ª The Author(s) 2015.

This article is published with Abdom Imaging (2015) 40:2710–2722

Abdominal open access at Springerlink.com
Published online: 26 May 2015
DOI: 10.1007/s00261-015-0429-5

Imaging

The subperitoneal space and peritoneal cavity:

basic concepts
Harpreet K. Pannu,1 Michael Oliphant2
1
Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
2
Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA

Abstract The peritoneum is analogous to the pleura which has a

visceral layer covering lung and a parietal layer lining the
The subperitoneal space and peritoneal cavity are two thoracic cavity. Similar to the pleural cavity, the peri-
mutually exclusive spaces that are separated by the toneal cavity is visualized on imaging if it is abnormally
peritoneum. Each is a single continuous space with in- distended by fluid, gas, or masses.
terconnected regions. Disease can spread either within
the subperitoneal space or within the peritoneal cavity to
distant sites in the abdomen and pelvis via these inter-
Location of the abdominal and pelvic organs
connecting pathways. Disease can also cross the peri- There are two spaces in the abdomen and pelvis, the
toneum to spread from the subperitoneal space to the peritoneal cavity (a potential space) and the subperi-
peritoneal cavity or vice versa. toneal space, and these are separated by the peritoneum
(Fig. 1). Regardless of the complexity of development in
Key words: Subperitoneal space—Peritoneal
the embryo, the subperitoneal space and the peritoneal
cavity—Anatomy
cavity remain separated from each other, and each re-
mains a single continuous space (Figs. 2A, 3A). Distin-
guishing the subperitoneal space from the potential space
The article is based on the comprehensive and of the peritoneal cavity is important for understanding
authoritative book by Drs Meyers, Charnsangavej, and the distinct patterns of disease spread in each.
Oliphant titled Meyers’ Dynamic Radiology of the The term subperitoneal refers to tissue that is deep to
Abdomen [1]. Key concepts from the book are high- the peritoneum and includes the extraperitoneal space,
lighted in the following text and in Table 1. The text and the ligaments and the mesenteries and their suspended
accompanying illustrative images are divided into 3 sec- organs (Fig. 2A). Organs whose surfaces are covered by
tions on anatomy, an overview of the spread of disease, peritoneum are therefore subperitoneal. Subperitoneal
and disease spread for selected organs. organs that are deep to the posterior peritoneum are
called extraperitoneal. Since there are only 2 spaces in the
Anatomy abdomen and there are no organs in the peritoneal cav-
Lack of organs in the peritoneal cavity ity, all the abdominal pelvic organs, and their associated
vessels, lymphatics, and nerves are in the subperitoneal
The peritoneum is a serous membrane made up of vis- space. In other words, all the structures seen in the
ceral and parietal layers. The visceral layer of the peri- abdomen and pelvis on cross-sectional imaging are in the
toneum lines the surface of organs and the parietal subperitoneal space. The organs lie in the abdominal
peritoneum lines the coelomic cavity. The peritoneal cavity, not the peritoneal cavity (Figs. 1, 2A). The peri-
cavity is a potential space between the visceral and toneal cavity is a potential space devoid of organs.
parietal layers of the peritoneum. There are no organs in
the peritoneal cavity. The potential space of the peri-
toneal cavity is normally not visible on imaging as it
Importance of visualizing the subperitoneal space
contains only a small amount of fluid (about 100 mL).
as a single space
The subperitoneal space is a large continuous space that
is formed by regions interconnected by ligaments and
Correspondence to: Harpreet K. Pannu; email: pannuh@mskcc.org mesenteries. Ligaments and mesenteries refer to the
H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity 2711

Table 1. Key concepts regarding the peritoneal cavity and subperitoneal space (SPS)
Concept Discussion

