【解剖】腹腔間隙影像解剖課件

腹腔間隙影像解剖

AnatomyofthePeritonealSpaces主要內(nèi)容一、腹膜網(wǎng)膜大網(wǎng)膜小網(wǎng)膜系膜腸系膜乙狀結(jié)腸系膜橫結(jié)腸系膜闌尾系膜肝的韌帶韌帶胃的韌帶脾的韌帶皺襞二、隱窩和陷凹胃胰襞、肝胰襞十二指腸上、下襞三、腹膜腔結(jié)腸上區(qū)結(jié)腸下區(qū)四、腹膜后間隙*addfooterhere(gotoviewmenuandchooseheader)*LessoromentumGreateromentum網(wǎng)膜*addfooterhere(gotoviewmenuandchooseheader)*大網(wǎng)膜（Greateromentum）

連接于胃大彎及橫結(jié)腸之間，由四層腹膜返折而成，前兩層由胃大彎及十二指腸上段前后壁漿膜延續(xù)而成，呈圍裙?fàn)钕麓?，遮蓋橫結(jié)腸、空回腸前面，而后返折向上附著于橫結(jié)腸前后壁漿膜層，成人前兩層與后兩層通常愈著，形成連接胃大彎及橫結(jié)腸的胃結(jié)腸韌帶當(dāng)腹腔發(fā)生感染時(shí)，炎性分泌物能刺激大網(wǎng)膜粘連包繞感染器官，限制炎癥蔓延，局限感染范圍，避免彌漫性腹膜炎；手術(shù)有時(shí)也將大網(wǎng)膜覆蓋在肝的斷面、胃穿孔縫合處、十二指腸斷端，以促進(jìn)其愈合。*addfooterhere(gotoviewmenuandchooseheader)*胃結(jié)腸韌帶*addfooterhere(gotoviewmenuandchooseheader)*小網(wǎng)膜（Lesseromentum）

分為左、右兩部分，左側(cè)部從膈、肝靜脈韌帶裂連于胃小彎，成為肝胃韌帶；右側(cè)部從肝門連于十二指腸上部，成為肝十二指腸韌帶（內(nèi)有進(jìn)入肝門的三個(gè)重要結(jié)構(gòu)，膽總管、肝固有動(dòng)脈、門靜脈）小網(wǎng)膜右側(cè)游離，其后方為網(wǎng)膜孔*addfooterhere(gotoviewmenuandchooseheader)*系膜腸系膜闌尾系膜橫結(jié)腸系膜乙狀結(jié)腸系膜*addfooterhere(gotoviewmenuandchooseheader)*肝的韌帶鐮狀韌帶是雙層腹膜結(jié)構(gòu)，聯(lián)系肝臟與前腹壁及膈肌，鐮狀韌帶在膈肌連接處向兩側(cè)分開包繞肝裸區(qū)，其左層向左延續(xù)為左冠狀韌帶上層，并繼續(xù)延續(xù)為左三角韌帶，其右層延續(xù)為右冠狀韌帶上層，并繼續(xù)向右下延續(xù)為右三角韌帶，右三角韌帶下層越過下腔靜脈形成小網(wǎng)膜右葉，然后在尾狀葉前方呈半圓形繞過，左三角韌帶下層延續(xù)為小網(wǎng)膜左葉肝臟三處未被腹膜覆蓋的區(qū)域—肝裸區(qū)、膽囊床、肝門—是與膈腹膜、小網(wǎng)膜及韌帶連接處肝胃韌帶及肝十二指腸韌帶*addfooterhere(gotoviewmenuandchooseheader)*Ligamentsofliver

*addfooterhere(gotoviewmenuandchooseheader)*胃的韌帶肝胃韌帶－如前所述胃脾韌帶－聯(lián)系胃底和脾門的雙層腹膜，其內(nèi)包含胃短動(dòng)脈及胃網(wǎng)膜左動(dòng)脈胃膈韌帶－由胃底后面連至膈下的雙層腹膜結(jié)構(gòu)，兩層間相距較遠(yuǎn)，形成胃裸區(qū)胃結(jié)腸韌帶－如前所述胃胰韌帶－由胃幽門竇后壁至胰頭、頸及頸與體的移行部的腹膜皺襞*addfooterhere(gotoviewmenuandchooseheader)*Ligamentsofstomach

