volume de fluido peritoneal mahmud 2005

1. ORIGINAL COMMUNICATION
Distribution of Fluid within the Peritoneal Cavity:
A Cadaveric Study
T. MAHMUD,* M. ARASTU, AND H. ELLIS
Department of Anatomy, Guy’s, King’s, and St. Thomas’s, School of Biomedical Science, London, United Kingdom
This study assesses the distribution of varying volumes of fluid within the peritoneal cavity
of cadavers of different sizes (small 60 kg; medium ¼ 60–100 kg; large 100 kg). The
results help to predict the volumes of therapeutic solutions (e.g., adhesiolysis solutions
used in the prevention of post-operative adhesion formation) that would be required to
reach all the relevant spaces within the greater sac of the peritoneal cavity. Twenty-one
cadavers (9 male, 12 female) were selected randomly. Midline laparotomy and bilateral
subcostal incisions were made to visualize the distribution of 500 ml of water into the
pelvic cavity, paracolic gutters, right subhepatic, and subphrenic spaces. A further 500 ml
of water was then added and the distribution was again recorded. The results showed that
500 ml of water was found to distribute to all areas in 47.8% of cadavers, and 1,000 ml
distributed to all areas in 81.0% of cadavers. One hundred percent of small cadavers
achieved maximum distribution with 500 ml irrespective of gender. Seventy percent
of medium cadavers achieved maximum distribution with 1,000 ml, and 75% of large
cadavers achieved maximum distribution with 1,000 ml. Anatomical variation in the
size of the phrenicocolic ligament was found to be an important limiting factor in the
distribution of fluid to the space inferior to the left lobe of the liver and the left subphrenic
space. Pre-existing intra-abdominal pathology and previous abdominal surgery also
influenced the distribution of fluid within the peritoneal cavity. Clin. Anat. 18:443–445,
2005. VVC 2005 Wiley-Liss, Inc.
Key words: cadavers; supracolic compartment; infracolic compartment; pelvic
cavity; phrenicocolic ligament; fluid distribution; adhesions-
adhesiolysis
INTRODUCTION
Intra-abdominal fluid distribution is important not
only in understanding disease but in certain thera-
peutic applications such as continuous ambulatory
peritoneal dialysis and intraperitoneal administration
of adhesiolysis solutions. Post-operative adhesions
are the commonest cause of small bowel obstruction
in the Western world (Ellis, 1998), and adhesiolysis
solutions are used to reduce post-operative adhesion
formation. The changes in intra-abdominal pressure
with breathing and capillary action, cause intraperito-
neal fluids to travel in an upward direction to the
subphrenic regions (Russell et al., 2000). It is this
upward movement of intra-abdominal fluids that is
responsible for the subphrenic distribution of many
intra-abdominal purulent collections (Mitchell,
1940). Larger volumes of fluid entering the perito-
neal cavity secondary to visceral perforation result in
fluid distribution caudally, directed by normal perito-
neal attachments (Russell et al., 2000).
The anatomical configuration of the peritoneal
cavity greatly influences the distribution of fluid
within it. The greater sac is divided into three
compartments: supracolic, infracolic, and pelvic
(Asgeirsson and Macmillan, 2002). The supracolic
and infracolic compartments are separated by the
*Correspondence to: Mr Tahir Mahmud, 5 Mount Pleasant
Close, Hatfield, Hertfordshire, AL9 5BZ, UK.
E-mail: mahmudtahir@hotmail.com
Received 13 November 2003; Revised 10 December 2004;
Accepted 12 February 2005
Published online 13 July 2005 in Wiley InterScience (www.
interscience.wiley.com). DOI 10.1002/ca.20134
VVC 2005 Wiley-Liss, Inc.
