Gallium Scan Colon

Gastric Perforation Omentum

Fig. 3-89. Left subphrenic abscess from anterior gastric perforation.

(a) Extensive scirrhous carcinoma of the stomach. (b and c) Following gastroscopy, with accidental perforation of the anterior gastric wall, repeat study shows contrast material extends from the stomach (S) anterior to the lesser omentum (LO). It tracks to a large abscess (arrow) beneath the diaphragm and above the colon (C), which is opacified by residual barium. (Reproduced from Meyers.6)

Bruxism MriRadiology Guided Abscess Drainage

Fig. 3—90. Left subphrenic abscess, postsplenectomy.

(a and b) Erect frontal and lateral views demonstrate a large air-fluid collection extending lateral and superior to the stomach.

(c) Barium enema study shows a postsurgical perforation of the splenic flexure with a sinus tract leading to the subphrenic abscess.

Mri Splenic AbscessSinus Tract From Colonal Anastomosis

Fig. 3-91. Chronic loculated left subphrenic abscess secondary to anastomotic leak, following gastrectomy and esophagojejunostomy. Frontal (a) and lateral (b) views.

Fig. 3-91. Chronic loculated left subphrenic abscess secondary to anastomotic leak, following gastrectomy and esophagojejunostomy. Frontal (a) and lateral (b) views.

by its distortion and by overlying bony structures.61,64 In addition, retained sponges may even now be found in patients operated on before the use of radiopaque sponges. Plain film radiography has at least a 25% false-negative rate.65 Other radiographic signs suggesting the presence of retained surgical sponges include a well-circumscribed mass, whorl-like gas patterns in the sponge's meshwork, abnormal gas collections owing to abscess formation adjacent to the sponge, and rarely, de

Subphrenic Abscess

Fig. 3-92. Left subphrenic abscess secondary to anastomotic leak, post-Billroth II.

(a and b) Contrast injection through drainage tube shows loculated cavity beneath the central tendon of the diaphragm anterior to the left lobe of the liver.

Fig. 3-92. Left subphrenic abscess secondary to anastomotic leak, post-Billroth II.

(a and b) Contrast injection through drainage tube shows loculated cavity beneath the central tendon of the diaphragm anterior to the left lobe of the liver.

velopment of calcification around a retained sponge59-61 (Fig. 3-115). In patients with a sinus tract, injection of contrast material usually identifies the meshwork of the retained sponge, and a bizarre filling defect in the intestinal lumen may be found on contrast examination in patients with sponges that erode into the intestine.

Ultrasonography of retained surgical sponges typically shows a hyperechogenic mass with a well-defined acoustic shadow.64,66-68 A retained towel may be revealed by a folded appearance of echogenic material inside a cystic mass.63

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What Left Subphrenic

Fig. 3-93. Left subphrenic abscess secondary to anastomotic leak, post-Billroth II.

The collection, first filled with gas and later opacified, seeks the subphrenic area anterior to the left lobe of the liver (LL).

Fig. 3-93. Left subphrenic abscess secondary to anastomotic leak, post-Billroth II.

The collection, first filled with gas and later opacified, seeks the subphrenic area anterior to the left lobe of the liver (LL).

Fig. 3—94. Perforation of an anterior wall gastric ulcer leads to abscesses of the left sub-phrenic space (LSubS), Mori-son's pouch (MP), and the right subphrenic space (RSubS). The gas-containing exudate extends along the visceral surface of the liver to the right paracolic gutter (arrows). This case illustrates the flow of exudate across three quadrants of the abdomen. (Reproduced from Meyers.6)

Trans Splenic Portal VenographySplenoportography

Fig. 3-95. Extravasated contrast material in the left upper quadrant (1) at the time of percutaneous splenoportography can be traced to overflow the phrenicocolic ligament (PL) and proceed down the left paracolic gutter (2) to the pelvis (3). From here it ascends the right para-colic gutter (4) to the subhepatic spaces (5). This illustrates the dynamic pathways of fluid across the four quadrants of the abdo-

Liver Stab Wound

Fig. 3-96. Stab wound of liver.

