Abstract
Essential to understanding disease spread in abdomen is to separate the peritoneum from the extraperitoneum. These areas have distinct anatomy with well-define separate pathways. The peritoneum is comprised of connected recesses that are potential spaces, normally not imaged except when containing excess fluid or air. Peritoneal recesses are formed by the opposing peritoneal surfaces and subdivided by the attachments of the ligaments and mesenteries to the parietal peritoneum. Disease flows within the recesses by changes in abdominal pressure. This forms a distinct spread pattern. The extraperitoneum is traditionally stratified by the renal fascia into the anterior and posterior pararenal spaces and the perirenal space. The fascia contains and directs spread from the contained organs with the compartments. Each space has a unique spread pattern defined by the containing fascia. The extraperitoneum is connected to the mesenteries and ligaments forming the subperitoneal space. This space interconnects the extraperitoneum with the mesenteries allowing for the normal continuum of blood vessels, lymphatics, and nerves but also forms the pathways for bidirectional spread of disease.
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Learning objectives
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Understand what constitutes the peritoneal recesses and extraperitoneal spaces
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Understand their distinct pathways of disease spread
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Diagnostic importance of recognizing the different disease spread patterns in the peritoneal recesses compared to the extraperitoneal spaces
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Understand the concept of the subperitoneal spread interconnecting the extraperitoneum to the mesentery for bidirectional spread of disease
Introduction
Understanding disease spread in the abdomen requires a recognition of the differences between the peritoneum and extraperitoneum [1,2,3,4]. Peritoneal spread of disease has a distinct pattern dictated by its anatomy and flow pattern. The extraperitoneal space is defined as the space between the peritoneum and transversalis fascia [2, 5]. Posteriorly, the extraperitoneum is stratified by the anterior and posterior renal fascia into the pararenal space, perirenal space, and posterior pararenal space [2]. Disease spread within these spaces is dictated by fascial planes [6,7,8,9,10,11,12,13]. The subperitoneal space is an extension of the extraperitoneal space into the suspended abdominal viscera via their corresponding mesenteries [1,2,3,4,5, 14,15,16]. Subperitoneal spread of disease occurs along the avenues formed by the vessels connecting the intraperitoneal spaces and the mesenteries.
Peritoneum
The peritoneal cavity is the potential space containing the suspended abdominal viscera and their mesenteries [2, 5, 16,17,18]. It is formed from the primitive coelom when the lateral mesoderm splits into the somatic and splanchnic layers [2, 18,19,20]. The somatic mesoderm covered by parietal peritoneum lines the coelomic wall. The splanchnic mesoderm lined by visceral peritoneum covers the suspended viscera and mesenteries (Fig. 1).
The transverse mesocolon divides the peritoneal cavity into the supramesocolic and inframesocolic portions [2, 19]. The supramesocolic recesses are divided ventrally by the falciform ligament. The right subphrenic space continues lateral to the liver and inferiorly to the subhepatic spaces (Figs. 2, 3). The subhepatic space continues posteromedial to the liver into the lesser sac via the epiploic foramen (Figs. 2, 3 and 4).
The lesser sac is a peritoneal recess formed by the elongation and rotation of the dorsal mesogastrium [2, 5, 19] (Figs. 2,3). It lies posterior to the stomach and anterior to the transverse colon. The lesser sac is bordered by the stomach, duodenum, pancreas, spleen, as well as the gastrohepatic, hepatoduodenal, and gastrosplenic ligaments.
The gastrohepatic and gastrosplenic recesses subdivide the left subphrenic space [5] (Fig. 5). The splenorenal recess is the posterior left supramesocolic recess formed by the splenorenal ligament [5]. The left supramesocolic recesses are separated from the right supramesocolic recesses by the falciform ligament ventrally, lesser sac medially, and inframesocolic recesses laterally the phrenicocolic ligament (Figs. 2, 3, 4, 5 and 6).
The right supramesocolic recesses continue to the right inframesocolic recesses by the right paracolic gutter (recess) (Figs. 2,3,6) [2, 5]. This recess is in continuity with the recesses between the small intestine and its mesentery (Fig. 7). The right paracolic gutter continues inferiorly to the pelvic peritoneal recesses. Ventrally, these recesses are divided by the urachus (medial umbilical ligament), the obliterated umbilical arteries (median umbilical ligament, and inferior epigastric vessels (lateral umbilical ligament) into the left and right inguinal recess and supravesical recess [2] (Fig. 3). Dorsally, these recesses are divided in the male by the urinary bladder and rectum to the rectovesical recess and in the female by the rectum, uterus, and urinary bladder to the rectovesical recess (Douglas pouch, cul-de-sac) and the uterovesical recess. The pelvic recesses continue lateral to the paravesical recesses and to the right and left paracolic gutters. Prior literature further details the pelvic peritoneal recesses [2, 5].
Gravity predominately determines flow within these recesses with contribution from changes in intra-abdominal pressure and gastrointestinal peristalsis [2, 17, 19,20,21] (Figs. 2, 3). Note that fluid flow is unidirectional from interloop fluid in the inframesocolic recesses (Figs. 2, 3, 8), sequestered in the left subphrenic and posterior supramesocolic recesses (Figs. 2, 3, 5), and in the lesser sac (Figs. 3, 9).