Clinical Anatomy 18:443–445 (2005)

2. transverse colon and mesocolon. The supracolic com-
partment of the greater sac is further divided into
the right and left subphrenic spaces and the right
subhepatic space (hepatorenal recess, Morison’s
pouch) (Bannister, 1995). In the infracolic compart-
ment four paracolic gutters are found on the medial
and lateral sides of the ascending and descending
colons. Apart from the right medial paracolic gutter,
which is closed off inferiorly by the mesentery of
the small bowel, the other gutters are in free com-
munication with the pelvic cavity. The right lateral
paracolic gutter is in direct communication with the
right subhepatic space. In contrast, the left lateral
paracolic gutter is separated from the area around
the spleen, and therefore from the left subphrenic
space, by the phrenicocolic ligament. This ligament
is a fold of peritoneum that passes from the dia-
phragm to the splenic flexure of the colon (Bannis-
ter, 1995). This study assessed the distribution of
varying volumes of fluid within the peritoneal cavity
of cadavers of differing size.
MATERIALS AND METHODS
Studies were carried out on 21 (9 male, 12 female)
cadavers in the Anatomy Department of the Guy’s,
King’s, and St. Thomas’s School of Biomedical Sci-
ence, London. The cadavers were classified as small
(60 kg), medium (60–100 kg), and large (100 kg).
Previous surgery or co-existing pathology was also
documented. A midline laparotomy incision was
made from the epigastrium to the suprapubic region.
Bilateral subcostal incisions were also made to visu-
alize the supracolic compartment. Excess formalin in
the abdominal cavity was removed before introduc-
ing 500 ml of water into the abdominal cavity over
the region of the small bowel in the infracolic com-
partment. Two minutes were given for the water to
distribute and the presence of water in the pelvic
cavity, paracolic gutters, subphrenic spaces, right
subhepatic space, and the space inferior to the left
lobe of the liver was noted by direct observation and
recorded. The lesser sac was not examined. The
abdominal wall was supported manually while the
fluid was given time to distribute itself. An addi-
tional 500 ml of water was then introduced and the
distribution of fluid recorded again. Care was taken
to avoid disturbing the organs and displacing fluid
from one area to another.
RESULTS
The results are shown in Table 1. In 10 of 21
cadavers (48%), 500 ml of water was sufficient to dis-
tribute to all areas of the peritoneal cavity. One
thousand millilitres of water was sufficient to distrib-
ute to all areas of the peritoneal cavity in 17 of 21
(81%) of the cadavers. Of the four cadavers in which
TABLE 1. Distribution of Water in Peritoneal Cavitya
Cadaver Age Gender Size 500 ml 1,000 ml Notes
1 88 Female Small All All
2 76 Male Small All All Midline laparotomy with adhesions
3 84 Female Small All All
4 85 Female Small All All
5 79 Female Small All All
6 89 Female Small All All
7 87 Female Small All All
8 88 Male Medium A–D All
9 81 Female Medium A–E A–F Ileostomy and adhesions to
anterior abdominal wall
10 79 Male Medium All All
11 89 Male Medium All All
12 77 Female Medium A–C,F,G All Gross hepatomegaly with metastases
13 91 Male Medium A–E All
14 93 Female Medium All All Small phrenicocolic ligament
15 87 Male Medium A–E All
16 88 Female Medium A–E A–E Large phrenicocolic ligament
17 85 Male Medium A–D,F,G A–D,F,G Right paramedian incision,
adhesions to anterior abdomen
and right subphrenic region
18 85 Female Large A–E All
19 88 Male Large A–E All
20 81 Female Large A–E A–E Large phrenicocolic ligament
21 90 Male Large A–E All
a
A, pelvic cavity; B, right paracolic gutter; C, left paracolic gutter; D, right subhepatic space; E, right subphrenic space; F, space
inferior to left lobe of liver; G, left subphrenic space; All, all the above spaces.
444 Mahmud et al.

3. 1,000 ml failed to distribute to all areas, two of the
cadavers had comparatively large phrenicocolic liga-
ments, which prevented drainage of water from the
left lateral paracolic gutter into the left supracolic
compartment. One cadaver required 3,500 ml of
water to overcome the damming effect of the phre-
nicocolic ligament. One of the cadavers had previ-
ously had a right paramedian incision with extensive
adhesion formation to the anterior abdominal wall
and right subphrenic region. The fourth cadaver had
previously had an ileostomy with resultant adhesions
to the anterior abdominal wall.
