1、腹腔間隙影像解剖Anatomy of the Peritoneal Spaces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Lessor omentumGreater omentum網(wǎng) 膜大網(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)

2、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。胃結(jié)腸韌帶小網(wǎng)膜（Lesser omentum） 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)膜孔系膜腸系膜闌尾系膜橫結(jié)腸系膜乙狀結(jié)腸系膜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

3、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Ligaments of liver 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)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Ligaments of stoma

4、ch Hepatogastric ligament 肝胃韌帶Gastrosplenic ligament 胃脾韌帶Gastrophrenic ligament 胃膈韌帶Gastrocolic ligament 胃結(jié)腸韌帶Gastropancrestic ligament 胃胰韌帶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Ligaments of spleenGastrosplenic ligament 胃脾韌帶Splenorenal ligam

5、ent 脾腎韌帶Phrenicosplenic ligament 膈脾韌帶Splenocolic ligament 脾結(jié)腸韌帶皺 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Folds and recesses of posterior abdominal wallSuperior 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

6、recess 乙狀結(jié)腸間隱窩formed by the inverted V attachment of sigmoid mesocolon 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，是仰臥位腹腔最低點Pouches In malerectovesical 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 bladder and ute

7、rus 為腹盆腔積液和腫瘤種植轉(zhuǎn)移的好發(fā)部位結(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（the foramen of Winslow）與腹腔交通Perihepatic spacesPerihepatic spaces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)膜孔網(wǎng)膜囊

8、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；下隱窩位于胃胰襞以下，在胃與胰及橫結(jié)腸系膜之間。1 = peritoneal reflection of cava forming roof of foramen of W

9、inslow; 2= peritoneal reflection of cava adjacent to bare area of right 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; Lesser sacCT sca

10、n shows fluid in the superior (*) and splenic (S) recesses of lesser sac outlining the gastropancreatic fold (arrowhead).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。肝周積液與胸腔積液鑒別右肝上前間隙積液右側(cè)胸腔積液胃裸區(qū)Bare area of stomach是否侵犯胃裸區(qū)是胃癌預(yù)后的影響因素之一Infracolic partments 結(jié)腸下區(qū) 位于橫結(jié)腸及橫結(jié)腸系膜以

11、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 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

12、散，易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。腹膜后隙Retroperitoneal 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

13、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Retroperitoneal space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 see

14、n to contain fat and opacified blood vessels.In this patient, ligament is redundant 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 con

15、tains proximal part of splenic vein, opacified by contrast mediumA，lambdashaped fluid collection (arrows) adjacent to caudate lobeB, Abscess (arrow) from pancreatitis contains numerous gas bubblesFig. 4.-Medial displacement of stomach by pseudocyst in lateral partment of lesser sac. Pseudocyst is in

16、terposed between contrast-filled stomach,gastrosplenic ligament (arrow), and spleen Fig. 7.-Perforation of posterior-wall gastric ulcer into lateral partment of lesser peritoneal sac. Lesser sac fluid collection (arrow) interposed between stomach, pancreatic tail, and spleen. No evidence of fluid wi

17、thin greater peritoneal cavity.Fig. 8.-Spontaneous fistula (arrow) between jejunal loop and pancreatic pseudocyst located within lateral partment of lesser peritoneal sac. Gas = fluid level within pseudocyst. Followup study 4 weeks later showed nearly plete resolution of pseudocyst.Fig. 9.-Pancreati

18、c cavernous lymph hemangioma that occupies lateral partment 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, imm

19、ediately vantral to opacified splenic vein. SarcoidosisIt shows irregularly enhancing omental soft tissue (arrows) secondary to sarcoidosis.Hemoperitoneum55-year-old woman with intraperitoneal subacute hematoma. A and B show subacute blood,best seen in perihepatic space (arrows). Hemoperitoneum48-ye

20、ar-old man with infected intraperitoneal hematoma. 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 leakT1-weighted images 1 hr after IV administration of mangafodipir

21、 trisodium show hyperintense perihepatic fluid denoting bile leak.Peritoneal NeoplasmsBenign Tumors These lesions include lipomas, neurofibromas, and other mesenchymal tumors.39-year-old woman with neurofibromatosis type 1Mesenteric cystMalignant TumorsPeritoneal metastasesPeritoneal carcinomatosis

22、is typically manifested by enhancing peritoneal nodules or a rind of enhancing perihepatic soft tissue.44-year-old woman with metastases from ovarian cancerMalignant TumorsPeritoneal metastasesPeritoneal pseudomyxomaMalignant TumorsCT scan shows gastric carcinoma invading the gastrocolic ligament .Malignant TumorsA，Small bowel mesentery 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 rightparacohic gutter (*).Malignant TumorsPeritoneal mesothelioma58-year-old man with mesothelioma.