1、腹腔間隙影像解剖Anatomy of the Peritoneal Spaces,2020/7/28,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,7/28/2020,add footer here (go to view menu and choose header),3,網(wǎng) 膜,7/28/2020,add 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，

2、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)钕麓梗谏w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。,7/28/2020,add footer here (go to view menu and choose header),5,胃結(jié)腸韌帶,2020/7/28,add footer here (go to vi

3、ew menu and choose header),6,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(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,2020/7/28,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,2020/7/28,add footer here (go to view menu and choose head

4、er),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,2020/7/28,add footer here (go to view menu and choose header),9,Ligaments of liver,

5、2020/7/28,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(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,2020/7/28,add footer here (go to view menu and choose header),11,Ligaments of stomach,Hepatogastric ligament 肝胃韌帶

6、 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,2020/7/28,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,2020/7/28,add foot

7、er 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 Splenocolic ligament 脾結(jié)腸韌帶,2020/7/28,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(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

8、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,7/28/2020,add footer here (go to 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 乙狀結(jié)腸間隱窩formed by the inverted V attachment

9、 of sigmoid mesocolon,7/28/2020,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，是仰臥位腹腔最低點(diǎn),7/28/2020,add footer here (go to view menu and choose header),17,Pouches In malerectovesical pouch 直腸膀胱陷窩 In female Rectouterine pou

10、ch 直腸子宮陷窩between rectum and uterus Vesicouterine pouch 膀胱子宮陷窩between bladder and uterus,為腹盆腔積液和腫瘤種植轉(zhuǎn)移的好發(fā)部位,2020/7/28,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 Winslow）與腹腔交通,

11、2020/7/28,add footer here (go to view menu and choose header),19,Perihepatic spaces,2020/7/28,add footer here (go to view menu and choose header),20,Perihepatic spaces,2020/7/28,add footer here (go to view menu 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,2020/

12、7/28,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,2020/7/28,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

13、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。,2020/7/28,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 right hepatic lobe; 3 =medial segment

14、 of left inferior coronary ligament; 4 = peritoneum of ligamentum teres; 5 = gastrophrenic ligament; 6 = gastrosplenic ligament; 7 = splenorenal ligament; 8 = transverse mesocolon;,2020/7/28,add footer here (go to view menu and choose header),25,Lesser sac,CT scan shows fluid in the superior (*) and

15、 splenic (S) recesses of lesser sac outlining the gastropancreatic fold (arrowhead).,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(dá)脊柱旁，可與胸腔積液區(qū)別。,Company Logo,27,肝周積液與胸腔積液鑒別,2020/7/28,add footer here (go to view menu and choose header),28,胃裸區(qū)Bare area of stomach,是否侵犯胃裸

16、區(qū)是胃癌預(yù)后的影響因素之一,2020/7/28,add footer here (go to view menu and choose header),29,2020/7/28,add footer here (go to view menu and choose header),30,7/28/2020,add footer here (go to view menu and choose header),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

17、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 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,7/28/2020,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

18、，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 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。,2020/7/28,add footer here (go to view menu and choose header),33,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

19、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,2020/7/28,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,2020/7/28,add footer here (go to view menu and choose header),35,Retroperitoneal space,2020/7/28,a

20、dd footer here (go to view menu and choose header),36,2020/7/28,add 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,2020/7/28,add footer here (go to view menu and choose header),38,Fig. 5.-Delineation of lesser sac anatomy by ascites. A, Patient

21、 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 redundant and forms several ruffles (arrows). B, Patient with carcinoma of pancreatic tail. Malignant

22、ascitic fluid outlines gastrosplenic ligament (arrows). Short, rudimentary splenorenal ligament is identifled because it contains proximal part of splenic vein, opacified by contrast medium,2020/7/28,add footer here (go to view menu and choose header),39,A，lambdashaped fluid collection (arrows) adja

23、cent to caudate lobe B, Abscess (arrow) from pancreatitis contains numerous gas bubbles,2020/7/28,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 interposed between contrast-filled stomach

24、,gastrosplenic ligament (arrow), and spleen,2020/7/28,add footer here (go to view menu and choose header),41,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 spl

25、een. No evidence of fluid within greater peritoneal cavity. Fig. 8.-Spontaneous fistula (arrow) 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 resolut

26、ion of pseudocyst.,2020/7/28,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 stomach, which it displaces medially. spleen. and gastrospleni

27、c ligament (arrow).B, Several centimeters lower at level of pancreas.Tumor (T) arises from pancreas, immediately vantral to opacified splenic vein.,2020/7/28,add footer here (go to view menu and choose header),43,Sarcoidosis,It shows irregularly enhancing omental soft tissue (arrows) secondary to sa

28、rcoidosis.,2020/7/28,add footer here (go to view menu and choose header),44,Hemoperitoneum,55-year-old woman with intraperitoneal subacute hematoma. A and B show subacute blood,best seen in perihepatic space (arrows).,2020/7/28,add footer here (go to view menu and choose header),45,Hemoperitoneum,48

29、-year-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.,2020/7/28,add footer here (go to view menu and choose header),46,Bil

30、e leak,T1-weighted images 1 hr after IV administration of mangafodipir trisodium show hyperintense perihepatic fluid denoting bile leak.,2020/7/28,add footer here (go to view menu and choose header),47,Peritoneal NeoplasmsBenign Tumors,These lesions include lipomas, neurofibromas, and other mesenchy

31、mal tumors.,39-year-old woman with neurofibromatosis type 1,2020/7/28,add footer here (go to view menu and choose header),48,Mesenteric cyst,2020/7/28,add footer here (go to view menu and choose header),49,Malignant TumorsPeritoneal metastases,Peritoneal carcinomatosis is typically manifested by enh

32、ancing peritoneal nodules or a rind of enhancing perihepatic soft tissue.,44-year-old woman with metastases from ovarian cancer,2020/7/28,add footer here (go to view menu and choose header),50,Malignant TumorsPeritoneal metastases,2020/7/28,add footer here (go to view menu and choose header),51,Peri

33、toneal pseudomyxoma,2020/7/28,add footer here (go to view menu and choose header),52,Malignant Tumors,CT scan shows gastric carcinoma invading the gastrocolic ligament .,2020/7/28,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 mesentery in a patient with carcinomatosis. CT scan shows masses in the small bowel mesentery (M) and right paracohic gutter (*