【解剖】腹腔间隙影像解剖课件

腹腔间隙影像解剖

AnatomyofthePeritonealSpaces主要内容一、腹膜网膜大网膜小网膜系膜肠系膜乙状结肠系膜横结肠系膜阑尾系膜肝的韧带韧带胃的韧带脾的韧带皱襞二、隐窝和陷凹胃胰襞、肝胰襞十二指肠上、下襞三、腹膜腔结肠上区结肠下区四、腹膜后间隙*addfooterhere(gotoviewmenuandchooseheader)*LessoromentumGreateromentum网膜*addfooterhere(gotoviewmenuandchooseheader)*大网膜（Greateromentum）

连接于胃大弯及横结肠之间，由四层腹膜返折而成，前两层由胃大弯及十二指肠上段前后壁浆膜延续而成，呈围裙状下垂，遮盖横结肠、空回肠前面，而后返折向上附着于横结肠前后壁浆膜层，成人前两层与后两层通常愈着，形成连接胃大弯及横结肠的胃结肠韧带当腹腔发生感染时，炎性分泌物能刺激大网膜粘连包绕感染器官，限制炎症蔓延，局限感染范围，避免弥漫性腹膜炎；手术有时也将大网膜覆盖在肝的断面、胃穿孔缝合处、十二指肠断端，以促进其愈合。*addfooterhere(gotoviewmenuandchooseheader)*胃结肠韧带*addfooterhere(gotoviewmenuandchooseheader)*小网膜（Lesseromentum）

分为左、右两部分，左侧部从膈、肝静脉韧带裂连于胃小弯，成为肝胃韧带；右侧部从肝门连于十二指肠上部，成为肝十二指肠韧带（内有进入肝门的三个重要结构，胆总管、肝固有动脉、门静脉）小网膜右侧游离，其后方为网膜孔*addfooterhere(gotoviewmenuandchooseheader)*系膜肠系膜阑尾系膜横结肠系膜乙状结肠系膜*addfooterhere(gotoviewmenuandchooseheader)*肝的韧带镰状韧带是双层腹膜结构，联系肝脏与前腹壁及膈肌，镰状韧带在膈肌连接处向两侧分开包绕肝裸区，其左层向左延续为左冠状韧带上层，并继续延续为左三角韧带，其右层延续为右冠状韧带上层，并继续向右下延续为右三角韧带，右三角韧带下层越过下腔静脉形成小网膜右叶，然后在尾状叶前方呈半圆形绕过，左三角韧带下层延续为小网膜左叶肝脏三处未被腹膜覆盖的区域—肝裸区、胆囊床、肝门—是与膈腹膜、小网膜及韧带连接处肝胃韧带及肝十二指肠韧带*addfooterhere(gotoviewmenuandchooseheader)*Ligamentsofliver

*addfooterhere(gotoviewmenuandchooseheader)*胃的韧带肝胃韧带－如前所述胃脾韧带－联系胃底和脾门的双层腹膜，其内包含胃短动脉及胃网膜左动脉胃膈韧带－由胃底后面连至膈下的双层腹膜结构，两层间相距较远，形成胃裸区胃结肠韧带－如前所述胃胰韧带－由胃幽门窦后壁至胰头、颈及颈与体的移行部的腹膜皱襞*addfooterhere(gotoviewmenuandchooseheader)*Ligamentsofstomach

Hepatogastricligament肝胃韧带Gastrosplenicligament胃脾韧带Gastrophrenicligament胃膈韧带Gastrocolicligament胃结肠韧带Gastropancresticligament胃胰韧带*addfooterhere(gotoviewmenuandchooseheader)*脾的韧带胃脾韧带－如前所述脾肾韧带－是自脾门至左肾前面的双层腹膜结构，内含胰尾及脾血管、淋巴结构和神经丛等。膈脾韧带－由脾肾韧带向上延伸至膈，此韧带很短脾结肠韧带－位于脾前端和结肠左曲之间，此韧带也很短*addfooterhere(gotoviewmenuandchooseheader)*LigamentsofspleenGastrosplenicligament胃脾韧带Splenorenalligament脾肾韧带Phrenicosplenicligament膈脾韧带Splenocolicligament

