lig. gastrocolicum; behind it is represented by the parietal peritoneum, from below this cavity is limited by the transverse colon and its mesentery; above - the gastro-pancreatic ligaments with the gastro-pancreatic opening between them; on the left - splenic eversion of the cavity of the greater omentum, recessus lienalis cavi omenti majoris and on the right - the pancreatic-duodenal recess of the cavity of the greater omentum, recessus pancreaticoduodenalis cavi omenti majoris.

In the cavity of the greater omentum there are four eversion: 1) superior gastro-pancreatic eversion, recessus gastropancreaticus; 2) lower eversion, recessus inferior; 3) on the left - splenic inversion, recessus lienalis and the hilum of the spleen; 4) on the right - pancreatic-duodenal eversion, recessus pancreaticoduodenalis.

In children, the greater omentum is located in the left half of the abdomen, along the lower edge of the transverse colon; it is short and only partially covers the intestinal loops. By 2-3 years of age, the size of the greater omentum increases, but the layers of peritoneum that form it remain very thin, and there is almost no fatty tissue between them.

Omentum minus(lesser omentum) - is a duplication of the peritoneum, stretching from the gate of the liver, as well as from the posterior half of the left sagittal groove of the liver to the lesser curvature of the stomach and to the initial section of the horizontal part of the duodenum. It consists of three ligaments: hepatogastric, hepatopyloric and hepatoduodenal. The lesser omentum has the shape of a trapezoid with a lower base of about 15-18 cm and an upper short base of about 6 cm. The posterior wall of the cavity of the lesser omentum is formed by the parietal peritoneum lying on the aorta; the upper wall is represented by the left and caudate lobes of the liver; the lower wall is the gastropancreatic ligaments, the left wall is represented by the peritoneum, lying on the right surface of the abdominal part of the esophagus, and also lining the posterior surface of the cardia. The depression located here can be called the cardiac eversion of the cavity of the lesser omentum, recessus cardialis cavi omenti minoris.

Top floor: liver with gall bladder, stomach, spleen, upper half of the duodenum, pancreas and four spaces: right and left subdiaphragmatic, pregastric, subhepatic, and also the omental bursa. Ground floor: the lower half of the duodenum, the small and large intestine, two lateral peritoneal canals (right and left) and two mesenteric - mesenteric sinuses (right and left).

Bursa omentalis(bursa omental) - is a slit-like cavity located behind the stomach. In this cavity, the following six walls can be distinguished: anterior, posterior, upper, lower, right and left.

The anterior wall is formed by: the lesser omentum, the posterior surface of the stomach and the gastrocolic ligament. The posterior wall is represented by the parietal peritoneum, lining the pancreas and large vessels lying on the spine. The upper wall is formed by the left and caudate lobes of the liver, the lower wall is formed by the transverse colon and its mesentery, mesocolon; the left and right borders of the bursa are formed by transitional folds of the peritoneum.

The gastropancreatic ligaments divide the cavity of the bursa into clearly defined two floors: the upper one - the cavity of the lesser omentum, cavum omenti minorls, lower - the cavity of the greater omentum, cavum omenti majoris. This cavity has the following boundaries: in front it is formed by the ligaments of the lesser omentum ( lig. hepatogastricum, lig. hepatopyloricum And lig. hepatoduodenal).

Bursa hepatica dextra(right hepatic bursa) - located between the diaphragm and the right lobe of the liver. It is limited: from above - by the tendon center of the diaphragm; below - the upper surface of the right lobe of the liver, behind - the right coronary ligament of the liver, lig. coronanum hepatis dextrum, from the inside - by the suspensory or falciform ligament, lig.falciforme s.suspensorium hepatis, outside - the muscular part of the diaphragm, . This bag often serves as a container for subphrenic abscesses

Bursa hepatica sinistra(left hepatic bursa) - located between the left lobe of the liver and the diaphragm. Its boundaries: in front - the muscular part of the diaphragm, pars muscularis diaphragmatis, behind - the left coronary ligament of the liver, lig. coronarium hepatls sinistrum, from the inside - the suspensory, or falciform, ligament of the liver, lig. suspensorium s.falciforme hepatis, and outside - the left triangular ligament of the liver, lig. triangulare hepatis sinistrum.

Bursa praegastrica(pregastric bursa) - located between the stomach and the left lobe of the liver. More precise boundaries are as follows: in front - the lower surface of the left lobe of the liver, behind - the anterior wall of the stomach, above - the lesser omentum and the porta hepatis.

In the lower floor of the abdominal cavity there are the right and left mesenteric sinuses, sinus mesentericus dexter And sinus mesentericus sinister. Both sinuses are triangular in shape. The right sinus is bounded on the right by the ascending colon, colon ascendens, on the left - the root of the mesentery, radix mesenterii, and from above - the transverse colon, colon transversum.

The left mesenteric sinus is bounded on the left by the descending colon, colon descendens, on the right - the obliquely extending root of the mesentery, radix mesenterii, and below - the sigmoid colon, colon sigmoideum.

There are two canals in the abdominal cavity, located in the longitudinal direction - the right and left lateral canals, canales longitudinales s. laterales, dexter et sinister.

The right lateral canal is located between the parietal peritoneum and the ascending colon. It extends from the lower surface of the liver, where it communicates with the hepatic bursa, to the cecum, near which it passes into the retrocecal eversion.

The left lateral canal is located between the parietal peritoneum and the descending colon. It begins below the left diaphragmatic-colic ligament, stretches down and between the parietal peritoneum and the sigmoid colon freely communicates with the pelvic cavity.

Recessus duodenojejunalis - duodenojejunal pouch- enclosed between two folds of peritoneum, plica duodenojejunalis superior And plica duodenojejunalis inferior, within flexura duodenojejunalis between these folds a depression is formed, which is called the duodenojejunal pouch. The superior mesenteric vein is contained in the superior fold. v. mesenterica inferior.

Recessus iliocaecalis superior- superior ileocecal pouch - enclosed in the upper corner between the ileum and cecum. It is bounded superiorly by the ileocolic fold, plica iliocolica, from below - the horizontally extending terminal part of the ileum, and from the outside - the initial section of the ascending colon, colon ascendens.

Recessus iliocaecalis inferior - inferior ileocecal recess- is a depression located below the distal part of the ileum. The pocket is limited: from above - by the ileum, from behind - by the mesentery of the appendix, mesenteriolum processus appendicularis, and in front - the ileocecal fold of the peritoneum, plica iliocaecalis, stretched between the distal part of the ileum and the cecum.

Clinical significance: Accumulations of pathological fluids formed in the right sinus are initially limited to the boundaries of this sinus. Below, the left sinus is open into the pelvic cavity, which allows the spread of pus or blood. Inflammatory processes can spread along the left and right lateral canals. Pockets are places where internal hernias form. The right hepatic bursa is often the site of subphrenic abscesses.

MINISTRY OF HEALTH OF THE REPUBLIC OF BELARUS

EDUCATIONAL INSTITUTION

"GOMEL STATE MEDICAL UNIVERSITY"

Department of Human Anatomy

With a course of operative surgery and topographic anatomy

E. Y. DOROSHKEVICH, S. V. DOROSHKEVICH,

I. I. LEMESHEVA

SELECTED ISSUES

TOPOGRAPHIC ANATOMY

AND OPERATIVE SURGERY

Educational and methodological manual

To practical classes on topographic anatomy

And operative surgery for 4th year medical students,

Medical diagnostic faculties and faculty of training

Specialists for foreign countries studying in their specialty

"General Medicine" and "Medical Diagnostics"

Gomel

GomSMU

CHAPTER 1

SURGICAL ANATOMY OF THE ABDOMINAL CAVITY

TOPOGRAPHY OF UPPER FLOOR BODIES

ABDOMINAL

1.1 Abdomen (cavitas abdominis) and its floors (boundaries, contents)

Borders of the abdominal cavity.

