腹腔间隙影像解剖培训课件

主要内容主要内容一、腹膜一、腹膜网膜网膜大网膜大网膜小网膜小网膜系膜系膜肠系膜肠系膜乙状结肠系膜乙状结肠系膜横结肠系膜横结肠系膜阑尾系膜阑尾系膜肝的韧带肝的韧带韧带韧带胃的韧带胃的韧带脾的韧带脾的韧带皱襞皱襞二、二、隐窝和陷凹隐窝和陷凹胃胰襞、肝胰襞胃胰襞、肝胰襞十二指肠上、下襞十二指肠上、下襞三、三、腹膜腔腹膜腔结肠上区结肠上区结肠下区结肠下区四、四、腹膜后间隙腹膜后间隙7/19/20241腹腔间隙影像解剖LessoromentumGreateromentum网 膜7/19/20242腹腔间隙影像解剖大网膜（Greater omentum）l连接于胃大弯及横结肠之间，由四层腹膜返折而成，前两层由胃大弯及十二指肠上段前后壁浆膜延续而成，呈围裙状下垂，遮盖横结肠、空回肠前面，而后返折向上附着于横结肠前后壁浆膜层，成人前两层与后两层通常愈着，形成连接胃大弯及横结肠的胃结肠韧带胃结肠韧带l当腹腔发生感染时，炎性分泌物能刺激大网膜粘连包绕感染器官，限制炎症蔓延，局限感染范围，避免弥漫性腹膜炎；手术有时也将大网膜覆盖在肝的断面、胃穿孔缝合处、十二指肠断端，以促进其愈合。7/19/20243腹腔间隙影像解剖胃结肠韧带胃结肠韧带7/19/20244腹腔间隙影像解剖小网膜小网膜（Lesser omentum）l分为左、右两部分，左侧部从膈、肝静脉韧带裂连于胃小弯，成为肝肝胃韧带胃韧带；右侧部从肝门连于十二指肠上部，成为肝十二指肠韧带肝十二指肠韧带（内有进入肝门的三个重要结构，胆总管、肝固有动脉、门静脉）l小网膜右侧游离，其后方为网膜孔网膜孔7/19/20245腹腔间隙影像解剖系膜系膜肠系膜肠系膜阑尾系膜阑尾系膜横结肠系膜横结肠系膜乙状结肠系膜乙状结肠系膜7/19/20246腹腔间隙影像解剖肝的韧带肝的韧带镰状韧带镰状韧带是双层腹膜结构，联系肝脏与前腹壁及膈肌，镰状韧带在膈肌连接处向两侧分开包绕肝裸区，其左层向左延续为左冠状韧带上层左冠状韧带上层，并继续延续为左三角韧带左三角韧带，其右层延续为右冠状韧带上层右冠状韧带上层，并继续向右下延续为右三角韧带右三角韧带，右三角韧右三角韧带下层带下层越过下腔静脉形成小网膜右小网膜右叶叶，然后在尾状叶前方呈半圆形绕过，左三角韧带下层左三角韧带下层延续为小网膜小网膜左叶左叶肝脏三处未被腹膜覆盖的区域肝肝裸区裸区、胆囊床、肝门胆囊床、肝门是与膈腹膜、小网膜及韧带连接处肝胃韧带肝胃韧带及肝十二指肠韧带肝十二指肠韧带7/19/20247腹腔间隙影像解剖Ligaments of liver7/19/20248腹腔间隙影像解剖胃的韧带胃的韧带肝胃韧带肝胃韧带如前所述如前所述胃脾韧带胃脾韧带联系胃底和脾门的双联系胃底和脾门的双层腹膜，其内包含胃短动脉及胃层腹膜，其内包含胃短动脉及胃网膜左动脉网膜左动脉胃膈韧带胃膈韧带由胃底后面连至膈下由胃底后面连至膈下的双层腹膜结构，两层间相距较的双层腹膜结构，两层间相距较远，形成远，形成胃裸区胃裸区胃结肠韧带胃结肠韧带如前所述如前所述胃胰韧带胃胰韧带由胃幽门窦后壁至胰由胃幽门窦后壁至胰头、颈及颈与体的移行部的腹膜头、颈及颈与体的移行部的腹膜皱襞皱襞7/19/20249腹腔间隙影像解剖Ligaments of stomachHepatogastricligament肝胃肝胃韧带韧带Gastrosplenicligament胃脾胃脾韧带韧带Gastrophrenicligament胃膈胃膈韧带韧带Gastrocolicligament胃胃结肠韧带结肠韧带Gastropancresticligament胃胰胃胰韧带韧带7/19/202410腹腔间隙影像解剖脾的韧带脾的韧带胃脾韧带胃脾韧带如前所述如前所述脾肾韧带脾肾韧带是自脾门至左肾前面是自脾门至左肾前面的双层腹膜结构，内含胰尾及脾的双层腹膜结构，内含胰尾及脾血管、淋巴结构和神经丛等。血管、淋巴结构和神经丛等。