腹膜后j解剖
腹膜后间隙教学
02
腹膜后间隙的疾病
腹膜后间隙肿瘤
总结词
腹膜后间隙肿瘤是一种常见的疾病，通常是由于遗传、环境、生活习惯等多种 因素引起的。
详细描述
腹膜后间隙肿瘤是指发生在腹膜后区域内的肿瘤，包括良性肿瘤和恶性肿瘤。 良性肿瘤通常生长缓慢，不会扩散，而恶性肿瘤则可能迅速扩散并危及生命。
腹膜后间隙感染
总结词
腹膜后间隙教学
汇报人：可编辑 2024-01-10
目录 CONTENTS
• 腹膜后间隙概述 • 腹膜后间隙的疾病 • 腹膜后间隙疾病的诊断与治疗 • 腹膜后间隙手术 • 腹膜后间隙病例分析
01
腹膜后间隙概述
定义与位置
定义
腹膜后间隙是指位于腹膜壁层与 腹内筋膜之间的潜在间隙，是人 体解剖学中的重要结构。
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其他腹膜后间隙疾病
总结词
除了上述几种疾病外，腹膜后间隙还可能发生其他多种疾病，如囊肿、脓肿等。
详细描述
除了肿瘤、感染和出血外，腹膜后间隙还可能发生囊肿、脓肿等其他疾病。这些 疾病通常需要不同的治疗方法，因此及时诊断和治疗非常重要。
03
腹膜后间隙疾病的诊断与治疗
诊断方法
影像学检查
通过腹部超声、CT或MRI 等影像学检查，观察腹膜 后间隙的结构和异常病变 ，为诊断提供依据。
实验室检查
进行血液、尿液等实验室 检查，了解全身及腹膜后 间隙的炎症反应和代谢状 况。
临床诊断
结合患者的病史、症状、 体征以及影像学和实验室 检查结果，进行综合分析 ，做出临床诊断。
治疗方法
药物治疗
根据腹膜后间隙疾病的病因和病 理生理机制，选择适当的药物进 行治疗，如抗生素、抗炎药、镇
腹膜后间隙影像解剖
介入治疗后，通过影像学检查评估治 疗效果、观察并发症的发生情况，为 后续治疗提供指导。
THANKS
感谢观看
总结词
CT检查具有高分辨率和高灵敏度，能够清晰显示腹膜后间隙的解剖结构和病变特 征。
详细描述
CT检查通过多层扫描技术，能够获取腹膜后间隙的横断面图像，从而清晰地显示 腹膜后间隙的解剖结构、肿瘤位置、大小以及与周围组织的毗邻关系。CT检查对 于腹膜后肿瘤、炎症、出血等疾病的诊断具有重要价值。
MRI检查
腹膜后间隙影像解剖
目录
• 腹膜后间隙概述 • 腹膜后间隙的影像学检查方法 • 腹膜后间隙的正常影像解剖 • 腹膜后间隙的异常影像解剖 • 腹膜后间隙影像解剖的临床应用
01
腹膜后间隙概述
定义与位置
定义
腹膜后间隙是位于腹膜壁层与腹膜腔之间的潜在间隙， 是人体最大的隐秘间隙。
位置
腹膜后间隙上起横膈，下至骨盆上缘，左右两侧大致与 腹膜腔对称，但腹膜后间隙并不与腹膜腔相通。
粘连，影响正常的生理功能。治疗需要根据炎症的原因和严重程度进行针对性处理。
腹膜后间隙出血
总结词
腹膜后间隙出血是指腹膜后间隙内的血管破裂导致的出血。
详细描述
腹膜后间隙出血的原因可能包括外伤、肿瘤侵蚀、自身免疫性疾病等。出血可能导致腹膜后间隙的肿胀、疼痛和 压迫症状，严重时可能危及生命。治疗需要及时止血、补充血容量和针对病因进行治疗。
01 腹膜后间隙的主要器官包括肾脏、胰腺、十二指 肠等，这些器官在影像学上呈现出不同的密度或 信号。
02 腹膜后间隙内还有一些重要的结构，如输尿管、 精索或卵巢动静脉等，这些结构在影像学上也有 一定的特征。
02 在腹膜后间隙内，还存在着一些淋巴结和脂肪组 织，这些组织在影像学上也有一定的表现。
腹膜后间隙影像解剖
泌尿生殖嵴残留部分，以上组织均可成为肿瘤起源
。
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腹膜后间隙 第二节
腹膜后间隙分为三个解剖区： 肾筋膜前后两层，即肾前筋膜和肾后筋膜以 及二者在升、降结肠后融合形成的侧锥筋膜， 将腹膜后间隙分为三个间隙及前肾旁间隙、肾 周间隙及后肾旁间隙。
急性重症胰腺炎渗液是腹膜后间隙的指示剂。
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第二节
急性胰腺炎， 肾周筋膜增厚
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肾旁前间隙
第二节
(1) 肾旁前间隙：位于肾前筋膜与后壁腹
膜之间，外侧止于侧锥筋膜、两侧的间隙
潜在相通，其内含胰腺、十二指肠的降部
、水平部及升部，升、降结肠以及供应肝
、脾、胰腺和十二指肠的血管。
肾旁前间隙内的任何结构的病变都可
能引起肾前筋膜和侧锥筋膜的增厚，最常
肾旁后间隙的病变常常与其他腹膜后间隙 的病变有关。
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腹膜后间隙
第二节
(4)腹膜后间隙之间的交通：
尽管腹膜后三个间隙解剖上是完整的，
但它们之间存在潜在的交通，一个间隙的
病变可波及另外的间隙：
1）同侧的三个腹膜后间隙在髂嵴平面下
潜在相通。
2）两侧的肾旁前间隙在中线潜在相通。
3）两侧的肾周间隙在中线是否相通，存
➢ 腹膜后间隙肿块的特点（与腹腔肿瘤鉴别的要 点）：
（1）肿块使腹膜后脏器移位，尤其是向前移位 （2）肿块与腹膜后脏器分界不清，脂肪间隙消失
，但肿块最大径线仍在脏器之外 （3）主动脉或下腔静脉受累或包埋
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异常影像表现 第二节
（4）肿块使腹腔内脏器向前方或侧方移位，但其 间的脂肪间隙仍存在；
重下降，实验室可有血沉增快，累及输尿管时可有尿路
腹膜后腔及器官课件
及时就医，遵医嘱治疗，避免自行 盲目使用药物。
腹膜后出血的诊断与治疗
诊断方法
临床表现、实验室检查 （如血常规、凝血功能 等）、影像学检查（如超 声、CT等）。
治疗方式
根据出血量和部位，选择 保守治疗、介入治疗或手 术治疗，同时注意控制血 压和补充血容量。
注意事项
如有疑虑，及时就医；遵 循医生建议，按时进行复 查和随访。
基于患者的基因、表型和环境因素，制定个体化的治疗方案，提高 治疗效果和患者生存率。
跨学科合作与转化研究
加强医学、生物学、物理学、工程学等多学科的合作，促进研究成 果的转化和应用。
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04 腹膜后腔手术的注意事项 与技巧
手术前准备
术前评估
对患者的身体状况进行全面评估， 包括心肺功能、肝肾功能、营养 状况等，以确保患者能够耐受手
术。
肠道准备
术前需进行严格的肠道准备，包 括饮食调整、灌肠等，以减少术
后感染的风险。
心理准备
术前对患者进行心理疏导，减轻 其焦虑和恐惧，增强其对手术的
信心。
输尿管
输尿管是腹膜后腔内一条细长的 管道，连接肾脏和膀胱，主要功
能是输送尿液。
输尿管全程位于腹膜后，分为腰 部、盆部和壁内部三个部分。
输尿管壁由肌肉和粘膜组成，可 以自主蠕动，帮助尿液顺畅流动。
肾上腺
肾上腺是腹膜后腔内一对重要 的内分泌腺体，位于肾脏上方， 主要功能是分泌激素和调节生 理活动。
பைடு நூலகம்
肾上腺分为皮质和髓质两部分， 皮质分泌多种激素，如皮质醇、 醛固酮等，髓质分泌肾上腺素 等。
治疗方式
手术切除、化疗、放疗等 综合治疗手段，根据肿瘤 的性质和分期制定个性化 的治疗方案。
局部解剖学16.腹膜后隙课件
纤维囊 肾 脂肪囊
肾筋膜
右肾矢状位图
腹膜后隙
输尿管腹部
输尿管分部： 腹部 盆部 壁内部
3处狭窄：如图示
局部解剖学
腹段 盆段
壁内段
腹膜后隙
肾上腺
动脉： 肾上腺上动脉（发自膈下动脉） 肾上腺中动脉（发自腹主动脉） 肾上腺下动脉（发自肾动脉）
静脉： 左肾上腺静脉（注入左肾静脉） 右肾上腺静脉（注入下腔静脉）
肾
腹膜后隙
局部解剖学
肾门、肾窦、肾蒂
肾 窦
肾蒂内主要结构排列顺序： 由前向后（静、动、盂） 由前向后（动、静、盂）
肾
肾血管与肾段 上段 上前段 下前段 下段 后段
腹膜后隙
局部解剖学
腹膜后隙
局部解剖学
肾表面的三层被膜：
由内向外依次为：
（1）纤维囊： 包裹于肾实质表面。
（2）脂肪囊： 又名肾床。
局部解剖学
第十六次课：腹膜后隙
学习要点 1.腹膜后隙概念 2.肾（位置、毗邻、肾门、被膜等） 3.腹主动脉、下腔静脉 4.腰交感干
腹膜后隙
局部解剖学
介于腹后壁腹膜与腹内筋膜之间，有肾、肾上腺、 输尿管、腹部大血管、神经和淋巴结等重要结构。
肾
位置与毗邻
肾的毗邻：
左右前方结 构不同；
局部解剖学
局部解剖学
肾上腺动脉
局部解剖学
腹主动脉
壁支：
膈下动脉 腰动脉 骶正中动脉
成对脏支：
肾动脉 肾上腺中动脉 睾丸(卵巢)动脉
腹膜后隙
局部解剖学
局部解剖学
腹主动脉 不成对脏支 胃左动脉
腹腔干 肝总动脉
断面腹膜后隙PPT课件
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2 胰腺的应用解剖
胰腺的位置与大小 胰腺的形态与分部 胰腺形态的分型 胰腺的毗邻 脾动静脉与胰腺的关系 肝门静脉系与胰颈的关系
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（2）脾的结构与毗邻
脾门：位于脏面中部， 有血管出入。
脾切迹：位于脾上缘 的不规则裂隙（数条）
膈面：对向膈肌的腹 腔面。
脏面：胃底、左肾、 左肾上腺、结肠左曲、 胰腺等。
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（3）副脾及其形态
出现率：6—35% 位置：不恒定，多
在脾门、脾蒂、大 网膜处。 数目：常见2-3个， 最多可达400个 形态：不规则，多 呈小结节状
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（2）两肾的毗邻差别
1 左肾：上有左肾上腺； 前有胃底、胰尾、空肠； 外侧为脾和结肠左曲； 后面为膈肌和腹后壁。
2 右肾：上有右肾上腺； 前面有肝和结肠右曲； 内侧邻十二指肠； 后面为膈肌和腹后壁。
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（3）肾门与肾血管的位置
左右肾门平均高度： 约与L1-2高度平齐
腹主动脉：居中偏左 下腔静脉：中线右侧 腹腔干：肠系膜上动
脉上0.5-0.8cm起始。 肠系膜上动脉：L1高
度起始 门静脉;L1的高度汇合
而成 脾动静脉：在胸腰间盘与
L1的高度斜行。 肾动脉：L1-2高度走行
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二 腹膜后间隙在水平断面上的解剖
肝蒂、左肾上腺层面 脾血管层面 肠系膜上动脉根部层面 肾血管层面 胰头中份层面 胰头下份层面
断面部位：
腹膜后间隙解剖及CT诊断
及时就医：出现不 适症状，及时就医 ，避免延误治疗
预防腹膜后间隙疾病的措施
保持良好的生活习惯，如合理饮食、适量运 动、戒烟限酒等
避免剧烈运动，防止腹膜后间隙损伤
定期进行体检，早期发现疾病
保持良好的心理状态，避免过度紧张和焦虑
避免长时间保持同一姿势，如久坐、久站等
及时治疗相关疾病，如糖尿病、高血压等， 降低腹膜后间隙疾病的发生风险
腹膜后间隙病变的鉴别诊断
腹膜后间隙肿 瘤：包括脂肪 肉瘤、平滑肌 肉瘤、神经鞘
瘤等
腹膜后间隙炎 性病变：包括 结核、克罗恩 病、溃疡性结
肠炎等
腹膜后间隙血 管病变：包括 动脉瘤、静脉 曲张、动静脉
瘘等
腹膜后间隙先 腹膜后间隙创 腹膜后间隙其
天性病变：包 伤性病变：包 他病变：包括
括腹膜后囊肿、 括外伤性血肿、 腹膜后纤维化、
腹膜后间隙的功能：保护内脏 器官，参与腹腔内的血液循环
和淋巴回流
腹膜后间隙的分区
肾前间隙：位于肾前筋膜与腹膜之间，包含肾、肾上腺、肾血管等结构 肾后间隙：位于肾后筋膜与腹膜之间，包含肾、肾上腺、肾血管等结构 肾旁间隙：位于肾旁筋膜与腹膜之间，包含肾、肾上腺、肾血管等结构 肾下间隙：位于肾下筋膜与腹膜之间，包含肾、肾上腺、肾血管等结构 肾前间隙与肾后间隙的分界：肾前筋膜与腹膜之间的间隙 肾旁间隙与肾下间隙的分界：肾旁筋膜与腹膜之间的间隙
