Peritoneal Folds Research Articles

Intra-Abdominal Hernia or Intestinal Incarceration: Two Verified Cases Pre-Operatively Diagnosed

THIS paper does not present anything original or new. Attention is simply called to a condition which can be diagnosed pre-operatively only by the roentgenologist, but by him very readily recognized. It is usually overlooked and found accidentally at operation or postmortem, yet the diagnosis is simple and obvious and is missed only because time is seldom taken to outline the jejunum with barium. This condition has been fully described in the literature and the literature, in turn, has been reviewed several times in recent years, the last review being presented by Alexander, in 1937. Paraduodenal or intra-abdominal hernia was described anatomically by Neubauer, 163 years ago, but the literature since then has not been voluminous. Treitz, in 1857, and Moynihan, in 1899, published monographs covering the condition in detail. A majority of the cases reported have been described by surgeons who have found an intra-abdominal hernia in the course of an operation, usually for small bowel obstruction or suspected appendicitis. In all, only a few over 200 cases of intra-abdominal hernia have been described, and of these only four were diagnosed pre-operatively, that is, by x-ray examination, the only means by which a pre-operative diagnosis can be reached. Kummer diagnosed a left-sided hernia in 1921, Taylor a right-sided hernia in 1930, and Exner one of each, reported in 1933. Alexander reported five cases, in 1937, in which he was able to make the diagnosis, but in none of these was surgery necessary, so that these cases have not been confirmed. In this communication, two more cases, diagnosed pre-operatively and confirmed, are added to the literature. Both are of the right-sided variety, although only about a third as many have been reported as having occurred on the right side as on the left. One case presents the anatomy usually described in the cases previously reported as paraduodenal hernias, except that failure of descent of the cecum was associated with the hernial sac. In the other case, there was no true hernial sac present. The cecum and ascending colon and hepatic flexure were attached by a true mesentery which formed a sac only when this portion of the colon was carried mesially. But these two cases are presented because basically the anatomic anomaly, abnormal peritoneal folds, is the same, and the diagnosis and treatment are identical with true intra-abdominal hernias. The exact cause of the occurrence of these peritoneal abnormalities has not been demonstrated. Treitz felt that fossæ about the junction of the duodenum and jejunum were the result of failure of fusion of the peritoneum during the third stage of the process of intestinal rotation. Moynihan thought the fossæ were the result of a failure of fusion of the mesenteric root with the peritoneum covering the posterior abdominal wall.

The Physiologic Interpretation of Duodenal Motility

THIS subject is far from settled and unanimity of opinion is still being sought in the interpretation of duodenal motility. Various clinicians are attributing symptom-complexes to supposedly pathologic contractions of the duodenum (19), and are suggesting operative procedures as a cure. Certainly a disturbance demanding such radical treatment cannot be studied too carefully or too frequently. The following impressions are the result of five years of observation. At first, all gastric cases were observed and studied and notes were made on the motility, form, and size of the duodenal curve. This group comprises well over two thousand cases studied at the Cook County Hospital. Later, as comparative studies became necessary, five other groups were added. These were as follows: 1. Visceroptosis with no abdominal complaints, 50 cases. 2. Hypertonicity with no abdominal complaints, 50 cases. 3. Proven gall-bladder pathology, 50 cases. 4. Gastric ulcer, 25 cases. 5. Active duodenal ulcer, 100 cases. Before one can appreciate the possible disturbances in motility in the duodenum, a short review of the anatomic relations is necessary (8). The first portion, or duodenal cap, usually leads upward and obliquely backward into the descending portion. The second portion comes in relation with the gall bladder, so that infections in this organ have been frequently blamed for stasis and surging in the duodenal curve. The third, or horizontal, portion crosses the spine and the aorta, and lies underneath the mesentery and superior mesenteric artery. Various authors have attributed apparent obstructive signs to a narrowing of the opening at the duodenojejunal flexure, at which the ligament of Treitz is found. Many peritoneal folds have been described, but they are rather rare and of little importance. Plain muscular fibers have been delineated in the ligament of Treitz. The possibility of sphincteric action at this point will be considered later. The nerve supply of the duodenum arises in the solar plexus, but there is also an intrinsic nerve supply from the Meissner plexus. This double nerve control may account for some of the variations seen in normal cases. In the study of our cases, careful notes were taken of the size of the duodenal cap, the angle formed by the cap and the descending portion, which we have called the cap angle, the size of the descending portion, the course over the spine, the length and steepness of the ascending portion, which we have called the duodenal climb, and the angle at the duodenojejunal junction, which we have called the Treitz angle. Observers at different times have pointed to all of these anatomic divisions as the locations of frequent obstructions. Keeping this in mind, we studied the flow of the barium through these areas with and without manual aid, and in the upright, horizontal, and reversed Fowler positions. Visceroptosis with No Abdominal Complaints In the normal hypotonic individual, the duodenal curve is usually “V”-shaped.

THE CAUSE AND CURE OF HIGH RECTOCELE

Blaisdell,¹in his studies of the parametrium, has demonstrated that, in man and the higher primates, considerable muscle tissue exists under the peritoneal folds of the pouch of Douglas, which gives a strong support to the pelvic organs. These muscle bundles, with the meshwork of elastic and fibrous tissue around the blood vessels of the parametrium and the pelvic fascia, give the true support to the pelvic organs. The pelvic floor below, the weaker accessory ligaments above, and the intra-abdominal pressure act only in an accessory way to relieve the strain on the parametrium and the pelvic fascia. The cardinal part of the pelvic fascia is a strong band of fibrous tissue called the arcus tendineus, which runs from the posterior surface of the symphysis upward and backward along the lines of the anterior fornices of the vagina, to a point in the neighborhood of the spine of the

FETAL PERITONEAL FOLDS

In the region of the caput coli and ileoceca junction, there appear frequently after the fifth fetal month certain peritoneal folds of fairly constant form and distribution which stand forth without manipulation and spread out so prominently that they can scarcely be overlooked. They are either anatomic or pathologic entities, and surely are not brought into existence by any artifice of traction or manipulation. Frequently sheets or broad bands of serous membrane pass from the mural peritoneum over the front of the cecum and ascending colon, sometimes greatly lessening the caliber of this part of the large intestine. These are the bloodless fold of Treves and the parietocolic fold. The latter, according to Douglas Reid, was first described by Jonnesco. It resembles the pericolic membrane of Jackson as seen in children and adults. Other fetal folds suggest by their position and attachments a causal relationship to gravitations and angulations of

PERITONEAL SUPPORTS—(LIGAMENTUM PERITONEI.)

The hepatic artery produces only a slight elevation of peritoneum until it reaches the hepato-duodenal ligament, whence it aids in giving distinct outline to the border of Winslow's foramen on the right. By opening an adult cadaver, well prepared for inspection, and then carefully incising the gastro-colic omentum, one can see with perfection the shape and form of the left opening of Winslow into the lesser omental bag. To obtain the best view of Winslow's foramen, however, the ribs on both sides should be removed and the stomach lifted well up. Winslow's foramen will then be seen to have a distinct oval form as seen from inside the lesser bag, whose circumference is nearly all produced by peritoneal folds projected by the gastric and hepatic arteries. The splenic artery, I must say, contrary to some anatomists, does not run into the gastro-splenic ligament until it nears its termination. Beginning at

The Histological Phenomena Involved in the Union of Peritoneal Folds

The Histological Phenomena Involved in the Union of Peritoneal Folds