THE ABDOMINAL REGION

CONTINUED
 The Spermatic Cord
• The spermatic cord comprises:
• three layers of fascia
• —the external spermatic fascia: from the external oblique aponeurosis
• — the cremasteric fascia: from the internal oblique aponeurosis containing muscle fibres (cremaster muscle)
• — the internal spermatic fascia: from the transversalis fascia
• three arteries: —the testicular art. : from the aorta
— the cremasteric art.: from the inferior epigastric artery
— the artery of the vas: from the inferior vesical artery
• three veins _the pampiniform plexus of veins: draining: the right testis into the IVC
: the left into the left renal vein
_ the cremasteric vein (or external spermatic vein)
_vein of the vas (or vas deferens, or ductus deferens)
•three nerves — the nerve to the cremaster: from the genito-femoral nerve
— sympathetic fibres from T10–11 spinal segments
— the ilio-inguinal nerve (strictly, on and not in the cord)
• three other structures—the vas deferens, lymphatics of the testis, which pass to the para-aortic lymph nodes
and, pathologically present as the third structure, a patent processus vaginalis in patients with an indirect
inguinal hernia!
 Some Common Abdominal Surgical Incisions
• Midline Incision

• Paramedian Incision

• Transrectus Incision

• Gridiron Incision

• Subcostal Incision

• Suprapubic Incision

• Transverse and Oblique incisions

• Thoraco-abdominal incisions

• Incision for Paracentesis Abdominis

 The Anatomy of Abdominal Incisions 1
• Incisions: _are made to expose the intraperitoneal structures
_represent a compromise on the part of the operator:
* the need for maximum access
*the wishes to leave a scar which lies in an unobtrusive crease
* minimal damage to the muscles and their nerve supply

NB: The nerve supply to the lateral abdominal muscles forms a richly communicating
network so that cuts across the lines of fibers of these muscles, with division of one or
two nerves, produce no clinical ill-effects

The segmental nerve supply to the rectus abdominis muscle, however, has little cross-
communication and damage to these nerves must, if possible, be avoided
 The Anatomy of Abdominal Incisions 2
1. Midline Incision
• is a vertical incision over the linea alba
• performed for access to the stomach, duodenum, transverse colon, or abdominal aorta
• provides an almost bloodless line along which the abdomen is superiorly wide and fibrous
• is almost hair-line below the umbilicus
(surgeon may experience difficulty in finding the exact point of cleavage between the recti at this
level)

2. The Paramedian Incision

• is placed 1-1.5 inch (2.5-4cm) lateral, and parallel, to the midline (for same access)
• the anterior rectus sheath is opened,
• the rectus displaced laterally and
• the posterior sheath, together with peritoneum incised
• This incision has the advantage that, on suturing the peritoneum, the rectus slips back into place to
cover and protect the peritoneal scar
 The Paramedian incision
• the adherence of the anterior sheath to the rectus muscle at its tendinous intersections
means that the sheath must be dissected off the muscle at each of these sites, and at each
of these a segmental vessel requires division

• the rectus is easily slid laterally from the posterior sheath from which it is quite free

• the posterior sheath and the peritoneum form a tough membrane down to half-way
between pubis and umbilicus, but it is much thinner and more fatty below this where, it
loses its aponeurotic component and is made up of only transversalis fascia and
peritoneum

• the inferior epigastric vessels are seen passing under the arcuate line of Douglas in the
posterior sheath and usually require division in a low paramedian incision
3. The Transrectus Incision
• Occasionally, the rectus muscle is split in the line of the paramedian incision

• The rectus receives its nerve supply laterally

• thus the muscle medial to the incision must, in consequence, be deprived of its
innervation and undergo atrophy