腹膜后淋巴管 腹膜后血肿等 腹膜后脂肪坏
畸形等
死等
腹膜后间隙疾病 的治疗
腹膜后间隙疾病的手术治疗
手术适应症：明确诊断为腹膜后间隙疾病，且保守治疗无效 手术方式：腹腔镜手术、开放手术、机器人辅助手术等 手术风险：出血、感染、损伤周围器官等 术后护理：注意观察病情变化，及时处理并发症，促进患者恢复
腹膜后解剖结构及器官
腹膜后解剖结构及器官*导读：腹膜后腔是指腹后壁腹膜与腹后壁的腹内筋膜之间的间隙，上达膈肌，下抵骶胛，两侧向外接连腹膜外脂肪。
……腹膜后腔是指腹后壁腹膜与腹后壁的腹内筋膜之间的间隙，上达膈肌，下抵骶胛，两侧向外接连腹膜外脂肪。
间隙内充以疏松结缔组织，主要结构有位于脊柱前方的腹主动脉及其分支;下腔静脉及其属支;脊柱两侧的腰交感干，以及围绕腹腔干和肠系膜上动脉周围的腹腔神经丛，还有腹主动脉神经丛、肠系膜下丛和上腹下丛等植物神经丛;再向两侧为左、右肾和肾上腺以及输尿管。
胰和12指肠虽也位于此间隙内，但已述于前。
此外还有位于腰大肌深面的腰丛及其分支。
一、肾脏1. 肾的形态、位置和毗邻肾kidney是泌尿系统的主要器官，呈红褐色，可分为上、下两端，内、外两缘和前、后两面。
前面略凸隆，后面平坦;外侧缘呈弓形，凸弯向外侧，内侧缘中部凹陷，有肾动、静脉，淋巴管和输尿管出入，叫做肾门。
进出肾门的诸结构为结缔组织所包绕，叫做肾蒂。
右侧肾蒂较短。
肾蒂内结构排列的顺序是：从前向后依次是肾静脉、肾动脉、输尿管;从上向下为肾动脉、肾静脉、输尿管。
从肾门进入为一扩大的腔隙，叫做肾窦，为肾血管的分支、肾盂和肾大盏、肾小盏所占据，中间充填以脂肪组织。
肾位于脊柱两侧，两肾上端较为靠近，而下端则相距略远，即肾的长轴由风上斜向外下。
左肾上端平第11肋下缘，下端约平第二腰椎下缘。
右肾上、下端均较左肾低约半个椎骨。
第12肋斜越左肾后面中部、右肾后面上部。
肾门约平第一腰椎高度，幽门平面通过右肾门上部和左肾门下部。
两肾上端有肾上腺复盖，左肾前面从上向下分别与胃、胰尾、空肠相邻，外侧缘上部接脾，下部邻结肠左曲。
右肾前面上2/3部邻肝，下1/3部接结肠右曲，内侧缘与12指肠降部相贴。
两肾后面第12肋以上部分，隔膈肌对向肋膈隐窝(窦)，故肾手术经后入路时，应予注意勿损伤肋膈隐窝，以免造成气胸。
第12肋以下部分，肾后面从内侧向外侧依次与腰大肌、腰方肌和腹横肌相邻接。
腹膜后间隙解剖及疾病诊断
脂肪肉瘤
• 脂肪肉瘤是一组多样化的肿瘤，是最常见的原发性腹膜后肿瘤。 10%~15%的脂肪肉瘤起源于腹膜后间隙。
脂肪肉瘤
• 脂肪肉瘤最常见的类型为高分化组，包括脂肪细胞型、硬化型和 炎症型亚型。
• 脂肪细胞性脂肪肉瘤类似于脂肪瘤,主要由脂肪组成，伴有胶原带 成分的条索状组织。
脂肪肉瘤
• 随着恶性程度的增加,脂肪肉瘤还可呈黏液型、圆形细胞型、多形 型或去分化。
腹膜后间隙解剖及疾病诊断
腹膜后间隙解剖
• 后腹膜可以被分成三部分:肾前筋膜、肾后筋膜和侧锥筋膜。 • 肾上腺和肾脏位于腹膜后间隙的肾周间隙内。 • 升结肠 、降结肠、第2和第3段十二指肠以及胰腺位于腹膜后间隙
的肾旁前间隙内。
腹膜后间隙解剖
• 后腹膜的第三部分,即肾旁后间隙，是临床上重要的一个潜在腔隙， 可因炎症或肿瘤而成为潜在的疾病播散途径。
• 侵袭性越高的亚型含极少或肉眼看不到的脂肪成分，并难以与其 他恶性软组织肿块相鉴别。
Hale Waihona Puke 腹膜后纤维化• 腹膜后纤维化是一种罕见的炎性疾病，造成后腹膜间隙过多的纤 维沉积，常导致输尿管梗阻。
• 与恶性腹膜后淋巴结增大不同，腹膜后纤维化往往不会使主动脉 远离脊柱。
腹膜后位器官总结
腹膜后位器官总结1. 引言腹膜后位于腹腔内，背靠腰椎。
腹膜后是一个重要的解剖区域，包含着多个器官，这些器官的位置和关系对于临床医生的诊断和治疗具有重要意义。
本文将对腹膜后的主要器官进行总结和介绍。
2. 肾脏肾脏是腹膜后最重要的器官之一。
它位于腰椎的两侧，下方稍低于腰节的平面。
肾脏具有排泄废物、调节水盐平衡、产生尿液等重要功能。
在腹膜后的解剖位置上，左肾通常比右肾略高并位于后腹壁较外侧。
3. 肾上腺肾上腺是一个位于肾脏上方的椭圆形器官。
它在腹膜后区域内位于肾脏的上极部分。
肾上腺主要分为皮质和髓质两部分。
皮质分泌多种激素，如皮质醇和醛固酮等。
髓质则分泌肾上腺素和去甲肾上腺素，对调节机体应激反应具有重要作用。
4. 胰腺胰腺是位于胃后方的一个腺体器官。
它分为头、体和尾三部分，处于腹膜后方的位置。
胰腺具有分泌胰液和多种消化酶的功能，以帮助消化食物。
此外，胰腺还分泌胰岛素和胰高血糖素等激素，参与调节血糖水平。
5. 十二指肠十二指肠是小肠的起始段，位于胃和空肠之间。
它从胰头周围穿过，处于腹膜后区域的上部。
十二指肠是消化道的一个重要部分，它接受来自胆囊和胰腺的排泄物，并分泌黏液和多种消化酶，促进食物的消化和吸收。
6. 大血管腹膜后区域还包含一些重要的大血管。
这些大血管主要有腹主动脉、下腔静脉、肾动脉和肾静脉等。
腹主动脉是主要的供血动脉，负责向下肢、内脏器官和腹壁提供血液。
下腔静脉是主要的回血大静脉，负责将下肢和腹壁的静脉血汇集到心脏。
7. 直肠和结肠腹膜后还包括直肠和结肠的部分。
直肠是位于盆腔的最末端的结肠段，负责储存和排泄粪便。
结肠是位于直肠上方的结肠管，并分为升结肠、横结肠、降结肠和乙状结肠等。
结肠的主要功能是吸收水分和电解质。
8. 总结腹膜后是一个重要的解剖区域，包含着多个重要的器官和血管。
肾脏、肾上腺和胰腺是其中最重要的器官。
了解腹膜后的器官及其位置与关系，有助于临床医生更好地进行诊断和治疗。
此外，腹膜后的大血管和消化道也具有重要的生理功能，对人体健康至关重要。
腹膜后解剖
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肾旁后间隙交通
• 两侧肾旁后间隙在内侧中线处不相通，但 通过前腹壁的腹膜外脂肪层使两侧间隙在 前方潜在相通。
• 小结：一个间隙的病变，可因脓液、胰酶 、肿瘤侵蚀，波及其他间隙。
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肾旁前间隙感染
• 常来源于胰腺炎，及升降结肠、十二指肠 的腹膜后穿孔。
主支。
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肾旁前间隙交通
• 该间隙内侧位于胰腺水平，中线处相交通 ，其余方向不相通。下方同其余间隙相通 。
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肾旁后间隙
• 肾后筋膜和锥侧筋膜后外方与腹横筋膜之 间的区域。
• 内无脏器，主要为脂肪组织。向前与腹膜 外脂肪层连续，上至横膈，下达盆腔。
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腹膜后间隙
肝胆外科
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• 腹膜后间隙是指位于腹膜壁层后部分与腹 后壁腹横筋膜之间，上至横膈，下达盆腔 的一个立体间隙。
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解剖划分（meyers）
• 根据尸体断面间隙灌注后对比，以肾筋膜 为主要解剖标志，将其划分为：
• 肾旁前间隙 • 肾旁后间隙 • 肾周间隙
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肾周间隙
• 由肾前筋膜、肾后筋膜构成。 • 包括肾脏、肾上腺 • 输尿管（近段） • 肾血管及肾周脂肪。
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肾周间隙交通
• 内侧：一般认为不相通 • 上方：不相通 • 下方：肾周间隙呈开放性，同侧三间隙在髂棘平面以下相
通。
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腹膜后隙解剖
腹膜后隙的解剖结构与多种疾病的发生、发展密切相关，研究者对腹膜 后隙在肿瘤、炎症等疾病中的作用进行了深入研究，为疾病的诊断和治 疗提供了新的思路。
未来发展方向
1 2 3
基础研究
未来将继续深入开展腹膜后隙的基础研究，进一 步揭示其解剖结构、功能和疾病相关性等方面的 奥秘。
临床应用
随着研究的深入，将开发出更多基于腹膜后隙解 剖结构的治疗方法和手术方案，提高疾病的治疗 效果和患者的生存质量。
大血管和神经
大血管
腹膜后隙内有多个大血管，如腹主动脉、下腔静脉等，这些血管为腹部和下肢 提供血液。
神经
腹膜后隙内有许多神经，包括Fra bibliotek感神经和副交感神经，它们控制着腹部器官的 功能。
淋巴结和淋巴管
淋巴结
腹膜后隙内有淋巴结，它们是免疫系 统的重要组成部分，可以过滤并清除 体内的有害物质。
淋巴管
淋巴管是淋巴液循环的通道，它们将 淋巴液从组织引流到淋巴结，再进一 步输送到血液中。
结缔组织
结缔组织由纤维和基质组成，它们为 腹膜后隙提供支持和结构。
腹膜后隙内的结缔组织还包含脂肪组 织和筋膜，它们为器官提供保护和支 持。
脂肪和筋膜
脂肪组织
腹膜后隙内含有脂肪组织，它们可以提供能量、保温和缓冲作用。
筋膜
筋膜是一种坚韧的结缔组织，它包裹和分隔腹膜后隙内的各个器官，为器官提供支持和固定。
腹膜后肿瘤是指在腹膜后间隙内生长的肿瘤，包括良性肿瘤和恶性肿瘤。恶性肿瘤如脂肪肉瘤、平滑 肌肉瘤和神经鞘瘤等。
腹膜后癌症
腹膜后癌症是指发生在腹膜后间隙内的恶性肿瘤，如肾癌、肾上腺癌和结直肠癌等。这些癌症可能通 过直接浸润或淋巴结转移等方式侵犯腹膜后组织。
腹膜后间隙的断层解剖学研究进展
型 ：型、 Ｉ Ⅱ型 、 Ⅲ型 、 型 。 Ⅳ
内侧与围绕腹部大血管的结缔组织 附着 ， 进而粘附于腰椎 并
前的结缔组织 ， 两侧的肾周间 隙不 相通。陈成春等 研究表 明两侧肾周间隙存 在着 连通 和不连 通陌种类 型 ， 分别 占 ６ ． ９ ４ ％和 ３ ． ％。在连通类 型 中， ４ ０５ ６ 连通 部 位主要 在 肾门及其
２ １１ 旁前 间隙 Ｍ ｙｒ ．． ｅｅ 认 为 由于胰 腺特 殊 的位置本 身 ｓ
就是潜在的通 道 ， 肾旁前间隙左 、 右两侧是 相互通连 的； 间隙
内注入对 比剂后 Ｃ＇ Ｉ 扫描 也说 明两侧是相通 的。 ２ １２ 肾周 间隙 ．． 两侧 肾周间 隙是否 越 中线 连通 ， 过去 一 直存 在争议和意见分歧 。有研 究表 明’ 肾前筋膜 经腹部 大血 管前跨越 中线 ， 提示左右’ 肾周间隙相通 。多数研究认 为在肠
膜后间隙分为 肾旁前 间隙 、 肾周间 隙 、 肾旁后间隙 。近年来 ，
由于感染扩 散 、 科 引 流 和肿瘤 研 究等 领 域 的进 展 ， Ｔ和 外 ｃ
ＭＩ Ｒ 的广泛应用 ， 腹膜后间隙解剖 Ｅ渐为人们 所重视 。近年 ｔ
研究主要集 中在肾筋膜 的附着及 腹膜 后间 隙的横 向和纵 向
腹 膜 后 间隙 的断层 解 剖 学 研 究 进 展
李玮 毛赛 张峰 金 玉祥 杨德 军
【 关键词 】 腹膜后间隙； 解剖 【 中图分 类号 】 Ｒ８３ 【 １ 文献标识码】 Ａ 【 文章编号 】 １７ — ８６ ２０ ）１ ０２ — ３ ６２ ２７ （ ８０ — ０５ ０ ０
腹 膜 后 间 隙 （ｅｏｅｉｎａ ｓａｅ是 腹 后 壁 的 壁 腹 膜 和腹 ｒ ｒ ｒｏｅｌｐｃ） ｔｐ ｔ 横 筋 膜 之 间 区域 的 总 称 。腹 膜 后 间 隙 向 上 延 续 为 肝 脏 ， 向下
腹膜后解剖外文