Injection through cholecysto-tomy tube shows extravasation from left lobe of liver (1). This seeks the left subphrenic space (2), overflows the phrenicocolic ligament (PL), and progresses down the left paracolic gutter (3) to the pelvis.

Fig. 3-97. Left subphrenic abscess partially separated from abscess in left paracolic gutter by phrenicocolic ligament. (a) Diagram and (b) CT. Following splenectomy, an intact phrenicocolic ligament (arrows) through its slanted course partially divides the caudal edge of an abscess in the splenorenal recess (1) from a gross abscess in the paracolic gutter overflowing to the infracolic space (2). K = kidney; C = splenic flexure of colon.

(Reproduced from Kumpan. )

Paracolic LigamentSubphrenic Space

Fig. 3—98. Slow flow up the shallow left paracolic gutter is arrested at the level of the phrenicocolic ligament.

Hysterosalpingography with overzealous contrast injection through patent fallopian tube opacifies the left paracolic gutter. Cephalad flow is arrested at the level of the phrenicocolic ligament (arrow).

Left Paracolic GutterLeft Paracolic Gutter

Fig. 3—99. Phlegmon in left paracolic gutter, postappendectomy.

Gallium-67 scan demonstrates activity extending up the left paracolic gutter with an abrupt cutoff at the level of the phrenicocolic ligament (arrow). This activity is not in the colon and did not clear following repeated enemas. Activity in the pelvis is associated with surgical drains in this area. (Courtesy of Paul B. Hoffer, M.D., Yale University School of Medicine, New Haven, CT.)

Fig. 3—99. Phlegmon in left paracolic gutter, postappendectomy.

Gallium-67 scan demonstrates activity extending up the left paracolic gutter with an abrupt cutoff at the level of the phrenicocolic ligament (arrow). This activity is not in the colon and did not clear following repeated enemas. Activity in the pelvis is associated with surgical drains in this area. (Courtesy of Paul B. Hoffer, M.D., Yale University School of Medicine, New Haven, CT.)

Fig. 3—100. Localized abscess of the left paracolic gutter, 2 weeks after a cesarean section.

The mass displaces the descending colon (C) medially and bulges the flank structures laterally. It is ill defined inferiorly and superiorly, at which point several small discrete gas bubbles are present (arrow). Cephalad flow to the left subphrenic space is prevented by the phrenicocolic ligament in this case.

Fig. 3-101. Abscess of left paracolic gutter extending into the perisplenic space.

Following a resection of the sigmoid colon with mobilization of the splenic flexure and excision of the phrenicocolic ligament, the large gas-producing infected collection in the gutter is not restrained from progressing into the perisplenic area.

Subphrenic And Perisplenic

Fig. 3-102. Left paracolic and subphrenic abscesses.

Following splenectomy and excision of the phrenicocolic ligament, intestinal infarction within the pelvis leads to infected exudate in the left paracolic gutter (arrows). This progresses without interruption to the development of a left subphrenic abscess (LSA).

Fig. 3-102. Left paracolic and subphrenic abscesses.

Following splenectomy and excision of the phrenicocolic ligament, intestinal infarction within the pelvis leads to infected exudate in the left paracolic gutter (arrows). This progresses without interruption to the development of a left subphrenic abscess (LSA).

Left Upper Quadrant ColostomyLeft Upper Quadrant Colostomy

Fig. 3-103. Left paracolic and subphrenic abscesses, following sigmoidectomy with descending colostomy for perforated diverticulitis.

(a) CT shows a large fluid and gas-containing abscess (A), displacing bowel and the left kidney.

(b) At a higher level, continuity to a prominent abscess in the left upper quadrant anterior to the gastrosplenic ligament lateral to the stomach (S) has developed.

(Courtesy of Ann Singer, M.D., Cleveland Clinic, Cleveland, OH.)

Fig. 3-103. Left paracolic and subphrenic abscesses, following sigmoidectomy with descending colostomy for perforated diverticulitis.

(a) CT shows a large fluid and gas-containing abscess (A), displacing bowel and the left kidney.

(b) At a higher level, continuity to a prominent abscess in the left upper quadrant anterior to the gastrosplenic ligament lateral to the stomach (S) has developed.

(Courtesy of Ann Singer, M.D., Cleveland Clinic, Cleveland, OH.)