Spaces of the abdomen and pelvis There are 2 mutually exclusive spaces—the peritoneal cavity and the SPS
The structure that defines the SPS & separates The peritoneum
it from the peritoneal cavity
The peritoneal cavity The peritoneal cavity is a potential space and is inconspicuous
on normal imaging studies. There are no organs in the peritoneal cavity.
The SPS The SPS is a single extraperitoneal space encompassing the entire abdomen
and pelvis. It is divided into regions but remains one interconnected space.
The SPS contains all the organs, vessels, lymphatics, and nerves of
the abdomen and pelvis.
The importance of distinguishing the SPS from The routes of disease spread differ for the SPS and the peritoneal cavity
the peritoneal cavity
The distinct patterns of disease spread in the SPS Disease spread can occur via mesenteries, ligaments, and lymphatics, and
by periarterial, perineural, transvenous, and intratubular routes
The distinct patterns of disease spread within Disease spreads along the pathways of fluid flow in the single continuous
the peritoneal cavity space of the peritoneal cavity
Transperitoneal disease spread Transperitoneal spread occurs when disease crosses the peritoneum which
separates the SPS from the peritoneal cavity. Transperitoneal spread is bidirectional

Fig. 1. The peritoneal cavity vs the subperitoneal space. all the abdominal pelvic organs which are interconnected via
This is a schematic diagram showing the peritoneal cavity ligaments and mesenteries. Dotted lines show some of these
(PC) on the left and the subperitoneal space (SPS) on the interconnections which allow for disease spread. Abbre-
right. The diagram illustrates that these are 2 completely se- viations for the peritoneal cavity: IC inframesocolic compart-
parate spaces within the abdominal cavity. The peritoneal ment, LP left paracolic recess, LS lesser sac, M Morison’s
cavity and the subperitoneal space are separated by the pouch, RP right paracolic recess, RS right subphrenic space,
peritoneum. The peritoneal cavity is one continuous space and RV rectovesical space. Abbreviations for the subperi-
with interconnecting recesses, some of which are shown. The toneal space: B bladder, C colon, K kidney, L liver, P pan-
subperitoneal space is also one continuous space containing creas, S spleen, SB small bowel, and ST stomach.

subperitoneal tissue between suspended organs and the The relationship between the bowel mesentery
extraperitoneal space. Visualizing the subperitoneal and the peritoneum
space as a single space explains the spread of disease
between different regions of the abdomen pelvis and The mesenteries of the abdomen and pelvis are composed
between the organs covered by peritoneum and the ex- of subperitoneal tissue between 2 layers of visceral peri-
traperitoneum. toneum. Comparing an axial CT image with a cross-
2712 H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity

Fig. 2. Relationship between the mesentery and the peri- area). Spine is shown on the diagram only for orientation pur-
toneum. A Diagram of a 4-week-old embryo shows the coe- poses. A aorta, K kidney, S spine, and VM ventral mesentery. B
lomic cavity which will form the peritoneal cavity (PC) Axial CT image shows the dorsal mesentery of the small bowel
surrounding the primitive gut (G). The medial visceral layer as subperitoneal tissue (arrowhead) between 2 layers of vis-
(arrows) of the peritoneum is apposed on the gut and the me- ceral peritoneum (black arrows). The parietal peritoneal reflec-
sentery, while the parietal layer is lateral. The dorsal mesentery tion (white arrows) is also seen anterior to the colon (C), kidney,
(DM) conveys vessels from the aorta to the gut. Other than the and in the anterior and lateral abdomen. There is fluid (asterisk)
peritoneal cavity, all the tissue in the abdominal cavity portion of in the peritoneal cavity between the visceral (black arrows) and
the diagram is the subperitoneal space (light gray shaded parietal (white arrows) layers of the peritoneum.

