腹腔間隙影像解剖課件

1、1腹腔間隙影像解剖anatomy of the peritoneal spaces主要內(nèi)容主要內(nèi)容一、腹膜一、腹膜網(wǎng)膜網(wǎng)膜大網(wǎng)膜大網(wǎng)膜小網(wǎng)膜小網(wǎng)膜系膜系膜腸系膜腸系膜乙狀結腸系膜乙狀結腸系膜橫結腸系膜橫結腸系膜闌尾系膜闌尾系膜肝的韌帶肝的韌帶韌帶韌帶胃的韌帶胃的韌帶脾的韌帶脾的韌帶皺襞皺襞二、隱窩和陷凹二、隱窩和陷凹胃胰襞、肝胰襞胃胰襞、肝胰襞十二指腸上、下襞十二指腸上、下襞三、三、腹膜腔腹膜腔結腸上區(qū)結腸上區(qū)結腸下區(qū)結腸下區(qū)四、腹膜后間隙四、腹膜后間隙lessor omentumgreater omentum網(wǎng) 膜大網(wǎng)膜（greater omentum） l連接于胃大彎及橫結腸之間，由四層腹

2、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，遮蓋橫結腸、空回腸前面，而后返折向上附著于橫結腸前后壁漿膜層，成人前兩層與后兩層通常愈著，形成連接胃大彎及橫結腸的胃結腸韌帶胃結腸韌帶l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。胃結腸韌帶胃結腸韌帶小網(wǎng)膜小網(wǎng)膜（lesser omentum） l分為左、右兩部分，左側部從膈、肝靜脈韌帶裂連于胃小彎，成為肝肝胃韌帶胃韌帶；右側部從肝門連于十二指腸上部，成為肝十二指腸韌帶肝十二指腸韌帶（內(nèi)

3、有進入肝門的三個重要結構，膽總管、肝固有動脈、門靜脈）l小網(wǎng)膜右側游離，其后方為網(wǎng)膜孔網(wǎng)膜孔系膜系膜 腸系膜腸系膜 闌尾系膜闌尾系膜 橫結腸系膜橫結腸系膜 乙狀結腸系乙狀結腸系膜膜肝的韌帶肝的韌帶 鐮狀韌帶鐮狀韌帶是雙層腹膜結構，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分開包繞肝裸區(qū)，其左層向左延續(xù)為左冠狀韌帶上層左冠狀韌帶上層，并繼續(xù)延續(xù)為左三角韌帶左三角韌帶，其右層延續(xù)為右冠狀韌帶上層右冠狀韌帶上層，并繼續(xù)向右下延續(xù)為右三角韌帶右三角韌帶，右三角韌右三角韌帶下層帶下層越過下腔靜脈形成小網(wǎng)膜右小網(wǎng)膜右葉葉，然后在尾狀葉前方呈半圓形繞過，左三角韌帶下層左三角韌帶下層延續(xù)為小網(wǎng)膜小網(wǎng)膜

4、左葉左葉 肝臟三處未被腹膜覆蓋的區(qū)域肝肝裸區(qū)裸區(qū)、膽囊床、肝門膽囊床、肝門是與膈腹膜、小網(wǎng)膜及韌帶連接處 肝胃韌帶肝胃韌帶及肝十二指腸韌帶肝十二指腸韌帶ligaments of liver 胃的韌帶胃的韌帶 肝胃韌帶肝胃韌帶如前所述如前所述 胃脾韌帶胃脾韌帶聯(lián)系胃底和脾門的雙聯(lián)系胃底和脾門的雙層腹膜，其內(nèi)包含胃短動脈及胃層腹膜，其內(nèi)包含胃短動脈及胃網(wǎng)膜左動脈網(wǎng)膜左動脈 胃膈韌帶胃膈韌帶由胃底后面連至膈下由胃底后面連至膈下的雙層腹膜結構，兩層間相距較的雙層腹膜結構，兩層間相距較遠，形成遠，形成胃裸區(qū)胃裸區(qū) 胃結腸韌帶胃結腸韌帶如前所述如前所述 胃胰韌帶胃胰韌帶由胃幽門竇后壁至胰由胃幽門竇后壁至胰

5、頭、頸及頸與體的移行部的腹膜頭、頸及頸與體的移行部的腹膜皺襞皺襞ligaments of stomach hepatogastric ligament 肝胃韌帶肝胃韌帶gastrosplenic ligament 胃脾韌帶胃脾韌帶gastrophrenic ligament 胃膈韌帶胃膈韌帶gastrocolic ligament 胃結腸韌帶胃結腸韌帶gastropancrestic ligament 胃胰韌帶胃胰韌帶脾的韌帶脾的韌帶 胃脾韌帶胃脾韌帶如前所述如前所述 脾腎韌帶脾腎韌帶是自脾門至左腎前面是自脾門至左腎前面的雙層腹膜結構，內(nèi)含胰尾及脾的雙層腹膜結構，內(nèi)含胰尾及脾血管、淋巴結構和神

