Peritoneum

4th stage

SURGERY
Lec-2
د.أحمد ابراهيم

Peritoneum II

Subphrenic abscess
Further divided to subhepatic and suprahepatic , the falciform ligament divide it to RT and LT.
Sub- phrenic space :
1- Right supra hepatic space :between R. leaf of diaph. And the sup. And ant. Surface of the liver. Medially falciform ligament.
2- Right infrahepatic (hepato renal pouch of Morison):
above and ifront:the liver and GB
below and behind: upper pole of kidney ,lower part of RT suprarenal gland, 2nd part of the duodenum.
3- RT extra peritoneal space: between bare area of liver and the diaphragm.
4- Lt suprahepatic space:between diaph. Above and the stomach , spleen below.
5- LT ant. Infrahepatic space :liver above ,stomach and lesser omentum below and behind.
6- LT post. Infrahepatic: liver above ,stomach anteriorly, pancrease posteriorly.
7- LT extra peritoneal space :around the upper part of the left kidney
Aetiology:
Residual pus collection from generalized peritonitis.
Perforated viscous.
Lymphatic spread from chest infection.
Post-operative collection(bile, blood).
Clinical picture :
Eigastric Pain may referred to shoulder.
Hectic temp.
Tachycardia .
Anorexia, vomiting, sweating and wasting.
Persistent hicough


Examination:
Inspection: diminished chest wall movement with respiration and rarely bulging upper abdomen.
Palpation: - tenderness below costal margin.
rigidity on upper abdomen
Downward displacement of the liver and upward displacement of apex beat.
Percussion :
- Dullness of the pleural effusion
- Resonance in the gas of abscess
- Dullness of the liver and the pus of the abscess
Auscultation: impaired air entry over the lung base .
Investigations :
1- WBC count
2- CXR shows:
Thickened elevated diaph.
pleural effusion
air under diaph.(gas forming)
3- U/S
4- CT
Treatment:
If conservative treatment failed ,
Drainage by aspiration extraperitoneal or extrapleural better.
1-post. Extraperitoneal by excision of 12th rib +drain
Ant. Extraperitoneal by incision subcostal.
Aspiration under CT or U/S guide .
Open drainage .


TB peritonitis
Secondary to primary focus that reach the peritoneum :
1- direct spread from L .N. ,salpingitis ,enteritis.
2- blood spread from pulmonary TB
3- lymphatic spread from pleura to bowel.Pathology:
Acute type: the peritoneum studded with tubercles, straw color exudates.
Caseous :also tubercles ,multiple collections, cold abscess , sinus.
Ascetic type:(commonest)also tubercles , straw color fluid ,thickened greater omentum,fibrous.
Encysted type(localized ascetic type).
Adhesive type: adhesions leads to I. O.

Clinical picture :
Children,young adult
Abdominal pain ,distention,vomiting.
High fever, anorexia, night sweating
Palpable swelling,ascitis.
Tenderness ,guarding may be.
Mass of rolled omentum above umbalicus.
PV. May reveal pelvic mass.
Investigation :
CBP and ESR
Tuberculin test Positive.
CXR
U/S
Ascetic fluid aspiration
Diagnostic laparoscopy, biopsy
Exploration laparotomy


Treatment :
Medical anti TB like INH, Rifadin
Surgery for Intestinal obstruction
Ascitis
Pathological accumulation of fluid in the peritoneal cavity. It can be diagnosed clinically when >1500 cc
Causes:
General causes:-liver ,cardiac, renal and nutritional disease
Local:- TB peritonitis, malignancy,chylous ascitis or pancreatic ascitis
Rare :- Meig’s syndrom(ovarian fibroma) , pseudomyxoma peritoni
Peritoneal tumor
Carcinoma peritonea:
Pathology
implantation from stomach, colon,overy.
peritoneal nodules, bloody fluid
Treatment :
Radioactive gold intraperitonealy

Pseudomyxoma peritoni :

Causes: - rupture of pseudomucinous cyst of the overy
rupture of mucocele or mucoid carcinoma of the appendix
Pathology :-
Abdomen full with jelly like material,
Clinically : abdomen distended with multiple masses
Treatment :
laparatomy and removal of the material and the primary pathlogy.
liable for recurence.


Mesothelioma :
Primary neoplasm of the peritoneum .
either present with ascitis or abdominal mass.

Mesenteric cyst

Collection of fluid between 2 layers of small bowel mesentry , 2 type:
1- False mesenteric cyst: - no epithelial lining like blood cyst due to trauma or caseating L N (cold abscess)
2- True cyst:
chylolymphatic cyst
enterogenous cyst
teratomatous dermoid cyst
hydatid cyst
Clinical picture :
Abdominal mass,pain,vomiting,dyspepsia
The site near the umbalicus
Moved in one direction
Dull on percussion
Treatment : excision
Mesenteric lymphadenitis
Commonest cause of acute abdominal pain in children
Causes : unknown, viral following respiratory tract infection
Clinical picture :
Affect children
Upper abdominal pain and localized to RT side
Pain colicky ,nausea, vomiting, anorexia and fever.


On examination :
Guarding
Tenderness
PR tenderness positive
Shifting tenderness
Treatment : conservative and in doubtful cases appendicectomy
The retroperitoneum
Bounded by post. Perit. Anteriorly and spine and post. Abdominal muscles posteriorly.
Superiorly the 12th rib and the diaphragm and inferiorly the pelvis

Retroperitoneal tumors

1- Renal ,adrenal gland tumors and L N
2- Retroperitoneal sarcoma
presented with mass (abdominal),pain,uretric obstruction and hadronephrosis.
Dx : CT,MRI,u/s.
Treated by surgery , radiotherapy as pallative .
3- Retroperitoneal lipoma

SH.J