膈脾韧带膈脾韧带由脾肾韧带向上延伸由脾肾韧带向上延伸至膈，此韧带很短至膈，此韧带很短脾结肠韧带脾结肠韧带位于脾前端和结肠位于脾前端和结肠左曲之间，此韧带也很短左曲之间，此韧带也很短7/19/202411腹腔间隙影像解剖Ligaments of spleenGastrosplenicligament胃脾韧带胃脾韧带Splenorenalligament脾肾韧带脾肾韧带Phrenicosplenicligament膈脾韧带膈脾韧带Splenocolicligament 脾结肠韧带脾结肠韧带7/19/202412腹腔间隙影像解剖皱 襞胃胰襞和肝胰襞胃胰襞和肝胰襞 胃胰襞胃胰襞是胃左动脉从腹后壁走向胃小弯时形成的腹膜皱襞分隔网膜囊中间部及侧部 肝胰襞肝胰襞是肝总动脉或肝固有动脉从腹后壁向前进入小网膜时所形成的腹膜皱襞十二指肠上、下襞十二指肠上、下襞7/19/202413腹腔间隙影像解剖Folds and recesses of posterior abdominal wallnSuperiorduodenalfold and recess十二指肠上襞和上隐窝十二指肠上襞和上隐窝nInferiorduodenalfold and recess十二指肠下襞和下隐窝十二指肠下襞和下隐窝nIntersigmoidrecess 乙状结肠间隐窝乙状结肠间隐窝formed by the inverted V attachment of sigmoid mesocolon 7/19/202414腹腔间隙影像解剖nRetrocecalrecess盲肠后隐窝盲肠后隐窝阑尾常位于其中nHepatorenalrecess肝肾隐窝肝肾隐窝位于肝右后叶与右肾及结肠肝曲之间，是仰卧位腹腔最低点7/19/202415腹腔间隙影像解剖Pouches nIn malerectovesicalpouch直肠膀胱陷窝直肠膀胱陷窝nIn female qRectouterinepouch 直肠子宫陷窝直肠子宫陷窝between rectum and uterus qVesicouterinepouch膀胱子宫陷窝膀胱子宫陷窝between bladder and uterus 为腹盆腔积液和肿为腹盆腔积液和肿瘤种植转移的好发瘤种植转移的好发部位部位7/19/202416腹腔间隙影像解剖结肠上区（膈下间隙）结肠上区（膈下间隙）右膈下腹膜外间隙（右膈下腹膜外间隙（肝裸区肝裸区）左膈下腹膜外间隙（左膈下腹膜外间隙（胃裸区胃裸区）肝周间隙肝周间隙右肝上间隙左肝上后间隙左肝上间隙左肝上前间隙右肝下间隙肝下间隙肝上间隙左肝下间隙左肝下前间隙左肝下后间隙（网膜囊网膜囊）肝脏肝脏左三角韧带左三角韧带镰状韧带镰状韧带肝圆韧带肝圆韧带胃及小网膜胃及小网膜肝周间隙相互沟通，其中小网膜分隔右肝下间隙和网肝周间隙相互沟通，其中小网膜分隔右肝下间隙和网膜囊，网膜囊仅借网膜孔（膜囊，网膜囊仅借网膜孔（the foramen of the foramen of WinslowWinslow）与腹腔交通）与腹腔交通7/19/202417腹腔间隙影像解剖Perihepaticspaces7/19/202418腹腔间隙影像解剖Perihepaticspaces7/19/202419腹腔间隙影像解剖网膜囊借网膜网膜囊借网膜孔与腹腔相通孔与腹腔相通境界：前方为肝十二指肠韧肝十二指肠韧带带，后方为覆盖下腔静脉下腔静脉的腹膜，上界为肝尾状叶肝尾状叶，下界为十二指肠上部十二指肠上部网膜孔网膜孔7/19/202420腹腔间隙影像解剖网膜囊网膜囊位置：位置：位于小网膜和胃的后方境界：境界：前壁前壁由上而下依次为小网膜、胃后壁腹膜和大网膜前两层；下壁下壁为大网膜前两层与后两层返折处；后壁后壁由下而上依次为大网膜后两层、横结肠及其系膜、覆盖胰、左肾、左肾上腺的腹膜；上壁上壁为膈下面的腹膜，此处肝尾状叶自右侧套入网膜囊内形成网膜囊上隐窝；左界左界为胃脾韧带、脾和脾肾韧带；右界右界为网膜孔7/19/202421腹腔间隙影像解剖四部分：四部分：网膜孔所对的前庭部前庭部；胃胰襞以上为上隐窝上隐窝，位于小网膜与膈之间，内有尾状叶套入；沿胰体伸向左后上方达脾门部分为脾隐窝脾隐窝；下隐窝下隐窝位于胃胰襞以下，在胃与胰及横结肠系膜之间。