sectional diagram of an embryo, the dorsal mesentery tissues anterior to the kidney leaving a connecting
carries vessels from the aorta to the gut (Fig. 2). The splenorenal ligament that contains the distal splenic ar-
visceral peritoneum surrounds the mesentery, forms the tery and vein. The midgut and hindgut form within the
serosal layer of the gut, and is in continuity with the dorsal mesentery creating the small intestine mesentery
parietal peritoneum which covers the extraperitoneal and the mesocolon.
space. As the ligaments, mesenteries, and suspended or- Anteriorly, the liver forms in the subperitoneal tissues
gans develop, the peritoneal cavity forms recesses that anterior to the stomach, or the ventral mesogastrium.
remain interconnected as the peritoneal cavity and se- This divides the subperitoneal tissues into the gastro-
parate from the subperitoneal space (Fig. 3A). hepatic ligament between the stomach and liver, and the
falciform ligament between the liver and abdominal wall.
The free edge of the gastrohepatic ligament is the
Correlation between embryonic development and
hepatoduodenal ligament. The visceral peritoneum con-
the abdominal ligaments
tinues over the stomach forming the serosal layer and
The spleen, pancreas, liver, and gut form within the over the liver and spleen forming their capsules.
mesentery that surrounds and suspends the primitive gut
in the embryo. The development of these organs results
in the creation of the abdominal ligaments that can be
Identifying the ligaments and bowel mesenteries
identified on CT.
on imaging
Posteriorly, the spleen and pancreas form in the The ligaments and mesenteries are named according to
dorsal mesogastrium, or the part of the dorsal mesentery the viscera they connect and are identified by the vessels
suspending the stomach (Fig. 3). The splenic artery runs that run in them. For example, the hepatoduodenal
from the aorta through the dorsal mesogastrium to the ligament is identified by the portal vein, hepatic artery,
spleen with branches continuing to the stomach. The part and common bile duct. Selected ligaments and their as-
of the dorsal mesogastrium between the stomach and the sociated vessels are described in Table 2. The ligaments
spleen becomes the gastrosplenic ligament containing the and mesenteries are a pathway for disease spread be-
short gastric vessels. The part of the dorsal mesogastrium tween organs. The vasculature within the mesenteries
containing the pancreas fuses with the subperitoneal often acts as a scaffold for disease spread. The utility of
 H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity 2713

Fig. 3. Abdominal ligaments. A Diagram showing develop- mesentery between the spleen and pancreas is called the
ment of an embryo. The liver develops in the ventral me- splenorenal ligament. Dotted lines approximate the paths of
sentery anterior to the stomach. The residual part of the the ventral and dorsal mesenteries. A aorta, K kidney, L liver,
ventral mesentery between the liver and stomach is called the PC peritoneal cavity, S spine, and ST stomach. Subperitoneal
gastrohepatic ligament in the adult. The spleen and pancreas space = light gray shaded area in abdominal cavity portion of
form in the dorsal mesentery posterior to the stomach. The diagram. Spine is shown on the diagram only for orientation
residual part of the dorsal mesentery between the spleen and purposes. B Axial CT image of the upper abdomen shows the
stomach is called the gastrosplenic ligament in the adult. The gastrohepatic (arrow) and gastrosplenic (arrowhead) liga-
pancreas fuses with the tissues anterior to the kidney to lie in ments containing the left gastric artery and short gastric
the anterior pararenal space. The residual part of the dorsal vessels, respectively.

Table 2. Selected abdominal and pelvic ligaments and mesenteries

Ligament From To Identified By

Hepatoduodenal Hepatic hilum Duodenum Portal vein, hepatic artery

Gastrohepatic Lesser curvature of stomach Fissure of ligamentum venosum Left and right gastric artery, replaced
(lesser omentum) left hepatic artery
Gastrosplenic Greater curvature of proximal Splenic hilum Left gastroepiploic and short gastric vessels
stomach
Gastrocolic Greater curvature of gastric body Transverse colon Right and left gastroepiploic vessels
Splenorenal Left anterior pararenal Splenic hilum Splenic vessels near hilum
Small bowel mesentery root Duodenal-jejunal junction Right iliac fossa Superior mesenteric vessels
Greater omentum Transverse colon Apron anterior to small bowel Epiploic vessels
Transverse mesocolon Transverse colon Pancreas Middle colic vessels, gastrocolic trunk
Ascending mesocolon Ascending colon Mesenteric root Marginal, ileocolic and right colic vessels
Descending mesocolon Descending colon Left superior duodenal fold Marginal and left colic vessels, inferior
mesenteric vein
Sigmoid mesocolon Sigmoid colon Root at origin of inferior Marginal and sigmoid vessels
mesenteric artery