The upper wall of the abdominal cavity is formed by the diaphragm, the posterior wall is formed by the lumbar vertebrae and muscles of the lumbar region, the anterolateral wall is formed by the abdominal muscles, the lower border is the terminal line. All these muscles are covered by the circular fascia - the fascia of the abdomen, which is called the intra-abdominal fascia (fascia endoabdominalis); it directly limits the space called the abdominal cavity (or abdominal cavity).

The abdominal cavity is divided into 2 sections:

​peritoneal cavity (cavitas peritonei)- a slit-like space located between the layers of the parietal and visceral peritoneum and containing intraperitoneal and mesoperitoneal organs;

​retroperitoneal space (spatium retroperitoneale)- located between the parietal layer of peritoneum, covering the posterior abdominal wall, and the intra-abdominal fascia; it contains extra-peritoneal organs.

The transverse colon and its mesentery form a septum that divides the abdominal cavity into 2 floors - upper and lower.

In the upper floor of the abdominal cavity there are: liver, stomach, spleen, pancreas, upper half of the duodenum. The subgastric gland is located behind the peritoneum; however, it is considered as an organ of the abdominal cavity, since surgical access to it is usually carried out by transection. In the lower floor there are loops of the small intestine (with the lower half of the duodenum) and the large intestine.

Topography of the peritoneum: course, canals, sinuses, bags, ligaments, folds, pockets

Peritoneum (peritoneum)– a thin serous membrane with a smooth, shiny, uniform surface. Consists of parietal peritoneum (peri-toneum parietale) lining the abdominal wall, and visceral peritoneum (peritoneum viscerale) covering the abdominal organs. Between the leaves there is a slit-like space called the peritoneal cavity and containing a small amount of serous fluid, which moisturizes the surface of the organs and facilitates peristalsis. The parietal peritoneum lines the inside of the anterior and lateral walls of the abdomen, at the top it goes to the diaphragm, at the bottom to the large and small pelvis, at the back it does not reach the spine, limiting the retroperitoneal space.

The relationship of the visceral peritoneum to the organs is not the same in all cases. Some organs are covered with it on all sides and are located intraperitoneally: the stomach, spleen, small, cecum, transverse and sigmoid colons, and sometimes the gall bladder. They are completely covered with peritoneum. Some organs are covered with visceral peritoneum on 3 sides, i.e. they are located mesoperitoneally: liver, gall bladder, ascending and descending colons, initial and final sections of the duodenum.

Some organs are covered by peritoneum on only one side - extraperitoneally: duodenum, pancreas, kidneys, adrenal glands, bladder.

Course of the peritoneum

The visceral peritoneum, covering the diaphragmatic surface of the liver, passes to its lower surface. The leaves of the peritoneum, one from the anterior part of the lower surface of the liver, the other from the posterior, meet at the gate and descend down towards the lesser curvature of the stomach and the initial part of the duodenum, participating in the formation of the ligaments of the lesser omentum. The leaves of the lesser omentum diverge at the lesser curvature of the stomach, cover the stomach in front and behind, and, reuniting at the greater curvature of the stomach, descend downwards, forming the anterior plate of the greater omentum (omentum majus). Having gone down, sometimes to the pubic symphysis, the leaves are wrapped and directed upward, forming the posterior plate of the greater omentum. Having reached the transverse colon, the layers of the peritoneum bend around its anterosuperior surface and go to the posterior wall of the abdominal cavity. At this point they diverge, and one of them rises upward, covering the pancreas, the posterior wall of the abdominal cavity, partially the diaphragm and, having reached the posteroinferior edge of the liver, passes to its lower surface. The other layer of the peritoneum wraps up and goes in the opposite direction, i.e., from the posterior wall of the abdomen to the transverse colon, which it covers, and again returns to the posterior wall of the abdomen. This is how the mesentery of the transverse colon is formed (mesocolon transversum), consisting of 4 layers of peritoneum. From the root of the mesentery of the transverse colon, the layer of peritoneum descends and, as the parietal peritoneum, lines the posterior wall of the abdomen, then covers the ascending (right) and descending (left) colons on 3 sides. Inward from the ascending and descending colons, the parietal layer of the peritoneum covers the organs of the retroperitoneal space and, approaching the small intestine, forms its mesentery, enveloping the intestine on all sides.

From the posterior wall of the abdomen, the parietal layer of the peritoneum descends into the pelvic cavity, where it covers the initial sections of the rectum, then lines the walls of the small pelvis and passes to the bladder (in women, it first covers the uterus), covering it from behind, from the sides and from above. From the top of the bladder, the peritoneum passes to the anterior wall of the abdomen, closing the peritoneal cavity. For a more detailed course of the peritoneum in the pelvic cavity, see the topic “Topographic anatomy of the pelvis and perineum.”

Channels

On the sides of the ascending and descending colons are the right and left abdominal canals (canalis lateralis dexter et sinister), formed as a result of the transition of the peritoneum from the side wall of the abdomen to the colon. The right channel has a connection between the upper floor and the lower one. In the left channel there is no connection between the upper floor and the lower floor due to the presence of the diaphragmatic-colic ligament (lig. phrenicocolicum).

Abdominal sinuses(sinus mesentericus dexter et sinus mesentericus sinister)

The right sinus is limited: on the right - by the ascending colon; above - the transverse colon, on the left - the mesentery of the small intestine. Left sinus: on the left - the descending colon, below - the entrance to the pelvic cavity, on the right - the mesentery of the small intestine.

Bags

Omental bag(bursa omentalis) limited: anteriorly by the lesser omentum, posterior wall of the stomach and gastrocolic ligament; behind - the parietal peritoneum, covering the pancreas, part of the abdominal aorta and the inferior vena cava; above - the liver and diaphragm; below - the transverse colon and its mesentery; on the left - the gastrosplenic and diaphragmatic-splenic ligaments, the hilum of the spleen. Communicates with the peritoneal cavity through stuffing box hole(foramen epiploicum, foramen of Winslow), bounded in front by the hepato-duodenal ligament, below by the duodenal-renal ligament and the upper horizontal part of the duodenum, behind by the hepatorenal ligament and parietal peritoneum covering the inferior vena cava, above by the caudate lobe of the liver.

Right hepatic bursa(bursa hepatica dextra) It is bounded above by the tendon center of the diaphragm, below by the diaphragmatic surface of the right lobe of the liver, behind by the right coronary ligament, on the left by the falciform ligament. It is the site of subphrenic abscesses.

Left hepatic bursa(bursa hepatica sinistra) bounded above by the diaphragm, behind by the left coronary ligament of the liver, on the right by the falciform ligament, on the left by the left triangular ligament of the liver, below by the diaphragmatic surface of the left lobe of the liver.

Pregastric bursa(bursa pregastrica) It is limited from above by the left lobe of the liver, in front - by the parietal peritoneum of the anterior abdominal wall, behind - by the lesser omentum and the anterior surface of the stomach, on the right - by the falciform ligament.

Preomental space(spatium preepiploicum)- a long gap located between the anterior surface of the greater omentum and the inner surface of the anterior abdominal wall. Through this gap, the upper and lower floors communicate with each other.

