腹腔間隙影像解剖

1、腹腔間隙影像解剖Anatomy of the Peritoneal Spaces,2024/3/30,add footer here (go to view menu and choose header),2,主要內(nèi)容,一、腹膜,,皺襞,二、隱窩和陷凹,四、腹膜后間隙,3/30/2024,add footer here (go to view menu and choose header),3,,網(wǎng) 膜,3/30/2024,ad

2、d footer here (go to view menu and choose header),4,大網(wǎng)膜（Greater omentum）,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，呈圍裙狀下垂，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)腸韌帶當腹腔發(fā)生感染時，炎性分泌物能刺激大網(wǎng)膜粘連包繞感染器官，限

3、制炎癥蔓延，局限感染范圍，避免彌漫性腹膜炎；手術(shù)有時也將大網(wǎng)膜覆蓋在肝的斷面、胃穿孔縫合處、十二指腸斷端，以促進其愈合。,3/30/2024,add footer here (go to view menu and choose header),5,胃結(jié)腸韌帶,2024/3/30,add footer here (go to view menu and choose header),6,小網(wǎng)膜（Lesser omentum）,分為左、右

4、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)有進入肝門的三個重要結(jié)構(gòu)，膽總管、肝固有動脈、門靜脈）小網(wǎng)膜右側(cè)游離，其后方為網(wǎng)膜孔,,2024/3/30,add footer here (go to view menu and choose header),7,系膜,腸系膜闌尾系膜橫結(jié)腸系膜乙狀結(jié)腸系膜,,2024/3/30,add footer here (go

5、to view menu and choose header),8,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

6、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,2024/3/30,add footer here (go to view menu and choose header),9,Ligaments of liver,,2024/3/30,add footer here (go to view menu and choose header),10,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)包含胃短動脈及胃網(wǎng)

7、膜左動脈胃膈韌帶－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，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,2024/3/30,add footer here (go to view menu and choose header),11,Ligaments of stomach,Hepatogastric ligament 肝胃韌帶Gastrosplenic ligament

8、 胃脾韌帶Gastrophrenic ligament 胃膈韌帶Gastrocolic ligament 胃結(jié)腸韌帶Gastropancrestic ligament 胃胰韌帶,,2024/3/30,add footer here (go to view menu and choose header),12,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－

9、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,2024/3/30,add footer here (go to view menu and choose header),13,Ligaments of spleen,Gastrosplenic ligament 胃脾韌帶Splenorenal ligament 脾腎韌帶Phrenicosplenic ligament 膈脾韌帶Spleno

10、colic ligament 脾結(jié)腸韌帶,,2024/3/30,add footer here (go to view menu and choose header),14,皺 襞,胃胰襞和肝胰襞 胃胰襞是胃左動脈從腹后壁走向胃小彎時形成的腹膜皺襞—分隔網(wǎng)膜囊中間部及側(cè)部 肝胰襞是肝總動脈或肝固有動脈從腹后壁向前進入小網(wǎng)膜時所形成的腹膜皺襞十二指腸上、下襞,,3/30/2024,add footer here (go to

11、 view menu and choose header),15,Folds and recesses of posterior abdominal wall,Superior duodenal fold and recess 十二指腸上襞和上隱窩Inferior duodenal fold and recess 十二指腸下襞和下隱窩Intersigmoid recess

12、 乙狀結(jié)腸間隱窩－formed by the inverted V attachment of sigmoid mesocolon,3/30/2024,add footer here (go to view menu and choose header),16,,Retrocecal recess 盲腸后隱窩－闌尾常位于其中Hepatorenal recess 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

13、腔最低點,3/30/2024,add footer here (go to view menu and choose header),17,,Pouches In male－rectovesical pouch 直腸膀胱陷窩In female Rectouterine pouch 直腸子宮陷窩－between rectum and uterus Vesicouterine pouch 膀胱子宮陷窩－between b

14、ladder and uterus,,為腹盆腔積液和腫瘤種植轉(zhuǎn)移的好發(fā)部位,2024/3/30,add footer here (go to view menu and choose header),18,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（the foramen of Win