identifying the mesenteries and ligaments is to more ac- rior layer that is continuous with the anterior renal fascia
curately and efficiently recognize sites of disease spread. and a posterior layer that forms the lateroconal fascia
which in turn goes anterolaterally to blend with the
peritoneum.
Anatomic continuity between the pararenal
Laterally at the level of the kidney, the lateroconal
spaces
fascia separates the anterior pararenal space from the
The posterior portion of the extraperitoneal space, the posterior pararenal space. Below the level of the kidney
retroperitoneum, in the abdomen is divided by the renal and the iliac crest, the anterior and posterior renal fasciae
fascia into the anterior pararenal, perinephric, and pos- tend to fuse resulting in anatomic continuity between the
terior pararenal spaces (Fig. 4). The anterior pararenal anterior and posterior pararenal spaces continuing infe-
space is between the parietal peritoneum and the anterior riorly as the infrarenal space.
renal fascia; the perinephric space is between the anterior The anterior pararenal space contains the pancreas,
and posterior renal fascia; the posterior pararenal space duodenum, and ascending and descending colon. The
is between the posterior renal fascia and the transversalis perinephric space contains the kidney and adrenal gland.
fascia. The posterior renal fascia has 2 layers. An ante- The posterior pararenal space has no organs and is
2714 H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity

Fig. 4. Renal fasciae. A Axial CT image shows the anterior between the 2 layers of the posterior renal fascia. Fluid from
and posterior renal fascia (black arrows). Arrowheads show the anterior pararenal space can extend into this potential
the posterior pararenal space extending laterally as the space between the 2 layers. Arrowhead points to the lower
properitoneal fat. B Axial CT image shows fluid (arrows) in pole of the kidney.

continuous laterally with the extraperitoneal fat of the This forms the pathways for the subperitoneal spread of
properitoneal flank stripe. disease.

Compartmentalization of the pelvic Overview of disease spread

subperitoneal tissues The pathways of disease spread in the abdominal
Anteriorly, the umbilicovesical fascia encloses the blad- cavity
der and urachus in the perivesical space (Fig. 5). The Since all organs are subperitoneal, the subperitoneal
umbilicovesical fascia also defines the prevesical space space is a natural pathway for disease spread (Fig. 6).
anteriorly and laterally. Posteriorly, the rectum is in the Potential routes are along the mesenteries and ligaments,
perirectal space which is defined laterally by the via visceral lymphatics to nodes, and by periarterial,
perirectal fascia, posteriorly by the posterior pelvic fas- perineural, or transvenous routes as well as along ducts.
cia, and anteriorly by the rectovesical fascia in the male Continuity of the subperitoneal space explains the spread
and the rectovaginal fascia in the female. The aggregate of disease from one organ to another. Disease can spread
of these fasciae is also referred to as the mesorectal fas- bidirectionally within the subperitoneal space using the
cia. Superiorly, the perirectal space communicates with pathways created by normal structures. If a tumor is
the sigmoid mesocolon. The presacral space is posterior present, tracing the organ’s blood supply helps identify
to the perirectal space. nodes that are potential pathways for spread. If an ab-
The peritoneum reflects over the dome of the bladder, normal node is discovered, knowing its location helps in
the uterine body, and the rectouterine recess (Fig. 5). the search for the primary site.
Laterally, in the female, the peritoneum forms the folds For organs which are covered by peritoneum, there is
of the broad ligament. In the female, the broad ligament an additional pathway for spread (Fig. 6). Transperi-
suspends the female pelvic organs and is in continuity toneal spread occurs when disease traverses the visceral
with the extraperitoneal space. Regions within the broad peritoneum along the surface of the organ. This route is
ligament form the mesometrium, mesosalpinx, and the possible because the peritoneum consists of a single layer
mesovarium. These mesenteries are all in continuity of mesothelial cells on a bed of loose connective tissue [2].
within the broad ligament. The serosa of the fallopian Neoplastic and inflammatory cells, gas, and hemorrhage
tube is continuous as part of the broad ligament and its in the subperitoneal space can therefore cross the peri-
fimbriated end is open to the peritoneal cavity. The ovary toneum to enter the peritoneal cavity. Subsequently,
lies within the broad ligament immediately beneath the peritoneal spread occurs via the circulating peritoneal
peritoneum. The arteries, veins, lymphatics, and nerves fluid to the peritoneal recesses in the abdomen and pelvis.
to the female pelvic organs all course within the broad In summary, the pathways of disease spread are
ligament and connect with the extraperitoneal space. subperitoneal and peritoneal. In addition, transperi-
H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity 2715

Fig. 6. Diagram shows the 2 routes of disease spread for

viscera which are covered by peritoneum–transperitoneal and
subperitoneal. Disease can cross the visceral peritoneum
(solid arrow) to enter and subsequently spread in the peri-
toneal cavity. Alternatively, disease can follow the vessels
and lymphatics (open arrow) of the viscera to spread in the
subperitoneal space (SPS).

toneal spread occurs when subperitoneal disease crosses

the peritoneal lining and spreads within the peritoneal
cavity.

