Spread of Infection via Perihepatic Ligaments

Intraabdominal infections and inflammatory processes may spread and localize not only within the recesses of the peritoneal cavity but along the peritoneal ligaments and mesenteries as well. I have previously recognized that these structures may provide the avenues of spread

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by direct invasion by malignancies. Mori and colleagues have reported the exophytic spread of he-patobiliary disease along the perihepatic ligaments,74 and Arenas et al.75 have further detailed inflammatory and infectious dissemination along these anatomic pathways.

The liver is fixed in the peritoneal cavity by various ligaments, and their radiologic appearance with CT and MR imaging has been well described.34,35 The perihe-patic ligaments are generally identifiable by their locations and relationships to organs or by the landmarks provided by their major constituent vessels along with ligamental fat.

Focal hepatic diseases adjacent to the attachments of the perihepatic ligaments can show contiguous extra-hepatic spread along these ligaments. Any hepatic lesion adjacent to the hepatic hilus can exhibit ligamentous spread via the hepatoduodenal ligament and the liga-

Hepatic Ligaments Radiology

Fig. 3-112. Abscess localization in postoperative neocompartment.

Following splenectomy with resection of the gastrosplenic and splenorenal ligaments, communication is established between the left subphrenic (perisplenic) space and the lesser sac.

(a) Axial diagram. SP = spleen; GSL = gastrosplenic ligament; SRL = splenorenal ligament; LS = lesser sac; St = stomach; P = pancreas; K = kidney

(b) Axial anatomic section with injection after removal of spleen to simulate abscess (A). Arrow = gastropancreatic plica. (This figure also appears in the color insert.)

(c) CT demonstrates gross abscess (A) in postoperative neocompartment. The vestibule of the lesser sac is not involved. At the level of the caudate lobe, the gastropancreatic plica has a fatty triangular configuration, within which course the left gastric artery and vein, extending to the posterior wall of the stomach. St = stomach; CL = caudate lobe; arrowheads = gastropancreatic plica; asterisk = pleural fluid.

(Reproduced from Kumpan. )

Fig. 3-112. Abscess localization in postoperative neocompartment.

Following splenectomy with resection of the gastrosplenic and splenorenal ligaments, communication is established between the left subphrenic (perisplenic) space and the lesser sac.

(a) Axial diagram. SP = spleen; GSL = gastrosplenic ligament; SRL = splenorenal ligament; LS = lesser sac; St = stomach; P = pancreas; K = kidney

(b) Axial anatomic section with injection after removal of spleen to simulate abscess (A). Arrow = gastropancreatic plica. (This figure also appears in the color insert.)

(c) CT demonstrates gross abscess (A) in postoperative neocompartment. The vestibule of the lesser sac is not involved. At the level of the caudate lobe, the gastropancreatic plica has a fatty triangular configuration, within which course the left gastric artery and vein, extending to the posterior wall of the stomach. St = stomach; CL = caudate lobe; arrowheads = gastropancreatic plica; asterisk = pleural fluid.

(Reproduced from Kumpan. )

Gastrocolic Gutter

Fig. 3-113. Steps in colectomy of the splenic flexure with surgical transection of ligaments.

After division of the gastrocolic ligament toward the left, the peritoneum of the left paracolic gutter is divided to mobilize the proximal descending colon. This permits gentle traction on the colon and careful dissection of the splenic flexure and its mesentery.

(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.)

mentum teres and then can show spread to the gastrohepatic ligament, the gastrocolic ligament, the duoden-ocolic ligament, the transverse mesocolon, and the falciform ligament. Disease processes of the biliary tract in the hepatic hilus and in the hepatoduodenal ligament can also show the same mode of exophytic spread (Figs. 3-117 through 3-124).

Similarly, a lesion originating in the stomach or pancreas can spread upward along the gastrohepatic ligament to involve the liver (Figs. 3-125 and 3-126).

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