• it is an incision therefore best avoided

4. Subcostal Incision
• the subcostal incision is aka Kocher’s incision
• is used on the right side in biliary surgery (access for gallbladder)
• is used on the left, in exposure of the spleen
• incision is made at the midline and extends parallel to, and 1inch (2.5 cm) below, the
costal margin
• the anterior rectus sheath is opened, the rectus cut and the posterior sheath with
underlying adherent peritoneum incised
• the small 8th ICN branch to the rectus is sacrificed but the larger and more important
9th nerve, in the lateral part of the wound, is preserved
• the divided rectus muscle is held by the intersections above and below and retracts
very little
• it subsequently heals by fibrous tissue
• this incision is valuable in the patient with the wide subcostal angle
• where this angle is narrow, the paramedian incision is usually preferred
5. The Gridiron or Muscle Split Incision

• The oblique skin incision centered at McBurney’s point ( ⅔ of the way lat. along the line from the
umbilicus to ASIS) is now less popular than an almost transverse incision in the line of the skin crease
forwards from, and 1 inch (2.5cm) above, the ASIS

• The aponeurosis of the external oblique is incised in the line of its fibres (obliquely downwards and
medially);

• the internal oblique and transversus muscles are then split in the line of their fibres, and retracted
without their having to be divided

• On closing the incision, these muscles snap together again, leaving a virtually undamaged abdominal
wall

• made for an appendectomy, but a longer incision on the right side is for access to the cecum and ascending
colon & on the left side; for access to the sigmoid colon and rectum
 6. Suprapubic Incision

• a transverse incision just superior to the pubic hair line

• for a hysterectomy (surgically removing all or part of the uterus)

• or for access to other pelvic viscera

7. Transverse and Oblique Incisions
• Incisions cutting through the lateral abdominal muscles do not damage their richly
anastomosing nerve supply and heal without weakness

• Used to expose: _the sigmoid colon or

_the caecum

• or, by displacing the peritoneum medially, extraperitoneal structures such as:

_the ureter

_the sympathetic chain

_the external iliac vessels

8. Thoraco-abdominal incisions
• is an upper paramedian or upper oblique abdominal incision

• it can be extended through the 8th or 9th ICS

• the diaphragm get incised and an extensive exposure achieved of both upper abdomen
and thorax

• Used on: _the left in removing growths of the upper stomach or lower oesophagus

_the right in resection of the right lobe of the live

 9. Paracentesis Abdominis
• Intraperitoneal fluid collections can be evacuated via a cannula inserted through the
abdominal wall

• The bladder having been first emptied with a catheter, the cannula is introduced on a
trocar either through the midline (where the linea alba is relatively bloodless) or
lateral to McBurney’s point (where there is no danger of wounding the inferior
epigastric vessels)

• The coils of gut are not in danger in this procedure because they are mobile and are
pushed away by the tip of the trocar

• These two landmarks are also used for insertion of cannulae for laparoscopic surgery
Essentials Clinical Anatomy, 4th Ed. Moore et. al., 2010
 Clinical Correlations of the Abdominal Wall
 Infection of the umbilicus: common in children
 Caval obstruction:
 Obstruction of the SVC or IVC causes distention of the veins running from the anterior
chest wall to the thigh
 The lat. thoracic vein anastomoses with the superf. epig. vein, a tributary of the great
saphenous vein of the leg
 In these circumstances, a tortuous varicose vein may extend from the axilla to the lower
abdomen

 Portal vein obstruction

 In cases of portal vein obstruction, the superficial veins around the umbilicus and the
paraumbilical veins become grossly distended radiating out from the umbilicus
 Clinical Correlations of the Abdominal Wall cont’d
 Enlarged superficial lymph nodes: a swelling in the groin may be caused by an infection or malignant
tumor of the skin of the lower part of the anterior abdominal wall or that of the buttock

 Hematoma of the rectus sheath: is uncommon but important, often overlooked

 It occurs most often on the right side below the level of the umbilicus

 results from bleeding of the inferior epigastric vein or, rarely, the inf. epig. artery