Omental tumor: subperitoneal disease or

peritoneal carcinomatosis
The surface of the greater omentum is lined by visceral
peritoneum and the internal composition is of subperi-
toneal fat, lymphatics, and vessels. Communicating
channels allow fluid in the peritoneal cavity to be ab-
sorbed by the omental lymphatics. Thus, tumor cells that
are in the peritoneal cavity being disseminated by the
peritoneal route can traverse the visceral peritoneum to
grow in the richly vascular subperitoneal tissues of the
omentum. In addition to the omentum, common sites of
peritoneal tumor implants are the diaphragm and the
dependent peritoneal recesses.

Fig. 5. Pelvic spaces. A axial CT image of the pelvis. The

Peritoneal fluid flow in the abdomen and pelvis
urachus (arrowhead) and obliterated umbilical arteries (ar- The transverse mesocolon divides the peritoneal cavity
rows) form the median umbilical ligament and the medial into the supramesocolic and inframesocolic compart-
umbilical folds, respectively, and are encased within the um- ments. The latter is divided into right and left infracolic
bilicovesical fascia forming the perivesical space. The pre- recesses by the root of the small bowel mesentery. Peri-
vesical space is anterior and lateral to the bladder. The
toneal fluid is drawn into the upper abdomen by low
perirectal space (asterisk) surrounds the rectum. B Sagittal
CT image shows the peritoneum (arrows) along the anterior
subdiaphragmatic pressures and is pulled into the pelvis
abdominal wall and reflecting over the bladder and rectum. under the influence of gravity. Fluid travels from the
Peritoneal fluid in the inframesocolic compartment (IM) com- pelvis to the abdomen via the paracolic gutters and
municates with the rectovesical recess (asterisk). The bladder travels from the abdominal infracolic compartment to
is inferiorly displaced by the peritoneal fluid. B bladder, R the pelvis (Fig. 7). It pools in dependent recesses, the
rectum. most prominent of which are the pouch of Douglas in the
2716 H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity

