Correlative

anatomy

computed

tomography:

A module

on the pancreas

abdominal

Carl

J.

w.

Pallie,

An

Zylak,

M.D.

of the

ofits

Several

layered

texts

images

scans

lases.

appeared
anatomy

as represented

they

are

of limited

by clinical

drawings

illustrating

2.

layered
Normal
CT

3.

Abnormal

An appreciation

with

Introduction

relate

old anatomic

at-

of living

To facilitate

the

the following:

the basic

morphologic

concept

of

of the anatomy.

interpretation

Considered

tomothey

interpretation

tomography.

presents

of the retroperitoneum
nature.

computed

by various

retroperitoneum.
images
with interpretation
CT images

of its layered

an under-

In general,

in the

computed

this exhibit

the

from

to correlate

anatomy.

value

of CT scans,

Schematic

stems

seek

human

as recorded

interpretation

which

cross-sectional

to cadaveric

anatomy

retroperitoneum

nature.

have

with

Accordingly,

posterior

MB.

standing

CT

and

wall

appreciation

graphic

and

of the pathology.
stems

from

from

posterior

an understanding

to anterior,

one

may

distinguish:
1

A musculoaponeurotic

and

psoas

mentous

The

2.

3.

plane,

muscles,

the

posterior

pararenal

space,

which

fat, the extraperitoneal

wall.
The perirenal

space

anterior

the Departments

Hamilton,

which

pararenal

posterior
peritoneum,
It lies immediately

From

the quadratus
crura

and

lumborum

associated

liga-

fascia.

properitoneal

4. The

Centre,

embracing

diaphragmatic

space

anteriorly

which

by the renal
is limited

Anatomy,

McMaster

the

abdominal
fascias.

anteriorly

which
is continuous
across
to the perirenal
space.

and

into

fat of the anterior

is contained

and
anterior

of Radiology

continues

University

the

by

the

midline.

and

Medical

Ontario.

Volume

1, Number

May

1981

RadioGraphics

61

Zylak, Pallie
Correlative

Anatomy

Normal

anatomy,

LIGAMENTS

Figure

AND

Computed

Tomography

posterior

abdominal

wall:

MUSCLES

lA

Coronal

schematic.

Heavy

lines indicate
the median
ligament
across
the crura

black
arcuate
of the

diaphragm
(dotted
lines),
medial
arcuate
ligament
over
psoas muscle,
ate ligament

the
the

and the lateral

arcuover the quadratus

lumborum

muscle.

Figure

lB

Cross-sectional
strating
the
the right
phragm,

schematic
demonfascial
relationships
of

and left crura of the diathe

psoas
muscle,
the

quadratus
the

and

lumborum

sacrospinalis

muscle

and

muscle.

FAT

FASCIA

(A

ontenor

M)

middle
poster

TRANSVERSAHS

Laminae

(P

or

B
Key:

CRL

#{174}
=
aorta;
=

muscle;
posterior
crospinalis

Ab-R

left diaphragmatic
10 = internal
inferior
muscle;
muscle;
TD

rectus

aixlominis

crus; CRR
oblique
muscle;

muscle;
right
MLD

Ps
psoas muscle;
thoracic
duct; TR

ALL

diaphragmatic
latissimus
QL

anterior

longitudinal

crus; EO
dorsi muscle;

ligament;

external
MSPI

quadratus
lumborum
muscle;
SSp
satransverse
abdominis
muscle;
VA
azygos

vein.

62

RadioGraphics

May

oblique
serratus

1981

Volume

1, Number

Zylak, Pallie
Correlative

Normal

anatomy,

Anatomy

and

Computed

Tomography

retroperitoneum:

KIDNEYS

Figure

2A

Coronal
schematic
showing
position
of
kidneys,
adrenals
and the aorta relative
to the muscles
and ligaments
of the postenor

abdominal

Figure

wall.