7/19/202422腹腔间隙影像解剖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 of left inferior coronary ligament;4=peritoneum of ligamentum teres;5=gastrophrenic ligament;6=gastrosplenic ligament;7=splenorenal ligament;8=transverse mesocolon;7/19/202423腹腔间隙影像解剖LessersacCTscanshowsfluidinthesuperior(*)andsplenic(S)recessesoflessersacoutliningthegastropancreaticfold(arrowhead).7/19/202424腹腔间隙影像解剖肝裸区肝裸区v于第一肝门以上平面，可见此间隙位于冠状韧带上、下层于第一肝门以上平面，可见此间隙位于冠状韧带上、下层之间。之间。“肝右后上间隙肝右后上间隙”是不存在的，由于肝裸区存在，是不存在的，由于肝裸区存在，腹腔积液不能到达脊柱旁，可与胸腔积液区别。腹腔积液不能到达脊柱旁，可与胸腔积液区别。7/19/202425腹腔间隙影像解剖肝周积液与胸腔积液鉴别肝周积液与胸腔积液鉴别右肝上前间隙积液右肝上前间隙积液右侧胸腔积液右侧胸腔积液7/19/202426腹腔间隙影像解剖胃裸区胃裸区Bareareaofstomach是否侵犯胃裸区是胃癌预后的影响因素之一7/19/202427腹腔间隙影像解剖7/19/202428腹腔间隙影像解剖7/19/202429腹腔间隙影像解剖Infracoliccompartments结结肠下区肠下区位于横结肠及横结肠系膜以下 nRightparacolicsulcus(gutter)右结肠旁沟右结肠旁沟位于升结肠旁，是联系肝肾隐窝和盆腔的通路；感染可通过此途径传播，如膈下脓肿可经此沟流入右髂窝和盆腔，阑尾化脓时也可向上蔓延至肝下nLeftparacolicsulcus(gutter)左结肠旁沟左结肠旁沟位于降结肠旁，上缘由左膈结肠韧带（the phrenicocolic ligament）与结肠上区分隔,因此左结肠旁沟积液只能向下流入盆腔7/19/202430腹腔间隙影像解剖nRightmesentericsinus 右右肠系膜窦肠系膜窦为一三角形间隙，位于为一三角形间隙，位于肠系膜根部、升结肠及右肠系膜根部、升结肠及右 2/3 2/3 横横结肠及其系膜之间，其下方有回肠结肠及其系膜之间，其下方有回肠末端阻隔，近乎封闭，当此窦有炎末端阻隔，近乎封闭，当此窦有炎症时，不易扩散，易形成肠间脓肿症时，不易扩散，易形成肠间脓肿或局限性腹膜炎或局限性腹膜炎nLeftmesentericsinus 左左肠系膜窦肠系膜窦为向下开口的斜方形，为向下开口的斜方形，位于肠系膜根部、降结肠、左位于肠系膜根部、降结肠、左 1/3 1/3 横结肠及其肠系膜之间，左肠系膜横结肠及其肠系膜之间，左肠系膜窦可向下越过小骨盆口通入盆腔，窦可向下越过小骨盆口通入盆腔，因此此窦内感染易蔓延入盆腔因此此窦内感染易蔓延入盆腔n上下流通，左沟不畅，右窦封闭，上下流通，左沟不畅，右窦封闭，左入盆腔。左入盆腔。7/19/202431腹腔间隙影像解剖腹膜后隙腹膜后隙Retroperitonealspace定义：位于腹后壁壁腹膜与定义：位于腹后壁壁腹膜与腹内筋膜之间，上界为腹内筋膜之间，上界为膈膈，下至下至骶骨岬骶骨岬，两侧向外延伸，两侧向外延伸为腹前外侧壁的腹膜外筋膜，为腹前外侧壁的腹膜外筋膜，该间隙感染可上经腰肋三角该间隙感染可上经腰肋三角可通到后纵隔，下与盆腔的可通到后纵隔，下与盆腔的腹膜后隙相续。腹膜后隙相续。组成：肾旁前间隙；肾周间组成：肾旁前间隙；肾周间隙；肾旁后间隙隙；肾旁后间隙7/19/202432腹腔间隙影像解剖肾周间隙肾周间隙肾周间隙上方肾周间隙上方右侧通向肝裸区；左侧通向左膈下腹膜外间隙肾周间隙下方肾周间隙下方通向下腹部及盆腔腹膜外间隙（髂窝）双侧肾周间隙之间双侧肾周间隙之间肾门及肠系膜上动脉平面以下肾前间隙相交通，以上不交通7/19/202433腹腔间隙影像解剖Retroperitonealspace7/19/202434腹腔间隙影像解剖7/19/202435腹腔间隙影像解剖病病例例网膜囊病变网膜囊病变腹膜病变腹膜病变a.