female and the rectovesical recess in the male, along the perivesical fat that encases the urachus (median umbilical
superior portion of the sigmoid mesocolon, ileocolic re- ligament) and the obliterated umbilical arteries (medial
gion, right paracolic gutter, and Morison’s pouch. umbilical ligament). If prevesical fluid penetrates the
All the peritoneal recesses communicate, however, overlying transversalis fascia, it can involve the rectus
peritoneal fluid preferentially flows in certain directions and muscle. Conversely, rectus hematomas can extend into
is anatomically limited in some locations. Peritoneal fluid the prevesical fat.
from the pelvis primarily goes up the right paracolic gutter Ascites travels superiorly from the lateral paravesical
(recess) forming continuity of the inframesocolic and peritoneal recesses to the paracolic gutters. Prevesical
supramesocolic recesses on the right. On the left, the fluid travels superiorly into the infrarenal space and
phrenicocolic ligament limits the left paracolic gutter subsequently into the pararenal spaces. Posteriorly, ex-
(recess) to the inframesocolic recess. From the right para- traperitoneal fluid extends into the presacral space. As-
colic gutter, fluid enters the right subhepatic space (Mor- cites can go into the inguinal canal along a hernia, while
ison’s pouch) and may subsequently enter the lesser sac via prevesical fluid can go to the inguinal ring along the vas
the epiploic foramen (of Winslow) between the main portal deferens. Unlike ascites, prevesical fluid abuts the lateral
vein and the inferior vena cava (Fig. 7). Fluid also goes pelvic musculature and can extend along the external
superiorly into the right subphrenic space but the falciform iliac vessels and femoral sheath.
ligament limits flow from the right to the left subphrenic
space. Abscesses secondary to intraperitoneal infections are
Distinguishing intraperitoneal and
therefore common in the pouch of Douglas, right paracolic
extraperitoneal free air in the abdomen
gutter, right subhepatic space, and right subphrenic space.
Fluid flow patterns are mostly bidirectional. The shape of the subdiaphragmatic air and change with
Although the falciform and phrenicocolic ligaments respiration and position help distinguish intraperitoneal
typically limit fluid flow across them, large volumes of and extraperitoneal free air. On an upright chest radio-
fluid can overflow under the free edge of the falciform graph, free intraperitoneal air follows the contour of the
ligament and over the phrenicocolic ligament. Left sub- dome of the hemidiaphragm, while extraperitoneal air is
phrenic fluid is more commonly seen due to gastric, usually medial or lateral to the apex of the hemidi-
splenic, or splenic flexure colonic pathology. There is aphragm. The volume of free intraperitoneal air seen
continuity between the left subphrenic space, the gas- under the hemidiaphragm increases on inspiration due to
trohepatic space, and the perisplenic spaces such as the decreased subdiaphragmatic pressure. The volume of free
gastrosplenic recess and splenorenal recess. These are extraperitoneal air seen under the hemidiaphragm in-
separated from the lesser sac by the gastrohepatic, gas- creases on expiration due to decreased compression by the
trosplenic, and splenorenal ligaments, respectively. diaphragm. Free intraperitoneal air fills the potential re-
cesses of the peritoneal cavity and can outline ligaments
such as the falciform ligament. Free extraperitoneal air
Distinguishing intraperitoneal and can occupy extraperitoneal spaces and can outline the
extraperitoneal fluid in the pelvis psoas muscle and follow the flank stripe if within the
Intraperitoneal pelvic fluid (ascites) occurs in the pouch posterior pararenal space. Peritoneal air shifts readily with
of Douglas and in the lateral recesses which lie on either position change, while extraperitoneal air does not.
side of the sigmoid colon and are referred to as par-
avesical recesses of the peritoneal cavity (Fig. 8). Ex-
Potential routes of spread of extraperitoneal free
traperitoneal pelvic fluid in the subperitoneal space
air
occurs in the prevesical space which is anterior and lat-
eral to the bladder. Since the bladder is positioned more Extraperitoneal free air originating anywhere in the ab-
inferiorly in the pelvis than the sigmoid colon, ascites is domen can spread throughout the abdomen and pelvis
seen superior to the bladder. Ascites displaces the blad- via the interconnecting subperitoneal space.
der inferiorly, while prevesical space fluid displaces the Air from a duodenal perforation can go from the
bladder posteromedial. Extraperitoneal fluid in the pre- anterior pararenal space to the infrarenal space and then
vesical space extends bilaterally forming a symmetric or to the posterior pararenal space or to the prevesical space
asymmetric ‘‘molar tooth’’ appearance of fluid both of the pelvis.
anterior and lateral to the bladder (Fig. 8). Extraperitoneal pelvic free air from a rectal perfora-
Ascites preserves the properitoneal fat which is the tion can go from the mesorectum to the sigmoid meso-
lateral extension of the posterior pararenal space and colon to the prevesical space. From the prevesical space
outlines the medial umbilical folds anteromedial. Ex- air can go inferiorly along the vas deferens to the scro-
traperitoneal fluid in the prevesical space can extend to tum, laterally outside the pelvic cavity via the sciatic
the lower abdomen and obliterate the properitoneal fat. foramen and into the thighs along the scaffold of the
The anterior extension spares the midline triangle of the femoral sheath. From the prevesical space air can also go
H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity 2717

Fig. 7. Peritoneal cavity fluid flow and recesses. A coronal (asterisk). C coronal CT image in a different patient shows fluid in
CT image shows peritoneal carcinomatosis demonstrating the the superior recess of the lesser sac (SR) and in the gastro-
peritoneal recesses. Tumor in the right subdiaphragmatic hepatic recess (black arrow) separated by the gastrohepatic
recess (black arrow) and Morison’s pouch (double black arrows). ligament (black arrowheads). Fluid in the gastrohepatic recess
Tumor (arrowheads) is also seen along the peritoneal reflection communicates with fluid in the left subphrenic space (LS). D
over the bladder (B). White arrows show continuity between the coronal CT image in a different patient shows fluid in the lesser
paravesical and paracolic recesses. B Axial CT image in a dif- sac (asterisk) and in the gastrosplenic recess (GS) separated by
ferent patient shows the epiploic foramen (arrow) between the the gastrosplenic ligament (arrow). There is continuity between
portal vein and inferior vena cava and fluid in the lesser sac the gastrosplenic and left subphrenic (LS) recesses.

