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StatPearls . Sweetheart Island (FL): StatPearls Publishing; 2021 Jan-.


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Introduction

The peritoneum is the serous membrane that lines the abdominal muscle cavity. That is composed of mesothelial cells that are supported by a slim layer the fibrous tissue and is embryologically obtained from the mesoderm. The peritoneum offer to support the offal of the abdomen and also acts together a conduit for the passage of nerves, blood vessels, and lymphatics. Return the peritoneum is thin, it is made of 2 layers with a potential an are between them. The potential an are between the 2 great contains about 50 to 100 ml of serous fluid that prevents friction and allows the layers and organs come glide freely.<1> The outer layer is the parietal peritoneum, which attaches to the abdominal muscle and pelvic walls. The inner visceral class wraps roughly the internal organs situated inside the intraperitoneal space. The frameworks bound by the peritoneal cavity may be intraperitoneal or retroperitoneal.


Structure and Function

The borders of the peritoneal cavity include:


Anterior abdominal muscle muscles
Vertebrae
Pelvic floor
Diaphragm

The peritoneum is made up of 2 layers: the superficial parietal layer and also the deep visceral layer. The peritoneal cavity contains the omentum, ligaments, and also mesentery. Intraperitoneal organs incorporate the stomach, spleen, liver, first and 4th parts of the duodenum, jejunum, ileum, transverse, and also sigmoid colon. Retroperitoneal offal lie behind the posterior sheath of the peritoneum and also include the aorta, esophagus, second and third parts of the duodenum, ascending and descending colon, pancreas, kidneys, ureters, and adrenal glands.

An important space in the peritoneal cavity is the epiploic foramen, also known together the foramen that Winslow. This foramen allows communication in between the greater and lesser sacs. That is bordered by the hepatoduodenal ligament anteriorly, the worse vena cava (IVC) posteriorly, duodenum inferiorly, and also the caudate lobe the the liver superiorly. The foramen provides access to a surgeon, should they need to clamp the hepatoduodenal ligament to stop a hemorrhage or gain anatomical access to the lesser sac. The foramen can likewise serve as a ar for a lesser sac hernia.

The better omentum loose hangs indigenous the better curvature of the stomach and folds over the anterior that the intestine before curving earlier superiority to affix to the transverse colon. It acts together a security or insulating layer. The mesentery helps connect the ab organs to the abdominal wall surface and contains many blood vessels, nerves, and lymphatics. Intraperitoneal organs space usually mobile while those in the retroperitoneum room usually fixed to the posterior ab wall. The dorsal mesentery likewise gives turn off the transverse and also sigmoid mesocolons, which room important as result of them include the blood, nerve, and also lymphatic supply for associated structures.


Embryology

The peritoneum is derived from mesoderm and also helps suspend the primitive gut tube throughout development. Special, the parietal peritoneum is derived from the somatic mesoderm, and also visceral peritoneum is derived from the splanchnic mesoderm. It help suspend the gut pipe via ventral and also dorsal mesenteries. The mesenteries are extensions of the peritoneum that anchor the anterior and posterior abdominal muscle walls. The ventral mesentery eventually develops into the lesser omentum, which deserve to be further explained as the gastrohepatic and also hepatoduodenal ligaments, which contains the portal triad and plays a clinical duty in potential hemorrhage manage in trauma situations. The dorsal mesentery remains as a mesentery, and gives turn off the gastrosplenic ligament, better omentum, and helps store midgut and foregut organs anchored come the posterior ab wall.<2>


Blood Supply and Lymphatics

The parietal peritoneum obtain blood native the abdominal wall vasculature, consisting of the iliac, lumbar, epigastric, and also intercostal arteries. The visceral peritoneum receives it is provided from the superior and inferior mesenteric arteries. The two parts of the peritoneum additionally differ in their venous drainage: the parietal peritoneum drains right into the inferior vena cava if the visceral peritoneum drains right into the portal vein.<3>


Nerves

A thorough understanding of the innervation of the peritoneum is crucial as it has actually clinical implications. The peritoneum has actually both somatic and also autonomic innervations that assist explain why various ab pathologies, such as peritonitis or appendicitis present the way they do. The parietal peritoneum receives its innervation indigenous spinal nerves T10 v L1. This innervation is somatic and allows for the sensation of pain and also temperature that can be localized. The visceral peritoneum obtain autonomic innervation indigenous the Vagus nerve and sympathetic innervation that result in the difficult come localize ab sensations prompted by organ distension.<2><4>


Surgical Considerations

Inguinal Hernia Repair

The peritoneum theatre a far-reaching role in surgical planning because that inguinal hernia repairs. The peritoneum is significant enough that the laparoscopic ideologies refer to the relationship to the peritoneum with choices of a transabdominal pre-peritoneal (TAPP) or total extra pre-peritoneal (TEPP) repairs. In a TAPP, the peritoneum is penetrated, and the surgeon works to fix a hernia from an iatrogenic feet dissected to accessibility the hernia sac that is then generally closed. A TEPP prevents the peritoneum altogether by continuing to be superficial to it to access the hernia sac and repair it.<5>

Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

A new method to control malignancies that have originated or extensively metastasized to the peritoneum is being investigated.<6> The principle behind HIPEC is come directly administer chemotherapy come the peritoneal surface ar in the hopes of commonly reducing tumor burden. Prior to the advent of HIPEC, surgical treatment was made use of to resect involved areas but was not feasible when widely disseminated, conferring a negative prognosis because that the patient. While still requiring substantial research, over there is hope the HIPEC will be a brand-new tool for surgeons to use in the battle versus cancer.

Adhesions

Anything the injures the peritoneum, such together infection, trauma, or surgery can cause scar formation. This scar development is described as adhesions and also has this name because the development can result in pathologic attachments in between structures. This have the right to be problematic as it deserve to lead to little or big bowel obstructions and serve together a nidus for volvulus.<7>

FAST Exam

In trauma situations, the is important to assess free intraperitoneal fluid in the abdomen in a time-efficient way to help determine if the patience will need emergent surgery. Spaces in the peritoneum can often house large amounts that blood and are therefore important to critically assess. A noninvasive method to attain this is the concentrated Assessment through Sonographic Trauma (FAST) scan, which is the use of ultrasound to assess for liquid in 4 windows where liquid can accumulate.<8> The 4 locations are the: hepatorenal recess (also recognized as Morrison"s pouch), splenorenal recess, the pelvis, and also pericardium. A positive an outcome as signified by an anechoic region representing fluid in any of these locations in the setting of hemodynamic instability says that the patient experience emergency surgical treatment to localize and stop the bleed and also repair any kind of other injury.

Peritoneal Closure

Any major defect in the peritoneum is classically close up door using gradually absorbable monofilament sutures if the closure deserve to be performed. However, recent research has indicated that non-closure of the peritoneum might be connected with far better outcomes. Some studies have indicated the peritoneal defects in open appendectomy, caesarian section, gastric bypass, and much more may be avoided in certain conditions. Because that example, non-closure the the peritoneum to be recommended in c-section patient who have actually renal insufficiency or hypertensive disorders. This is an area of arising research the may guide future practice.<9><10><11><12>


Clinical Significance

Peritonitis

The peritoneum is of far-reaching clinical importance. The peritoneum can construct inflammation that can current as peritonitis. The condition is frequently associated with perforation that the intestinal viscera and florid infection. Other reasons of peritonitis include cost-free blood, gastric and also pancreatic juices, medications, and chemicals in the peritoneal cavity. Peritonitis might be localized or diffuse and also often gift with indications of an acute abdomen, such as rigidity, fag tenderness, or guarding. Treatment depends on the cause. All perforations require surgical treatment. Infections need to be treated with antibiotics. Mortality is highest possible in elderly patients.

Ascites

Normally, the peritoneal room only contains up come 100 mL of serous fluid. In miscellaneous situations, such together cirrhosis or chyle leaks, there can be a pathologic rise in peritoneal fluid volume. Cirrhotic ascites is believed to be as result of portal hypertension, leading to raised permeability in blood vessels, allowing for altered oncotic and also hydrostatic pressure that result in an imbalance the protein and electrolytes, thus changing the fluid flow.<13> In chylous ascites, there is rise in lymphatic fluid in the peritoneal cavity, which deserve to be secondary to a chyle leak or can happen from surgical treatment or trauma.<14> Treatment is mainly medical but can be operation on occasion.

Peritoneal DialysisInfusion the a hypertonic liquid in the peritoneal cavity performs peritoneal dialysis. Once the rubbish products are absorbed, the liquid is then drained out. Several cycles space performed every time. The most typical complication the peritoneal dialysis is the risk of infection. Another complication the is no rare is a perforation of bowel when the dialysis catheter is inserted inside the peritoneal cavity.

Malignancy

The peritoneal cavity is sometimes affected by malignancy of i beg your pardon the most common is mesothelioma. In addition, cancer can metastasize leading to peritoneal carcinomatosis. A rarer manifestation of cancer presenting in the peritoneum is pseudomyxoma peritonei, which is believed to be a cancer that appendiceal or colon origin. Treatment is mainly surgical come resect involved areas.

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Hydrocephalus

The peritoneum is additionally utilized in therapeutic viewpoints for hydrocephalus. Patients who want definitive therapy for your hydrocephalus or room refractory to clinical management can pursue surgical monitoring via a ventriculoperitoneal shunt wherein the overabundance cerebrospinal fluid is shunted to the peritoneum, whereby it is then reabsorbed by the body more appropriately.