Diagnostic and Interventional Imaging(2015)96,171—186PICTORIAL REVIEW/GastrointestinalimagingRadioanatomy of the retroperitoneal spaceA.Coffin∗,I.Boulay-Coletta,D.Sebbag-Sfez,M.ZinsRadiology department,Paris Saint-Joseph Hospitals,185,rue Raymond-Losserand,75014Paris,FranceKEYWORDSRetroperitonealspace;Kidneys;Cross-sectionalanatomyAbstract The retroperitoneum is a space situated behind the parietal peritoneum and in frontof the transversalis fascia.It contains further spaces that are separated by the fasciae,betweenwhich communication is possible with both the peritoneal cavity and the pelvis,according tothe theory of interfascial spread.The perirenal space has the shape of an inverted cone andcontains the kidneys,adrenal glands,and related vasculature.It is delineated by the anteriorand posterior renal fasciae,which surround the ureter and allow communication towards thepelvis.At the upper right pole,the perirenal space connects to the retrohepatic space at thebare area of the liver.There is communication between these two spaces through the Kneelandchannel.The anterior pararenal space contains the duodenum,pancreas,and the ascending anddescending colon.There is free communication within this space,and towards the mesenteriesalong the vessels.The posterior pararenal space,which contains fat,communicates with thepreperitoneal space at the anterior surface of the abdomen between the peritoneum and thetransversalis fascia,and allows communication with the contralateral posterior pararenal space.This space follows the length of the ureter to the pelvis,which explains the communicationbetween these areas and the length of the pelvic fasciae.©2014Éditions franc¸aises de radiologie.Published by Elsevier Masson SAS.All rights reserved.An accurate understanding of the anatomy of the retroperitoneum is essential in orderto understand most of the pathological phenomena that occur in this space and howthey spread within the various retroperitoneal compartments.As well as knowledge ofthe retroperitoneal compartments,an accurate understanding of the interconnectionsbetween the retroperitoneum,peritoneal cavity,and other extra-peritoneal spaces is cru-cial in order to understand the spread of inflammatory pathological processes or tumours.Abbreviations:APR,Anterior Pararenal Space;PPR,Posterior Pararenal Space;ARf,Anterior Renal Fascia;PRf,Posterior Renal Fascia.∗Corresponding author.E-mail address:alex surikat@yahoo.fr(A.Coffin)./10.1016/j.diii.2014.06.0152211-5684/©2014Éditions franc¸aises de radiologie.Published by Elsevier Masson SAS.All rights reserved.172A.Coffin et al.This review based on a description and interpretation of imaging findings aims to review the radiological anatomy of the retroperitoneum,with emphasis on the theory of interfascial spread to explain the various communications between this space and the peritoneal cavity .Review of anatomyThe retroperitoneal space is an anatomical structure delin-eated by the parietal peritoneum and the transversalis fascia.It is divided into five compartments (Fig.1).a)The lateral compartments:these are an asymmetrical pair containing the kidneys and other organs.Each lateral com-partment is divided by the fasciae into three separate spaces:the anterior pararenal (APR),perirenal,and pos-terior pararenal (PPR)spaces.The APR space contains part of the ascending colon,descending colon,and the duode-num and pancreas.The perirenal spaces contain the kidneys,adrenal glands,ureters,blood vessels and lymphatics.The PPR space only contains fat.b)A central vascular compart-ment,extending from D12to L4-L5,located between the two perirenal spaces,behind the anterior perirenal space,and in front of the spine.This contains the abdominal aorta and its branches,the inferior vena cava and its afferent vasculature,lymphatic chains and the abdominal sympa-thetic trunk.c)T wo symmetrical posterior compartments,containing the psoas major ,which joins the iliacus muscle and sometimes the psoas minor ,terminating at the arch of the hip bone.The psoas major extends from T12to the lesser trochanter ,and it is covered with transversalis fas-cia,which is known as iliac fascia in this area.The iliopsoas compartment is generally considered to be retroperitoneal even though it is behind the transversalis fascia because it is frequently involved in processes that begin in the retroperi-toneum.Review of embryologyIt is necessary to review the embryology in order to under-stand the formation of the perirenal compartment and to introduce the theory of planes of interfascialspread.Figure 1.Mapping the retroperitoneum.a):view of the retroperitoneal space on an axial CT cross-section passing through both kidneys:the retroperitoneal space (in red)is located between the parietal peritoneum (in green)and the transversalis fascia (in brown).b):the five retroperitoneal compartments:Lateral retroperitoneal compartments (in blue),median ‘‘vascular’’retroperitoneal compartment (in red),posterior ‘‘iliospsoas’’retroperitoneal compartments (in orange).c):three spaces of the lateral compartment:APR (in blue),perirenal (in yellow),PPR (in purple).The mesenchyme is the posterior part of the embryo,and it develops into the elements of the body wall [1].It is covered by the transversalis