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1、腹腔间隙影像解剖Anatomy of the Peritoneal Spaces,主要内容,一、腹膜,皱襞,二、隐窝和陷凹,四、腹膜后间隙,网 膜,大网膜（Greater omentum）,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
2、合。,胃结肠韧带,小网膜（Lesser omentum）,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,系膜,肠系膜 阑尾系膜 横结肠系膜 乙状结肠系膜,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
3、，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,Ligaments of liver,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,Ligaments of stomach,Hepatogastric ligament 肝胃韧带 Gastrosplenic ligament 胃脾韧带 Gastrophrenic
4、 ligament 胃膈韧带 Gastrocolic ligament 胃结肠韧带 Gastropancrestic ligament 胃胰韧带,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,Ligaments of spleen,Gastrosplenic ligament 胃脾韧带 Splenorenal ligament 脾肾韧带 Phrenicosplenic ligament 膈脾韧带 Splenocolic ligament
5、脾结肠韧带,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,Folds and recesses of posterior abdominal wall,Superior duodenal fold and recess 十二指肠上襞和上隐窝 Inferior duodenal fold and recess 十二指肠下襞和下隐窝 Intersigmoid recess 乙状结肠间隐窝formed by the inverted V attachment o
6、f sigmoid mesocolon,Retrocecal recess 盲肠后隐窝阑尾常位于其中 Hepatorenal recess 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,Pouches In malerectovesical pouch 直肠膀胱陷窝 In female Rectouterine pouch 直肠子宫陷窝between rectum and uterus Vesicouterine pouch 膀胱子宫陷窝between bladder and uterus,为腹盆腔积液和肿瘤种植转移的好发部位,结肠上区（膈下间隙）,右膈下腹膜外间隙（肝裸区）
7、左膈下腹膜外间隙（胃裸区）,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（the foramen of Winslow）与腹腔交通,Perihepatic spaces,Perihepatic spaces,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,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
8、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,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。,1 = peritoneal reflection of cava forming roof of foramen of Winslow; 2= peritoneal reflection of cava adjacent to bare area of right hepatic lobe; 3 =m
9、edial segment of left inferior coronary ligament; 4 = peritoneum of ligamentum teres; 5 = gastrophrenic ligament; 6 = gastrosplenic ligament; 7 = splenorenal ligament; 8 = transverse mesocolon;,Lesser sac,CT scan shows fluid in the superior (*) and splenic (S) recesses of lesser sac outlining the ga
10、stropancreatic fold (arrowhead).,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。,肝周积液与胸腔积液鉴别,胃裸区Bare area of stomach,是否侵犯胃裸区是胃癌预后的影响因素之一,Infracolic compartments 结肠下区 位于横结肠及横结肠系膜以下 Right paracolic sulcus (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
11、也可向上蔓延至肝下 Left paracolic sulcus (gutter) 左结肠旁沟位于降结肠旁，上缘由左膈结肠韧带（the phrenicocolic ligament）与结肠上区分隔, 因此左结肠旁沟积液只能向下流入盆腔,Right mesenteric sinus 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 Left mesenteric sinus 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
12、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。,腹膜后隙Retroperitoneal space,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,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,Retroperitoneal space,病 例,网膜囊病变 腹膜病变
13、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,Fig. 5.-Delineation of lesser sac anatomy by ascites. A, Patient with alcoholic cirrhosis. Fluid within lesser and greater peritoneal cavities outlines gastrosplenic ligament, which is seen to contain fat and opacified blood vessels.In this patient, ligament is r
14、edundant and forms several ruffles (arrows). B, Patient with carcinoma of pancreatic tail. Malignant ascitic fluid outlines gastrosplenic ligament (arrows). Short, rudimentary splenorenal ligament is identifled because it contains proximal part of splenic vein, opacified by contrast medium,A，lambdas
15、haped fluid collection (arrows) adjacent to caudate lobe B, Abscess (arrow) from pancreatitis contains numerous gas bubbles,Fig. 4.-Medial displacement of stomach by pseudocyst in lateral compartment of lesser sac. Pseudocyst is interposed between contrast-filled stomach,gastrosplenic ligament (arro
16、w), and spleen,Fig. 7.-Perforation of posterior-wall gastric ulcer into lateral compartment of lesser peritoneal sac. Lesser sac fluid collection (arrow) interposed between stomach, pancreatic tail, and spleen. No evidence of fluid within greater peritoneal cavity. Fig. 8.-Spontaneous fistula (arrow
17、) between jejunal loop and pancreatic pseudocyst located within lateral compartment of lesser peritoneal sac. Gas = fluid level within pseudocyst. Followup study 4 weeks later showed nearly complete resolution of pseudocyst.,Fig. 9.-Pancreatic cavernous lymph hemangioma that occupies lateral compart
18、ment of lesser peritoneal sac. A, Tumor (T) interposed between contrast-filled stomach, which it displaces medially. spleen. and gastrosplenic ligament (arrow).B, Several centimeters lower at level of pancreas.Tumor (T) arises from pancreas, immediately vantral to opacified splenic vein.,Sarcoidosis
19、,It shows irregularly enhancing omental soft tissue (arrows) secondary to sarcoidosis.,Hemoperitoneum,55-year-old woman with intraperitoneal subacute hematoma. A and B show subacute blood,best seen in perihepatic space (arrows).,Hemoperitoneum,48-year-old man with infected intraperitoneal hematoma.