2B

Cross-sectional
perirenal
anterior
fascia.

schematic

fat
and
The

(black

extraperitoneal
wall. The

fat of the abtransversalis

fascia

line)

lies

external

to

the

extra

fat.
2C

Coronal
blends

the

by the
of renal

renal fat (hatched)

with the flank fat

peritoneal
Figure

showing
enclosed
layers

posterior
laterally

is continuous

and the
dominal

(stippled)
posterior

schematic.
with

the

The
adjacent

renal

fascia

fascias

in

all

directions.

Figure
Parasagittal
lationships
posterior

Volume

1, Number

May

1981

RadioGraphics

2D
schematic
of the
pararenal

showing

perirenal
(hatched)

the

(stippled)

reand

spaces.

63

Zylak,

Pallie

Correlative

Anatomy

Normal

anatomy,

INFERIOR

Figure

Computed

Tomography

retroperitoneum:

VENA

CAVA,

RENAL

VEINS,

KIDNEYS,

URETERS

3A

Coronal

cava,

and

schematic

with

renal

veins

the

the

inferior

and

the

vena

ureters

added.

Figure

3B

Cross-sectional

schematic.

(stippled)

is enclosed

posterior

which
space

layers

aorta,
the
structures

perirenal

by the

of the

lie anterior
(hatched).

The
renal

fat

anterior
fascia

to the posterior
In the midline

and
both

of

pararenal
region,
the

inferior
of the

vena cava and the

kidneys
with their

rounding

fascias

effectively

perirenal

spaces.

shut

hilar
sur-

off

the

Figure
3C
A radiograph
showing

of a cadaver

the

conspicuous

cross

fat in the

section

perirenal

.---

64

space

and

its delimitation

in the

midline

by fascial

tissue

II

area.

RadioGraphics

May

1981

Volume

1, Number

.
_%_

Zylak, Pallie
Correlative

Normal
VASCULAR

anatomy,

Anatomy

and

Computed

Tomography

retroperitoneum:

RELATIONSHIPS

Figure

4A

Coronal
itoneum

schematic
showing

tionships

as well

the spleen.
vein

joins

of the retropervascular
relaas the

The

inferior

position

of

mesenteric

the splenic

vein

which

in

turn is joined
by the superior
mesenteric
vein to form the portal vein
which
crosses to the right. The left
renal
vein lies posterior
to the superior
splenic

mesenteric
vein crosses

superior

mesenteric

vessels;
anterior

the
to the

artery.

Figure
4B
Cross-sectional
again demonstrating
relationships.
The
lies anterior

aorta

and

to the

the vena

schematic
vascular
portal vein
plane

of the

cava.

Key:
=

IMV

inferior mesenteric vein; IVC

vena cava; PV
vein; SA = splenic

renal

mesenteric
SV

aorta;

inferior

artery;

SMV

portal
artery;

vein; RV(L) = left

SMA = superior

superior

mesenteric

vein;

splenic vein.

Volume

1, Number

May

1981

RadioGraphics

65

Zylak,

Pallie

Correlative

Anatomy

Normal

anatomy,

DUODENUM,

Figure

and

Computed

Tomography

retroperitoneum:

PANCREAS

5A

Coronal

schematic

ships

of the

showing

duodenum

the

and

relation-

pancreas.

The

uncinate
process
of the pancreas
behind
the superior
mesenteric
which
lie anterior
to the horizontal
portion
of the duodenum.
The
artery

is shown

above

Figure
5B
Cross-sectional
pararenal

the duodenum.

schematic.

The

compartment

the pancreas,
posteriorly,

anterior

(stippled)

contains

duodenum
and,
the aorta, inferior

duodenojejunal

hooks
vessels
(third)
hepatic

flexure

and

imbedded
vena cava,

the

ascending

and descending
colon.
On each side, extensions
of this space in the flanks,
merge
with the extraperitoneal
fat layers.
Figure

5C

Parasaggital
tionship

schematic
of the

pararenal
stippled),
(hatched).

showing

three

spaces:

(stippled),
and
the
(1)
5D
section

demonstrating

creatic

(anterior

pararenal

connecting

the

peripancompartment)

with

transverse

rela-

the perirenal
(finely
posterior
pararenal

Figure
Saggital
spaces

the

the anterior

the

colon

mesenteries

and

the

of

small

bowel.

