This article discusses the patent and potential spaces of the abdominal region.
The spaces of the infracolic region, along with their related structures, boundaries and contents, as well as some clinical notes will be reviewed.
Right Infracolic Compartment
The infracolic compartment is located caudal to the transverse mesocolon. The oblique root of the mesentery of the small intestines further divides the compartment into a left and right infracolic compartment.
The smaller right infracolic space is a triangular region whose base is the transverse mesocolon, right border is the medial wall of the ascending colon and left border is the lateral part of the root of the small intestinal mesentery. The apex of the space continues inferiorly towards the ileocecal junction and may contain the vermiform appendix. Also traveling behind the peritoneum of the right infracolic space are the right colic and ileocolic branches of the superior mesenteric artery and their corresponding veins. The right gonadal vessels and the right ureter also pass through the space.
Left Infracolic Compartment
The larger left infracolic compartment is more quadrilateral in shape. It is bordered superiorly by the transverse mesocolon, laterally by the medial wall of the descending colon, inferolaterally by the superior part of the sigmoid mesocolon and medially by the medial part of the root of the small intestinal mesentery. Inferomedially, the left infracolic space communicates with the pelvic cavity.
Posterior to its peritoneal sheath, this space is traversed by the:
- distal half of the right ureter
- left ureter
- gonadal vessels
- inferomedial part of the left kidney
- common iliac vessels
- inferior mesenteric vessels traverse this space, posterior to its peritoneal sheath
Jejunoileal loops of small intestines also occupy the infracolic space.
Right Paracolic Gutter
There are paracolic gutters adjacent to the infracolic compartments that are clinically significant. On the right hand side, the right lateral paracolic gutter is found lateral to the ascending colon and medial to the lateral part of the anterior abdominal wall. It extends from the right colic (hepatic) flexure, surrounds the cecum and enters the pelvic cavity.
Right Medial Paracolic Gutter
A right medial paracolic gutter has also been described in cases where the ascending colon has a mesentery; it is limited inferiorly by the ilium and its mesentery.
Left Lateral Paracolic Gutter
Similar to the right, the left lateral paracolic gutter extends from the left colic (splenic) flexure adjacent to the lateral wall of the descending colon and medial to the left lateral part of the anterior abdominal wall, to its termination at the at the sigmoid mesocolon’s lateral edge. Unlike the right lateral paracolic gutter, the left lateral paracolic gutter is limited superiorly by the phrenicocolic ligament (phrenico = relating to the diaphragm). Therefore the left lateral paracolic gutter does not communicate with the supracolic compartment, but the right lateral paracolic gutter does.
There are numerous peritoneal folds around the duodenum that create potential spaces within the peritoneal cavity. These spaces have been classified as duodenal recesses. There are four duodenal recesses:
- Superior duodenal recess - it lies at the termination of the pars ascendens (fourth part) of the duodenum, anterior to the L2 vertebra. The inferior mesenteric vein and left colic branch of the inferior mesenteric artery are located lateral to the caudal opening of the space.
- Inferior duodenal recess - it is usually found in association with the superior duodenal recess, anterior to L3 vertebra. It is located lateral to the proximal part of pars ascendens of the duodenum and its opening is located cranially and medial to the inferior mesenteric vein and right colic artery.
- Paraduodenal recess - it is a more prominent paediatric structure located behind the free border of the inferior mesenteric vein and the left colic artery. Commonly associated with the superior and inferior duodenal recesses, it rests posterior to falciform paraduodenal fold with its opening towards the right, opposite to the pars ascendens of the duodenum.
- Retroduodenal recess - this inconstant recess is larger than the previously mentioned spaces with its opening pointing to the left and inferiorly. When present, it extends behind the pars horizontalis and pars ascendens of the duodenum, anterior to the abdominal aorta. Its superior limit approaches the duodenojejunal flexure and it is bounded laterally by duodenuparietal folds.
Similar phenomena of peritoneal folds occur around the caecum as previously described around the duodenum. There are three paracaecal recesses to be discussed in this article:
- Superior ileocecal recess - it is another space that is more prominent in paediatric patients. The posterior limit of the fold is formed by the mesentery of the ilium with the posterior caecal and appendicular branches of the ileocolic artery. Inferiorly, it is bounded by the terminal ilium and anteriorly by the caecal fold along with the anterior caecal artery.
- Inferior ileocecal recess - it is formed beneath the bloodless fold of Treves (ileocecal fold). Posterior to the space is the proximal part of the mesentery of the appendix along with the appendicular artery. The medial border is formed by part of the terminal ileum while its lateral limit is the proximal part of the vermiform appendix and the medial surface of the cecum.
- Retrocecal (retrocolic) recess - it is found posterior to the caecum and may extend as far as the proximal ascending colon. Caecal folds on either side of the space form its lateral and medial limits. On occasions when the vermiform appendix is in a retrocecal position, it would be found in this space.
The intersigmoidal recess is a space formed between and inferior to the Λ-shaped (capital lambda shaped) sigmoid mesocolon above the left sacroiliac joint at the brim of the pelvis. Travelling through this recess are the left common iliac artery and vein and the left ureter.
Fluid accumulation in the infracolic region of the abdomen can result in lower abdominal and pelvic complications. If the patient is in a sitting position, fluid from the supracolic compartment, namely from a ruptured gallbladder, duodenal or stomach ulcers can travel through the foramen of Winslow, down the right paracolic gutter and collect in the lower right quadrant or further inferiorly to the pelvic cavity. This can result in misdiagnosis as the symptomacity is similar to acute appendicitis or may progress to form pelvic abscesses.
If the patient is in the supine position, retrograde transmission of peritoneal fluid can occur from right paracolic gutter and can travel superiorly to lesser omental bursa. It is less likely for fluid to enter the left lateral paracolic gutter from the supracolic region, and vice versa, due to the presence of the phrenicocolic ligament. The size of the left lateral paracolic gutter and restriction from the supracolic compartment makes it less likely for fluid to travel from this space to the pelvic cavity.