superiorly into the infrarenal space and then to the (Fig. 9). In the anterior pararenal space air can surround
posterior pararenal space or to the anterior pararenal the pancreas and extend to the porta hepatis, to the bare
space. Extraperitoneal air in the posterior pararenal areas of the liver and spleen, and to the root of the me-
space can extend laterally within the properitoneal fat senteries of the small bowel and transverse colon. Con-
and superiorly to the level of the respiratory diaphragm tinuity within the anterior pararenal space allows
2718 H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity

Fig. 8. Pelvic intraperitoneal fluid vs extraperitoneal fluid. prevesical space (asterisk) anterior to the decompressed
Pelvic fluid is shown in 2 different patients. The patient in A has bladder (arrowhead) containing a catheter. The bladder is dis-
intraperitoneal fluid. The patient in B and C has extraperitoneal placed posteriorly. Fluid extends within the prevesical space
fluid. A axial CT image shows intraperitoneal fluid in the right (arrows) lateral to the bladder giving a ‘‘molar tooth’’ appear-
and left paravesical recesses (asterisks) lateral to the sigmoid ance. C sagittal CT image in the same patient as in B shows
colon (S) and superior to the bladder (not shown). B Axial CT extraperitoneal fluid in the prevesical space (asterisk) anterior to
image of a different patient shows extraperitoneal fluid in the the posteriorly displaced bladder (arrows) containing a catheter.

for bidirectional spread between the organs of the Disease spread for selected organs
extraperitoneum and suspended organs via their mesen-
teries all within the subperitoneal space. Potential routes of spread of pancreatic disease
Extraperitoneal air can also track along the aorta and The spread of pancreatic disease highlights the concept
into the chest through the aortic hiatus. Extraperitoneal of the subperitoneal space as a single space (Fig. 10). The
air in the gastrohepatic ligament can enter the chest pancreas lies in the anterior pararenal space. This space
through the esophageal hiatus. This spread is bidirec- is a natural pathway as it connects with the base of
tional and air from the mediastinum can spread several mesenteries. The tail of the pancreas lies in
throughout the abdomen within the subperitoneal space. the splenic hilum so disease can spread along the
H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity 2719

(Fig. 11). The peritoneum covering the liver reflects on

itself to form the right coronary ligament and attach the
right lobe to the right hemidiaphragm. The liver posterior
and medial to this reflection is left bare of peritoneum and
abuts the diaphragm. In addition, the parietal peritoneum
of the inferior right coronary ligament also fuses with the
anterior renal fascia. Posteriorly, the diaphragmatic fascia
fuses with the right posterior renal fascia. As a result, the
space between the anterior and posterior renal fascia, or
the right perinephric space, communicates with the bare
area of the liver. Hemorrhage from the hepatic bare area
can therefore present as a retroperitoneal bleed in the right
perinephric space. Similarly, a right perinephric abscess
can directly spread to the liver and diaphragm.
On the left, the perinephric space communicates with the
left subphrenic extraperitoneal space (Fig. 11) [2]. This is the
result of the left anterior renal fascia fusing with the gas-
trosplenic ligament and the posterior renal fascia fusing with
the diaphragm [2]. In addition, the peritoneum covers most
of the spleen except for the splenic hilum. The splenorenal
ligament connects the bare area of the spleen at the hilum
with the left anterior pararenal space. Bleeding from a rup-
tured splenic artery aneurysm can therefore result in a
retroperitoneal bleed in the anterior pararenal space.