6、經(jīng)叢等。血管、淋巴結構和神經(jīng)叢等。 膈脾韌帶膈脾韌帶由脾腎韌帶向上延伸由脾腎韌帶向上延伸至膈，此韌帶很短至膈，此韌帶很短 脾結腸韌帶脾結腸韌帶位于脾前端和結腸位于脾前端和結腸左曲之間，此韌帶也很短左曲之間，此韌帶也很短ligaments of spleen gastrosplenic ligament 胃脾韌帶胃脾韌帶 splenorenal ligament 脾腎韌帶脾腎韌帶 phrenicosplenic ligament 膈脾韌帶膈脾韌帶 splenocolic ligament 脾結腸韌帶脾結腸韌帶皺 襞 胃胰襞和肝胰襞胃胰襞和肝胰襞 胃胰襞胃胰襞是胃左動脈從腹后壁走向胃小彎時形成的腹

7、膜皺襞分隔網(wǎng)膜囊中間部及側部 肝胰襞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、下襞十二指腸上、下襞folds and recesses of posterior abdominal wallnsuperior duodenal fold and recess 十二指腸上襞和上隱窩十二指腸上襞和上隱窩ninferior duodenal fold and recess 十二指腸下襞和下隱窩十二指腸下襞和下隱窩nintersigmoid recessintersigmoid recess 乙狀結腸間隱窩乙狀結腸間隱窩formed by the inverte

8、d v attachment of sigmoid mesocolon nretrocecal recess 盲腸后隱窩盲腸后隱窩闌尾常位于其中nhepatorenal recess 肝腎隱窩肝腎隱窩位于肝右后葉與右腎及結腸肝曲之間，是仰臥位腹腔最低點pouches nin malerectovesical pouch 直腸膀胱陷窩直腸膀胱陷窩nin female qrectouterine pouch 直腸子宮陷窩直腸子宮陷窩between rectum and uterus qvesicouterine pouch 膀胱子宮陷窩膀胱子宮陷窩between bladder and uteru

9、s 為腹盆腔積液和為腹盆腔積液和腫瘤種植轉移的腫瘤種植轉移的好發(fā)部位好發(fā)部位結腸上區(qū)（膈下間隙）結腸上區(qū)（膈下間隙）右膈下腹膜外間隙（肝裸區(qū)）右膈下腹膜外間隙（肝裸區(qū)）左膈下腹膜外間隙（胃裸區(qū)）左膈下腹膜外間隙（胃裸區(qū)）肝周間隙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)膜囊網(wǎng)膜囊）肝臟肝臟左三角韌帶左三角韌帶鐮狀韌帶鐮狀韌帶肝圓韌帶肝圓韌帶胃及小網(wǎng)膜胃及小網(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)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（膜囊，網(wǎng)膜囊僅借網(wǎng)膜孔（the foramen

10、of winslowthe foramen of winslow）與腹腔交通與腹腔交通perihepatic spacesperihepatic spacesperihepatic spacesperihepatic spaces網(wǎng)膜囊借網(wǎng)膜網(wǎng)膜囊借網(wǎng)膜孔與腹腔相通孔與腹腔相通 境界：前方為肝十二指腸韌肝十二指腸韌帶帶，后方為覆蓋下腔靜脈下腔靜脈的腹膜，上界為肝尾狀葉肝尾狀葉，下界為十二指腸上部十二指腸上部網(wǎng)膜孔網(wǎng)膜孔網(wǎng)膜囊網(wǎng)膜囊 位置：位置：位于小網(wǎng)膜和胃的后方 境界：境界：前壁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；下壁下壁為大網(wǎng)膜前兩層與后兩層返折處；后壁后壁由下而上依次為大

11、網(wǎng)膜后兩層、橫結腸及其系膜、覆蓋胰、左腎、左腎上腺的腹膜；上壁上壁為膈下面的腹膜，此處肝尾狀葉自右側套入網(wǎng)膜囊內(nèi)形成網(wǎng)膜囊上隱窩；左界左界為胃脾韌帶、脾和脾腎韌帶；右界右界為網(wǎng)膜孔四部分：四部分：網(wǎng)膜孔所對的前庭部前庭部；胃胰襞以上為上隱窩上隱窩，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脾隱窩；下隱窩下隱窩位于胃胰襞以下，在胃與胰及橫結腸系膜之間。1 = peritoneal reflection of cava forming roof of foramen of winslow; 2= peritoneal reflection of cava adjace

12、nt 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 saclesser sacct scan shows fluid in the superior (*) and

13、 splenic (s s) recesses of lesser sac outlining the gastropancreatic fold (arrowhead).肝裸區(qū)肝裸區(qū)v 于第一肝門以上平面，可見此間隙位于冠狀韌帶上、下層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。之間。“肝右后上間隙肝右后上間隙”是不存在的，由于肝裸區(qū)存在，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。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肝周積液與胸腔積液鑒別右肝上前間隙積液右肝上前間隙積液右側胸腔積液右側胸腔積液胃裸區(qū)胃裸區(qū)bare area