fascia,a lamina of contin-uous connective tissue that separates its components from the abdominal cavity .Fig.2a summarizes the embryological organization of the retroperitoneal space.The intermedi-ary mesoderm forms the primordium of the genitourinary system,and it is shown in Fig.2b and c.The metanephros develops into the secretory urinary apparatus,and from here the initially caudal renal primordia will ascend in a posterior and caudo-rostral direction,in parallel with the descent of the excretory urinary apparatus and gonads.Fig.3summarizes the organization of the retroperi-toneum after the ascension of the renal primordia.This is a key moment in the formation of the retroperi-toneum,delineating a fat-containing space into different spaces bordered by fasciae.The fasciae are lamina of con-nective tissue approximately 2mm thick that will make up the partitions between the various compartments of the retroperitoneum [1].Perirenal spaceThe fasciaeThe perirenal space has the shape of an inverted cone with the point directed at the pelvis,and the base resting on the diaphragm [5].Fig.4summarizes the borders of the perire-nal space.The PRf is in fact made up of two apposed lamina,one superficial and one deep,which explains why it is more easily visible on imaging [1].The superficial lamina of the PRf is made up of the lateroconal fascia,which extends in front and attaches to the peritoneum.Fig.5summarizes the anatomy of the PRf.Fig.6shows invasion of the renal fasciae secondary to acute pancreatitis.Superior border of the perirenal spaceThe right perirenal space has an unusual feature.Here,the perirenal space is in direct contact with the posterior sur-face of the right kidney ,and has no peritoneal covering:this is the bare area of the liver .This feature is explained by theRadioanatomy of the retroperitoneal space173Figure 2.Diagram of the embryological origins of the components of the retroperitoneum.a:axial view.The mesenchyme will form the vertebral bodies (in blue)and the muscular components of the abdominal wall,which are the paraspinal,psoas,and transverse abdominal muscles (in orange)[1].Isolated between the transversalis fascia (in brown)and the parietal peritoneum (in green),fatty tissue is found at the dorsal side of the embryo (in yellow),which will become the posterior pararenal space.This fatty space will contain the renal primordia,which originates from the intermediary mesoderm.b:sagittal cross-sectional diagram of an embryo showing the intermediary mesoderm.It is divided into three parts organized rostro-caudally:the pronephros (in blue),which is most cranial,the mesonephros (in orange),and the metanephros (in green),the most caudal.The pronephros eventually atrophies.The mesonephros will develop into the excretory urinary apparatus and the genital organs.The mesonephric or Wolffian duct develops in males into the vas deferens,the ejaculatory duct,and the ureteric bud.The paramesonephric or Müllerian ducts develop into the components of the female genital system.c:organization of the mesonephros.Wolffian duct (in blue),Müllerian duct (in pink),primitive gonads (in red).Primitive gut in front (in yellow),parietal and visceral peritoneum (in light green),posterior vertebral primordium (white star).formation of peritoneal folds at the posterior part of the liver ,creating the falciform,coronary ,right triangular and left triangular ligaments,and it directly exposes the liver to the retroperitoneal space behind.Fig.7summarizes the anatomy of the bare area of the liver .On the left,the ARf fuses with the diaphragm leaving a free space above the adrenal gland,which is in fact part of the perirenal space (Fig.8shows that the bare area of the liver is visible on a CT scan.Midline extension of the perirenal fasciaeThe PRf fuses with the fascia of the quadratus lumborum muscle at the posterior part of the perirenal space,as shown in Fig.10.The ARf adheres to the connective tissue that surrounds the large vessels at L3—L5[3].Here,there is a theoretical conduit between the two perirenal spaces known as the ‘‘Kneeland channel’’,and it is thought to allow free diffusion within the trabecula of the connective tissue,in front of the aorta and the vena cava (Fig.11).Inferior extension of the perirenal fasciaeThe fusion of the PRf and ARf around the ureter borders the inferior part of the cone of renal fascia.Among the theories contested,there has for a long time been a lack of certainty over the inferior part of this space,with some describing free communication to this area [5],which would allow for a connection between the APR and PPR space,as if the cone was opened into the other retroperitoneal spaces;other articles describe the inferior part of the perirenal space as being a true anatomical border ,while sometimes allow-ing for an extension towards the pelvis,without giving any further details about how this communication operates [5].We have used the results of a number of cadaver studies [1—4],as well as the embryology of the renal and urinary system,with the metanephros (renal primordium)attaching to the ureteric bud that forms the ureter ,and