Peritoneal ligaments

In places where the peritoneum transitions from the abdominal wall to an organ or from organ to organ, ligaments are formed (ligg. peritonei).

Hepatoduodenal ligament(lig. hepatoduodenale) stretched between the porta hepatis and the upper part of the duodenum. On the left it passes into the hepatogastric ligament, and on the right it ends with a free edge. Between the leaves of the ligament pass: on the right - the common bile duct and the common hepatic and cystic ducts that form it, on the left - the proper hepatic artery and its branches, between them and behind - the portal vein ("TWO"- ductus, vein, artery from right to left), as well as lymphatic vessels and nodes, nerve plexuses.

Hepatogastric ligament(lig. hepatogastricum) It is a duplication of the peritoneum, stretched between the gates of the liver and the lesser curvature of the stomach; on the left it passes to the abdominal esophagus, on the right it continues into the hepatoduodenal ligament.

The hepatic branches of the anterior vagus trunk pass through the upper part of the ligament. At the base of this ligament, in some cases, there is the left gastric artery, accompanied by a vein of the same name, but more often these vessels lie on the wall of the stomach along the lesser curvature. In addition, often (in 16.5%) an accessory hepatic artery is located in the tense part of the ligament, coming from the left gastric artery. In rare cases, the main trunk of the left gastric vein or its tributaries passes here.

When mobilizing the stomach along the lesser curvature, especially if the ligament is dissected near the portal of the liver (for stomach cancer), it is necessary to take into account the possibility of the left accessory hepatic artery passing here, since its intersection can lead to necrosis of the left lobe of the liver or part of it.

On the right, at the base of the hepatogastric ligament, the right gastric artery passes, accompanied by the vein of the same name.

Hepatorenal ligament(lig. hepatorenal) is formed at the site of transition of the peritoneum from the lower surface of the right lobe of the liver to the right kidney. The inferior vena cava passes through the medial part of this ligament.

Gastrophrenic ligament(lig. gastrophrenicum) located to the left of the esophagus, between the bottom of the stomach and the diaphragm. The ligament has the shape of a triangular plate and consists of one layer of peritoneum, at the base of which there is loose connective tissue. On the left, the ligament passes into the superficial layer of the gastrosplenic ligament, and on the right - onto the anterior semicircle of the esophagus.

The transition of the peritoneum from the gastrophrenic ligament to the anterior wall of the esophagus and to the hepatogastric ligament is called diaphragmatic-esophageal ligament(lig. phrenicooesophageum).

Diaphragmatic-esophageal ligament (lig. phrenicoesophageum) represents the transition of the parietal peritoneum from the diaphragm to the esophagus and the cardiac part of the stomach. At its base in loose tissue along the anterior surface of the esophagus there are r. esophageus from a. gastrica sinistra and the trunk of the left vagus nerve.

Gastrosplenic ligament (lig. gastrolienale), stretched between the fundus of the stomach and the upper part of the greater curvature and the hilum of the spleen, is located below the gastrophrenic ligament. It consists of 2 layers of peritoneum, between which short gastric arteries pass, accompanied by veins of the same name. Continuing downwards, it passes into the gastrocolic ligament.

Gastrocolic ligament (lig. gastrocolicum) consists of 2 layers of peritoneum. It is the initial section of the greater omentum and is located between the greater curvature of the stomach and the transverse colon. This is the widest ligament, which runs in the form of a strip from the lower pole of the spleen to the pylorus. The ligament is loosely connected to the anterior semicircle of the transverse colon, as well as to tenia omentalis. It contains the right and left gastroepiploic arteries.

Gastropancreatic ligament (lig. gastropancreaticum) located between the upper edge of the pancreas and the cardiac part, as well as the fundus of the stomach. It is quite clearly defined if the gastrocolic ligament is cut and the stomach is pulled anteriorly and upward.

In the free edge of the gastro-pancreatic ligament there is the initial section of the left gastric artery and the vein of the same name, as well as lymphatic vessels and gastro-pancreatic lymph nodes. In addition, at the base of the ligament along the upper edge of the pancreas there are pancreasplenic lymph nodes.

Pyloropancreatic ligament (lig. pyloropancreaticum) in the form of a duplication of the peritoneum, it is stretched between the pylorus and the right part of the body of the pancreas. It has the shape of a triangle, one side of which is fixed to the posterior surface of the pylorus, and the other to the anteroinferior surface of the body of the gland; the free edge of the ligament is directed to the left. Sometimes the ligament is not expressed.

Small lymph nodes are concentrated in the pyloropancreatic ligament, which can be affected by cancer of the pyloric part of the stomach. Therefore, during gastric resection it is necessary to completely remove this ligament along with the lymph nodes.

Between the gastropancreatic and pyloric-pancreatic ligaments there is a slit-like gastropancreatic opening. The shape and size of this hole depend on the degree of development of the mentioned ligaments. Sometimes the ligaments are so developed that they overlap each other or grow together, closing the gastro-pancreatic opening.

This leads to the fact that the cavity of the omental bursa is divided by ligaments into 2 separate spaces. In such cases, if there is pathological content in the cavity of the omental bursa (effusion, blood, gastric contents, etc.), it will be located in one or another space.

Phrenic-splenic ligament (lig. phrenicolienale) located deep in the posterior part of the left hypochondrium, between the costal part of the diaphragm and the hilum of the spleen.

There is tension between the costal part of the diaphragm and the left flexure of the colon diaphragmatic-colic ligament (lig. phrenicocolicum). This ligament, together with the transverse colon, forms a deep pocket in which the anterior pole of the spleen is located.

Duodenal-renal ligament (lig. duodenorenale) located between the posterosuperior edge of the duodenum and the right kidney, limits the omental foramen from below.

Suspensory ligament of the duodenum or ligament of Treitz (lig. suspensorium duodeni s. lig. Treitz) formed by a fold of peritoneum covering the muscle that suspends the duodenum (m. suspensorius duodeni). The muscle bundles of the latter arise from the circular muscular layer of the intestine at the point of its inflection. The narrow and strong muscle is directed from flexura duodenojejunalis upward, behind the pancreas it expands fan-shaped and is woven into the muscle bundles of the legs of the diaphragm.

Pancreasplenic ligament (lig. pancreaticolienale) is a continuation of the diaphragmatic-splenic ligament and is a fold of peritoneum that stretches from the tail of the gland to the gate of the spleen.

1. Around the beginning of the jejunum, the parietal peritoneum forms a fold bordering the intestine from above and to the left - this is the superior duodenal fold (plica duodenalis superior). The superior duodenal recess is localized in this area (recessus duodenalis superior), on the right it is limited by the duodenum-jejunal flexure 12, on the top and on the left - by the superior duodenal fold, in which the inferior mesenteric vein passes.

2. To the left of the ascending part of the duodenum there is a paraduodenal fold (plica paraduodenalis). This fold limits the inconstant paraduodenal recess anteriorly. (recessus paraduodenalis), the posterior wall of which is the parietal peritoneum.

3. To the left and below from the ascending part of the duodenum passes the lower duodenal fold (plica duodenalis inferior), which limits the inferior duodenal recess (recessus duodenalis inferior).

4. To the left of the root of the mesentery of the small intestine, behind the ascending part of the duodenum, there is a retroduodenal recess (recessus retroduodenalis).