All small cadavers achieved total intra-abdominal
distribution with 500 ml of water independent of
gender. Seven of the ten (70%) medium-sized cadav-
ers achieved distribution of water to all areas with
1,000 ml of water. Three of the four (75%) large
cadavers achieved distribution to all areas with 1,000
ml of water. The one large cadaver not achieving
maximum distribution had a large phrenicocolic liga-
ment preventing water getting to the left subphrenic
space.
DISCUSSION
Adhesions from previous surgery are a major prob-
lem and an important cause of impaired organ func-
tion, decreased fertility, small bowel obstruction, dif-
ficult re-operation, and perhaps chronic abdominal
pain. Menzies and Ellis (1990) reported intra-
abdominal adhesions in 93% of patients who had
had a previous laparotomy and only 10% of patients
who had never had previous abdominal surgery.
Parker et al. (2001) reported that in a study of
12,584 patients undergoing lower abdominal surgery
in 1986, 32.6 percent of patients were readmitted a
mean of 2.2 times in the subsequent 10 years for a
potential adhesion-related problem. Of the patients
readmitted, there were a total of 430 abdominal sur-
gical interventions (3.4%) for adhesion-related dis-
ease (Parker et al., 2001).
We investigated whether volumes of 500 and
1,000 ml are sufficient to reach all the spaces within
the greater sac of the peritoneal cavity. The results
of this experiment will help us to predict the volume
of therapeutic solution, such as hydroflotation solu-
tions used to prevent post-operative adhesion forma-
tion after abdominal or pelvic surgery, that would be
required to reach all the relevant spaces within the
peritoneal cavity.
Conclusions to be drawn from this experiment are
that 500 ml of fluid is sufficient to distribute fluid to
all areas of the greater sac of the peritoneal cavity in
small cadavers irrespective of gender. In medium- to
large-sized cadavers, 1,000 ml of fluid is more effec-
tive than 500 ml in distributing to all areas of the
greater sac. Anatomical and pathological factors seem
to play important roles in the ability of fluid to dis-
tribute freely within the peritoneal cavity. Cadavers
with a larger phrenicocolic ligament require a greater
volume of fluid to allow adequate distribution to the
left subphrenic space than those with a smaller phre-
nicocolic ligament. There was difficulty at times in
distributing fluid to all areas of the peritoneal cavity
in subjects who had undergone previous abdominal
surgery with adhesion formation, or who had exten-
sive intra-abdominal pathology.
REFERENCES
Asgeirsson KS, Macmillan RD. 2002. Intra-abdominal
abscesses. Surgery 20:108–112.
Bannister LH. 1995. Peritoneum. In: Williams PL, editor.
Gray’s anatomy. 38th Ed. New York: Churchill Living-
stone. p 1734–1747.
Ellis H. 1998. The magnitude of adhesion related problems.
Ann Chirurg Gynaecol 87:9–11.
Menzies D, Ellis H. 1990. Intestinal obstruction from adhe-
sions—how big is the problem? Ann Roy Coll Surg Eng
72:60–63.
Mitchell GAG. 1940. The spread of acute intraperitoneal
effusions. Br J Surg 28:291–313.
Parker MC, Ellis H, Moran BJ, Thompson JN, Wilson MS,
Menzies D, McGuire A, Lower AM, Hawthorn RJ,
O’Briena F, Buchan S, Crowe AM. 2001. Postoperative
adhesions: ten-year follow-up of 12, 584 patients under-
going lower abdominal surgery. Dis Colon Rectum 44:
822–829.
Russell RCG, Williams NS, Bulstrode CJK. 2000. The peri-
toneum, omentum, mesentery and retroperitoneal space.
Bailey and Love’s short practice of surgery. 23rd Ed.
London: Arnold Publishers. p 1008–1025.
445Fluid in the Peritoneal Cavity