20、AC, T2-weighted image (A) and T1-weighted images (B) and (C) contrasted image show linear smooth peritoneal enhancement, with presence of intraperitoneal blood-intensity signal.,Bile leak,T1-weighted images 1 hr after IV administration of mangafodipir trisodium show hyperintense perihepatic fluid de
21、noting bile leak.,Peritoneal NeoplasmsBenign Tumors,These lesions include lipomas, neurofibromas, and other mesenchymal tumors.,39-year-old woman with neurofibromatosis type 1,Mesenteric cyst,Malignant TumorsPeritoneal metastases,Peritoneal carcinomatosis is typically manifested by enhancing periton
22、eal nodules or a rind of enhancing perihepatic soft tissue.,44-year-old woman with metastases from ovarian cancer,Malignant TumorsPeritoneal metastases,Peritoneal pseudomyxoma,Malignant Tumors,CT scan shows gastric carcinoma invading the gastrocolic ligament .,Malignant Tumors,A，Small bowel mesenter
23、y in a patient with non-Hodgkin lymphoma. B，Small bowel mesentery in a patient with carcinomatosis. CT scan shows masses in the small bowel mesentery (M) and right paracohic gutter (*).,Malignant TumorsPeritoneal mesothelioma,58-year-old man with mesothelioma. AB, GRE out-of-phase image (A) and enha
24、nced T1-weighted image (B ) show enhancing large mass (arrows, A and B), representing mesothelioma,which is entangling bowel loops.,Malignant TumorsMesenteric carcinoid,Mesenteric carcinoid tumors are usually seen as nodular masses associated with mesenteric stranding.,Enhancing mass (arrows) is see
25、n on portal venous phase images, with involvement of draining veins,要 点,炎症或肿瘤性病变可通过横结肠系膜到达结肠，如胰腺病变易通过横结肠系膜累及横结肠下面，而胃部疾病则易累及横结肠上面。 胃部肿瘤易沿着肝胃韧带侵犯，因此常常可以在肝胃韧带的脂肪组织中看到结节状的转移病灶；胃恶性肿瘤也可沿该韧带侵犯肝脏，如侵犯 Glissons 系统。 肝十二指肠韧带为肝胃韧带的游离边，胆胰疾病可沿此途径蔓延。 胰尾、脾和胃部疾病可沿胃脾韧带蔓延。,最常见的腹膜肿瘤为继发于卵巢、结肠、胃及胰腺的转移性肿瘤。其影像特征包括：(1)腹膜增厚伴结节影；(2)腹水;(3)分隔性囊性积液;(4)小肠壁增厚;(5)网膜增厚，呈饼征。 常见的网膜病变有转移、间皮瘤和结核等，网膜囊性病变多见于原发囊肿、胰腺炎、脓肿、血肿或坏死的肿瘤病变。 腹膜假性粘液瘤往往继发于阑尾或卵巢的粘液腺瘤或腺癌，呈凝胶样，肝周可见扇贝形压迹。,要 点,