• Causes: _stretched during a severe bout of coughing

_ stretched during the later months of pregnancy

_ usually blunt trauma to the abdominal wall, such as a fall or a kick

• Post-traumatic symptoms: midline abdominal pain diagnosed by an acute tender mass confined to one
rectus sheath
 Clinical Correlations of the Abdominal Wall cont’d
 Abdominothoracic Rhythm and Visceroptosis
• Abdominal muscles contract and relax with respiration: abdominothoracic rhythm
• Abdominal wall conforms to the volume of the abdominal viscera
• The shape of the anterior abdominal wall depends on the tone of its muscles
• If chest expands and the anterior abdominal wall remains stationary or contracts inward 
 highly probable that the parietal peritoneum is inflamed and has caused a reflex
contraction of the abdominal muscles
• NB: _a multiparous middle-aged woman with poor abdominal muscles is often incapable of
supporting her abdominal viscera
_The lower part of the anterior abdominal wall protrudes forward = visceroptosis
_ do not confused this with an abdominal tumor e.g. ovarian cyst or with the
excessive accumulation of fat in the fatty superficial fascia
 Clinical Correlations of the Abdominal Wall cont’d

• Muscle Rigidity and Referred Pain

• A pleurisy involving the lower costal parietal pleura causes pain in the
overlying skin that may radiate down into the abdomen
• NB: Dermatomes over: _ the xiphoid process–T7
_ the umbilicus–T10
_ the pubis–L1
 Clinical Correlations of the Abdominal Wall cont’d
• The processus Vaginalis

• Normally, its upper part becomes obliterated just before birth and the lower part remains as
the tunica vaginalis

• but it may remain open partially or in its entirety as a preformed hernial sac for an indirect
inguinal hernia

• It may become very much narrowed, but its lumen remains in communication with the
abdominal cavity  Peritoneal fluid accumulates in it, forming a congenital hydrocele

• The upper and lower ends of the processus may become obliterated, leaving a small
intermediate cystic area referred to as an encysted hydrocele of the cord
Common Congenital Anomalies of the Processus Vaginalis

Congenital hydrocele Encysted hydrocele of the cord Preformed hernial sac

for indirect inguinal hernia
 The Testes (pl. of testis)
• They are ovoid in shape: _at birth 1.5cm (Lth.) × 1cm (wd) and vol. 4ml

_in Adult 3-5cm (Lth) ×3cm(AP) ×2-4cm (Transv) and 12.5-19ml vol.

• They are suspended in the scrotum by the spermatic cords

• They have a tough outer surface, the tunica albuginea, that forms a ridge on its internal, posterior
aspect as the mediastinum of the testis

• The tunica vaginalis is a closed serous peritoneal sac covering the testis, except at the level of
attachment of Epididymis and spermatic cord

• They produce sperms (spermatozoa) and hormones, principally testosterone

• The sperms are formed in the seminiferous tubules that are joined by straight tubules to the rete
testis
Orchiopexy used to correct
Cryptorchydism

Orchidotomy or
Orchiotomy or
Orchiectomy or
Gonadotomy, literally =
castration/(neutering in
animals)
 Vasculature of the Testes

Testicular Arteries
 arise from the abdominal aorta (@ L2) just inferior to the renal arteries
 pass retroperitoneally in an oblique direction, crossing over the ureters and the inferior parts
of the external iliac arteries inguinal canal  spermatic cord
Testicular Veins
emerge from the testis and epididymis and form the pampiniform venous plexus consisting
of 8- 12 anastomosing veins
lie anterior to the ductus deferens and surrounding the testicular artery in the spermatic cord
the pampiniform plexus is a thermoregulatory system of the testis, helping to keep this
gland at a constant temperature
the left testicular vein originates as the veins of the pampiniform plexus coalesce and
empties into the left renal vein
the right testicular vein has a similar origin and course but drains to the IVC
Testis And Surrounding Structures
 Testicular Lymphatic drainage and Innervation
 The lymphatic drainage follows:

• the testicular artery and vein to the right pre-aortic lymph nodes

• the testicular artery and vein to left lumbar  caval or aortic lymph nodes

 The autonomic nerves of the testis arise as the testicular plexus of nerves on the testicular
artery
 the testicular plexus of nerves contains: _vagal parasympathetic
_visceral afferent
_sympathetic fibers from T7 segment of spinal cord
 Clinical Correlations
 Cremasteric Reflex for Ilio-inguinal nerve assessment
• is the rapid elevation of the testis on the same side and is extremely active in children
• Contraction of the cremaster muscle—producing the reflex—can be induced by lightly stroking the
skin on the medial aspect of the superior part of the thigh with an applicator stick or tongue
depressor. This area is supplied by the ilio-inguinal nerve

