EPIPLOON

From Big Medical Encyclopedia

EPIPLOON (omentum) — fold of a visceral peritoneum. Distinguish small and big S. Maly S. (omentum minus) represents the duplikatura of a peritoneum going from portal fissures to small curvature of a stomach and a duodenum. Big S. (omentum majus, epiploon) departs from big curvature of a stomach.

Embryology

Small and big S. are derivatives of primary mesenteries (see. Bryushina, embryology ). Small S. is formed of a ventral mesentery of a stomach and a duodenum (a ventral mesogaster), edges as a result of embryonal turn of a stomach and a duodenum are got by cross situation. Big S. develops from the dorsal mesentery of a stomach (a dorsal mesogaster), in process of turn of a stomach moving to the left and extending in the caudal direction. Meeting a mesentery of a cross colon, big S. grows together with it and deviates ventrally, laying down on loops of a small bowel. Small and big S.'s development is connected with formation of an omental bursa (bursa omentalis). Its rudiment is formed prior to the beginning of a dorsal mesogaster, a cut increases to the left therefore the stomach, having made turn, is lying ventrally from an omental bursa. Further growth of an omental bursa happens in the caudal direction — it is located between plates of a big epiploon.

Anatomy

the Upper part of an abdominal cavity (the stomach, a middle part of a cross colon and its mesentery, a part of an omentulum are removed, visible a back wall and deepening of an omental bursa, a liver with a gall bladder are delayed up): 1 — the left hepatic lobe; 2 — a gastropankreatichesky fold; 3 — the gullet (is crossed); 4 — a gastrophrenic sheaf; 5 — a gastrosplenic sheaf; 6 — a diaphragm; 7 — splenic deepening of an omental bursa; 8 — a spleen; 9 — the left bend of a colon; 10 — phrenic obodochnokishechnaya a sheaf; 11 and 19 — the gastrolic sheaf (is crossed); 12 — the descending colon; 13 — a tail of a pancreas (behind a peritoneum); 14 — a body of a pancreas (behind a peritoneum); 15 — the ascending part of a duodenum; 16 — the jejunum with a mesentery (is crossed); 17 — a mesentery of a cross colon; 18 — the lower deepening of an omental bursa; 20 — an upper part of a duodenum; 21 — the ascending colon; 22 — the right bend of a colon; 23 — the probe which is carried out through an epiploic foramen; 24 — the right hepatic lobe; 25 — the right gastric artery and a vein; 26 — a gall bladder; 27 — a hepatoduodenal sheaf; 28 — a square hepatic lobe; 29 — a round ligament of a liver; 30 — a hepatic lobe having a tail; 31 — a vestibulum bursae omentalis; 32 — a hepatogastric sheaf.
Fig. 5. Course of a peritoneum: 1 — lig. coronarium hepatis; 2 — sternum; 3 — hepar; 4 — omentum minus; 5 — bursa omentalis; 6 — pancreas; 7 — ventriculus; 8 — duodenum; 9 — mesocolon; 1 0 — recessus omentalis; 11 — colon transversum; 12 — jejunum; 13 — omentum majus; 1 4 — peritoneum parietale; 15 — ileum; 16 — excavatio rectovesicalis; 17 — vesica urinaria; 18 — symphysis pubica; 19 — rectum; 20 — prostata; 21 — corpus cavernosum penis; 22 — epididymis; 23 — tunica vaginalis testis; 24 — testis.

Small S. consists from hepatogastric (lig. hepato-gastricum) and hepatoduodenal (lig. hepatoduodenale) the sheaves originating at portal fissures (fig). A hepatogastric sheaf thin, near small curvature of a stomach the leaves of a peritoneum making it, being separated, pass to front and back walls of a stomach. The hepatoduodenal sheaf more powerful, goes to an upper part of a duodenum; contains the general bilious channel (ductus choledochus), a portal vein (v. portae) and own hepatic artery (a. hepatica propria). The leaves of a peritoneum covering walls of a stomach connect on its big curvature, forming big Page again. From big S.'s stomach goes to a cross colon and proceeds down, covering like an apron of a loop of a small bowel. Then it is wrapped up, grows together with a cross colon and its mesentery and passes into a parietal peritoneum of a back wall of an abdominal cavity. Thus, below a cross colon of big S. consists of 4 leaves of a peritoneum which are in pairs forming its front and back plates (see tsvetn. fig. 5). After the birth these plates grow together among themselves, and the cavity between them regional is iterated. The big S.'s part located between a stomach and a cross colon is called a gastrolic sheaf (lig. gasfcroco-licum). To the left and it moves up in sheaves stomach (see) — gastrosplenic and gastrophrenic (ligg. gastrolienale et gast-roplirenicum). Plates of a gastrosplenic sheaf cover a spleen and pass in selezenochno-renal (diafragmalno - splenic) a sheaf (lig. lienorenale s. lig. phrenicosplenicum).