14、of stomachbare area of stomach 是否侵犯胃裸區(qū)是胃癌預后的影響因素之一infracolic compartments 結結腸下區(qū)腸下區(qū) 位于橫結腸及橫結腸系膜以下 nright paracolic sulcus (gutter) 右結腸旁溝右結腸旁溝位于升結腸旁，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nleft paracolic sulcus (gutter) 左結腸旁溝左結腸旁溝位于降結腸旁，上緣由左膈結腸韌帶（the phrenicocolic ligament）與結腸上區(qū)分隔, 因

15、此左結腸旁溝積液只能向下流入盆腔nright mesenteric sinus 右右腸系膜竇腸系膜竇為一三角形間隙，位于為一三角形間隙，位于腸系膜根部、升結腸及右腸系膜根部、升結腸及右 2/3 2/3 橫橫結腸及其系膜之間，其下方有回腸結腸及其系膜之間，其下方有回腸末端阻隔，近乎封閉，當此竇有炎末端阻隔，近乎封閉，當此竇有炎癥時，不易擴散，易形成腸間膿腫癥時，不易擴散，易形成腸間膿腫或局限性腹膜炎或局限性腹膜炎nleft mesenteric sinus 左左腸系膜竇腸系膜竇為向下開口的斜方形，為向下開口的斜方形，位于腸系膜根部、降結腸、左位于腸系膜根部、降結腸、左 1/3 1/3 橫結腸及其

16、腸系膜之間，左腸系膜橫結腸及其腸系膜之間，左腸系膜竇可向下越過小骨盆口通入盆腔，竇可向下越過小骨盆口通入盆腔，因此此竇內(nèi)感染易蔓延入盆腔因此此竇內(nèi)感染易蔓延入盆腔n上下流通，左溝不暢，右竇封閉，上下流通，左溝不暢，右竇封閉，左入盆腔。左入盆腔。腹膜后隙腹膜后隙retroperitoneal spaceretroperitoneal space 定義：位于腹后壁壁腹膜與定義：位于腹后壁壁腹膜與腹內(nèi)筋膜之間，上界為腹內(nèi)筋膜之間，上界為膈膈，下至下至骶骨岬骶骨岬，兩側向外延伸，兩側向外延伸為腹前外側壁的腹膜外筋膜，為腹前外側壁的腹膜外筋膜，該間隙感染可上經(jīng)腰肋三角該間隙感染可上經(jīng)腰肋三角可通到后縱隔

17、，下與盆腔的可通到后縱隔，下與盆腔的腹膜后隙相續(xù)。腹膜后隙相續(xù)。 組成：腎旁前間隙；腎周間組成：腎旁前間隙；腎周間隙；腎旁后間隙隙；腎旁后間隙腎周間隙腎周間隙 腎周間隙上方腎周間隙上方右側通向肝裸區(qū)；左側通向左膈下腹膜外間隙 腎周間隙下方腎周間隙下方通向下腹部及盆腔腹膜外間隙（髂窩） 雙側腎周間隙之間雙側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 spaceretroperitoneal space病病 例例 網(wǎng)膜囊病變網(wǎng)膜囊病變 腹膜病變腹膜病變 非腫瘤性腹腔積液：漏出液、炎非腫瘤性腹腔積液：漏出液、炎性滲出、血腫、膽漏、尿漏性滲出、血腫、

18、膽漏、尿漏 良性腫瘤良性腫瘤a.a.惡性腫瘤惡性腫瘤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 seen to contain fat and opacified blood vessels.in this patient, ligament is redundant an

19、d 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 mediuma，lambdashaped fluid

20、collection (arrows) adjacent to caudate lobeb, abscess (arrow) from pancreatitis contains numerous gas bubblesfig. 4.-medial displacement of stomach by pseudocyst in lateral compartment of lesser sac. pseudocyst is interposed between contrast-filled stomach,gastrosplenic ligament (arrow), and spleen

21、 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) between jejun

22、al 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 compartment of lesser p

23、eritoneal 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. s sarcoidosisit shows irreg

24、ularly 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-year-old man with infected intraperitoneal hematoma. ac, t2-weighted im

25、age (a) and t1-weighted images (b) and (c) contrasteded image show linear smooth peritoneal enhancement, with presence of intraperitoneal blood-intensity signal.b bile leakt1-weighted images 1 hr after iv administration of mangafodipir trisodium show hyperintense perihepatic fluid denoting bile leak

26、. .peritoneal neoplasmsbenign tumors these lesions include lipomas, neurofibromas, and other mesenchymal tumors.39-year-old woman with neurofibromatosis type 1m mesenteric cystmalignant tumorsperitoneal metastasesperitoneal carcinomatosis is typically manifested by enhancing peritoneal nodules or a

27、rind of enhancing perihepatic soft tissue.44-year-old woman with metastases from ovarian cancermalignant tumorsperitoneal metastasesp peritoneal pseudomyxomamalignant tumorsct scan shows gastric carcinoma invading the gastrocolic ligament . .malignant tumorsa a，small bowel mesentery in a patient wit

28、h non-hodgkin lymphoma. b b，small bowel mesentery in a patient with carcinomatosis. ct scan shows masses in the small bowel mesentery (m) and rightparacohic gutter (*).malignant tumorsperitoneal m mesothelioma58-year-old man with mesothelioma.ab b, grere 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.malignant tumorsmesenter