5. At the point where the ileum enters the cecum, an ileocecal fold is formed (plica ileocecalis). It is located between the medial wall of the cecum, the anterior wall of the ileum, and also connects the medial wall of the cecum with the lower wall of the ileum at the top and with the base of the appendix at the bottom. Under the ileocecal fold lie the pockets located above and below the ileum: the upper and lower ileocecal recesses (recessus ileocecalis superior et recessus ileocecalis inferior). The superior ileocecal recess is bounded at the top by the ileocolic fold, at the bottom by the terminal section of the ileum, and externally by the initial section of the ascending colon. The lower ileocecal recess is limited at the top by the terminal ileum, behind - by the mesentery of the appendix and in front - by the ileocecal fold of the peritoneum.

6. Postcolic recess (recessus retrocecalis) bounded anteriorly by the cecum, posteriorly by the parietal peritoneum and externally by the cecum-intestinal folds of the peritoneum (plicae cecales), stretched between the lateral edge of the bottom of the cecum and the parietal peritoneum of the iliac fossa.

7. Intersigmoid recess (recessus intersigmoideus) located on the left at the root of the mesentery of the sigmoid colon.

1. Upper floor of the peritoneal cavity decays into t three bursa: bursa hepatica, bursa pregastrica and bursa omentalis. Bursa hepatica covers the right lobe of the liver and is separated from bursa pregastrica through lig. falciforme hepatis; at the back it is limited by lig. coronarium hepatis. In depth bursa hepatica, under the liver, the upper end of the right kidney with the adrenal gland is palpated. Bursa pregastrica covers the left lobe of the liver, the anterior surface of the stomach and the spleen; the left part of the coronary ligament runs along the posterior edge of the left lobe of the liver; The spleen is covered on all sides by peritoneum, and only in the area of ​​the hilum does its peritoneum pass from the spleen to the stomach, forming lig. gastroliennale, and to the diaphragm - lig. phrenicolenale.

Bursa omentalis, omental bursa,

It is a part of the general cavity of the peritoneum, lying behind the stomach and lesser omentum. Part lesser omentum, omentum minus, includes, as stated, two ligaments of the peritoneum: lig. hepatogastricum, going from the visceral surface and gates of the liver to the lesser curvature of the stomach, and lig. hepatoduodenal, connecting the porta hepatis with the pars superior duodeni. Between the sheets lig. hepatoduodenal pass the common bile duct (right), common hepatic artery (left) and portal vein (posteriorly and between these formations), as well as lymphatic vessels, nodes and nerves.

Cavity omental bag communicates with the general cavity of the peritoneum only through the relatively narrow foramen epipldicum. Foramen epiploicum bounded above by the caudate lobe of the liver, in front by the free edge of the lig. hepatoduodenale, from below - by the upper part of the duodenum, from behind - by a sheet of peritoneum covering the inferior vena cava passing here, and more outwardly - by a ligament passing from the posterior edge of the liver to the right kidney, lig. hepatorenal. The part of the omental bursa directly adjacent to the omental opening and located behind the lig. hepatoduodenale, is called the vestibule - vestibulum bursae omentalis; above it is limited by the caudate lobe of the liver, and below by the duodenum and the head of the pancreas.

Top wall omental bag The lower surface of the caudate lobe of the liver serves, and the processus papillaris hangs in the bursa itself. The parietal layer of the peritoneum, forming the posterior wall of the omental bursa, covers the aorta, inferior vena cava, pancreas, left kidney and adrenal gland located here. Along the anterior edge of the pancreas, the parietal layer of peritoneum extends from the pancreas and continues forward and downward as the anterior layer of the mesocolon transversum or, more precisely, the posterior plate of the greater omentum, fused with the mesocolon transversum, forming the lower wall of the omental bursa.

The left wall of the omental bursa is made up of ligaments of the spleen: gastrosplenic, lig. gastrolienale, and phrenic-splenic, lig. phrenicosplenicum.

Greater omentum, omentum majus,

in the form of an apron hangs down from the colon transversum, covering a greater or lesser extent of the loops of the small intestine; It got its name from the presence of fat in it. It consists of 4 layers of peritoneum, fused in the form of plates.

The anterior plate of the greater omentum are two layers of peritoneum, extending down from the greater curvature of the stomach and passing in front of the colon transversum, with which they grow together, and the transition of the peritoneum from the stomach to the colon transversum is called lig. gastrocolicum.

These two leaves of the omentum can descend in front of the loops of the small intestine almost to the level of the pubic bones, then they bend into the posterior plate of the omentum, so that the entire thickness of the greater omentum consists of four leaves; the omentum leaves do not normally fuse with the loops of the small intestines. Between the leaves of the anterior plate of the omentum and the posterior leaves there is a slit-like cavity, communicating at the top with the cavity of the omental bursa, but in an adult the leaves usually grow together with each other, so that the cavity of the greater omentum is obliterated over a large area.

Along the greater curvature of the stomach, the cavity sometimes continues in adults for a greater or lesser extent between the leaves of the greater omentum.

In the thickness of the greater omentum there are lymph nodes, nodi lymphatici omentales, which drain lymph from the greater omentum and the transverse colon.

Educational video anatomy of floors, canals, bags, peritoneal pockets and omental foramen

1. Embryogenesis of the peritoneum.

2. Functional significance of the peritoneum.

3. Features of the structure of the peritoneum.

4. Topography of the peritoneum:

4.1 Top floor.

4.2 Middle floor.

4.3 Ground floor.

Embryogenesis of the peritoneum

As a result of embryonic development, the secondary body cavity is generally divided into a number of separate closed serous cavities: this is how 2 pleural cavities and 1 pericardial cavity are formed in the chest cavity; in the abdominal cavity - the peritoneal cavity.

In men, there is another serous cavity between the membranes of the testicle.

All these cavities are hermetically sealed, with the exception of women - with the help of the fallopian tubes during ovulation and menstruation, the abdominal cavity communicates with the environment.

In this lecture we will touch on the structure of such a serous membrane as the peritoneum.

PERITONEUM (peritoneum) is a serous membrane that is divided into parietal and visceral layers that cover the walls and internal organs of the abdominal cavity.

The visceral layer of peritoneum covers the internal organs located in the abdominal cavity. There are several types of relationship of an organ to the peritoneum or coverage of an organ by the peritoneum.

If the organ is covered with peritoneum on all sides, then it is said to be in an intraperitoneal position (for example, small intestine, stomach, spleen, etc.). If the organ is covered by peritoneum on three sides, then the mesoperitoneal position is meant (for example, the liver, ascending and descending colon). If the organ is covered by peritoneum on one side, then this is an extraperitoneal or retroperitoneal position (for example, kidneys, lower third of the rectum, etc.).

The parietal peritoneum lines the walls of the abdominal cavity. In this case, it is necessary to define the abdominal cavity.

ABDOMINAL CAVITY is the space of the body located below the diaphragm and filled with internal organs, mainly the digestive and genitourinary systems.

The abdominal cavity has walls:

the top one is the diaphragm

lower - pelvic diaphragm

posterior - spinal column and posterior abdominal wall.

anterolateral - these are the abdominal muscles: rectus, external and internal oblique and transverse.

The parietal layer lines these walls of the abdominal cavity, and the visceral layer covers the internal organs located in it, and between the visceral and parietal layers of the peritoneum a narrow gap is formed - the PERITONEAL CAVITY.

Thus, to summarize what has been said, it should be noted that a person has several separate serous cavities, including the peritoneal cavity, lined with serous membranes.