The form, the sizes and big S.'s position have specific features and change with age. At newborn S. short also does not contain fat. On the 1st year of life of S. quickly increases in sizes, in it fatty tissue appears. However most snowballing of fatty tissue in S. falls on the period of puberty.

Big S. it is rich with vaskulyarizo-van branches of the right and left gastroomental arteries (aa. gastro-epiploicae dext. et sin.). Outflow of blood happens on the veins of the same name in a portal vein. Limf, vessels fall in right and left gastrostuffing and average colonic limf. nodes.

The omental bursa (bursa omentalis) represents a part of a peritoneal cavity. This slit-like space located generally behind small S. and a stomach and which is reported with the general peritoneal cavity through an epiploic foramen. In it distinguish front, left, lower and back walls. The front wall is made by small S., a stomach and a gastrolic ligament; the left wall — gastrophrenic, zheludochnoselezenochny, selezenochno-renal sheaves and a part of a surface of a spleen; the lower wall — the left part of a mesentery of a cross colon; the back wall difficult in a form, is formed a parietal peritoneum, for a cut there are a pancreas, the left kidney and an adrenal gland, a belly part of an aorta with its branches, the lower vena cava, and also a costal and phrenic pleural sine. The epiploic foramen — foramen epiploicum (Wins-lowii) — with a diameter of 14 — 45 mm is limited in front to a hepatoduodenal sheaf, behind the peritoneum covering the lower vena cava and a hepatonephric sheaf, above a hepatic lobe having a tail, below a duodenum. The epiploic foramen is adjoined by a vestibulum bursae omentalis (vestibulum bursae omentalis) delimited from its other part by gastropankreatichesky folds, in to-rykh pass left gastric and the general hepatic arteries. In an omental bursa, in addition to a threshold, allocate top and bottom stuffing and splenic deepenings (recessus sup., inf. et lienalis omenta-les). The most constant lower omental deepening comes between plates big S. Forma and the sizes of an omental bursa are subject to considerable individual variability.

Histology

Bryushina (see), the forming S., consists of a mesothelium and own plate supporting friable network of elastic and collagenic fibers. In places where there pass vessels and nerves, connecting fabric more dense. Between trabeculas of connecting fabric in big S. there are fatty segments, and also the accumulations of macrophages and lymphocytes forming lacteal spots (see).

Functional value of an epiploon is up to the end not studied. The important role of big S. in protection of abdominal organs against an infection is known. M. I. The union (1913) showed that at administration of ink in an abdominal cavity of experimental animals the ground mass of its particles rezorbirutsya by big S. within 6 min.; it is not possible to wash away these particles or to separate them from S. whereas from other surface of a peritoneum ink is easily washed away. In 24 hours after administration of ink of S. accepts intensively black coloring, and unbound particles of ink in an abdominal cavity are not found. In S. ink is laid in limf, nodes, an endothelium limf, vessels and lacteal spots. At introduction to an abdominal cavity of a suspension of bacteria a part them perishes under the influence of bactericidal properties of serous liquid, and a part is taken and collapses S.'s mesothelium, cells of its lacteal spots and histiocytes of a connective tissue basis.

Reacts to intra belly immunization of S. active development of antibodies; at the same time the antiserum capacity in it is much higher, than in a spleen and a liver. At the getting wounds of a stomach of S., closing a wound opening, interferes with eventration and protects an abdominal cavity from infection.

At injuries of abdominal organs of experimental animals in limf, big S.'s vessels find particles of tissue of pancreas, a spleen, a liver, an epithelium of a gall bladder, erythrocytes, polymorphonuclear leukocytes, bacteria. The foreign bodys getting into an abdominal cavity and which are not giving in to a rassasyvaniye are sacculated in big S. irrespective of their injection site in an abdominal cavity. Big S.'s ability to encapsulation of foreign bodys in an abdominal cavity is shown also by a wedge, observations. At acute inflammatory diseases of abdominal organs during operation usually find out that big S. delimits the center of an inflammation from a free abdominal cavity.

Methods of inspection

Opportunities for a wedge, researches C. are limited since patol. changes in it are usually combined with diseases or injuries of other abdominal organs.

As a rule, the characteristic complaints or anamnestic data inherent to S.'s pathology, it is not possible to reveal. S. given physical inspection usually also maloinformativna since do not allow to differentiate S.'s disease and abdominal organs. Indirect information on S.'s condition manages to be obtained by means of contrast radiological and endoscopic methods of a research went. - kish. path. The deformation or shift of its various departments found at the same time can be caused patol. processes in S. V nek-ry cases (e.g., at cysts or S.'s tumors) important diagnostic value has ultrasonic diagnosis (see), and also a computer tomography (see. Tomography computer ). Widespread and very informative method of a research C. is the laparoscopy (see. Peritoneoskopiya ), allowing to examine a considerable part of big and small S., and if necessary to make also aim biopsy it with the subsequent gistol. and tsitol. research.

