To Review the imaging anatomy of peritoneal spaces

Poster No.: C-0730

Congress: ECR 2013
Type: Educational Exhibit
Authors: R. A. Tobias; Bangalore/IN
Keywords: Education and training, Diagnostic procedure, CT, Abdomen
DOI: 10.1594/ecr2013/C-0730

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Learning objectives

The objective of this presentation is to help understand the imaging anatomy of

peritoneum (Largest serous membrane in body) so as to better localize a disease process
and hence to:

• Formulate a differential diagnosis

• For surgical drainage
• For staging of neoplasm's

Background

Basic anatomy:

Meaning of terms (fig. 1):

Peritoneum- thin, translucent serosal membrane of mesodermal origin.

- Visceral peritoneum - lines the intraperitoneal organs

- Parietal peritoneum- lines walls of the peritoneal cavity

Ligament- two folds of peritoneum that support a structure within the

peritoneal cavity

Mesentery- connects small bowel to retroperitoneum

Mesocolon (true mesentery) - connects colon to retroperitoneum

Omentum (specialized mesentery) - does not connect structures to retroperitoneum and

includes:

- Greater omentum: connects the stomach to the colon

- Lesser omentum: connects the stomach to the liver

- Mesoappendix: connects the appendix to the ileum

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Basic embryology:

Knowledge of embryogenesis helps in understanding the origin and orientations of

various intra-abdominal compartments. A cross sectional diagram of 10 week fetus and
a comparative section of an adult at the level of upper abdomen will illustrate this concept
(Fig. 2).

Peritoneal spaces and compartment:

The peritoneum can be broadly divided into the supra and infra colic compartments by the
transverse colon. The various subdivisions in each compartment is depicted in a simple
chart (Fig. 3).

Supracolic compartment:

The various ligaments, organs and spaces of the supra colic compartment are depicted
in the axial section of the upper abdomen (Fig. 4, 5).

• Bare area of liver: It is the space between the reflections of coronary

Ligaments (Fig. 6).
• This area is continuous with the right anterior pararenal space- a pathway
for spread of a process (infection, tumour etc) to the retroperitoneum.
• Ascites or abscesses cannot extend medial to the right coronary ligament or
between the bare area of the liver and the diaphragm

• Omentum (Fig. 7):

• Greater omentum - connects the stomach to the colon and is composed of
three parts: gastrocolic, gastrosplenic and gastrophrenic ligaments.
• Lesser omentum- connects the stomach to the liver and is composed of two
parts: gastro hepatic and hepatoduodenal ligaments.

• Lesser sac/ omental bursa: This is a Remnant of primitive right peritoneal

space and a potential space for accumulation of fluid (Fig 8, 9).
• Its wall are formed by the lesser omentum anteriorly and by the splenorenal,
gastrosplenic, gastrocolic ligaments which are remnants of the dorsal
mesentery.
• The lesser sac communicates with the peritoneal spaces via Epiploic
foramen which is located between free edge of lesser omentum and the IVC.

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Infracolic compartment:

Transverse mesocolon form the superior boundary of the infracolic compartment and
also the posterior border of the lesser sac. It contains the middle colic vessels (Fig. 10).

The Infracolic compartment is divided into right and left compartments by Small bowel
mesentery which contains the superior mesenteric vessels (Fig. 11).

NB: The cecum is usually Retroperitoneal and hence -Retrocecal space Fluid would
generally mean appendicitis /diverticulitis (Fig. 12).

Pelvic ligaments and spaces:

These are depicted in the axial CT images of the pelvis (Fig. 13, 14).

NB: The peritoneum is continuous male pelvis and discontinuous in women at the Ostia
of the oviducts.

Flow of Ascites:

The Flow of ascitic fluid and most common sites of malignant seeding in the peritoneum /
areas of fluid stasis (in the watershed regions) are depicted in the following diagram
(Fig.15).

Images for this section:

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Fig. 1: Sagittal CT section demonstrating the peritoneal coverings.

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Fig. 2: Cross section of 10 week fetus and adult at the upper abdomen demonstrating
the development of peritoneal spaces.

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Fig. 3: Divisions of the peritoneal spaces.

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Fig. 4: Axial CT sections of the Supracolic compartment.

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Fig. 5: Axial CT of the Supracolic compartment depicting the various ligaments.

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Fig. 6: Bare area of the liver- sagittal CT and pictorial representation.

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Fig. 7: Sagittal CT section- greater omentum; Coronal CT section- lesser omentum.

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Fig. 8: The lesser sac- diagrammatic representation of 4 month foetus and adult (sagittal
view); Sagittal CT depicting fluid filled lesser sac in a patient with pancreatitis.

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Fig. 9: Axial and coronal CT sections of the same patient as in figure 8.

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Fig. 10: Axial and coronal Ct sections- infracolic compartment.

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Fig. 11: Coronal CT section- small bowel mesentery dividing the infracolic compartment
to right and left sides.

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Fig. 12: Axial CT sections demonstrating the paracolic gutters and retrocecal space.

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Fig. 13: Axial CT section demonstrating the pelvic ligaments in a patient with free fluid.

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Fig. 14: Axial CT section of the pelvis demonstrating the umbilical ligaments.

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Fig. 15: Pictorial depiction of the path for flow of ascites and free fluid in the peritoneum.

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Imaging findings OR Procedure details

Cross sectional imaging is the main stay in evaluating disease processes involving the
peritoneum.

• In this presentation, computed tomographic (CT) images are used to

describe the anatomy of the peritoneal spaces.
• Diagrams have been added to explain the important concepts.

Conclusion

Important concepts of this poster can be summarized as follows:

• Ligaments are named according to the structures they connect (e.g.

stomach and transverse colon- gastrocolic ligament )
• Most of the peritoneal spaces are potential spaces (become obvious
when they are fluid filled )
• Recto uterine pouch ( Women) / rectovesical pouch ( Men) are most
dependent portion of the pelvis for collection of Fluid, malignancies,
abscesses

References

1. De Meo JH, Fulchei AS, Austin RF. Anatomic CT Demonstration of the

Peritoneal Spaces, Ligaments, and Mesenteries: Normal and Pathologic.
RadioGraphics 1995; 15:755-770.
2. Kim S, Kim TU, Lee FW et.al. The Perihepatic Space: Comprehensive
Anatomy and CT Features of Pathologic Conditions. RadioGraphics 2007;
27:129-143.
3. Sadler TW, Bridges T, Montana. Langman's Medical Embryology 9th ed.
Baltimore, Lippincott Williams &Wilkins, 2004.

Personal Information

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