Speaking about serous membranes, one cannot help but touch upon their functional significance.

Functional significance of the peritoneum

1. Serous membranes reduce friction of internal organs against each other, because they secrete fluid that lubricates the contact surfaces.

2. The serous membrane has a transuding and exuding function. The peritoneum secretes up to 70 liters of fluid per day, and all this fluid is absorbed by the peritoneum itself during the day. Different parts of the peritoneum can perform one of the above functions. Thus, the diaphragmatic peritoneum has a predominantly absorptive function, the serous cover of the small intestine has a transudative ability, the neutral areas include the serous cover of the anterolateral wall of the abdominal cavity, and the serous cover of the stomach.

3. Serous membranes are characterized by a protective function, because they are unique barriers in the body: serous-hemolymphatic barrier (for example, peritoneum, pleura, pericardium), serous-hemolymphatic barrier (for example, greater omentum). A large number of phagocytes are localized in the serous membranes.

4 The peritoneum has great regenerative abilities: the damaged area of ​​the serous membrane is first covered with a thin layer of fibrin, and then simultaneously throughout the damaged area with mesothelium.

5. Under the influence of external irritations, not only the functions, but also the morphology of the serous cover change: adhesions appear - i.e. serous membranes are characterized by delimiting abilities; but at the same time, adhesions can lead to a number of pathological conditions requiring repeated surgical interventions. And, despite the high level of development of surgical technology, intraperitoneal adhesions are frequent complications, which forced us to distinguish this disease as a separate nosological unit - adhesive disease.

6. Serous membranes are the basis in which the vascular bed, lymphatic vessels and a huge number of nerve elements lie.

Thus, the serous membrane is a powerful receptor field: the maximum concentration of nerve elements, and in particular receptors, per unit area of ​​the serous membrane is called the REFLEXOGENIC ZONE. Such zones include the umbilical region, the ileocecal angle with the vermiform appendix.

7. The total area of ​​the peritoneum is about 2 square meters. meters and is equal to the area of ​​the skin.

8. The peritoneum performs a fixation function (attaches organs and fixes them, returns them to their original position after displacement).

That. serous membranes perform several functions:

protective,

trophic,

fixation

delimiting, etc.

TOPOGRAPHIC ANATOMY OF THE UPPER ABDOMINAL CAVITY

The abdominal cavity is a space lined from the inside with intra-abdominal fascia.

Borders: above – the diaphragm, below – the border line, in front – the anterolateral wall, behind – the posterior wall of the abdomen.

Departments:

abdominal (peritoneal) cavity - a space limited by the parietal layer of the peritoneum;

retroperitoneal space - the space located between the parietal peritoneum and the intra-abdominal fascia, lining the posterior wall of the abdomen from the inside.

Peritoneum

The peritoneum is a serous membrane that lines the inside of the abdominal wall and covers most of its organs. Departments:

Parietal(parietal) peritoneum– lines the walls belly.

Visceral peritoneum– covers the abdominal organs.

Options for covering organs with peritoneum:

intraperitoneal - from all sides; mesoperitoneal – on three sides (one side is not

covered); extraperitoneal - on one side.

Properties of the peritoneum : humidity, smoothness, shine, elasticity, bactericidal properties, adhesiveness.

Functions of the peritoneum : fixing, protective, excretory, absorption, receptor, conduction, depository (blood).

Course of the peritoneum

From the anterior abdominal wall, the peritoneum passes to the lower concave surface of the diaphragm, then to the upper

the surface of the liver and forms two ligaments: one in the sagittal plane - the falciform ligament, the second in the frontal plane - the coronary ligament of the liver. From the upper surface of the liver, the peritoneum passes to its lower surface and, approaching the gate of the liver, meets the layer of peritoneum, which goes to the liver from the posterior abdominal wall. Both layers go to the lesser curvature of the stomach and the upper part of the duodenum, forming the lesser omentum. Covering the stomach on all sides, the leaves of the peritoneum descend down from its greater curvature and, turning around, return and approach in front of the transverse colon to the body of the pancreas, forming the greater omentum. In the area of ​​the body of the pancreas, one leaf rises upward, forming the posterior wall of the abdominal cavity. The second leaf goes to the transverse colon, covers it on all sides, returns back, forming the mesentery of the intestine. Then the leaf descends, covers the small intestine on all sides, forms its mesentery and the mesentery of the sigmoid colon and descends into the pelvic cavity.

Floors of the abdominal cavity

The peritoneal cavity is divided into two floors by the transverse colon and its mesentery:

Top floor– located above the transverse colon intestine and its mesenteries. Contents: liver, spleen, stomach, partially duodenum; right and left hepatic, subhepatic, pregastric and omental bursae.

Ground floor– located below the transverse colon intestine and its mesenteries. Contents: loops of jejunum and ileum; cecum and vermiform appendix;

colon; lateral canals and mesenteric sinuses. The root of the mesentery of the transverse colon goes from right to left from the right kidney, slightly below its middle, to the middle of the left. On its way it crosses: the middle of the descending part of the duodenum; head of the pancreas

of the gland and runs along the upper edge of the gland body.

Upper abdominal bursae

Right hepatic bursa located between the diaphragm and the right lobe of the liver and limited behind the right coronary

ligament of the liver, on the left – the falciform ligament, and on the right and below it opens into the subhepatic bursa and the right lateral canal.

Left hepatic bursa lies between the diaphragm and the left lobe of the liver and is bounded posteriorly by the left coronary ligament of the liver, on the right by the falciform ligament, on the left by the left triangular ligament of the liver, and in front communicates with the pregastric bursa.

Pregastric bursa located between the stomach and the left lobe of the liver and is limited in front by the lower surface of the left lobe of the liver, behind by the lesser omentum and the anterior wall of the stomach, above by the porta hepatis and communicates with the subhepatic bursa and the lower floor of the abdominal cavity through the preepiploic fissure.

Subhepatic bursa it is limited in front and above by the lower surface of the right lobe of the liver, below - by the transverse colon and its mesentery, on the left - by the porta hepatis and on the right it opens into the right lateral canal.

Omental bag forms a closed pocket behind stomach and consists of the vestibule and the gastro-pancreatic sac.

Vestibule of the omental bursa limited at the top of the tail-

that lobe of the liver, in front - the lesser omentum, below - the duodenum, behind - the parietal part of the peritoneum lying on the aorta and the inferior vena cava.

Stuffing box hole bounded in front by the hepatoduodenal ligament, which contains the hepatic artery, common bile duct and portal vein, below by the duodenal-renal ligament, behind by the hepatorenal ligament, above by the caudate lobe of the liver.

Gastrointestinal- pancreas pouch limited front rear

the lower surface of the lesser omentum, the posterior surface of the stomach and the posterior surface of the gastrocolic ligament, behind - the parietal peritoneum lining the pancreas, aorta and inferior vena cava, above - the caudate lobe of the liver, below - the mesentery of the transverse colon, on the left - the gland - splenic and renal-splenic ligaments.

Topographic anatomy of the stomach Holotopia: left hypochondrium, epigastric region proper -

Skeletotopia:

cardiac foramen – to the left of Th XI (behind the cartilage of the VII rib);

bottom – Th X (V rib along the left midclavicular line); pylorus – L1 (VIII right rib in the midline).

Syntopy: at the top – the diaphragm and the left lobe of the liver, at the back

on the left - the pancreas, left kidney, adrenal gland and spleen, in front - the abdominal wall, below - the transverse colon and its mesentery.