both ascend-ing towards the lumbar fossae surrounded by their fasciae,to explain the anatomical relationships in the inferior part of the perirenal space.The authors of cadaver studies injected tracer dyes into different spaces in the retroperitoneum in order to observe how they diffused between the layers of fasciae and to explain the communications between them and the pelvis.Everything passes around the ureter as sum-marized in Fig.12.On MRI,the anterior and posterior fasciae are perfectly visualized as they surround the ureter ,then fuse together with the connective tissue surrounding it that delineates the inferior part of the cone of perirenal fascia.Behind,the fatty PPR space passes laterally to the ureter ,which is closer to the midline,and in this way ,continues without fusion between the peritoneum and the transver-salis (or iliac)fascia.Bridging septa of the perirenal spaceThere is a network of septa that supports the kidneys.Three types have been described,depending on where they attach,as summarized in Fig.13[3].Anterior pararenal space:APRContentsThe APR space is bordered anteriorly by the posterior pari-etal peritoneum,posteriorly by the ARf,and laterally by the lateroconal fascia.This means that it contains sections174 A.Coffin etal.Figure3.Sagittal diagram of the ascending renal capsule showing the lateral retroperitoneal compartment.a):The renal primordium (in yellow)originates from the metanephros,which is initially located in the pelvis.The space(in pink)behind the peritoneal cavity(in green)is shown to contain only fat.b)and c):The renal primordium(in yellow)with its surrounding fasciae forms the renal capsule,which ascends into the fatty retroperitoneal space.d)The fusion of the perirenal space(in yellow)to the diaphragm will delineate the APR space (in blue)in front and the PPR space behind(in pink),which will never contain anything other than fat[2].of the ascending colon,descending colon,duodenum and pancreas[6](Fig.14).Review of peritoneal radioanatomyThree fundamental events change the initial embryologi-cal arrangement of the peritoneum:the gastric primordium shifts by90◦and the primitive gut rotates around the supe-rior mesenteric artery towards the viscera;the omental bursa and greater omentum are formed;and the spleen and pancreas develop.The primitive gut develops outside the abdominal cavity.When the intestinal loops are reintegrated into the abdominal cavity,the colon is pushed back as a result,and in the majority of cases its peritoneum fuses with the posterior part of the underlying connective tis-sue through a process of mechanical change that leads to the formation of the fasciae of T oldt,which leads to the ascending and descending colons settling in theirfinal pos-itions,and becomingfixed in the abdominal cavity.Where there is abnormal intestinal rotation,variant positions may be seen for the ascending or descending colons,which can become mobile within the abdomen if the fasciae of T oldt are missing.Radiological anatomy considers an organ to be intraperitoneal when its whole outline is covered with peri-toneum,which means that the ascending and descending colons are considered to be‘‘retroperitoneal’’because of the posterior fusion of their peritoneum with the underly-ing connective tissue that leaves them in communication with the APR space.We see examples of this relationship, especially in retrocaecal appendicitis or ruptured posterior colonic diverticulitis causing pneumoretroperitoneum with no communication with the peritoneal cavity[7].The devel-opment of the spleen and pancreas,due to the growth of the spleen and its displacement into the left hypochondrium, explains how the head of the pancreas comes to be found in a retroperitoneal position,and this is summarized in Fig.15. The formation of the omental bursa and greater omen-tum also involves this same phenomenon of fusion betweenRadioanatomy of the retroperitoneal space175Figure4.Perirenal space.a:diagram of the‘‘renal cone’’.The anterior border of this cone is the anterior renal fascia(ARf)or Gerota’s fascia(in blue),and the posterior border is the posterior renal fascia(PRf)or Zuckerkandl’s fascia(in red)[3].These two fasciae are continuous with each other and constitute the walls of the cone.Kidney(star),adrenal gland(white arrow),ureter(black arrow).b:axial contrast-enhanced CT view,passing through the left renal hilum.Kidney(star),ARf(blue),and PRf(red).the different layers of fascia and peritoneum,as shown in Fig.16.Borders of the APR spaceThe superior and inferior borders of the APR space are sum-marized in Fig.17).Fig.9.Posterior pararenal spaceThe borders of the PPR space are summarized in Fig.18.At its upper part,the PPR space is bordered by the diaphragm, the PRf in front and the transversalis fascia behind.There is a weaker area at the lumbar triangle between the quadratus lumborum muscle and the lateral abdominal muscles,where there is only a single layer of transversalis fascia,which means that this area has less resistance to expanding lesions. Theory of interfascial spreadThe retroperitoneum forms when the renal primordia and