Peritoneum , Intraperitoneal Spaces
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The document summarizes normal retroperitoneal and abdominal wall anatomy. It describes the three compartments of the retroperitoneum - the anterior pararenal space, perirenal space, and posterior pararenal space. It also discusses the potential intraperitoneal spaces, including the supramesocolic space (divided into right and left spaces), inframesocolic space, and pelvic spaces. Key organs in the retroperitoneum like the kidneys, adrenal glands, pancreas, and parts of the colon and duodenum are also described.
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Peritoneum , Intraperitoneal Spaces
- 1. Normal Anatomy Retroperitoneum & Abdominal Wall (Perirenal Space, Anterior and Posterior Pararenal Space) Potential Intraperitoneal Spaces
- 2. Presented By: Gemora, Katrina Procianos, Geleen Anne Rodriguez, Jisa CLMMRH POST GRADUATE INTERNS 2015-2016
- 3. Learning Objectives 1. Understand Retroperitoneum and Abdl wall anatomy. 2. Normal appearance of the various compartments and recess. 3. To illustrate and describe the different types of Intraperitoneal space and their imaging features on CT.
- 4. Background Bounded anteriorly by the posterior parietal peritoneum and posteriorly by the transversalis fascia, and extends from the diaphragm superiorly to the linea terminalis of the lesser pelvis inferiorly.
- 5. RETROPERITONEUM • Behind the posterior parietal peritoneum • Between the diaphragm and the pelvic brim
- 7. RETROPERITONEUM • Divided into: 1. Anterior Pararenal Compartment 2. Perirenal Compartment 3. Posterior Pararenal Compartment RETROPERITONEUM
- 8. Anterior Pararenal Space • Between the posterior parietal peritoneum and the anterior renal fascia • Boundaries: – Anterior – Parietal Peritoneum – Posterior – Anterior Renal Fascia – Lateral – Conal Fascia
- 9. Anterior Pararenal Space • Organs: 1. Pancreas 2. Duodenal Loop 3. Ascending Colon 4. Descending Colon Anterior Pararenal Space
- 10. Perirenal Space • Boundaries: – Anterior: Anterior Renal Fascia – Posterior: Posterior Renal Fascia
- 11. Perirenal Space • Anterior Renal Fascia – one layer of connective tissue • Posterior Renal Fascia – two layers of connective tissue – Anterior layer of Posterior Renal Fascia is continuous with the Anterior Renal Fascia – Posterior layer of Posterior Renal Fascia is continuous with Lateroconal Fascia Perirenal Space
- 12. Perirenal Space • Bridging septum – between the renal fascia and the renal capsule – Can cause loculations of fluid processes in the perirenal space • Right Perirenal Space – open superiorly to the bare area of the liver Perirenal Space
- 13. Perirenal Space • Organs: 1. Kidneys 2. Adrenal Glands Perirenal Space
- 14. Perirenal Space
- 15. Perirenal Space
- 16. Posterior Pararenal Space • A potential space • Usually filled only with fat • Boundaries: 1. Anterior - Posterior Renal Fascia 2. Posterior - Transversalis Fascia • Limited medially by the lateral edges of the psoas and quadratus lumborum muscles
- 17. RETROPERITONEAL ORGANS 1. Pancreas 2. Duodenal Loop 3. Ascending Colon 4. Descending Colon 5. Kidneys 6. Adrenal Glands
- 18. Pancreas • Elongated, soft, grayish-pink digestive gland • Located inferior to the transpyloric plane • Posterior to the stomach • Transverse mesocolon attached to its anterior margin • Located in the epigastric and left hypochondriac regions
- 19. Pancreas • Parts: 1. Head – embraced by the curve of the duodenum – Rests against the IVC posteriorly 2. Neck – grooved posteriorly – Adjacent to pylorus of the stomach 3. Body – triangular in cross-section – Between celiac trunk and SMA 3. Tail – end usually contacts the hilum of spleen Pancreas
- 20. Pancreatic Duct • Main Pancreatic Duct – begins at the tail of the pancreas and runs through the gland • Accessory Pancreatic Duct – variable; usually connected to the main pancreatic duct • Ampulla of Vater – pancreatic duct + bile duct
- 21. Pancreatic Duct • ERCP provides visualization of the pancreatic duct • MRCP – noninvasive method of imaging the pancreatic duct – Secretin injection increases pancreatic secretions and improve visualization of the pancreatic duct Pancreatic Duct
- 23. Pancreas • CT, Ultrasound and MRI are primary imaging modalities of the pancreas • Delicate feathery appearance on CT