Gastric ligaments:

Hepatic- gastric ligament– between the porta hepatis and lesser curvature of the stomach; contains the left and right gastric arteries, veins, branches of the vagus trunks, lymphatic vessels and nodes.

Diaphragmatically- esophageal ligament– between the diaphragm

esophagus and cardiac part of the stomach; contains a branch of the left gastric artery.

Gastrointestinal- diaphragmatic ligament is formed as a result transition of the parietal peritoneum from the diaphragm to the anterior wall of the fundus and partially the cardiac part of the stomach.

Gastrointestinal- splenic ligament– between the spleen and greater curvature of the stomach; contains short arteries and veins of the stomach.

Gastrointestinal- colic ligament– between greater curvature stomach and transverse colon; contains the right and left gastroepiploic arteries.

Gastrointestinal- pancreatic ligament is formed during the transition

de peritoneum from the upper edge of the pancreas to the posterior wall of the body, cardia and fundus of the stomach; contains the left gastric artery.

Blood supply to the stomach provided by the celiac axis system.

Left gastric artery is divided into ascending esophageal and descending branches, which, passing along the lesser curvature of the stomach from left to right, give off anterior and posterior branches.

Right gastric artery starts from own hepatic artery. As part of the hepatoduodenal ligament, the artery reaches the pyloric

The lower part of the stomach and between the leaves of the lesser omentum along the lesser curvature is directed to the left towards the left gastric artery, forming the arterial arch of the lesser curvature of the stomach.

Left gastro- omental artery is a branch splenic artery and is located between the leaves of the gastrosplenic and gastrocolic ligaments along the greater curvature of the stomach.

Right gastrointestinal- omental artery starts from gastroduodenal artery and goes from right to left along the greater curvature of the stomach towards the left gastroepiploic artery, forming a second arterial arch along the greater curvature of the stomach.

Short gastric arteries in quantity 2-7 branches depart from the splenic artery and, passing in the gastrosplenic ligament, reach the bottom along the greater curvature

The veins of the stomach accompany the arteries of the same name and flow into the portal vein or one of its roots.

Lymphatic drainage

The efferent lymphatic vessels of the stomach empty into the first-order lymph nodes located in the lesser omentum, located along the greater curvature, at the hilum of the spleen, along the tail and body of the pancreas, into the subpyloric and superior mesenteric lymph nodes. The drainage vessels from all of the listed first-order lymph nodes are directed to the second-order lymph nodes, which are located near the celiac trunk. From them, lymph flows into the lumbar lymph nodes.

Innervation of the stomach provided by the sympathetic and parasympathetic parts of the autonomic nervous system. The main sympathetic nerve fibers are directed to the stomach from the celiac plexus, enter and spread in the organ along extra- and intraorgan vessels. Parasympathetic nerve fibers into the stomach come from the right and left vagus nerves, which form the anterior and posterior vagus trunks below the diaphragm.

Topographic anatomy of the duodenum Holotopia: in the epigastric and umbilical regions.

The duodenum has four sections: superior, descending, horizontal and ascending.

Top part ( bulb ) duodenum located between the pylorus of the stomach and the superior flexure of the duodenum.

Relation to the peritoneum: covered intraperitoneally in the initial part, mesoperitoneally in the middle part.

Skeletotopia– L1.

Syntopy: above the gallbladder, below is the head of the pancreas, in front is the antrum of the stomach.

Descending part the duodenum forms more or less pronounced bend to the right and goes from the upper to the lower bends. The common bile duct and the pancreatic duct on the major duodenal papilla open into this part. A little higher than it there may be a non-permanent small duodenal papilla, on which the accessory duct of the pancreas opens.

Relation to the peritoneum:

Skeletotopia– L1-L3.

Syntopy: on the left is the head of the pancreas, behind and on the right is the right kidney, right renal vein, inferior vena cava and ureter, in front is the mesentery of the transverse colon and loops of the small intestine.

Horizontal part duodenum goes from the inferior bend to the intersection with the superior mesenteric vessels.

Relation to the peritoneum: located retroperitoneally.

Skeletotopia– L3.

Syntopy: superiorly the head of the pancreas, behind inferior vena cava and abdominal aorta, anterior and inferior loops of the small intestine.

Rising part The duodenum extends from the intersection with the superior mesenteric vessels to the left and up to the duodenojejunal flexure and is fixed by the suspensory ligament of the duodenum.

Relation to the peritoneum: located mesoperitoneally.

Skeletotopia– L3-L2.

Syntopy: above the lower surface of the body of the pancreas, behind the inferior vena cava and abdominal aorta, in front and below the loops of the small intestine.

Duodenal ligaments

Hepatic- duodenal ligament– between the gates liver and the initial part of the duodenum and contains its own hepatic artery, located in the ligament on the left, the common bile duct located on the right, and between them and behind – the portal vein.

Duodenum- renal ligament in the form of a fold of the belly

The splint is stretched between the outer edge of the descending part of the intestine and the right kidney.

Blood supply to the duodenum provide

It comes from the system of the celiac trunk and the superior mesenteric artery.

Posterior and anterior superior pancreas- twelve-

duodenal arteries arise from the gastroduodenal arteries.

Rear and anterior inferior pancreas-

duodenal arteries arise from the superior mesenteric arteries, go towards the two upper ones and connect with them.

The veins of the duodenum follow the course of the arteries of the same name and drain blood into the portal vein system.

Lymphatic drainage

The draining lymphatic vessels empty into the first-order lymph nodes, which are the superior and inferior pancreaticoduodenal nodes.

Innervation duodenum is carried out from the celiac, superior mesenteric, hepatic and pancreatic nerve plexuses, as well as branches of both vagus nerves.

Intestinal suture

Intestinal suture is a collective concept that unites all types of sutures that are placed on hollow organs (food, stomach, small and large intestines).

Primary requirements, presented to the intestinal suture:

Tightness– is achieved by contact of the serous membranes of the stitched surfaces.

Hemostatic– is achieved by capturing the submucosal base of a hollow organ into the suture (the suture should provide hemostasis, but without significant disruption of the blood supply to the organ wall along the suture line).

Adaptability– the seam must be made taking into account case structure of the walls of the digestive tract for optimal comparison with each other of the same membranes of the intestinal tube.

Strength– is achieved by capturing the submucosal layer into the suture, where a large number of elastic fibers are located.

Asepsis(purity, non-infection) – this requirement is met if the mucous membrane of the organ is not captured in the suture (using “clean” single-row sutures or immersing through (infected) sutures with a “clean” seromuscular suture).

The wall of the hollow organs of the abdominal cavity has four main layers: mucous membrane; submucosal layer; muscle layer; serous layer.

The serous membrane has pronounced plastic properties (the surfaces of the serous membrane brought into contact with the help of sutures are firmly glued together after 12-14 hours, and after 24-48 hours the connected surfaces of the serous layer firmly grow together). Thus, the application of sutures that bring the serous membrane closer together ensures the tightness of the intestinal suture. The frequency of such seams should be at least 4 stitches per 1 cm of the length of the stitched area. The muscular layer gives elasticity to the suture line and therefore its grasping is an indispensable attribute of almost any type of intestinal suture. The submucosal layer provides the mechanical strength of the intestinal suture, as well as good vascularization of the suture area. Therefore, the connection of the edges of the intestine is always carried out with the capture of the submucosa. The mucous membrane does not have mechanical strength. The connection of the edges of the mucous membrane ensures good adaptation of the wound edges and protects the suture line from the penetration of infection from the lumen of the organ.