 Gonads Relocation
• The fetal testes relocate from the dorsal abdominal wall in the superior lumbar region to the deep
inguinal rings during the 9th -12th fetal weeks
• The male gubernaculum, attached to the caudal pole of the testis and accompanied by an
outpouching of peritoneum, the processus vaginalis, projects into the scrotum
• The testis descends posterior to the processus vaginalis
• The inferior remnant of the processus vaginalis forms the tunica vaginalis covering the testis
• The ductus deferens, testicular vessels, nerves, and lymphatics accompany the testis
• The final location of the testis usually occurs before or shortly after birth
 The Epididymis
• is an elongated structure on the posterior surface of the testis
• is formed by minute tight convolutions of the duct of the epididymis
• the efferent ductules transport newly formed sperms from the rete testis to the epididymis,
where they are stored until mature
• the rete testis is a network of canals at the termination of the seminiferous tubules

• The epididymis (6-7cm long) is composed of 3 parts:

• Head: superior expanded part of lobules formed by coiled ends of 12-14 efferent ductules
• Body: the convoluted duct of the epididymis
• Tail: continuous with the ductus deferens
 The Scrotum
 is a cutaneous sac consisting of 2 layers

i. heavily pigmented skin and closely related dartos fascia

ii. a fat-free fascial layer including smooth muscle fibers (dartos muscle) responsible for the
rugose (wrinkled) appearance of the scrotum

 The Dartos Muscle: _ attaches to the skin

_its contraction causes the scrotum to wrinkle when cold, thus thickens the
integumentary layer while reducing the scrotal surface area

_assists the cremaster holding the testes closer to the body  reducing heat loss
 Scrotal Blood Supply and Innervation
 Arterial supply of scrotum is from 3 branches:
i. the internal pudendal artery  Posterior scrotal branches of the perineal artery
ii. the femoral artery  Anterior scrotal branches of the deep external pudendal artery
iii. the inferior epigastric artery  Cremasteric artery
 Scrotal veins accompany their arteries [respectively: to internal iliac (i) and external iliac (ii, iii)]
 The lymphatic vessels drain into the superficial inguinal lymph nodes
 The nerves of the scrotum include the:
1. Genital branch of the genitofemoral nerve (L1, L2) supplying the anterolateral surface
2. Anterior scrotal nerves, branches of the ilio-inguinal nerve (L1) supplying the anterior surface
3. Posterior scrotal nerves, branches of the perineal branch of the pudendal nerve (S2-S4)
supplying the posterior surface
4. Perineal branches of the posterior cutaneous nerve of the thigh (S2, S3) supplying the inferior
surface
 Clinical Correlations
Hydrocele of the Hematocele: a collection of
Hydrocele: presence of excess spermatic cord due to blood in the cavity of the
fluid in a persistent processus injury or inflammation tunica vaginalis
vaginalis is a of the testis of the epididymis

Essentials Clinical Anatomy, 4th Ed. Moore et. al., 2010

 Clinical Correlations
• Vasectomy or deferentectomy:
• the ductus deferens is isolated, ligated and transected bilaterally when sterilizing a man
• The testis continues to function as an endocrine gland for the production of testosterone

• Varicocele:
• the pampiniform plexus of veins may become varicose ie dilated and tortuous
• often result from defective valves in the testicular vein
• the palpable enlargement usually drains and seems to disappear when the person lies down

• Testicular Cancer: because of their lymphatic drainage from their fetal development
• Cancer of the testis metastasizes initially to the lumbar lymph nodes
• But Cancer of the scrotum metastasizes initially to the superficial inguinal lymph nodes
 Peritoneal cavity

• The abdominal peritoneum is derived from the endothelial lining of the primitive coelomic
cavity of the embryo (which also becomes the thoracic pleura)