the surrounding fasciae ascend,delineating the retroperi-toneum into different spaces.The fusion of the various fasciae,or of the peritoneum,creates potential spaces between the various compartments that slide against each other.If large volumes offluid accumulate quickly,the storage capacity of the retroperitoneal spaces may be over-whelmed,causing thefluid to seek decompression planes within these sliding potential spaces[1].This has been observed in a number of cadaver studies, with direct observation of the spread of dyedfluid along these potential spaces,between the compartments of the retroperitoneum.Anterior interfascial or retromesenteric planeThe mesoduodenum is found pressed against the posterior wall of the peritoneal cavity,due to intestinal rotation and the formation of the spleen.Its laminae eventually fuse with the parietal peritoneum and the fatty posterior struc-tures,creating a potential space that can become a sitefor Figure5.Posterior renal fascia.a:axial CT view at the left renal hilum.The deep lamina of the PRf(in pink)is continuous with the ARf(in blue).The superficial portion of the PRf(in purple)is continuous with the lateroconal fascia(in purple),which will itself fuse(black arrow) with the parietal peritoneum(in green)in front and form the lateral border between the APR and PPR spaces.Perirenal space(star).b: lateral border of the retroperitoneum.The lateroconal fascia delineates the lateral portion of the retroperitoneum.Border of the APR space (in blue)in front and laterally,fusing(thin white arrow)with the parietal peritoneum.Anterointernal border of the PPR space(in purple) fusing with the transversalis fascia,which it runs along laterally.It delineates the preperitoneal space,located between the transversalis fascia(wide black arrow)—which forms the external border of this space—and the fusion of the lateroconal fascia and the peritoneum(thin white arrow)(which forms the internal border of this space).Because of this,there is the possibility of communication between the PPR spaces,passing through this preperitoneal space to the anterior part of the abdomen(purple arrow).ARf(thin black arrow)and PRf(wide white arrow).176A.Coffin etal.Figure 6.Invasion of the renal fasciae secondary to a fluid collection in pancreatitis.A 46-year-old patient,contrast-enhanced abdominal CT .a):axial view:fluid collection in pancreatitis (white arrow)with effusion in the perirenal spaces (black arrow)and the APR space (red arrow).b):axial view:invasion along the ARf (white arrow),PRf (red arrow),and lateroconal fascia (black arrow).c):axial view:invasion of the APR space (white arrow)and lateroconal fascia (red arrow).fluid collections.For example,in their study ,Gore et al.[1]found that a fluid injected at the pancreas spread into a space located behind the APR space and in front of the ARf.They described the various communications of the interfas-cial retromesenteric plane,which are shown in Fig.19.The fluid eventually spreads to the fascial trifurcation:between the laminae of the ARf,superficial PRf,and lateroconal fas-cia,around the perirenal space,creating the lateroconal and posterior interfascial decompression planes.Combined interfascial planeThis is a potential space between the laminae of the ARf and the PRf around the ureter ,into which fluidcollections from the perirenal space can spread to reach the pelvis.Posterior interfascial planeThis space is related to the formation of the PRf and it con-sists of two laminae of fused connective tissue,and it is summarized in Fig.20a.Lateroconal interfascial plane (Fig.20b)This is described as being a potential space that is able to expand within the laminae of the connective tissue of the lateroconal fascia (which is made up of multiple layers of connectivetissue).Figure 7.Bare area of the liver .a:diagram of a posterior view of the liver .The ARf (in blue)fuses with the right part of the inferior layer of the coronary ligament (in green),leaving the bare area of the liver (in orange)in direct contact with the perirenal space.The APR space is not involved in this communication,as it is located in front,between the ARf and the parietal peritoneum (large white arrow)with the continuity of the coronary ligament.Falciform ligament (black arrow).b:diagram of a sagittal abdominal cross-section:superior border of the perirenal space.Liver (L),bare area of the liver (A),perirenal space (black star),ARf (in blue),PRf (in pink),diaphragm (in beige).On both the left and right the PRf fuses with the diaphragm,thus,enclosing the cone of the perirenal space.Radioanatomy of the retroperitoneal space177Figure 8.Superior border of the left perirenal space.Diagram of a sagittal cross-section through the left perirenal space.Spleen (S),diaphragm (beige),ARf in blue,PRf in pink.Perirenal space (star).Communication routesAPR spaceThe various midline communication routes of the APR space with the mesenteries and the pelvis are summarized in Fig.21.Fig.22illustrates the communication of a pan-creatic pseudocyst with the descending colon.The ureter runs towards the pelvis passing under the parietal