15、slow）與腹腔交通,2024/3/30,add footer here (go to view menu and choose header),19,Perihepatic spaces,2024/3/30,add footer here (go to view menu and choose header),20,Perihepatic spaces,,2024/3/30,add footer here (go to view me

16、nu and choose header),21,,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,2024/3/30,add footer here (go to view menu and choose header),22,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

17、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,2024/3/30,add footer here (go to view menu and choose header),23,四部分：網(wǎng)膜孔所對的前庭部；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脾門部分為脾隱窩；下隱

18、窩位于胃胰襞以下，在胃與胰及橫結(jié)腸系膜之間。,2024/3/30,add footer here (go to view menu and choose header),24,1 = peritoneal reflection of cava forming roof of foramen of Winslow; 2= peritoneal reflection of cava adjacent to bare area of righ

19、t hepatic lobe; 3 =medial segment of left inferior coronary ligament; 4 = peritoneum of ligamentum teres; 5 = gastrophrenic ligament; 6 = gastrosplenic ligament; 7 = splenorenal ligament; 8 = transverse mesocolon;,2024/3

20、/30,add footer here (go to view menu and choose header),25,Lesser sac,,CT scan shows fluid in the superior (*) and splenic (S) recesses of lesser sac outlining the gastropancreatic fold (arrowhead).,www.themegallery.com,

21、Company Logo,26,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?！案斡液笊祥g隙”是不存在的，由于肝裸區(qū)存在，腹腔積液不能到達脊柱旁，可與胸腔積液區(qū)別。,www.themegallery.com,Company Logo,27,肝周積液與胸腔積液鑒別,,2024/3/30,add footer here (go to view menu and choose header),28,胃裸區(qū)Bare area

22、 of stomach,是否侵犯胃裸區(qū)是胃癌預(yù)后的影響因素之一,,2024/3/30,add footer here (go to view menu and choose header),29,2024/3/30,add footer here (go to view menu and choose header),30,,3/30/2024,add footer here (go to view menu and choose he

23、ader),31,,Infracolic compartments 結(jié)腸下區(qū) －位于橫結(jié)腸及橫結(jié)腸系膜以下 Right paracolic sulcus (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，闌尾化膿時也可向上蔓延至肝下Left paracolic sulcus (gutter) 左結(jié)腸旁溝－位于降結(jié)腸旁，上緣由左膈結(jié)腸韌帶（the

24、 phrenicocolic ligament）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,3/30/2024,add footer here (go to view menu and choose header),32,,Right mesenteric sinus 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，當此竇有炎癥時，不易擴散，易

25、形成腸間膿腫或局限性腹膜炎Left mesenteric sinus 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。,,2024/3/30,add footer here (go to view menu and choose header),33,腹膜后隙Retro

26、peritoneal space,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,2024/3/30,add footer here (go to view menu and choose header),34,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

27、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—腎門及腸系膜上動脈平面以下腎前間隙相交通，以上不交通,2024/3/30,add footer here (go to view menu and choose header),35,Retroperitoneal space,2024/3/30,add footer here (go to view menu and choose header),36,2024/3/30,a

28、dd footer here (go to view menu and choose header),37,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,,2024/3/30,add footer here (go to view menu and choose header),38,,Fig. 5.-Delineation of lesser sac anatomy by a

29、scites. 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 redu

30、ndant 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 c

31、ontains proximal part of splenic vein, opacified by contrast medium,2024/3/30,add footer here (go to view menu and choose header),39,A，lambdashaped fluid collection (arrows) adjacent to caudate lobeB, Abscess (arrow) fr

32、om pancreatitis contains numerous gas bubbles,2024/3/30,add footer here (go to view menu and choose header),40,Fig. 4.-Medial displacement of stomach by pseudocyst in lateral compartment of lesser sac. Pseudocyst is inte

33、rposed between contrast-filled stomach,gastrosplenic ligament (arrow), and spleen,2024/3/30,add footer here (go to view menu and choose header),41,,Fig. 7.-Perforation of posterior-wall gastric ulcer into lateral compart

34、ment 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) betwe

35、en 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.,20

36、24/3/30,add footer here (go to view menu and choose header),42,Fig. 9.-Pancreatic cavernous lymph hemangioma that occupies lateral compartment of lesser peritoneal sac. A, Tumor (T) interposed between contrast-filled sto