- 24. PancreasPancreas
- 25. PancreasPancreas
- 27. Duodenal Loop • Descending (second) part and Horizontal (third) part of the duodenum are retroperitoneal • Descending – to the right and parallel to IVC • Horizontal – anterior to IVC, aorta and IMA • High quality Upper GI Series
- 29. Ascending Colon • 12 cm to 20 cm in length • Ascends on the right side of the abdominal cavity • Cecum to right lobe of the liver • Right colic (hepatic) flexure – where the ascending colon turns to the left • Separated from anterior abdominal wall by coils of small intestine and greater omentum
- 30. Ascending Colon • Right Paracolic Gutter – trench or groove at the lateral side of the ascending colon – Depth of this groove – how much gas the ascending colon contains – Passageway of fluid from the right hepatorenal recess to the rectouterine and/or rectovesical pouch Ascending Colon
- 31. Descending Colon • 20 cm to 30 cm in length • Descends from the left colic flexure to the left iliac fossa • Continuous with the sigmoid colon • Passes anterior to the lateral border of the left kidney • Caliber is smaller than ascending colon
- 32. Colon • CT Colonography – for polyp and cancer detection • Single Contrast Barium Enema – for intestinal obstruction • Double Contrast Barium Enema – for detection of small lesions and inflammatory bowel • CT – demonstrate intramural and extracolonic components
- 33. ColonColon
- 34. Kidneys • Lie in the paravertebral gutters at the level of T12 to L3 vertebrae • Moves about 3cm in vertical direction during movement of diaphragm • Ureter runs inferiorly from each kidney • Lies in a mass of perirenal fat • Posterior to peritoneum • On the posterior abdominal wall
- 35. Kidneys • Superior – protected by thoracic cage • Superior poles near median plane • Right lower than left • Left slightly longer than right • Lateral – convex • Medial – concave; where renal sinus and renal pelvis are located Kidneys
- 36. Kidneys • Renal Hilum – vertical cleft at the concave part of the kidney; lies in transpyloric plane • Renal Sinus – occupied by renal pelvis, calices, renal vessels and nerves Kidneys
- 37. Kidneys • Excretory Urography ( IV Pyelography ) • Multidetector CT with IV Contrast (CT-IVP) Kidneys
- 38. KidneysKidneys
- 39. KidneysKidneys
- 40. KidneysKidneys
- 41. Adrenal Glands • Superior to the kidneys • Enclosed within a fatty capsule and enveloped by renal fascia • Shape and relations differ from both sides • Consist of cortex and medulla
- 42. Adrenal Glands • CT- usually the imaging modality of choice in adults • MR – provide high quality images of adrenal lesions • Ultrasound – excellent for screening the adrenal glands in infants and children Adrenal Glands
- 46. Anterior Pararenal Space - Extends between the Post. Parietal peritoneum and the Ant. Renal fascia.
- 49. Posterior Pararenal Space Smallest and most clinically insignificant portion of the retroperitoneum Filled with fat, blood vessels and lymphatics, but contains no major organs Rarely subject to involvement in disease processes except where spread is from adjacent structures
- 51. Intraperitoneal Spaces Separate compartments within the peritoneal cavity. Separated or compartmentalized by various peritoneal ligaments and their attachments. Significant in the peritoneal diseases, ascites, intraperitoneal collections or peritoneal metastasis.
- 52. Intraperitoneal Spaces 1. Supramesocolic Space 2. Inframesocolic Space 3. Pelvic Spaces
- 53. Intraperitoneal Spaces 1.Supramesocolic Space 2.Inframesocolic Space 3. Pelvic Spaces Right Supramesocolic Space Left Supramesocolic Space
- 54. Intraperitoneal Spaces 1. Supramesocolic Space 2. Inframesocolic Space 3. Pelvic Spaces 1. R Inframesocolic Space 2. L Inframesocolic Space 3. R And L Para-colic Gutters
- 55. Intraperitoneal Spaces 1. Supramesocolic Space 2. Inframesocolic Space 3. Pelvic Spaces 1. Para-vesical Spaces 2. Rectovesical Pouch 3. Rectouterine Pouch (Pouch Of Douglas): In Females
- 56. Intraperitoneal Spaces Supramesocolic Space Intraperitoneal space above the root of the transverse mesocolon Arbitrarily divided into R and L spaces and subspaces These are normally in communication with each other, but may become separated by inflammatory membranes or disease. Subphrenic space is divided into R and L by the falciform ligament.