非肿瘤性腹腔积液：漏出液、炎非肿瘤性腹腔积液：漏出液、炎性渗出、血肿、胆漏、尿漏性渗出、血肿、胆漏、尿漏b.良性肿瘤良性肿瘤c.恶性肿瘤恶性肿瘤7/19/202436腹腔间隙影像解剖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 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 contains proximal part of splenic vein,opacified by contrast medium7/19/202437腹腔间隙影像解剖A，lambdashaped fluid collection(arrows)adjacent to caudate lobeB,Abscess(arrow)from pancreatitis contains numerous gas bubbles7/19/202438腹腔间隙影像解剖Fig.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 7/19/202439腹腔间隙影像解剖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 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.7/19/202440腹腔间隙影像解剖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 gastrosplenic ligament(arrow).B,Several centimeters lower at level of pancreas.Tumor(T)arises from pancreas,immediately vantral to opacified splenic vein.7/19/202441腹腔间隙影像解剖SarcoidosisIt shows irregularly enhancing omental soft tissue(arrows)secondary to sarcoidosis.7/19/202442腹腔间隙影像解剖Hemoperitoneum55-year-old woman with intraperitonealsubacute hematoma.A and B showsubacute blood,best seen in perihepaticspace(arrows).7/19/202443腹腔间隙影像解剖Hemoperitoneum48-year-oldmanwithinfectedintraperitonealhematoma.AC,T2-weighted image(A)and T1-weighted images (B)and(C)contrastedimageshowlinearsmoothperitonealenhancement,withpresenceofintraperitonealblood-intensitysignal.7/19/202444腹腔间隙影像解剖BileleakT1-weightedimages1hrafterIVadministration of mangafodipirtrisodiumshowhyperintenseperihepatic fluid denoting bileleak.7/19/202445腹腔间隙影像解剖PeritonealNeoplasmsBenignTumors Theselesionsincludelipomas,neurofibromas,andothermesenchymaltumors.39-year-oldwomanwithneurofibromatosistype17/19/202446腹腔间隙影像解剖Mesentericcyst7/19/202447腹腔间隙影像解剖MalignantTumorsPeritonealmetastasesPeritoneal carcinomatosis is typicallymanifested