37、mach, 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.,,2024/3/30,ad

38、d footer here (go to view menu and choose header),43,Sarcoidosis,It shows irregularly enhancing omental soft tissue (arrows) secondary to sarcoidosis.,2024/3/30,add footer here (go to view menu and choose header),44,Hemo

39、peritoneum,55-year-old woman with intraperitoneal subacute hematoma. A and B show subacute blood,best seen in perihepatic space (arrows).,2024/3/30,add footer here (go to view menu and choose header),45,Hemoperitoneum,48

40、-year-old man with infected intraperitoneal hematoma. A–C, T2-weighted image (A) and T1-weighted images (B) and (C) contrasted image show linear smooth peritoneal enhancement, with presence of intraperitoneal blood-int

41、ensity signal.,2024/3/30,add footer here (go to view menu and choose header),46,Bile leak,T1-weighted images 1 hr after IV administration of mangafodipir trisodium show hyperintense perihepatic fluid denoting bile leak.,

42、2024/3/30,add footer here (go to view menu and choose header),47,Peritoneal NeoplasmsBenign Tumors,These lesions include lipomas, neurofibromas, and other mesenchymal tumors.,39-year-old woman with neurofibromatosis typ

43、e 1,2024/3/30,add footer here (go to view menu and choose header),48,Mesenteric cyst,2024/3/30,add footer here (go to view menu and choose header),49,Malignant TumorsPeritoneal metastases,Peritoneal carcinomatosis is ty

44、pically manifested by enhancing peritoneal nodules or a rind of enhancing perihepatic soft tissue.,44-year-old woman with metastases from ovarian cancer,2024/3/30,add footer here (go to view menu and choose header),50,Ma

45、lignant TumorsPeritoneal metastases,2024/3/30,add footer here (go to view menu and choose header),51,Peritoneal pseudomyxoma,2024/3/30,add footer here (go to view menu and choose header),52,Malignant Tumors,CT scan show

46、s gastric carcinoma invading the gastrocolic ligament .,2024/3/30,add footer here (go to view menu and choose header),53,Malignant Tumors,A，Small bowel mesentery in a patient with non-Hodgkin lymphoma. B，Small bowel mes

47、entery in a patient with carcinomatosis. CT scan shows masses in the small bowel mesentery (M) and rightparacohic gutter (*).,2024/3/30,add footer here (go to view menu and choose header),54,Malignant TumorsPeritoneal

48、mesothelioma,58-year-old man with mesothelioma.A–B, GRE out-of-phase image (A) and enhanced T1-weighted image (B ) show enhancing large mass (arrows, A and B), representing mesothelioma,which is entangling bowel loops.,

49、2024/3/30,add footer here (go to view menu and choose header),55,Malignant TumorsMesenteric carcinoid,Mesenteric carcinoid tumors are usually seen as nodular masses associated with mesenteric stranding.,Enhancing mass (

50、arrows) is seen on portal venous phase images, with involvement of draining veins,2024/3/30,add footer here (go to view menu and choose header),56,要 點,炎癥或腫瘤性病變可通過橫結(jié)腸系膜到達結(jié)腸，如胰腺病變易通過橫結(jié)腸系膜累及橫結(jié)腸下面，而胃部疾病則易累及橫結(jié)腸上面。胃部腫瘤易沿著肝胃韌

51、帶侵犯，因此常?？梢栽诟挝疙g帶的脂肪組織中看到結(jié)節(jié)狀的轉(zhuǎn)移病灶；胃惡性腫瘤也可沿該韌帶侵犯肝臟，如侵犯 Glisson’s 系統(tǒng)。肝十二指腸韌帶為肝胃韌帶的游離邊，膽胰疾病可沿此途徑蔓延。胰尾、脾和胃部疾病可沿胃脾韌帶蔓延。,2024/3/30,add footer here (go to view menu and choose header),57,最常見的腹膜腫瘤為繼發(fā)于卵巢、結(jié)腸、胃及胰腺的轉(zhuǎn)移性腫瘤。其影像特征包括：(1)