The anatomy of the peritoneal recesses and their flow pattern provides a distinctive spread pattern for the peritoneal disease. Examples include tumor penetrating an organ’s peritoneal lining (transperitoneal spread) entering the peritoneal cavity and spread within the recesses to seed the parietal peritoneum and the visceral peritoneum. Fluid and gas from a perforated viscus may spread diffusely through interconnection of many of the peritoneal recesses (Fig. 6). Ligamentous boundaries may limit spread. For instance, the phrenicocolic ligament limits communication between the left inframesolic and supramesocolic recesses (Figs. 5 and 8). Gas or fluid in the lesser sac localizes disease from the surrounding organs (Figs. 9, 10). Interloop fluid localizes pathology to the small intestine or mesentery (Fig. 8). Pathology from the stomach can localize to the left subphrenic space (Fig. 5).
Extraperitoneum
The extraperitoneum is an actual space. It is lies between the peritoneum and transversalis fascia [2, 6, 7] (Fig. 11). Posteriorly, the renal fascia stratifies the extraperitoneum into the anterior and posterior pararenal spaces, as well as the perirenal space containing the kidneys and adrenal glands [2] (Fig. 11). A secondary extraperitoneum forms from fusion of viscera and mesenteries originally developed in the dorsal mesenteries [2, 22, 23] (Fig. 12). The duodenum and pancreas form in the dorsal mesogastrium and fuse onto the anterior pararenal space as the pancreaticoduodenal compartment. The ascending and descending colon form in the dorsal mesentery and fuse onto the anterior pararenal space as the right and left colonic compartments [2, 22, 23] (Fig. 12).
Figure 13 illustrates the spread patterns in the traditional extraperitoneal spaces. Spread of disease differs between these spaces and is useful for localization. Pathology in the anterior pararenal space localizes by its compartment. Pathology in the pancreaticoduodenal compartment localizes to the pancreas or duodenum (Figs. 14 and 15). Findings in the right colonic compartment localize to the right colon and mesocolon (Fig. 16) and findings in the left colonic compartment localize to the left colon and mesocolon (Fig. 17). Perirenal space pathology localizes to the kidneys or adrenals (Fig. 18). The posterior pararenal space does not contain organs (Fig. 19). There is a preferential pathway of spread inferolaterally in the anterior pararenal space (Figs. 14 and 15), dorsomedially to the lower pole in the perirenal space (Fig. 18) and inferolaterally in the posterior pararenal space often with superoanterior displacement of the kidney [2] (Fig. 19). Prior literature further details the extraperitoneal pelvic spaces [2, 5, 24].
Subperitoneum
The subperitoneum is an extension of the extraperitoneum, to include the suspended abdominal organs with their associated mesenteries and ligaments [2, 5] (Figs. 20 and 21).
During embryological development, the dorsal mesogastrium (Fig. 20) gives rise to the splenorenal ligament, gastrosplenic ligament, gastrocolic ligament, and greater omentum [1,2,3,4,5,6].The ventral mesogastrium (Fig. 20) gives rise to the gastrohepatic ligament, duodenohepatic ligament, as well as hepatic ligaments such as the falciform ligament, ligamentum teres, coronary ligament, and triangular ligaments.
The dorsal mesentery extends in continuity from the dorsal mesogastrium to the duodenum, small bowel, colon, and rectum (Fig. 20). These mesenteries are named by their organ attachments: mesoduodenum, jejunal and ileal mesentery, mesocolon, and mesorectum [2]. After fusions, the suspended bowel include the first portion of the duodenum, the small bowel, the transverse colon, and the sigmoid colon. Note that the entire dorsal mesentery remains in continuity and supplies the arteries, veins, lymphatics, and nerves to their respective organs.
Interconnection persists between the ventral and dorsal mesogastrium and the remaining dorsal mesentery [2]. Thus, the subperitoneal space includes the extraperitoneal spaces lying deep to the parietal peritoneum, and its continuity with the suspended mesenteries and organs lying deep to the visceral peritoneum, to form one contiguous space [1,2,3,4,5,6]. The subperitoneal space contains all the vascular, lymphatics, and nerve supply of the abdominal and pelvic organs. It also provides the pathway for bidirectional spread of disease to and from any organs or mesentery within the abdomen and pelvis [1,2,3,4,5, 16, 25]. Examples include the complex spread of pancreatitis (Fig. 22), spread of disease between suspended organs and mesentery (Fig. 23), and extraperitoneal organs, suspended organs, and mesentery (Fig. 24).
Conclusion
The peritoneum cavity is subdivided by the attachments of ligaments and mesenteries into interconnecting recesses. Knowing this anatomy and the flow of interperitoneal fluid explains the pathway of interperitoneal disease spread. The extraperitoneum is a space between the peritoneum and transversalis fascia, distinct from the peritoneum with a separate pathway of disease spread. This is stratified by the renal fascia into the anterior and posterior pararenal spaces, as well as the perirenal space. The anterior pararenal space is divided into the pancreaticoduodeal, left colonic, and right colonic compartments. These spaces and the connected organs have unique pathways of disease spread from each other as well compared to the peritoneal recesses. The subperitoneal space is an extension of the extraperitoneum. This includes the suspended organs along with their ligaments, mesenteries, and vessels which allows for pathways of bidirectional spread between the extraperitoneum and the suspended organs distinct from peritoneal spread of disease.
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Polamraju, P., Oliphant, M., Aribindi, S. et al. Navigating the labyrinth of peritoneal and extraperitoneal anatomy: abdominal spread made easy with a case based review. Abdom Radiol (2024). https://doi.org/10.1007/s00261-024-04429-y
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DOI: https://doi.org/10.1007/s00261-024-04429-y