- 57. Intraperitoneal Spaces RIGHT SUPRAMESOCOLIC SPACE 1. R Subphrenic Space 2. Ant. R Subhepatic Space 3. Post. R Subhepatic Space (Morison Pouch) LEFT SUPRAMESOCOLIC SPACE 1. Ant. L Perihepatic Space 2. Post. L Perihepatic Space 3. Ant. L Subphrenic Space 4. Post. L Subphrenic (Perisplenic) Space
- 61. Intra-peritoneal space below the root of the transverse mesocolon. The supramesocolic space lies above the transverse mesocolon's root. Contains the paracolic gutters are peritoneal recesses on the Post. abdl wall Lat. to the Asc and Desc. colon. Inframesocolic Space Intraperitoneal Spaces
- 62. R paracolic gutter is continuous superiorly with the R subhepatic and subphrenic spaces. Larger than the L paracolic gutter, which is partially separated from the L subphrenic spaces by the phrenicolic ligament. Inframesocolic Space Intraperitoneal Spaces Both paracolic spaces are in continuity with the pelvic peritoneal spaces.
- 63. R inframesocolic space - Smaller than its counterpart. Bounded SUP: Transverse colon To the right: Root of the Small Bowel Mesentery. Inframesocolic Space Intraperitoneal Spaces L inframesocolic space - Larger of the two compartments and is in free communication with the pelvic peritoneal space on the right of the midline. - The sigmoid colon and its associated mesentery form a partial barrier on the left of the midline.
- 66. Intraperitoneal Spaces Pelvic Space Inf. reflection of the peritoneum over the fundus of the urinary bladder and the front of the rectum at the junction of its middle and lower thirds In females, the reflection is also over the Ant. and Post. surface of the uterus and the upper Post. vagina. Urinary bladder subdivides the pelvis into R and L paravesical spaces
- 67. Intraperitoneal Spaces Pelvic Space Males there is only 1 potential space for fluid collection Post. to the bladder, the rectovesical pouch In females, the reflection is also over the Ant. and Post. surface of the uterus and the upper Post. vagina. Females there are 2 potential spaces Post to the bladder, the uterovesical pouch, and Post. to the uterus the deeper rectouterine pouch (Pouch of Douglas).
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- But can become huge when filed with fluid.
- These are two normal variations of the retroperitoneal spaces. In A, the descending colon is entirely retroperitoneal, while in B, the peritoneum forms a deep pocket lateral to the colon,
- But can become huge when filed with fluid.
- Diseases in the anterior pararenal space usually originates from these organs. Examples are pancreatitis, perforated ulcers and diverticulitis.
- This forms the boundary of the anterior pararenal space. The anterior and posterior layers of the posterior renal fascia may be separated by inflammatory processes, such as pancreatitis. Fluid collections in the perirenal space are usually renal in origin.
- This allows the spread of disease processes such as infection and tumor between the kidney and the liver.
- Isolated fluid collections are rare and most commonly caused by spontaneous hemorrhage into the psoas muscle as a result of anticoagulation therapy
- Radiograph from endoscopic retrograde cholangiopancreatogram demonstrates main duct of Wirsung (black arrows) and accessory duct of Santorini (white arrows)
- Because the gland is not encapsulated
- Ultrasound image of Normal pancreas
- CT Image of a normal pancreas. Majority lies anterior to the splenic vein,
- This shows pancreatic calcifications, extending upward across the left upper quadrant.
- A high quality upper GI Series provides excellent visualization of the duodenum together with the stomach
- The descending duodenum is faintly outlined by barium in the image.
- Double contrast – contrast + air
- Upright radiograph Double contrast barium enema demonstrating normal anatomy of the colon
- IVP is a traditional method to visualize the kidneys. Ultrasound, CT and MRI provide better images MDCT with IV Contrast is currently the best tool to detect and evaluate renal tumors. It is a multistage study utilizing thin slices.