Key:
CD

A
=

aorta;

HA

duodenum;
=
hepatic

Jejunum;

66

colon;

descending

pancreas;

colon;

CA

CT

D2
second
artery;
IVC
KL

St

left kidney;
stomach.

ascending
colon;
transverse
colon; D

portion
of duodenum;
inferior
vena cava;
KR

right kidney;
C

RadioGraphics

May

1981

Volume

1, Number

Zylak, Pallie
Correlative

Normal

anatomy,

and

Computed

May

1981

Tomography

retroperitoneum:

TOPOGRAPHY

PANCREATIC

SUBEOSTAL

Figure

Anatomy

PLANE

Volume

1, Number

RadioGraphics

67

Zylak, Pallie
Correlative

Normal

Anatomy

and

anatomy,

PANCREATIC

Computed

Tomography

retroperitoneum:

MEASUREMENTS,

VARIATIONS

IN

POSITION
PM

:------

TAIL

--

CT

SCAN

MEANIS
5w

!2
20

Sr

Figure

19rnr

95

Sagittal,

24

coronal

and

schematic

onstrating

the

positional

23mm
03)

crossdem-

relationships,

variation

measurements

and

of the

pan-

creas.

::iI
Figure
8A
Schematic
representation of the anatomic
relationships
of structures
about
the biliary
and
pancreatic

gram
illustrating

D2

duodenum;
HA

pancreatic
vein.

68

retroperitoneum:

RELATED

TO

DUCTS

relationships
in Figure

Key:

STRUCTURES

anatomy,

ducts.

Figure
8B
Endoscopic
retrograde
choledochopancreato

shown

Normal

8A.

second
GB

hepatic

duct;

portion

of

gallbladder;

artery;
PV

Pd
=

portal

RadioGraphics

May

1981

Volume

1, Number

51

9)

sectional

L4r

116

IT?

20

20w
3 0r

I!

17

ULTRASOUND

20
(14)

Zylak,
Correlative

Normal

cross-sectional

SUBCOSTAL

PLANE

(CT)

Anatomy

and

(L3)

PLANE

OF

L2

(INFERIOR)

The

uncinate

Figures
9A & B
This scan lies caudad
through

the

portion

of the

aorta,

vena

perirenal

perior

mesenteric

and

and

Key:

psoas

uncinate

of the
CA

scan

subcostal

Posteriorly

lie the

the

kidneys

and

(not

ureters,

lie

the

identified),
The

flank

pancreas

superior
su-

aorta

the

transverse

ascending

of the colon

lies

fied

(L2).
is defined

mesenteric
colon
(on

small

bowel

portion

of

cephalad
in the

vessels

posteriorly.

gallbladder

the

immediately

plane

the
(on

right),
the

midline

anteriorly

Anterior
(in the

to

midline),
and

to

the

process

these
the
loops

of

by

the

and

the

lie
liver

the
and

of opaci-

left).

kidneys
ascending

gallbladder;
IVC
muscle; SMA = superior
-

process

This

(third)

colon.

portions

cutting

1OA & B

horizontal

Anteriorly

transverse

aorta;
GB

cava,
vessels

poles

duodenum;

the

space.

descending

inferior

to the pancreas,
of

duodenum.

inferior

jejunum

Figures

plane

in the

Pallie

Tomography

anatomy:

PS

Computed

colon;

CD

descending

inferior
vena cava; K(R)
mesenteric
artery;
SMV

colon;

DII

& K(L)
superior

second

right and left kidneys;

mesenteric
vein; UP

of pancreas.

Volume

1, Number

May

1981

RadioGraphics

69

Zylak, Pallie
Correlative

Normal

cross-sectional

PLANE

OF

L2

Anatomy

(CT)

and

Computed

Tomography

anatomy:
TRANSPYLORIC

(SUPERIOR)

Scan

hA
at the

Figures

& B
level

of L2. Two

veins,

and splenic,
cross the midline
superior
mesenteric
vessels.
right

kidney

lies

the

the

left

separated
Anterior

duodenum,

the pancreas,
the inferior
right crus of the diaphragm.

vena

to the duodenum.

the

head

of

cava,

and

the

cross

RadioGraphics

the

perior
drium
flexure

Key (pages
(lenum;

12A & B

Scan through
transverse
The head of the pancreas

renal

by the
to the

aphragm;

70

(Li.)