脾结肠韧带*addfooterhere(gotoviewmenuandchooseheader)*皱襞胃胰襞和肝胰襞

胃胰襞是胃左动脉从腹后壁走向胃小弯时形成的腹膜皱襞—分隔网膜囊中间部及侧部

肝胰襞是肝总动脉或肝固有动脉从腹后壁向前进入小网膜时所形成的腹膜皱襞十二指肠上、下襞*addfooterhere(gotoviewmenuandchooseheader)*FoldsandrecessesofposteriorabdominalwallSuperiorduodenalfoldandrecess十二指肠上襞和上隐窝Inferiorduodenalfoldandrecess十二指肠下襞和下隐窝Intersigmoidrecess

乙状结肠间隐窝－formedbytheinvertedVattachmentofsigmoidmesocolon

*addfooterhere(gotoviewmenuandchooseheader)*Retrocecalrecess盲肠后隐窝－阑尾常位于其中Hepatorenalrecess肝肾隐窝－位于肝右后叶与右肾及结肠肝曲之间，是仰卧位腹腔最低点*addfooterhere(gotoviewmenuandchooseheader)*Pouches

Inmale－rectovesicalpouch直肠膀胱陷窝InfemaleRectouterinepouch

直肠子宫陷窝－betweenrectumanduterusVesicouterinepouch膀胱子宫陷窝－betweenbladderanduterus为腹盆腔积液和肿瘤种植转移的好发部位*addfooterhere(gotoviewmenuandchooseheader)*结肠上区（膈下间隙）右膈下腹膜外间隙（肝裸区）左膈下腹膜外间隙（胃裸区）肝周间隙右肝上间隙左肝上后间隙左肝上间隙左肝上前间隙右肝下间隙肝下间隙肝上间隙左肝下间隙左肝下前间隙左肝下后间隙（网膜囊）肝脏左三角韧带镰状韧带肝圆韧带胃及小网膜肝周间隙相互沟通，其中小网膜分隔右肝下间隙和网膜囊，网膜囊仅借网膜孔（theforamenofWinslow）与腹腔交通*addfooterhere(gotoviewmenuandchooseheader)*Perihepaticspaces*addfooterhere(gotoviewmenuandchooseheader)*Perihepaticspaces*addfooterhere(gotoviewmenuandchooseheader)*网膜囊借网膜孔与腹腔相通境界：前方为肝十二指肠韧带，后方为覆盖下腔静脉的腹膜，上界为肝尾状叶，下界为十二指肠上部网膜孔*addfooterhere(gotoviewmenuandchooseheader)*网膜囊位置：位于小网膜和胃的后方境界：前壁由上而下依次为小网膜、胃后壁腹膜和大网膜前两层；下壁为大网膜前两层与后两层返折处；后壁由下而上依次为大网膜后两层、横结肠及其系膜、覆盖胰、左肾、左肾上腺的腹膜；上壁为膈下面的腹膜，此处肝尾状叶自右侧套入网膜囊内形成网膜囊上隐窝；左界为胃脾韧带、脾和脾肾韧带；右界为网膜孔*addfooterhere(gotoviewmenuandchooseheader)*四部分：网膜孔所对的前庭部；胃胰襞以上为上隐窝，位于小网膜与膈之间，内有尾状叶套入；沿胰体伸向左后上方达脾门部分为脾隐窝；下隐窝位于胃胰襞以下，在胃与胰及横结肠系膜之间。*addfooterhere(gotoviewmenuandchooseheader)*1=peritonealreflectionofcavaformingroofofforamenofWinslow;2=peritonealreflectionofcavaadjacenttobareareaofrighthepaticlobe;3=medialsegmentofleftinferiorcoronaryligament;4=peritoneumofligamentumteres;5=gastrophrenicligament;6=gastrosplenicligament;7=splenorenalligament;8=transversemesocolon;*addfooterhere(gotoviewmenuandchooseheader)*LessersacCTscanshows