by enhancing peritonealnodulesorarindofenhancingperihepaticsofttissue.44-year-oldwomanwithmetastasesfromovariancancer7/19/202448腹腔间隙影像解剖MalignantTumorsPeritonealmetastases7/19/202449腹腔间隙影像解剖Peritonealpseudomyxoma7/19/202450腹腔间隙影像解剖MalignantTumorsCTscanshowsgastriccarcinomainvadingthegastrocolicligament.7/19/202451腹腔间隙影像解剖MalignantTumorsA，Small bowel mesentery in a patient with non-Hodgkinlymphoma.B，Smallbowelmesenteryinapatientwithcarcinomatosis.CTscanshowsmassesinthesmallbowelmesentery(M)andrightparacohicgutter(*).7/19/202452腹腔间隙影像解剖MalignantTumorsPeritonealmesothelioma58-year-oldmanwithmesothelioma.AB,GRE out-of-phase image(A)andenhanced T1-weighted image(B)showenhancing large mass(arrows,A and B),representingmesothelioma,whichisentanglingbowelloops.7/19/202453腹腔间隙影像解剖MalignantTumorsMesentericcarcinoidMesentericcarcinoidtumorsareusuallyseenasnodularmassesassociatedwithmesentericstranding.Enhancingmass(arrows)isseenonportalvenousphaseimages,withinvolvementofdrainingveins7/19/202454腹腔间隙影像解剖要要点点炎症或肿瘤性病变可通过横结肠系膜炎症或肿瘤性病变可通过横结肠系膜到达结肠，如胰腺病变易通过横结肠到达结肠，如胰腺病变易通过横结肠系膜累及横结肠下面，而胃部疾病则系膜累及横结肠下面，而胃部疾病则易累及横结肠上面。易累及横结肠上面。胃部肿瘤易沿着肝胃韧带侵犯，因此胃部肿瘤易沿着肝胃韧带侵犯，因此常常可以在肝胃韧带的脂肪组织中看常常可以在肝胃韧带的脂肪组织中看到结节状的转移病灶到结节状的转移病灶；胃恶性肿瘤也胃恶性肿瘤也可沿该韧带侵犯肝脏，如侵犯可沿该韧带侵犯肝脏，如侵犯 Glissons Glissons 系统。系统。肝十二指肠韧带为肝胃韧带的游离边，肝十二指肠韧带为肝胃韧带的游离边，胆胰疾病可沿此途径蔓延。胆胰疾病可沿此途径蔓延。胰尾、脾和胃部疾病可沿胃脾韧带蔓胰尾、脾和胃部疾病可沿胃脾韧带蔓延。延。7/19/202455腹腔间隙影像解剖l最常见的腹膜肿瘤为继发于卵巢、最常见的腹膜肿瘤为继发于卵巢、结肠、胃及胰腺的转移性肿瘤。其结肠、胃及胰腺的转移性肿瘤。其影像特征包括：影像特征包括：(1)(1)腹膜增厚伴结腹膜增厚伴结节影；节影；(2)(2)腹水腹水;(3)(3)分隔性囊性积分隔性囊性积液液;(4)(4)小肠壁增厚小肠壁增厚;(5)(5)网膜增厚，网膜增厚，呈呈饼征。饼征。l常见常见的的网膜病变网膜病变有有转移、间皮瘤和转移、间皮瘤和结核结核等等，网膜囊性病变多见于原发，网膜囊性病变多见于原发囊肿、胰腺炎、脓肿、血肿或坏死囊肿、胰腺炎、脓肿、血肿或坏死的肿瘤病变。的肿瘤病变。l腹膜假性粘液瘤往往继发于阑尾或腹膜假性粘液瘤往往继发于阑尾或卵巢的粘液腺瘤或腺癌，呈凝胶样，卵巢的粘液腺瘤或腺癌，呈凝胶样，肝周可见扇贝形压迹。肝周可见扇贝形压迹。要要点点7/19/202456腹腔间隙影像解剖