Classification of intestinal sutures

Depending on the application method

manual;

mechanical– applied with special devices;

combined.

Depending on , what layers of the gripping wall - fit into the seam

gray- serous; serous- muscular;

slimy- submucosal; seriously- muscularly- submucosal;

serous- muscularly- submucosal- mucous membranes(end-to-end).

Through seams are infected (“dirty”).

Sutures that do not pass through the mucous membrane are called non-infected (“clean”).

Depending on the row of intestinal sutures

single row seams(Bira-Pirogova, Mateshuka) – a thread passes through the edges of the serous, muscular membranes and submucosa (without capturing the mucous membrane), which ensures good adaptation of the edges and reliable immersion into the lumen of the intestinal mucosa without additional trauma to it;

double row seams(Alberta) – used as the first row is a through suture, on top of which (in the second row) a seromuscular suture is applied;

three-row seams– used as first a row of a through suture, over which serous-muscular sutures are applied in the second and third rows (usually used for application to the large intestine).

Depending on the characteristics of the sutures through the wall of the wound edge

edge seams; screw-in seams;

everting sutures; combined screwing- eversible seams.

By application method

nodal; continuous.

STOMACH OPERATIONS

Surgical interventions performed on the stomach are divided into palliative and radical. Palliative operations include: suturing a perforated gastric ulcer, gastrostomy and gastroenteroanastomosis. Radical operations on the stomach include removal of part (resection) or the entire stomach (gastrectomy).

Palliative operations on the stomach Gastrostomy– application of artificial gastric fistula

Indications : injuries, fistulas, burns and scar contractions esophagus, inoperable cancer of the pharynx, esophagus, cardia of the stomach.

Classification :

tubular fistulas– to create and operate a rubber tube is used (Witzel and Strain-Senna-Kader methods); are temporary and, as a rule, close on their own after the tube is removed;

labiform fistulas– artificial entrance is formed from stomach walls (Topver method); are permanent, since they require surgery to close them.

Gastrostomy according to Witzel

transrectal left-sided layer-by-layer laparotomy 10-12 cm long from the costal arch down;

removal of the anterior wall of the stomach into the wound, onto which a rubber tube is placed between the lesser and greater curvatures along the long axis, so that its end is located in the area of ​​the pyloric region;

application of 6-8 interrupted seromuscular sutures on both sides of the tube;

immersing the tube into the gray-serous canal formed by the anterior wall of the stomach by tying sutures;

placing a purse-string suture in the area of ​​the pylorus, opening the stomach wall inside the suture, inserting the end of the tube into the stomach cavity;

tightening the purse-string suture and placing 2-3 seromuscular sutures over it;

removing the other end of the tube through a separate incision along the outer edge of the left rectus muscle;

fixation of the stomach wall (gastropexy) along the formed edge to the parietal peritoneum and to the posterior wall of the rectus sheath with several seromuscular sutures.

Gastrostomy according to Stamm- Senna- Kadera

transrectal access; removal of the anterior wall of the stomach into the wound and application

closer to the cardia of three purse-string sutures (in children there are two) at a distance of 1.5-2 cm from each other;

opening the stomach cavity in the center of the internal purse-string suture and inserting a rubber tube;

sequential tightening of purse-string sutures, starting from the inner;

removal of the tube through an additional soft tissue incision;

gastropexy.

When creating tubular fistulas, it is necessary to carefully fix the anterior wall of the stomach to the parietal peritoneum. This stage of the operation allows you to isolate the abdominal cavity from the external environment and prevent serious complications.

Lip gastrostomy according to Topver

quick access; removal of the anterior wall of the stomach into the surgical wound

in the form of a cone and placing 3 purse string sutures on it at a distance of 1-2 cm from each other, without tightening them;

dissection of the stomach wall at the top of the cone and insertion of a thick tube inside;

alternately tightening the purse-string sutures, starting from the outer one (a corrugated cylinder is formed around the tube from the wall of the stomach, lined with the mucous membrane);

suturing the stomach wall at the level of the lower purse-string suture to the parietal peritoneum, at the level of the second suture - to

the sheath of the rectus abdominis muscle, at the third level - to the skin;

Upon completion of the operation, the tube is removed and inserted only during feeding.

Gastroenterostomy(the junction between the stomach and the small intestine) is performed when the patency of the pyloric part of the stomach is impaired (inoperable tumors, cicatricial stenosis, etc.) in order to create an additional path for the drainage of gastric contents into the jejunum. Depending on the position of the intestinal loop in relation to the stomach and transverse colon, the following types of gastroenteroanastomosis are distinguished:

anterior anterior colonic gastroenteroanastomosis;

posterior anterior colonic gastroenteroanastomosis;

anterior retrocolic gastroenteroanastomosis;

posterior retrocolic gastrojejunostomy. The first and fourth variants of the operation are most often used.

When applying the anterior anterior rim anastomosis, 30-45 cm are removed from the flexura duodenojejunalis (long-term anastomosis)

loop) and additionally, in order to prevent the development of a “vicious circle,” an anastomosis is formed between the afferent and efferent loops of the jejunum according to the “side to side” type. When a posterior retrocolic anastomosis is applied, 7-10 cm are removed from the flexura duodenojejunalis (short loop anastomosis). For the correct functioning of anastomoses, they are applied isoperistaltically (the afferent loop should be located closer to the cardiac part of the stomach, and the efferent loop should be closer to the antrum).

Severe complication after surgery to apply a gastrointestinal anastomosis - “ vicious circle"- occurs, most often, with anterior anastomosis with a relatively long loop. The contents from the stomach enter in the antiperistaltic direction into the adductor knee of the jejunum (due to the predominance of the motor force of the stomach) and then back to the stomach. Reasons This formidable complication is: incorrect suturing of the intestinal loop in relation to the axis of the stomach (in the antiperistaltic direction) and the formation of the so-called “spur”.

To avoid the development of a vicious circle due to the formation of a “spur,” the adducting end of the jejunum is strengthened to the stomach with additional seromuscular sutures 1.5-2 cm above the anastomosis. This prevents the intestine from bending and forming a “spur”.

Suturing of a perforated ulcer of the stomach and duodenum

With a perforated gastric ulcer, two types of urgent surgical interventions are possible: suturing the perforated ulcer or resection of the stomach along with the ulcer.

Indications for suturing a perforated ulcer :

sick children and young people; in persons with a short history of ulcers;

in elderly people with concomitant pathologies (cardiovascular failure, diabetes mellitus, etc.);

if more than 6 hours have passed since the perforation; with insufficient experience of the surgeon.

When suturing a perforation hole, it is necessary

adhere to the following rules:

a defect in the wall of the stomach or duodenum is usually sutured with two rows of Lambert seromuscular sutures;

the suture line should be directed perpendicular to the longitudinal axis of the organ (to avoid stenosis of the lumen of the stomach or duodenum);

Radical gastric surgery

Radical operations include gastric resection and gastrectomy. The main indications for performing these interventions are: complications of gastric and duodenal ulcers, benign and malignant tumors of the stomach.

Classification :

Depending on the location of the part of the organ being removed:

proximal resections(the cardiac part and part of the body of the stomach are removed);

distal resections(the antrum is removed and part of the body of the stomach).

Depending on the volume of the stomach part removed:

economical - resection of 1/3-1/2 of the stomach;

extensive – resection of 2/3 of the stomach;

subtotal – resection of 4/5 of the stomach.