Figures

PLANE

70 and
D

GB

May

aorta;

body

duodenum;

71): A

Dl

first

portion

gallbladder;

1981

Volume

head

midline

The

pyloric
plane (L12).
is shown in relation
pancreas

anterior

continues

to the

aorta

to

and

su-

mesenteric
vessels. The left hypochoncontains
loops
of jejunum,
splenic
and the lower end of the spleen.
of pancreas;
of duodenum;

of pancreas;

1, Number

IVC

colon;
D2
inferior

CRR

right

second

portion

vena

cava;

crus

of diof duo-

jejunum;

Zylak,
Correlative

Normal

cross-sectional

PLANE

OF

Li

(CT)

the

pancreas

creas;

SM
TO

crosses

superior

LO
lesser omentum;
& L(K)
right and

body of
anteri-

mesenteric

omentale

vessels;

left
Sp

OF

Li

(SUPERIOR)

Figures
14A & B
This
scan cuts the

the superior

lesser

curvature

of

the

stomach
(upper
L1). The lesser omentum
abuts
on the tuber omentale
of the body of the pancreas.
The pancreas
is well defined
by penpancreatic
fat and the tail of the pancreas
points
to the splenic
hilum.

lesser sac interposed

between
and omental
fat occupy
the left

tuber

Pallie

Tomography

PLANE

in

LCF = splenic
flexure;
left lobes of liver; RK
stomach;

Computed

anatomy:

the midline.
The
is related
to the stmoach

vessels

orly with the

them. Jejunum
hypochondrium.

and

(INFERIOR)

Figures
13A & B
The neck of the pancreas
mesenteric

Anatomy

L(R)
right lobe
kidneys;
RVL
spleen;

SV

1, Number

of liver; L(RL)
left renal vein;
splenic

vein;

May

1981

right and
S or St
tail of pan-

of pancreas.

Volume

RadioGraphics

71

Zylak,

Pallie

Correlative

Anatomy

Pathology,

anterior

CALCIFIC

Figures
A survey

i5A & B
radiograph

cation

and

of the

same

patient.

at successively
anatomic

The

(A) illustrates

topography

In the scans

relationships

pancreas

pancreatic

is opacified

which

(more

cranial)

of the

pancreas.

with
have

levels,

Tomography

pararenal

space:

The

calcifiCT scans
been made
note
head

the
lies

medial

to the

second

portion

of the

duodenum

by calcifications.

PSEUDOCYSTS

Computed

PANCREATITIS

for comparison

higher

and

OF

PANCREAS

A pseudocyst
in the head
(A). On the most caudal

72

of the pancreas
is identified
CT scan (B) the same cyst

RadioGraphics

May

by endoscopic
is indicated

1981

retrograde
by an arrow.

Volume

1, Number

choledochopancreatography

(B).

Zylak,
Correlative

The

neck

to the

The

lie anterior

and

to the superior

tail of the pancreas

Computed

mesentenic

abuts

Pallie

Tomography

artery

on the splenic

(arrow)

hilum

(C). The

stomach

lies anterior

(D).

16C & D

scans

in the

body

pancreas.

Figures
CT

and

Anatomy

body

of the same
and

patient

exposed

at higher

levels

(C and

D) demonstrate

additional

cysts

(arrows)

tail of the pancreas.

Volume

1, Number

May

1981

RadioGraphics

73

Zylak,

Pallie

Correlative

Anatomy

Pathology,

anterior

PHLEGMONOUS

The

inferior

aspect

level,

an

more

cranial

penirenal

inflammatory
scan

18A & B
radiograph

the

caudal

most

penipancreatic

74

mass
(B) the

right

space

is seen

kidney

Tomography

pararenal

space:

PANCREATITIS

perirenal
(M)

Computed

containing

surrounding

and

fat (arrows)
the

penirenal

right

fat appear

is recorded

renal

cone

normal,

in scan

laterally

indicating

and

A. At the same
anteriorly.

In a

no involvement

of the

space.