peri-toneum,crossing in front of the iliac vessels,and then once again meeting the bladder at the perivesical space.On the left the ureter runs under the primary root of the sigmoidmesocolon,in front of the iliac vessels (Fig.23).In the pelvic cavity ,the ureter with its surrounding renal fasciae passes between the sigmoid mesocolon,the rectal mesen-tery ,and the fasciae surrounding the neurovascular bundles as shown in Fig.24a,allowing for interfascial passage to the presacral space.Finally ,it is possible that anterior spread may occur along the umbilical prevesical fascia as described in Fig.24b.All of these fasciae are easily visible on MRI.Fig.25illustrates spread from the perivesical space to the retroperitoneum during a traumatic bladder lavage in a 54-year-old patient.Perirenal spaceThere is a midline passage between the two perirenal spaces in the form of the Kneeland channel [4].Mindell describes in his study one case in which a contrast medium was blocked from spreading between the perirenal spaces through this channel by a voluminous abdominal aor-tic aneurysm,and it was displaced in front of the bifurcation of the iliac vessels [4].There is also the possibility of upward spread:towards the bare area of the liver ,but also the medi-astinum and the sub-pleural space,via the lesser apertures of the crura of the diaphragm,and multiple lymphatics [1,3].The perirenal space communicates with the pelvis [4]along the combined interfascial plane (seen in 100%or 5cases in Mindell’s study [4]).Posterior pararenal (PPR)spaceThis space communicates with the preperitoneal fat by run-ning along the lateroconal fascia,which,in fusing with the parietal peritoneum,leaves a space for communication between the lateroconal fascia medially and the transver-salis fascia laterally .From here,the two PPR spaces can communicate with each other [3].Another communication route is towards the pelvis,following the ureter in the same way as in the APR space.MRI clearly demonstrates the pathway from the fatty PPR space along the length of the ureter between the fascia of the iliac perivascular spaces and the sigmoid mesocolon,then allowing spread into the perivesical space medially ,towards the sigmoid mesocolon behind and along the perivascular spaces laterally.Figure 9.Bare area of the liver .60-year-old patient,postoperative CT without contrast-enhancement.Axial view a and sagittal view b:Peritoneal effusion (white arrow)sparing the bare area of the liver (red arrow)delineated by the ARf (blue arrow).178 A.Coffin et al.Figure10.Medial border of the fasciae.a:axial CT view through the left renal hilum.The fusion of the PRf(in pink)to the quadratus lumborum muscle continues downwards to become increasingly medial,as far as the transversalis fascia(in light green)next to the psoas muscle.Parietal peritoneum(in green),ARf(in blue).Lateroconal fascia(in light pink),continuous with the PRf.b:a lower axial CT view through the inferior pole of the kidney.The PRf joins with the transversalis fascia increasingly medially.c:axial view lower still,the PRf is at the midline.Figure11.Medial extension of the ARf.a:diagram of an axial cross-section through the inferior pole of the kidneys.ARf(in blue). Perivascular connective tissue(in light blue).b:the theory of the Kneeland channel(light blue)is based on the spread of afluid collection between the two perirenal spaces(star)through the perivascular connective tissuefibres.Radioanatomy of the retroperitoneal space179Figure12.Inferior extension of the perirenal fasciae.a:diagram of an axial cross-section through the inferior part of the renal cone.In front:a lamina of parietal peritoneum(dark green),covering a strip of ARf(in blue)flattened against the ureter(in yellow),and continuous with the PRf(in purple)at the posterior part of the ureter.Behind:a layer of fatty tissue:the PPR space(in brown),andfinally the transversalis fascia(light green)which then covers the psoas muscle(shaded area).b:diagram of an oblique cross-section showing how the various laminae of the retroperitoneum are superimposed and attach to each other above at the diaphragm(D)with from front to back: the parietal peritoneum(dark green),the ARf in blue,the kidney and ureter(in yellow),the PRf(in pink),the PPR space in orange,the transversalis fascia(light green)andfinally the psoas muscle(P)in front of the iliac wing.Figure13.Bridging septa of the perirenal space.Axial CT view through the left kidney:from a)to c),ARf and PRf in beige.a)The type I septa(in yellow)extend from the perirenal fascia to the renal capsule.b)Type II(in red)run from capsule to capsule,forming a curved arch, of which one is constant:the posterior renorenal septum,where a perirenal haematoma bordered by this septum can mimic a subcapsular haematoma.c)Type III septa(in green)connect the ARf to the PRf.d)Network created by the bridging septa that support the kidney.180 A.Coffin et al.Figure14.APR space.Simplified axial CT view through the kid-neys and duodenum.Parietal peritoneum(in green)delineating theperitoneal cavity.The ARf(in blue)borders the posterior surface ofthe APR space.The lateroconal