• In the male, the peritoneal cavity is completely closed

• in the female it is perforated by the openings of the uterine tubes communicating with the
uterine cavity and vagina => a possible pathway of infection from the exterior

• Between the parietal and visceral peritoneum (ie the peritoneal cavity), there is no organ

• Peritoneal fluid contains leukocytes and antibodies that resist infection

THE PERITONEUM:

• is a glistening, transparent serous membrane

• consists of 2 continuous layers:

1. Parietal peritoneum: lining the internal surface of the abdominopelvic wall

2. Visceral peritoneum: investing viscera or organs e.g.: spleen, stomach

• The relationship of the viscera to the peritoneum is as follows:

• Intraperitoneal organs: almost completely covered with visceral peritoneum

• Extraperitoneal organs: retroperitoneal, and subperitoneal organs which are only partially
covered with peritoneum e.g.: kidneys,
• A cicatrix at the posterior aspect of the umbilicus is where the falciform ligament sweeps
upwards and slightly to the right of the midline to the liver

• In the free border of this ligament lies the ligamentum teres (the obliterated fetal left
umbilical vein) which passes into the groove between the quadrate lobe and left lobe of the
liver

• the peritoneum sweeps over the inferior aspect of the diaphragm, to be reflected on to the
liver (leaving a bare area demarcated by the upper and lower coronary ligaments of the
liver) and on to the right margin of the abdominal oesophagus
• After enclosing the liver, the peritoneum descends from the porta hepatis as a double
sheet, the lesser omentum, to the lesser curve of the stomach

• Here it again splits to enclose this organ, reforms at its greater curve, then loops
downwards, then up again to attach to the length of the transverse colon, forming the
apron-like greater omentum

• The transverse colon, in turn, is enclosed within this peritoneum which then passes
upwards and backwards as the transverse mesocolon to the posterior abdominal wall,
where it is attached along the anterior aspect of the pancreas
 The Mesentery of Transverse Colon
• The transverse mesocolon divides the abdominal cavity into 2 compartments:

1. Supracolic compartment: containing the stomach, liver, and spleen

2. Infracolic compartment:

 contains the small intestine, ascending colon and descending colon

 lies posterior to the greater omentum

 is divided into right and left infracolic spaces by the mesentery of the small intestine

Free communication occurs between the supracolic and the infracolic compartments through the
paracolic gutters (the grooves between the lateral aspect of the ascending or descending colon and
the posterolateral abdominal wall)
 Subdivisions of Peritoneal Cavity
The peritoneal cavity is divided into a Greater Sac and an Omental Bursa
 The Greater Sac
• is the main and larger part of the peritoneal cavity
• a surgical incision through the anterolateral abdominal wall enters the greater sac

 The Lesser Sac or Omental Bursa = Left Subhepatic space

• is the smaller part of the peritoneal cavity
• lies posterior to the stomach, lesser omentum, and adjacent structures
• permits free movement of the stomach on adjacent structures because the anterior and posterior walls of
the omental bursa slide smoothly over each other
• communicates with the greater sac through the Omental Foramen = Epiploic Foramen =Winslow F.
• has two recesses:
i. A superior recess: limited superiorly by the diaphragm and the posterior layers of the coronary ligament
of the liver
ii. An inferior recess: between the superior part of the layers of the greater omentum
• The Boundaries of the Omental Foramen or Foramen of Winslow
• Anteriorly—the hepatoduodenal ligament (free edge of lesser omentum) containing
the portal triad [Portal vein, Hepatic artery, and Bile duct]

• Posteriorly—the retroperitoneal IVC and right crus of diaphragm, covered with

parietal peritoneum

• Superiorly—the liver, covered with visceral peritoneum

• Inferiorly—superior or first part of the duodenum

 Clinical Features
1. Occasionally a loop of intestine passes through the foramen of Winslow into the lesser sac
and becomes strangulated by the edges of the foramen

Notice that none of these important boundaries can be incised to release the strangulation;
the bowel must be decompressed by a needle to allow its reduction