Pathology

Anomaly of development — inborn absence of big S. — meets seldom. At inborn openings in big S. infringement both parts C., and other abdominal organs is possible. Clinically it is shown by symptoms acute abdomen (see).

Damages Pages are often combined with injuries of other abdominal organs and can result from the closed and getting injuries of a stomach. The isolated S.'s damages meet seldom. S.'s hematoma with the subsequent suppuration can result from a stupid injury, and at ruptures of a hematoma — considerable intra belly bleedings. Treatment operational.

Acute inflammatory process in S. — an omentitis — usually arises owing to distribution on S. of an inflammation from abdominal organs and the wedge, is characterized by symptomatology of an acute abdomen. Hron. S.'s inflammation, as a rule, is a consequence of an acute omentitis, but sometimes has specific (more often tubercular) character. At the same time the affected area of S. is thickened due to development of connecting fabric and formation of commissures with abdominal organs. Inflammatory infiltrate in such cases can reach the considerable sizes and be palpated through a front abdominal wall. Treatment of a tubercular omentitis specific.

During the abscessing of inflammatory infiltrate the wedge, a picture delimited or diffusion develops peritonitis (see).

In case of big S.'s increment as a result hron. inflammations to lower parts of a front abdominal wall or bodies of a small pelvis the prelum an epiploon of nek-ry abdominal organs is possible, is more often than a small or large intestine that is clinically shown by symptoms of recurrent impassability of intestines (see). At the same time the syndrome of the tense S. (Knokh's syndrome) which is shown persistent pains, sometimes the vomiting arising in attempt to rise, reject a trunk back, to be unbent etc. sometimes meets.

S.'s infringement is more often observed at hernias of a front abdominal wall, but sometimes and at so-called omentoceles (see. Hernias ). At the same time part C., edges is implemented into an epiploic foramen then owing to disturbance of blood circulation is exposed to a necrosis. Clinically this state is shown by a picture of an acute abdomen and demands urgent operational treatment.

A rare disease is big S.'s torsion, as a rule, leading to its necrosis with development of symptoms of peritonitis. Treatment operational.

The thrombosis of vessels of S. which is found at the expressed atherosclerosis usually also leads to a necrosis of Page.

Parasitic diseases of S., usually echinococcus (see), meet seldom. At the same time in an abdominal cavity mobile tumorous education can be palpated more often. Treatment operational.

Benign tumors of S. (lipoma, angioma, limfangpoma, etc.) meet seldom; they represent the mobile new growths which sometimes are palpated through a front abdominal wall. From malignant tumors sarcoma is more often observed, cancer and an endothelioma are more rare. At malignant tumors of S. often is surprised for the second time owing to development of metastasises of tumors in it generally abdominal organs.

Operations

Operations at patol. processes in S. and its damages consist in the basic in its resection with removal of affected areas.

Anatomo-fiziologichesky features of big S. allow to use it at operative measures on a number of bodies of belly and chest cavities. E.g., big S. tampon with the haemo static purpose of a wound of a liver and spleen. At perforation of kallezny stomach ulcer or a duodenum big S.'s part on a leg is hemmed to edges of a perforative opening. Sites C. can be also used for peritonization of the line of the anastomosis imposed on bodies went. - kish. path. At operational treatment cirrhosis (see) big S. hem to a parietal peritoneum of a front abdominal wall (see. Talmas — Drummond operation) or the phrenic surface of a liver (omen-togepatopeksiya) that leads to development of an additional porto-caval anastomosis. Make an omentocardiopexy for improvement of blood circulation in a myocardium (see. Arterialization of a myocardium ).

At pancreas operations, and also at audit of a back wall of a stomach an upper part of big S. (a gastrolic sheaf) is cut and get into an omental bursa. Small S. is cut at operations on the extrahepatic bilious ways, a resection of a stomach, a gastrectomy, vagisection, at access to a pancreas of N drainage of an omental bursa.



Bibliography: Baron M. A. Reactive structures of internal covers (serous, brain, synovial, endocardium and amnion), L., 1949; Yelizarov en and y S. I. K of surgical anatomy of a cavity of an omentulum, Arkhangelsk, 1949, bibliogr.; Zaporozhets A. A. Infection of a peritoneum through physically tight intestinal seam, Minsk, 1968; Nechiporenko F. P. Anatomic options of a big epiploon of the person and their practical value in surgery, It is new. hir. arkh., No. 3, page 45, 1957; P and N of the h e N to about in H. The river and Sticks about in with to and y V. P. Twisting of a big epiploon, in book: Vopr. diagnoses and treatments zabol. digestive organs, under the editorship of S. I. Babichev and B. S. of Brie skin, page 125, M., 1974; Surgical anatomy of a stomach, under the editorship of A. N. Maxi-menkova, page 116, L., 1972; Are at L. Century of Developmental anatomy, Philadelphia, 1974.


G. A. Pokrovsky; V. S. Speransky (An., gist., embr.).

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