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 cavityof cadavers of different sizes (small �60 kg; medium ¼ 60–100 kg; large �100 kg). Theresults help to predict the volumes of therapeutic solutions (e.g., adhesiolysis solutionsused in the prevention of post-operative adhesion formation) that would be required toreach all the relevant spaces within the greater sac of the peritoneal cavity. Twenty-onecadavers (9 male, 12 female) were selected randomly. Midline laparotomy and bilateralsubcostal incisions were made to visualize the distribution of 500 ml of water into thepelvic cavity, paracolic gutters, right subhepatic, and subphrenic spaces. A further 500 mlof water was then added and the distribution was again recorded. The results showed that500 ml of water was found to distribute to all areas in 47.8% of cadavers, and 1,000 mldistributed to all areas in 81.0% of cadavers. One hundred percent of small cadaversachieved maximum distribution with 500 ml irrespective of gender. Seventy percentof medium cadavers achieved maximum distribution with 1,000 ml, and 75% of largecadavers achieved maximum distribution with 1,000 ml. Anatomical variation in thesize of the phrenicocolic ligament was found to be an important limiting factor in thedistribution of fluid to the space inferior to the left lobe of the liver and the left subphrenicspace. Pre-existing intra-abdominal pathology and previous abdominal surgery alsoinfluenced 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; pelviccavity; 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)

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 All2 76 Male Small All All Midline laparotomy with adhesions3 84 Female Small All All4 85 Female Small All All5 79 Female Small All All6 89 Female Small All All7 87 Female Small All All8 88 Male Medium A–D All9 81 Female Medium A–E A–F Ileostomy and adhesions to

anterior abdominal wall10 79 Male Medium All All11 89 Male Medium All All12 77 Female Medium A–C,F,G All Gross hepatomegaly with metastases13 91 Male Medium A–E All14 93 Female Medium All All Small phrenicocolic ligament15 87 Male Medium A–E All16 88 Female Medium A–E A–E Large phrenicocolic ligament17 85 Male Medium A–D,F,G A–D,F,G Right paramedian incision,

adhesions to anterior abdomenand right subphrenic region

18 85 Female Large A–E All19 88 Male Large A–E All20 81 Female Large A–E A–E Large phrenicocolic ligament21 90 Male Large A–E All

aA, 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.

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