Figures
A survey

(C) medial

of the right

and

(A) shows

of the

CT

to this,

located

fat

planes.

scans

the stomach
(B) fluid

in the

lesser

to be displaced

is evident

medial

omentum.

RadioGraphics

The

May

infeniorly
to the

liver

pancreatic

1981

Volume

and
(arrows)

head

laterally
with

a much

is probably

1, Number

by a large

enlarged

larger

mass.

On

collection
with

loss

of

Zylak,
Correlative

Figures

i7C

At a yet

higher

the

anterior

are

vessels

Anatomy

and

Computed

Pallie

Tomography

& D
level
pararenal

which

may

(C)

the

space.
represent

inflammatory
Dot

like
varices.

mass
opacities

(M)
adjacent

is seen

to extend

to the

lateral

across
margin

the

midline

of the

and

stomach

to distend
in scan

D,

Zylak,

Pallie

Correlative

Anatomy

Pathology,
AORTIC

Figure
l9A
The most caudal
calcification

scan

in the

of this

aorta

anterior

Computed

pararenal

Tomography

space:

ANEU

patient,

(A) which

and

Figure
i9B
In a more cranial

demonstrates

is only

slightly

di-

parent.

The

section,

lucent

the aneurysm

crescent

is readily

represents

thrombus.

lated.

LYMPHOMA

Figures
20A & B
In CT scan A, large
fat

76

planes.

In a more

nodal
cranial

masses
scan

(M) displace
(B) a large

RadioGraphics

the aorta
right

May

(cursor)

retrocrural

1981

to the right
lymph

Volume

and

node

1, Number

obliterate

(arrow)

the paravascular

displaces

the

crus.

ap-

Zylak,
Correlative

Figure

i9C

In a yet
bulge

Anatomy

Computed

Figure

more

from

calcification.

and

cranial

the right
Renal

Pathology,

scan,
side
cysts

the

aneurysm

of the aorta
are

perirenal

present

which
on the

Space:

is seen
contains
left.

to

Pallie

Tomography

i9D

At the level

of the superior

the aneurysm

is no longer

mesentenic
evident.

artery

(arrow),

Zylak,

Pallie

Correlative

Pathology,

Multiple

CT

be distended

The

posterior

scans

representing

successively

by an inflammatory

paranenal

and

process,

extrapenitoneal

Anatomy

and

perirenal

more
which

Computed

Tomography

Space:

cranial

planes

obliterates

fat planes

the

are

show
penirenal

preserved

the

penirenal

fat and

space

thickens

on the
the

renal

left

to

fascia.

(arrow).

URINOMA

I_c,____

A delayed
radiograph
a 70-year-old
male
shows

penirenal

from the excretory

urogram
of
with carcinoma
of the bladder

extravasation

of

contrast

material

(arrow).

78

CT scan
shows

at the level
a

medially.

fluid
The

(F)
renal

of the lower
collection
fascia

rows).

RadioGraphics

May

1981

Volume

1, Number

pole of the left kidney

in

the

is clearly

penirenal
delineated

space
(ar-

Zylak, Pallie
Correlative

A more
pelvis

posterior
kidney
medially

cranial
shows

scan

through

loculated

fluid

parts

of the

anterolaterally.
is well

defined

penirenal
The

the
(F)

plane
in

of the

the

space

Anatomy

and

renal

Computed

The

medial

and

displacing

the

scan

cranial

position

Tomography

)
shows

to the

fluid
left

(F) occupying

kidney.

of the left

kidney

This

may

the penirenal
account

for

space
the

low

in this case.

compartmentalization

(arrow).

Volume

1, Number

May

1981

RadioGraphics

79

Zylak,

Pallie

Correlative

Anatomy

Pathology,

posterior

LEAKING

In the

scan,

pararenal
aortic

fluid
space.

aneurysm.