fascia(in purple)borders the APRspace laterally.Ascending colon(brown,asterisk)on the right,anddescending colon(brown,white circle);duodenum and pancreas(inpurple).Figure15.Diagram of retropancreatic and peritoneal fusion.a)Axial cross-section at the embryonic stage with the primordia of various organs surrounded by peritoneum(in green).Primordium of liver(in orange),primitive gut(in yellow),primordium of spleen(in red),and primordium of pancreas(in purple).The folds of peritoneum form the various ligaments marked on the diagram.b)and c)Peritoneal and retropancreatic folds:the primordium of pancreas(in purple)is atfirst surrounded by peritoneum like the rest of the visceral primordia.The development of the spleen causes the pancreas to move to the left in a clockwise direction.This means that the left lateral fold of visceral peritoneum thatfinds itself in contact with the lamina of parietal peritoneum fuses with it(cross-hatched area),which leads in particular to the formation of the Treitz fascia at its uppermost part.d)The fusion of these layers of peritoneum with the posterior connective tissue through mechanical change is accompanied by a change in their texture,and leaves the duodenum and pancreas in communication with the retroperitoneal space,thus making them into‘‘retroperitoneal’’organs.Figure16.Formation of the omental bursa.Sagittal cross-sections through the lesser sac.a)Initially there is a vestigial yolk sac between the liver(L)above and in front,the stomach(S)below and in front,and the pancreas(P)below and behind,forming the omental bursa(in light green).The simplified laminae of peritoneum are shown(in dark green)around the organs represented in cross-section:the duodenum (D),transverse colon(C),and intestine(I).b)A small protuberance from the bursa will then infiltrate in front of the pancreas and behind the stomach,running downwards,accompanied by the peritoneum surrounding these viscera(four layers of peritoneal fascia).c)As it grows,this protuberance forms a true pocket,the walls of which,made up of peritoneum,will fuse together to form the greater omentum (corresponding to the four apposed layers of peritoneum,in blue)which fuses to its posterior part with the transverse colon.In parallel with the formation of the greater omentum,the pancreas and the duodenum behind become closer together until their peritoneal fasciaefuse(in pink),which explains how the duodenum,from around its second to fourth parts,is found in a retroperitoneal position.Figure17.Diagram of the borders of the APR space.a)Diagram of a sagittal cross-section through the kidney(K)and liver(L).The peritoneum(in green)forms the anterior border of the APR space.The ARf(in blue)is the posterior border.On the right,the superior border of the APR space is where the ARf behind and the peritoneum in front fuse(black arrow).The ARf fuses with the diaphragm on the left and at the inferior layer of the coronary ligament on the right.b)Inferior border of the APR space,diagram of an axial cross-section through the inferior point of the‘‘renal cone’’(shown by the white dotted line onfigure a).The inferior borders are the fusion of the ARf(in blue) to the parietal peritoneum(asterisk)in front,and the fusion of the ARf to the periureteral connective tissue(yellow)behind.The PRf(in pink)is joined to the posterior surface of the ureter,in front of the PPR space(in orange)with its fatty content resting on the transversalisfascia(light green)that covers the psoas muscle(P).。
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肾周间隙感染
• 主要来源于肾脓肿、肾盂肾炎的肾周蔓延 及胰腺炎向后扩散等。
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肾后间隙感染
• 内无器官，感染多继发于其他间隙的腹膜 后扩散或来自于后腹壁炎症。
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定位诊断：腹腔？腹膜后？
1.腹膜后器官向前向外侧移位(血管包绕其中 ) 2.肠管前移，无肠管包绕 3.肿块与腹膜后脏器分界不清，但肿块最大 径线仍在脏器之外 4.肿瘤与相邻腹腔内器官的脂肪间隔存在， 提示肿瘤位于腹膜后 5.脊柱、腰大肌受侵，肿块与后腹壁或盆壁 肌肉间脂肪间隙不清。
• 两侧肾旁后间隙在内侧中线处不相通，但 通过前腹壁的腹膜外脂肪层使两侧间隙在 前方潜在相通。
• 小结：一个间隙的病变，可因脓液、胰酶 、肿瘤侵蚀，波及其他间隙。
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肾旁前间隙感染
• 常来源于胰腺炎，及升降结肠、十二指肠 的腹膜后穿孔。
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腹膜后间隙
肝胆外科 拓航
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• 腹膜后间隙是指位于腹膜壁层后部分与腹 后壁腹横筋膜之间，上至横膈，下达盆腔 的一个立体间隙。
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解剖划分（meyers）
• 根据尸体断面间隙灌注后对比，以肾筋膜 为主要解剖标志，将其划分为：
• 肾旁前间隙 • 肾旁后间隙 • 肾周间隙
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肾周间隙
• 由肾前筋膜、肾后筋膜构成。 • 包括肾脏、肾上腺 • 输尿管（近段） • 肾血管及肾周脂肪。
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肾周间隙交通
• 内侧：一般认为不相通 • 上方：不相通 • 下方：肾周间隙呈开放性，同侧三间隙在髂棘平面以下相
通。
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肾旁前间隙
• 腹膜后以后与肾前筋膜锥侧筋膜之间的 区域。
• 包括胰腺大部分、升降结肠 • 十二指肠二三段、 • 腹主动脉重要分支和汇入下腔静脉的几个
主支。
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肾旁前间隙交通
• 该间隙内侧位于胰腺水平，中线处相交通 ，其余方向不相通。下方同其余间隙相通 。
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肾旁后间隙
• 肾后筋膜和锥侧筋膜后外方与腹横筋膜之 间的区域。
• 内无脏器，主要为脂肪组织。向前与腹膜 外脂肪层连续，上至横膈，下达盆腔。
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肾旁后间隙交通
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原发？腹膜后
• 鸟嘴征＋ • 肿瘤来源器官
鸟嘴征— 肿瘤不来源器官
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