2. It is important to the surgeon that the hepatic artery can be compressed between his index
finger within the foramen of Winslow and his thumb on its anterior wall

If the cystic artery is torn during cholecystectomy, haemorrhage can be controlled by this
manoeuvre (named after James Pringle), which then enables the damaged vessel to be
identified and secured
 Peritoneal Vessels and Nerves
1. The Parietal Peritoneum:
• has same blood and lymphatic vasculature and same somatic nerve supply as the region of the
abdominopelvic wall it lines
• is sensitive to Pressure, Pain, Heat, and Cold
• pain from the parietal peritoneum is generally well localized

2. The Visceral Peritoneum:

• has the same blood and lymphatic vasculature and same visceral nerve supply as the organs it covers
• is Insensitive to touch, heat, cold, and laceration
• is stimulated primarily by stretching and chemical irritation
• Pain from the visceral peritoneum is poorly localized and is referred to the dermatomes of the spinal
ganglia providing the sensory fibers
• Pain: _from the foregut derivatives is usually experienced in the epigastric region
_from the midgut derivatives, in the umbilical region
_from the hindgut derivatives, in the pubic region
 Peritoneal Formations
• A Mesentery

• A Peritoneal Ligament

• An Omentum: greater and lesser

• A Peritoneal Fold and its recess

 Peritoneal Formations
The Mesentery
• is a double layer of peritoneum
• occurs as a result of the invagination of the peritoneum by an organ
• constitutes a continuity of the visceral and parietal peritoneum
• provides a means for neurovascular communication between organs & body wall
• has a core of connective tissue containing blood& lymphatic vessels, nerves, fat, lymph nodes
• allows for visceral mobility (the degree of mobility depends on the length of the mesentery)

The Peritoneal Ligament

 consists of a double layer of peritoneum connecting organs or an organ to the abdominal wall
• e.g.: the falciform ligament connects the liver to the anterior abdominal wall
The Omentum
• is a double-layered extension of peritoneum passing from the stomach and proximal part of the
duodenum to adjacent organs
• it is divided into 2 :
1. The Greater Omentum:
• which extends superiorly, laterally to the left, and inferiorly from the greater curvature of the
stomach and the proximal part of the duodenum
• it also has 3 parts:
a) The gastrophrenic ligament between the greater curvature of the stomach and diaphragm
b) The gastrosplenic ligament between the greater curvature of the stomach and spleen
c) The gastrocolic ligament_from the inf. portion of greater curvature of the stomach to colon
_is the largest part, descending anteriorly and inferiorly beyond the transverse colon and then
ascending again posteriorly, fusing with the visceral peritoneum of the transverse colon and the
superior layer of its mesentery
its descending and ascending portions usually fuse together, forming a 4-layered fatty “omental
apron”
• The Lesser Omentum
• connects the lesser curvature of the stomach and proximal part of the duodenum to the liver

• is composed of the hepatogastric and hepatoduodenal ligaments which form the membranous
portion of the lesser omentum

• the hepatoduodenal ligament: _is the thickened free edge of the lesser omentum

_conducts the portal triad: portal vein, hepatic artery, & bile duct

• NB: a bare area of an organ -is not covered with visceral peritoneum

-allows for entrance and exit of neurovascular structures

-is formed in relation to the attachments of mesenteries, omenta, and ligaments

Essentials Clinical Anatomy, 4th Ed. Moore et. al., 2010
The Greater OmentumGreater Omentum Greater Omentum
Wrapped around an Adherent to the base
Inflamed Appendix of a Gastric Ulcer
Normal
Greater
Omentum
• A Peritoneal Fold (e.g., medial and lateral umbilical folds)
• is a reflection of peritoneum that is raised from the body wall by underlying blood vessels,
ducts, and obliterated fetal vessels