fluidinthesuperior(*)andsplenic(S)recessesof

lessersacoutliningthegastropancreaticfold(arrowhead).*addfooterhere(gotoviewmenuandchooseheader)*肝裸区于第一肝门以上平面，可见此间隙位于冠状韧带上、下层之间。“肝右后上间隙”是不存在的，由于肝裸区存在，腹腔积液不能到达脊柱旁，可与胸腔积液区别。CompanyLogo*肝周积液与胸腔积液鉴别右肝上前间隙积液右侧胸腔积液CompanyLogo*胃裸区

Bareareaofstomach是否侵犯胃裸区是胃癌预后的影响因素之一*addfooterhere(gotoviewmenuandchooseheader)**addfooterhere(gotoviewmenuandchooseheader)**addfooterhere(gotoviewmenuandchooseheader)*Infracoliccompartments结肠下区－位于横结肠及横结肠系膜以下

Rightparacolicsulcus(gutter)右结肠旁沟－位于升结肠旁，是联系肝肾隐窝和盆腔的通路；感染可通过此途径传播，如膈下脓肿可经此沟流入右髂窝和盆腔，阑尾化脓时也可向上蔓延至肝下Leftparacolicsulcus(gutter)左结肠旁沟－位于降结肠旁，上缘由左膈结肠韧带（thephrenicocolicligament）与结肠上区分隔,因此左结肠旁沟积液只能向下流入盆腔*addfooterhere(gotoviewmenuandchooseheader)*Rightmesentericsinus

右肠系膜窦－为一三角形间隙，位于肠系膜根部、升结肠及右2/3横结肠及其系膜之间，其下方有回肠末端阻隔，近乎封闭，当此窦有炎症时，不易扩散，易形成肠间脓肿或局限性腹膜炎Leftmesentericsinus

左肠系膜窦－为向下开口的斜方形，位于肠系膜根部、降结肠、左1/3横结肠及其肠系膜之间，左肠系膜窦可向下越过小骨盆口通入盆腔，因此此窦内感染易蔓延入盆腔上下流通，左沟不畅，右窦封闭，左入盆腔。*addfooterhere(gotoviewmenuandchooseheader)*腹膜后隙

Retroperitonealspace定义：位于腹后壁壁腹膜与腹内筋膜之间，上界为膈，下至骶骨岬，两侧向外延伸为腹前外侧壁的腹膜外筋膜，该间隙感染可上经腰肋三角可通到后纵隔，下与盆腔的腹膜后隙相续。组成：肾旁前间隙；肾周间隙；肾旁后间隙*addfooterhere(gotoviewmenuandchooseheader)*肾周间隙肾周间隙上方—右侧通向肝裸区；左侧通向左膈下腹膜外间隙肾周间隙下方—通向下腹部及盆腔腹膜外间隙（髂窝）双侧肾周间隙之间—肾门及肠系膜上动脉平面以下肾前间隙相交通，以上不交通*addfooterhere(gotoviewmenuandchooseheader)*Retroperitonealspace*addfooterhere(gotoviewmenuandchooseheader)**addfooterhere(gotoviewmenuandchooseheader)*病例网膜囊病变腹膜病变非肿瘤性腹腔积液：漏出液、炎性渗出、血肿、胆漏、尿漏良性肿瘤恶性肿瘤*addfooterhere(gotoviewmenuandchooseheader)*Fig.5.-Delineationoflessersacanatomybyascites.A,Patientwith

alcoholiccirrhosis.Fluidwithinlesserandgreaterperitonealcavitiesoutlines

gastrosplenicligament,whichisseentocontainfatandopacifiedbloodvessels.Inthispatient,ligamentisredundantandformsseveralruffles(arrows).B,