Depending on the shape of the part of the stomach being removed:

wedge-shaped;

stepped;

circular.

Stages of gastric resection

Mobilization(skeletonization) the part being removed-

Ludka– intersection of the gastric vessels along the small and large curvature between the ligatures throughout the resection area. Depending on the nature of the pathology (ulcer or cancer), the volume of the removed part of the stomach is determined.

Resection– the part planned for resection is removed stomach.

Restoring the continuity of the digestive tube( gastroduodenoanastomosis or gastroenteroanastomosis ).

In this regard, there are two main types of opera-

The operation according to the Billroth-1 method is the creation of an “end to end” anastomosis between the stump of the stomach and the stump of the duodenum.

Operation according to the Billroth-2 method - formation of a side-to-side anastomosis between the gastric stump and the jejunal loop, closure of the duodenal stump ( in class-

not applicable).

The operation using the Billroth-1 method has an important advantage compared to the Billroth-2 method: it is physiological, because The natural passage of food from the stomach to the duodenum is not disrupted, i.e. the latter is not excluded from digestion.

However, the Billroth-1 operation can be completed only with “small” gastric resections: 1/3 or antrum resection. In all other cases, due to anatomical features (due to

peritoneal location of most of the duodenum and fixation of the gastric stump to the esophagus), it is very difficult to form a gastroduodenal anastomosis (there is a high probability of sutures coming apart due to tension).

Currently, for resection of at least 2/3 of the stomach, the Billroth-2 operation, modified by Hoffmeister-Finsterer, is used. The essence of this modification is as follows:

the stump of the stomach is connected to the jejunum using an end-to-side anastomosis;

the width of the anastomosis is 1/3 of the lumen of the gastric stump;

the anastomosis is fixed in the “window” of the mesentery of the transverse colon;

The afferent loop of the jejunum is sutured with two or three interrupted sutures to the stump of the stomach to prevent the reflux of food masses into it.

The most important disadvantage of all modifications of the Billroth-2 operation is the exclusion of the duodenum from digestion.

5-20% of patients who have undergone gastrectomy develop diseases of the “operated stomach”: dumping syndrome, afferent loop syndrome (reflux of food masses into the afferent loop of the small intestine), peptic ulcers, cancer of the gastric stump, etc. Often such patients have to be operated on again - to perform reconstructive surgery, which has two goals: removal of the pathological focus (ulcer, tumor) and inclusion of the duodenum in digestion.

For advanced gastric cancer, perform gastrek- Tomia– removal of the entire stomach. It is usually removed together with the greater and lesser omentum, spleen, tail of the pancreas and regional lymph nodes. After removal of the entire stomach, the continuity of the digestive canal is restored by gastric plastic surgery. Plastic surgery of this organ is performed using a loop of the jejunum, a segment of the transverse colon, or other parts of the colon. The small or large intestinal insert is connected to the esophagus and duodenum, thus restoring the natural passage of food.

Vagotomy– dissection of the vagus nerves.

Indications : complicated forms of duodenal ulcer and pyloric stomach, accompanied by penetration and perforation.

Classification

1. Truncal vagotomy– intersection of the trunks of the vagus nerves before the origin of the hepatic and splanchnic nerves. Leads to parasympathetic denervation of the liver, gallbladder, duodenum, small intestine and pancreas, as well as gastrostasis (performed in combination with pyloroplasty or other drainage operations)

supradiaphragmatic; subphrenic.

Selective vagotomy– lies in the intersection trunks of the vagus nerves going to the entire stomach, after separating the branches of the hepatic and celiac nerves.

Selective proximal vagotomy– cross-

There are branches of the vagus nerves that go only to the body and fundus of the stomach. The branches of the vagus nerves innervating the antrum of the stomach and pylorus (Laterger branch) do not cross. The Laterger branch is considered purely motor, which regulates the motor activity of the forearm.

ric sphincter of the stomach.

Drainage operations on the stomach

Indications: ulcerative pyloric stenosis, duodenal bulbs and subbulbous section.

Pyloroplasty – surgery to expand the pyloric opening of the stomach while maintaining or restoring the pyloric closing function.

Heinecke's method – Mikulich – is to

longitudinal dissection of the pyloric part of the stomach and the initial part of the duodenum, 4 cm long, followed by cross-stitching of the resulting wound.

Finney's method – dissect the antrum stomach and the initial part of the duodenum with a continuous arcuate incision and

sutures are placed on the wound according to the principle of upper gastroduodenoanastomosis “side to side”.

Gastroduodenostomy

Jaboley's method – applies if available obstacles in the pyloroantral zone; A side-to-side gastroduodenoanastomosis is performed, bypassing the site of the obstruction.

Gastrojejunostomy – application of classic gastroenteroanastomosis to “off”.

Features of the stomach in newborns and children

In newborns, the stomach is round in shape, its pyloric, cardiac sections and fundus are poorly expressed. The growth and formation of the stomach sections is uneven. The pyloric part begins to stand out only by 2-3 months of a child’s life and develops by 4-6 months. The area of ​​the fundus of the stomach is clearly defined only by 10-11 months. The muscular ring of the cardiac section is almost absent, which is associated with a weak closure of the entrance to the stomach and the possibility of backflow of stomach contents into the esophagus (regurgitation). The cardiac part of the stomach is finally formed by the age of 7-8 years.

The mucous membrane of the stomach in newborns is thin, the folds are not pronounced. The submucosal layer is rich in blood vessels and has little connective tissue. The muscle layer is poorly developed in the first months of life. The arteries and veins of the stomach in young children differ in that the size of their main trunks and branches of the first and second orders is almost the same.

Developmental defects

Congenital hypertrophic pyloric stenosis– expressed-

severe hypertrophy of the muscular layer of the pylorus with narrowing or complete closure of the lumen by folds of the mucous membrane. The serous membrane and part of the circular muscle fibers of the pylorus along its entire length are dissected in the longitudinal direction, the mucous membrane of the pylorus is bluntly released from the deep muscle fibers until it bulges completely through the incision, the wound is sutured in layers.

Constrictions(strictures) body of the stomach– authority accepts hourglass shape.

Complete absence of stomach. Duplication of the stomach.

Features of the duodenum in newborns- money and children

The duodenum in newborns is often ring-shaped and less often U-shaped. In children of the first years of life, the upper and lower bends of the duodenum are almost completely absent.

The upper horizontal part of the intestine in newborns is higher than the usual level, and only by the age of 7-9 years does it descend to the body of the first lumbar vertebra. The ligaments between the duodenum and neighboring organs in young children are very delicate, and the almost complete absence of fatty tissue in the retroperitoneal space creates the possibility of significant mobility of this section of the intestine and the formation of additional kinks.

Malformations of the duodenum

Atresia– complete absence of lumen (characterized by strong expansion and thinning of the walls of those parts of the intestine that are located above the atresia).

Stenosis– due to localized hypertrophy of the wall, the presence of a valve, membrane in the intestinal lumen, compression of the intestine by embryonic cords, annular pancreas, superior mesenteric artery, and a highly located cecum.

In case of atresia and stenosis of the jejunum and ileum, resection of the atretic or narrowed section of the intestine is performed along with a stretched, functionally defective area for 20-25 cm. In the presence of an irremovable obstacle above the confluence of the common bile and pancreatic ducts, a posterior gastroenteroanastomosis is performed. In case of obstruction in the distal intestine, duodenojejunostomy is used.

Diverticula.

Incorrect position of the duodenum–

mobile duodenum.

Lecture No. 7