Hepatogastricligament肝胃韌帶Gastrosplenicligament胃脾韌帶Gastrophrenicligament胃膈韌帶Gastrocolicligament胃結(jié)腸韌帶Gastropancresticligament胃胰韌帶*addfooterhere(gotoviewmenuandchooseheader)*脾的韌帶胃脾韌帶－如前所述脾腎韌帶－是自脾門至左腎前面的雙層腹膜結(jié)構(gòu)，內(nèi)含胰尾及脾血管、淋巴結(jié)構(gòu)和神經(jīng)叢等。膈脾韌帶－由脾腎韌帶向上延伸至膈，此韌帶很短脾結(jié)腸韌帶－位于脾前端和結(jié)腸左曲之間，此韌帶也很短*addfooterhere(gotoviewmenuandchooseheader)*LigamentsofspleenGastrosplenicligament胃脾韌帶Splenorenalligament脾腎韌帶Phrenicosplenicligament膈脾韌帶Splenocolicligament

脾結(jié)腸韌帶*addfooterhere(gotoviewmenuandchooseheader)*皺襞胃胰襞和肝胰襞

胃胰襞是胃左動(dòng)脈從腹后壁走向胃小彎時(shí)形成的腹膜皺襞—分隔網(wǎng)膜囊中間部及側(cè)部

肝胰襞是肝總動(dòng)脈或肝固有動(dòng)脈從腹后壁向前進(jìn)入小網(wǎng)膜時(shí)所形成的腹膜皺襞十二指腸上、下襞*addfooterhere(gotoviewmenuandchooseheader)*FoldsandrecessesofposteriorabdominalwallSuperiorduodenalfoldandrecess十二指腸上襞和上隱窩Inferiorduodenalfoldandrecess十二指腸下襞和下隱窩Intersigmoidrecess

乙狀結(jié)腸間隱窩－formedbytheinvertedVattachmentofsigmoidmesocolon

*addfooterhere(gotoviewmenuandchooseheader)*Retrocecalrecess盲腸后隱窩－闌尾常位于其中Hepatorenalrecess肝腎隱窩－位于肝右后葉與右腎及結(jié)腸肝曲之間，是仰臥位腹腔最低點(diǎn)*addfooterhere(gotoviewmenuandchooseheader)*Pouches

Inmale－rectovesicalpouch直腸膀胱陷窩InfemaleRectouterinepouch

直腸子宮陷窩－betweenrectumanduterusVesicouterinepouch膀胱子宮陷窩－betweenbladderanduterus為腹盆腔積液和腫瘤種植轉(zhuǎn)移的好發(fā)部位*addfooterhere(gotoviewmenuandchooseheader)*結(jié)腸上區(qū)（膈下間隙）右膈下腹膜外間隙（肝裸區(qū)）左膈下腹膜外間隙（胃裸區(qū)）肝周間隙右肝上間隙左肝上后間隙左肝上間隙左肝上前間隙右肝下間隙肝下間隙肝上間隙左肝下間隙左肝下前間隙左肝下后間隙（網(wǎng)膜囊）肝臟左三角韌帶鐮狀韌帶肝圓韌帶胃及小網(wǎng)膜肝周間隙相互溝通，其中小網(wǎng)膜分隔右肝下間隙和網(wǎng)膜囊，網(wǎng)膜囊僅借網(wǎng)膜孔（theforamenofWinslow）與腹腔交通*addfooterhere(gotoviewmenuandchooseheader)*Perihepaticspaces*addfooterhere(gotoviewmenuandchooseheader)*Perihepaticspaces*addfooterhere(gotoviewmenuandchooseheader)*網(wǎng)膜囊借網(wǎng)膜孔與腹腔相通境界：前方為肝十二指腸韌帶，后方為覆蓋下腔靜脈的腹膜，上界為肝尾狀葉，下界為十二指腸上部網(wǎng)膜孔*addfooterhere(gotoviewmenuandchooseheader)*網(wǎng)膜囊位置：位于小網(wǎng)膜和胃的后方境界：前壁由上而下依次為小網(wǎng)膜、胃后壁腹膜和大網(wǎng)膜前兩層；下壁為大網(wǎng)膜前兩層與后兩層返折處；后壁由下而上依次為大網(wǎng)膜后兩層、橫結(jié)腸及其系膜、覆蓋胰、左腎、左腎上腺的腹膜；上壁為膈下面的腹膜，此處肝尾狀葉自右側(cè)套入網(wǎng)膜囊內(nèi)形成網(wǎng)膜囊上隱窩；左界為胃脾韌帶、脾和脾腎韌帶；右界為網(wǎng)膜孔*addfooterhere(gotoviewmenuandchooseheader)*四部分：網(wǎng)膜孔所對(duì)的前庭部；胃胰襞以上為上隱窩，位于小網(wǎng)膜與膈之間，內(nèi)有尾狀葉套入；沿胰體伸向左后上方達(dá)脾門部分為脾隱窩；下隱窩位于胃胰襞以下，在胃與胰及橫結(jié)腸系膜之間。*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)*肝裸區(qū)于第一肝門以上平面，可見此間隙位于冠狀韌帶上、下層之間。“肝右后上間隙”是不存在的，由于肝裸區(qū)存在，腹腔積液不能到達(dá)脊柱旁，可與胸腔積液區(qū)別。CompanyLogo*肝周積液與胸腔積液鑒別右肝上前間隙積液右側(cè)胸腔積液CompanyLogo*胃裸區(qū)