Patientwithcarcinomaofpancreatictail.Malignantasciticfluidoutlinesgastrosplenic

ligament(arrows).Short,rudimentarysplenorenalligamentisidentifled

becauseitcontainsproximalpartofsplenicvein,opacifiedbycontrast

medium*addfooterhere(gotoviewmenuandchooseheader)*A，lambdashapedfluidcollection(arrows)adjacenttocaudatelobeB,Abscess(arrow)from

pancreatitiscontainsnumerousgasbubbles*addfooterhere(gotoviewmenuandchooseheader)*Fig.4.-Medialdisplacementofstomachbypseudocystinlateralcompartment

oflessersac.Pseudocystisinterposedbetweencontrast-filledstomach,gastrosplenicligament(arrow),andspleen*addfooterhere(gotoviewmenuandchooseheader)*Fig.7.-Perforationofposterior-wallgastric

ulcerintolateralcompartmentoflesserperitoneal

sac.Lessersacfluidcollection(arrow)interposed

betweenstomach,pancreatictail,andspleen.No

evidenceoffluidwithingreaterperitonealcavity.Fig.8.-Spontaneousfistula(arrow)between

jejunalloopandpancreaticpseudocystlocated

withinlateralcompartmentoflesserperitoneal

sac.Gas=fluidlevelwithinpseudocyst.Followup

study4weekslatershowednearlycomplete

resolutionofpseudocyst.*addfooterhere(gotoviewmenuandchooseheader)*Fig.9.-Pancreaticcavernouslymphhemangioma

thatoccupieslateralcompartmentoflesser

peritonealsac.A,Tumor(T)interposedbetween

contrast-filledstomach,whichitdisplacesmedially.

spleen.andgastrosplenicligament(arrow).B,Severalcentimetersloweratlevelofpancreas.Tumor(T)arisesfrompancreas,immediatelyvantral

toopacifiedsplenicvein.*addfooterhere(gotoviewmenuandchooseheader)*SarcoidosisItshowsirregularly

enhancingomentalsoft

tissue(arrows)

secondaryto

sarcoidosis.*addfooterhere(gotoviewmenuandchooseheader)*Hemoperitoneum55-year-old

womanwith

intraperitonealsubacute

hematoma.

AandB

showsubacuteblood,bestseeninperihepatic

space(arrows).*addfooterhere(gotoviewmenuandchooseheader)*Hemoperitoneum48-year-oldmanwithinfectedintraperitonealhematoma.

A–C,T2-weightedimage(A)andT1-weightedimages(B)and(C)

contrastedimageshowlinearsmoothperitonealenhancement,withpresenceof

intraperitonealblood-intensitysignal.*addfooterhere(gotoviewmenuandchooseheader)*BileleakT1-weighted

images1hrafterIV

administrationof

mangafodipirtrisodium

showhyperintense

perihepaticfluid

denotingbileleak.*addfooterhere(gotoviewmenuandchooseheader)*PeritonealNeoplasms

BenignTumors

Theselesionsincludelipomas,neurofibromas,

andothermesenchymaltumors.39-year-oldwomanwithneurofibromatosistype1*addfooterhere(gotoviewmenuandchooseheader)*Mesentericcyst*addfooterhere(gotoviewmenuandchooseheader)*MalignantTumors

PeritonealmetastasesPeritoneal

carcinomatosisistypicallymanifested

byenhancingperitonealnodules

orarindofenhancing

perihepaticsofttissue.44-year-oldwomanwithmetastasesfromovariancancer*addfooterhere(gotoviewmenuandchooseheader)*MalignantTumors

Peritonealmetastases*addfooterhere(gotoviewmenuandchooseheader)*Peritonealpseudomyxoma*addfooterhere(gotoviewmenuandchooseheader)*MalignantTumorsCTscanshowsgastriccarcinomainvadingthegastrocolicligament.*addfooterhere(gotoviewmenuandchooseheader)*MalignantTumorsA，Smallbowelmesenteryinapatientwithnon-Hodgkinlymphoma.B，Smallbowel

mesenteryinapatientwithcarcinomatosis.CTscanshowsmassesinthesmallbowelmesentery(M)andrightparacohicgutter(*).*addfooterhere(gotoviewmenuan