Left Upper Quadrant Colostomy

Fig. 3-104. Diagram of the pathways of flow of intraperitoneal exudates.

(See Fig. 3-2) Broken arrows indicate spread anterior to the stomach to the left subphrenic area. C = splenic flexure of colon (Modified from Meyers. )

Subhepatic Space

Fig. 3—105. Diagram of abscess localization in intraperitoneal postoperative neo-compartments following transection of ligaments and mesenteries.

1 = right posterior subphrenic-subhepatic space; 2—5 = lesser sac-left subphrenic space (gastrohepatic, gastrosplenic, splenorenal recesses); A = abscess; L = liver; St = stomach; S = spleen; K = kidney; P = pancreas.

(Modified from Kumpan.27)

Fig. 3-106. Steps in right hepatic lobectomy with surgical transection of ligaments.

After division of the falciform ligament up to the inferior vena cava (IVC), further mobilization of the right lobe is achieved by transection of the right triangular ligament and the coronary ligament. This provides communication between the right sub-phrenic and subhepatic spaces. (From Braasch JW, Sedgwick CE, Veidenheimer MC, et al: Atlas of Abdominal Surgery. WB Saunders, Philadelphia, 1991. Illustration used with permission of The Lahey Clinic.)

Morison PouchSubphrenic Space

Fig. 3-107. Abscess localization in postoperative neocompartment. Excision of right coronary ligament associated with hemihepatectomy.

(a) Lateral diagram and (b) axial CT with sagittal reconstruction demonstrate abscess with gas formation in new right subphrenic-subhepatic compartment (arrows). The communication of the right subphrenic space with Morison's pouch may extend anteriorly to involve the right anterior subhepatic space as well. L = right lobe of liver; K = right kidney; D = descending duodenum; C = colon; asterisk = pleural fluid. (Reproduced from Kumpan.27)

Fig. 3-107. Abscess localization in postoperative neocompartment. Excision of right coronary ligament associated with hemihepatectomy.

(a) Lateral diagram and (b) axial CT with sagittal reconstruction demonstrate abscess with gas formation in new right subphrenic-subhepatic compartment (arrows). The communication of the right subphrenic space with Morison's pouch may extend anteriorly to involve the right anterior subhepatic space as well. L = right lobe of liver; K = right kidney; D = descending duodenum; C = colon; asterisk = pleural fluid. (Reproduced from Kumpan.27)

Morison Pouch

Fig. 3-108. Steps in gastrectomy with surgical transection of ligaments.

(a) With traction on the stomach and transverse colon, the greater curvature of the stomach is mobilized by excising the gastrocolic and gastrosplenic ligaments and dividing the short gastric and gastroepiploic vessels.

(b) The gastrohepatic ligament is entered in order to mobilize the distal stomach and first portion of the duodenum. An avascular plane is developed so that the caudate lobe of the liver is visualized. The right and then the left gastric vessels are ligated. This establishes communication between the lesser sac and the left subphrenic, gastrohepatic, and gastrosplenic spaces. (From Braasch JW, Sedgwick CE, Veidenheimer MC, et al: Atlas of Abdominal Surgery. WB Saunders, Philadelphia, 1991. Illustrations used with permission of The Lahey Clinic.)

Fig. 3-108. Steps in gastrectomy with surgical transection of ligaments.

(a) With traction on the stomach and transverse colon, the greater curvature of the stomach is mobilized by excising the gastrocolic and gastrosplenic ligaments and dividing the short gastric and gastroepiploic vessels.

(b) The gastrohepatic ligament is entered in order to mobilize the distal stomach and first portion of the duodenum. An avascular plane is developed so that the caudate lobe of the liver is visualized. The right and then the left gastric vessels are ligated. This establishes communication between the lesser sac and the left subphrenic, gastrohepatic, and gastrosplenic spaces. (From Braasch JW, Sedgwick CE, Veidenheimer MC, et al: Atlas of Abdominal Surgery. WB Saunders, Philadelphia, 1991. Illustrations used with permission of The Lahey Clinic.)