• A Peritoneal Recess or Intraperitoneal Fossa

• is a pouch formed by a peritoneal fold
A number of fossae occur within the peritoneal cavity into which loops of bowel may become
caught and strangulated
 Those of importance are:
• The lesser sac via the foramen of Winslow
• The paraduodenal fossa—between the duodenojejunal flexure and the inf. mesenteric vessels
• The retrocaecal fossa—in which the appendix frequently lies
• The intersigmoid fossa—formed by the inverted V attachment of the mesosigmoid
• The supravesical and umbilical fossae between the umbilical folds
 Clinical Correlations
• The Peritoneum and Surgical Procedures
• Because the peritoneum is well innervated, patients undergoing abdominal surgery
experience more pain with large, invasive, open incisions of the peritoneum (laparotomy)
than they do with small laparoscopic incisions or vaginal operations

• Because of the high incidence of complications such as peritonitis and adhesions after
operations in which the peritoneal cavity is opened, efforts are made to remain outside the
peritoneal cavity whenever possible (e.g., translumbar or extraperitoneal anterior approach
to the kidneys)

• When opening the peritoneal cavity is necessary, great effort is made to avoid contamination
of the cavity
 Peritonitis and Ascites
 Peritonitis: is a condition when bacterial contamination occurs during laparotomy, during
infection and inflammation of traumatically penetrated or ruptured gut like appendicitis,
thus allowing gas, fecal matter, and bacteria to enter the peritoneal cavity

In addition to the severe abdominal pain, tenderness, nausea and/or vomiting, fever, and
constipation are present

 Ascites: _excess fluid in the peritoneal cavity ,interfering with movements of the viscera
_may occur as a result of mechanical injury (causing internal bleeding) or
_other pathological conditions, e.g.: portal hypertension (venous congestion) or
_widespread metastasis of cancer cells to the abdominal viscera

NB: peritonitis or pneumonitis may be present in case of paradoxical abdominothoracic

rhythm and muscle rigidity is present
• Peritoneal Adhesions and Adhesiotomy
• If the peritoneum is damaged by a stab wound or infected, the peritoneal surfaces become
inflamed, making them sticky with fibrin

• As healing occurs, the fibrin may be replaced with fibrous tissue, forming abnormal
attachments between the visceral peritoneum of adjacent viscera, or between the visceral
peritoneum of a viscus and the parietal peritoneum of the adjacent abdominal wall

• Adhesions (scar tissue) may also form after an abdominal operation (e.g., owing to a
ruptured appendix) and limit the normal movements of the viscera

• This tethering may cause chronic pain or emergency complications such as intestinal
obstruction when the gut becomes twisted around an adhesion (volvulus)

• Adhesiotomy refers to the surgical separation of adhesions. Adhesions are often found during
dissection of cadavers (e.g., binding of the spleen to the diaphragm)
 The Subphrenic Spaces or Subphrenic Recesses
• Below the diaphragm are a number of potential spaces formed in relation to the attachments
of the liver. One or more of these spaces may become filled with pus (a subphrenic abscess)
walled off inferiorly by adhesions
• There are 5 subdivisions of clinical importance:
 The right and left subphrenic spaces lie between the diaphragm and the liver, separated from
each other by the falciform ligament
 The right and left subhepatic spaces lie below the liver
 The right subhepatic space = the pouch of Morison: bounded by the posterior abdominal
wall behind and liver above. It communicates anteriorly with the right subphrenic space
around the anterior margin of the right lobe of the liver and below both open into the general
peritoneal cavity from which infection may track, e.g.: a perforated appendix or a perforated
peptic ulcer
 The left subhepatic space = the lesser sac which communicates with the right through the
foramen of Winslow. It may fill with fluid as a result of a perforation in the posterior wall of
the stomach or from an inflamed or injured pancreas to form a pseudocyst of the pancreas
• The right extraperitoneal space lies between the bare area of the liver and the diaphragm

• It may become involved in retroperitoneal infections or directly from a liver abscess

• Posterior subphrenic abscesses are drained by an incision below, or through the bed of R12

• A finger is then passed upwards and forwards between liver and diaphragm to open into the
abscess cavity

• An anteriorly placed collection of pus below the diaphragm can alternatively be drained via
an incision placed below and parallel to the costal margin

• Nowadays, intra-abdominal fluid collections can often be drained percutaneously under

ultrasound or CT control