(F)
This

and

AORTIC

Computed

Tomography

pararenal

space:

ANEURYSM

is present

in the

right

posterior

In a scan

cranial

represents

blood

from

a leaking

of blood

(F)

bilateral

Large

renal

cysts

are

to the

in the

right

kidney,

posterior

craniad

pararenal

space

onstrated.

present.

ABSCESS

Figures
This

25A-D
series

of CT

in the

posterior

irenal

space

80

scans

shows

abdominal
and

propenitoneal

loculated
wall

and
fat

fluid

collections

encroaching
plane

RadioGraphics

(arrow)

(A)

on the
are

May

left

not

1981

with
posterior

enhancement

of their

pararenal

space.

involved.

Volume

1, Number

margins
Note

that

located
the

per-

extension
is dem-

Zylak,
Correlative

ScanCrepresenting
posterior

pararenal

the
space.

level

of the

This

Volume

Anatomy

superior

is shown

1, Number

and

Computed

mesentenic
in more

detail

May

Tomography

artery

(arrow)

in the

enlargement

1981

Pallie

RadioGraphics

demonstrates

fluid

(F)

in the

right

(D).

81

Zylak,

Pallie

Correlative

Anatomy

Pathology,

Figures
26A-D
This series of CT
the renal

fascia

to the left side.

scans

Fluid

within

Note

space

involvement

the anterior

In Figures
anterior

anterior

of penirenal

pararenal

space

1 through

Tomography

involvement:

of the

the obliteration

more

Computed

multiple

demonstrates

on the right.

and

paranenal

is shown

structures
recorded
in CT scans.
Examples
of pathologic
anatomy
are

interpreted

by reference

the retropenitoneum.
anterior
pararenal
space

by

the

and

demonstrating

are scans
volving

of a patient
multiple

cross-sectional
interpreting
individual

of pathologic

have

82

been

RadioGraphics

fossa.

of successively

are illustrated

with

coronal

by computed

anatomy

the
of

tomography

of the three

spaces

of

as the model for understanding

the
of pathology
within the penirenal

is illustrated

with

iliac

by several

examples,

including

space is illustrated
with
from an aortic aneurysm.

pancreatitis,

illustrating

that

clinical
scans
Also included

a pathologic

process

in-

spaces.

SUMMARY
This exhibit

the

fascia

of

as compared

the right

relationships

as recorded

to the normal

The posterior
pararenal
an abscess and leakage

transgression

These
schematics
emphasize
and clarify
the spatial
relations

Pancreatitis
serves
space. The confinement

renal

of a uninoma.

into

of the retropenitoneum

and cross-sectional
schematic
drawings.
concept
of the layered
retropenitoneum

with

on the night

extending

8, the positions

structures

space

fat anterolaterally

has

presented

an approach

to the

anatomy
of the retnopenitoneum
normal
and pathologic
CT scans.
compartments
processes

involving

demonstrated.

May

of the
them,

Clinical

1981

Volume

understanding

retroperitoneum
both

CT

and

individually

scans

1, Number

of the

that facilitates
the task
The normal
appearance

illustrating

and

of
of

the appearance
in combination,

the

findings

in

Zylak,
Correlative

pancreatitis,
and

1. Meyers

MA:

Heidelburg,
2.
3.

urinoma

and

have

been

lymphoma

Dynamic

renal

abscess,

Radiology

DeGraaff

re-evaluation

ment,

McMaster

adrenal

of the Abdomen.

pancreas:

of normal

BD,
of the

and

Mrs.

York,

AT:

Tomography

aortic

aneurysm,

Springer-Verlag,

Gray-scale

129:157-161,

pancreas.

for the excellent

University

Computed

tumor,

New

Rosenfield

size. Radiology

tomography

ACKNOWLEDGMENTS
Mrs. Deborah
Miller

and

presented.

1976, pp 113-190
CS, Taylor
KJW, Simonds

Kreel L: Computerized
287-297, 1977

Anatomy

Pallie

art work,

ecography

of the

1978

Computed

Axial

Tomography

the Audiovisual

L. MacRae

References

Berlin,

for

typing

1:

Departthe

manu-

script.

Volume

1, Number

May

1981

RadioGraphics

83