Bareareaofstomach是否侵犯胃裸區(qū)是胃癌預(yù)后的影響因素之一*addfooterhere(gotoviewmenuandchooseheader)**addfooterhere(gotoviewmenuandchooseheader)**addfooterhere(gotoviewmenuandchooseheader)*Infracoliccompartments結(jié)腸下區(qū)－位于橫結(jié)腸及橫結(jié)腸系膜以下

Rightparacolicsulcus(gutter)右結(jié)腸旁溝－位于升結(jié)腸旁，是聯(lián)系肝腎隱窩和盆腔的通路；感染可通過此途徑傳播，如膈下膿腫可經(jīng)此溝流入右髂窩和盆腔，闌尾化膿時(shí)也可向上蔓延至肝下Leftparacolicsulcus(gutter)左結(jié)腸旁溝－位于降結(jié)腸旁，上緣由左膈結(jié)腸韌帶（thephrenicocolicligament）與結(jié)腸上區(qū)分隔,因此左結(jié)腸旁溝積液只能向下流入盆腔*addfooterhere(gotoviewmenuandchooseheader)*Rightmesentericsinus

右腸系膜竇－為一三角形間隙，位于腸系膜根部、升結(jié)腸及右2/3橫結(jié)腸及其系膜之間，其下方有回腸末端阻隔，近乎封閉，當(dāng)此竇有炎癥時(shí)，不易擴(kuò)散，易形成腸間膿腫或局限性腹膜炎Leftmesentericsinus

左腸系膜竇－為向下開口的斜方形，位于腸系膜根部、降結(jié)腸、左1/3橫結(jié)腸及其腸系膜之間，左腸系膜竇可向下越過小骨盆口通入盆腔，因此此竇內(nèi)感染易蔓延入盆腔上下流通，左溝不暢，右竇封閉，左入盆腔。*addfooterhere(gotoviewmenuandchooseheader)*腹膜后隙

Retroperitonealspace定義：位于腹后壁壁腹膜與腹內(nèi)筋膜之間，上界為膈，下至骶骨岬，兩側(cè)向外延伸為腹前外側(cè)壁的腹膜外筋膜，該間隙感染可上經(jīng)腰肋三角可通到后縱隔，下與盆腔的腹膜后隙相續(xù)。組成：腎旁前間隙；腎周間隙；腎旁后間隙*addfooterhere(gotoviewmenuandchooseheader)*腎周間隙腎周間隙上方—右側(cè)通向肝裸區(qū)；左側(cè)通向左膈下腹膜外間隙腎周間隙下方—通向下腹部及盆腔腹膜外間隙（髂窩）雙側(cè)腎周間隙之間—腎門及腸系膜上動(dòng)脈平面以下腎前間隙相交通，以上不交通*addfooterhere(gotoviewmenuandchooseheader)*Retroperitonealspace*addfooterhere(gotoviewmenuandchooseheader)**addfooterhere(gotoviewmenuandchooseheader)*病例網(wǎng)膜囊病變腹膜病變非腫瘤性腹腔積液：漏出液、炎性滲出、血腫、膽漏、尿漏良性腫瘤惡性腫瘤*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