- Normal excretory urogram taken 5 mins after the contrast has been injected, showing the enhanced renal parenchyma and filled collecting system
- Reconstructed image from thin slices of multidetector CT demonstrating renal parenchyma and ureter. The calyces is not as well shown as on a traditional IV pyelogram
- Ultrasound image of normal kidneys
- Ultrasound image of a normal adrenal gland
- This is a CT image of adrenal hyperplasia. Limbs of both adrenal glands are somewhat nodular, somehow enlarged but maintains their normal shape.
- largest fat accumulation in the perirenal space is medial to the lower pole of the kidney; this is the preferential location where abscesses, hematomas and urinomas may accumulate.
- The anterior pararenal space is bounded anteriorly by the posterior parietal peritoneum, posteriorly by the anterior renal fascia (Gerota fascia), and laterally by the lateroconal fascia. Space is continuous across the midline except for the pancreatic processes, because this organ straddles this space across the midline; because of this many diseases remain localized to one side. The pancreas, duodenal loop and ascending and descending portions of the colon are within the anterior pararenal space.
- Axial view of Retroperitoneal space compartments
- Saggital view of Retroperitoneal space compartments
- limited anteriorly and medially by the Posterior renal fascia (Zuckerkandl fascia) and Lateroconal fascia, respectively, and posteriorly and laterally by the Transversalis fascia.
- the posterior pararenal fat continues into the flank as the properitoneal fat “stripe” seen in plain films of the abdomen. Medially this space is limited by the margin of the psoas muscle and by quadratus lumborus muscles, being parallel to them. Isolated fluid collections are rare and most commonly caused by spontaneous hemorrhage into the psoas muscle as a result of anticoagulant therapy
- Axial views from CT peritoneogram demonstrating peritoneal spaces in the upper abdomen. Correlated with schematic diagram The right subphrenic space communicates freely with the perihepatic and subhepatic spaces, including Morison's pouch, which communicates with the lesser sac via the epiploic foramen (foramen of Winslow)
- Coronal and sagittal view from CT peritoneogram demonstrating upper abdominal peritoneal spaces. These supramesocolic spaces are preferential sites for peritoneal fluid stasis and therefore are common sites to detect ascites, abcesses and peritoneal spread of metastases
- Diagram of an axial cross section of the abdomen illustrates the recesses of the greater peritoneal cavity and the lesser sac. B. CT scan of a patient with a large amount of ascites nicely demonstrates the recesses of the greater peritoneal cavity and the lesser sac. The lesser sac is bounded by the stomach ( St ) anteriorly, the pancreas ( P ) posteriorly, and the gastrosplenic ligament ( curved arrow ) laterally. The falciform ligament ( arrowhead ) separates the right and left subphrenic spaces. Fluid from the greater peritoneal cavity extends into Morison pouch ( arrow ) between the liver and the right kidney. Fluid in the gastrohepatic recess ( asterisk ) separates the stomach from the liver ( L ). S, spleen; GB, gallbladder; RK, right kidney; IVC, inferior vena cava; Ao, aorta; LK, left kidney
- Fig.: Diagram illustrating the omenta, mesenteries and spaces Lateral to the ascending and descending colons are the right and left paracolic gutters. The right paracolic gutter is continous with the right perihepatic space. Conversely on the left, the phrenicocolic ligament prevents direct communication between the left paracolic gutter and the left subphrenic space.
- Coronal CT peritoneogram showing peritoneal spaces supramesocolic compartments communicates with the inframesocolic compartments by way of the right paracolic gutter. Free communication between the left paracolic gutter and left subphrenic space is prevented by the phrenicocolic ligament.
- Sagittal and coronal views from CT peritoneogram demonstrating pelvic peritoneal folds and spaces The recto-uterine (females) and rectovesical (males) are the most dependent regions within the pelvis resulting in fluid stasis and therefore, these are common sites for abscesses, fluid collections and metastases.
- Top right: Sagittal schematic diagram of pelvic peritoneal spaces Bottom left and right: sagittal CT peritoneogram and MR demonstrating the recto-vesical space and rectouterine space, respectively. Top right: sagittal MR demonstrating hydatid disease within this dependent pelvic space.