Gastrohepatic Ligament

Fig. 3—110. Abscess localization in postoperative neocompartment following transection of gastrohepatic ligament. (See illustration on opposite page)

(a) Axial anatomic section with injection to simulate abscess formation within the vestibule (Vb) of the lesser sac clearly separated by an intact gastrohepatic ligament (between the clamps) from abscess within the gastrohepatic recess (GHR) of the greater peritoneal cavity. CL = caudate lobe; Ao = aorta; C = inferior vena cava; PV = portal vein. (This figure also appears in the color insert.) —>

Fig. 3-109. Abscess localization in postoperative neo-compartment following subtotal gastrectomy.

CT demonstrates a large abscess (A) with multiple air-fluid levels occupying the combined lesser sac and gastrohepatic recess. A drainage needle approaches the abscess. Left pleural fluid is also noted.

(Courtesy of Michael Oliphant, M.D., Crouse Hospital, Syracuse, NY.) (Left)

Fig. 3—110. Abscess localization in postoperative neocompartment following transection of gastrohepatic ligament. (See illustration on opposite page)

(a) Axial anatomic section with injection to simulate abscess formation within the vestibule (Vb) of the lesser sac clearly separated by an intact gastrohepatic ligament (between the clamps) from abscess within the gastrohepatic recess (GHR) of the greater peritoneal cavity. CL = caudate lobe; Ao = aorta; C = inferior vena cava; PV = portal vein. (This figure also appears in the color insert.) —>

Caudate Lobe ResectionsSpleen Cdolor ImageGastropancreatic Ligament Radiology

(b) After resection of the gastrohepatic ligament, a neocompartment (asterisk) is formed by communication of the gastrohepatic recess and vestibule. X = gastropancreatic plica; ST = stomach; LS = lesser sac; Sp = spleen. (This figure also appears in the color insert.) (c and d) Cross-sectional and sagittal diagrams showing spread of abscess (A) permitted by removal of the anatomic barrier of the gastrohepatic ligament. C = colon; L = liver; LS = lesser sac; ST = stomach. (e) Following operative transection of the gastrohepatic ligament, CT demonstrates spread of abscess (arrows) from the ventrally located gastrohepatic recess between the stomach (ST) and left lobe of the liver (L) to the superior recess of the lesser sac.

(Reproduced from Kumpan27 and Pokieser et al.58)

Superior Recess Lesser SacGastrohepatic Ligament Location

Fig. 3—111. Steps in splenectomy with surgical transection of ligaments.

In an elective splenectomy, the lesser sac is opened via the distal gastrocolic ligament and gastrosplenic ligament. The left gastroepiploic and short gastric vessels are divided and the splenic artery ligated.

(a and b) The spleen is then rotated to the right and the splenorenal ligament sectioned. This establishes communication between the lesser sac and the left subphrenic space.

(From Braasch JW, Sedgwick CE, Veidenheimer MC, et al: Atlas of Abdominal Surgery. WB Saunders, Philadelphia, 1991. Illustrations used with permission of The Lahey Clinic.)

Fig. 3—111. Steps in splenectomy with surgical transection of ligaments.

In an elective splenectomy, the lesser sac is opened via the distal gastrocolic ligament and gastrosplenic ligament. The left gastroepiploic and short gastric vessels are divided and the splenic artery ligated.

(a and b) The spleen is then rotated to the right and the splenorenal ligament sectioned. This establishes communication between the lesser sac and the left subphrenic space.

(From Braasch JW, Sedgwick CE, Veidenheimer MC, et al: Atlas of Abdominal Surgery. WB Saunders, Philadelphia, 1991. Illustrations used with permission of The Lahey Clinic.)

Computed tomography demonstrates a generally well-defined mass with a thick wall, internal heterogeneous densities with a wavy or striped appearance, and occasionally mottled calcifications and gas bub-bles.63,66-68 A retained towel may show multiple, thin linear densities with a peculiar infolded63 or whorled64 appearance (Fig. 3-116). Similar characteristics with signal intensity differences are evident by MR imaging.69 On CT scans, the appearance of an abscess can be closely mimicked by that of retained oxidized cellulose (Surgicel) .70,71 This is a commonly used knitted fabric used as an agent for intraoperative hemostasis. Unlike traditional surgical sponges, it is bioabsorbable and can be left in the surgical bed.

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