Anatomic basis for a hepatobiliary tumor

mimicking a pancreatic mass
Tumor from the liver and gallbladder can spread to the
nodes within the hepatoduodenal ligament. The anterior
Fig. 9. Extraperitoneal free air. Sagittal CT image shows
pneumatosis of the ascending colon and extraluminal air in the
periportal nodes follow the lymphatics along the hepatic
adjacent mesentery (asterisk). This extraperitoneal free air artery to the celiac artery and then to the cisterna chyli. The
tracks in the anterior and posterior pararenal spaces (arrows) posterior periportal nodes follow the lymphatics to the
to the bare area of the liver and diaphragm (arrowheads). retropancreatic nodes, aortocaval node, and then to the
cisterna chyli. Therefore, an enlarged retropancreatic node
from a metastatic hepatobiliary tumor can mimic a pan-
gastrosplenic ligament to the gastrocolic ligament along creatic mass. Other routes of nodal spread are the gastro-
the greater curvature of the stomach. The head of the hepatic ligament or adjacent to the suprahepatic inferior
pancreas is connected to the hepatic hilum by the vena cava to the juxtaphrenic and paraesophageal nodes.
hepatoduodenal ligament so disease can spread along the
gastrohepatic ligament to the lesser curvature of the
Diaphragmatic adenopathy secondary to
stomach. The root of the transverse mesocolon lies along
peritoneal carcinomatosis
the pancreas so disease can spread to the transverse colon.
Similarly, the root of the small bowel mesentery starts Similar to the omentum, the diaphragm has abundant
adjacent to the anterior inferior aspect of the pancreatic lymphatics for the absorption of peritoneal fluid. This
body so disease can spread to the ileocolic region. process can result in tumor cells being transported from
The peritoneum forming the posterior margin of the the peritoneal cavity to the diaphragmatic nodes. Me-
lesser sac is anterior to the pancreas. Disease can cross tastatic diaphragmatic adenopathy can therefore occur
the peritoneum (transperitoneal spread) to enter the secondary to peritoneal carcinomatosis from abdominal
lesser sac for subsequent peritoneal spread. and pelvic malignancies.

Anatomic basis for a hepatic laceration resulting Potential routes of peritoneal spread of blood
in a retroperitoneal hematoma following trauma
The bare area of the liver is that part of the posterior right Traumatic injuries of viscera can disrupt the capsule of
lobe of the liver that is not covered by peritoneum an organ. The visceral peritoneum forms the capsule of
2720 H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity

Fig. 10. Subperitoneal spread of disease. A Axial CT im- extending toward the ileocecal junction within the small
age shows a large pancreatic mass (white arrow) extending intestine mesentery (arrows). C Coronal CT image shows a
along the hepatoduodenal ligament to the porta hepatis heterogeneous mass (white arrows) around the inferior
(arrowheads). Mass also invades the left perinephric space vena cava and aorta. Mass extends superiorly, through the
and engulfs the adrenal gland (black arrow). Superiorly, the aortic hiatus, to the posterior mediastinum (black arrow-
mass extended into the gastrohepatic ligament with invasion heads). The mass also extended into the root of the small
of the left lobe of the liver (not shown). B Coronal CT image bowel mesentery (not shown) along the superior mesenteric
shows a hematoma in the root of the small bowel mesentery artery.

the liver and spleen, except for the bare areas described face of the liver, blood can spread into the right sub-
earlier. Therefore, a laceration allows for transperitoneal phrenic space and right subhepatic space and can
spread of blood from these organs into the peritoneal subsequently enter the lesser sac and right paracolic
cavity. Following a laceration of the peritonealized sur- gutter. Following a laceration of the peritonealized sur-
H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity 2721

Fig. 11. Extraperitoneal spaces in the upper abdomen. A the liver except for the bare area. B Sagittal CT image
Sagittal CT image shows the peritoneal reflections over the shows fluid in the left perinephric space (asterisk) extending
liver (arrows). The liver posterior and medial to these superiorly to abut the diaphragm (white arrow). The fluid is
reflections is left bare of peritoneum and abuts the posterior to the pancreas (P) and the splenorenal ligament
diaphragm (arrowhead). Note that peritoneal fluid surrounds (black arrow).

face of the spleen, blood can enter the perisplenic space, At any site in the abdomen and pelvis, once blood,
left subphrenic space, and gastrohepatic space. Larger air, or contrast has entered the peritoneal cavity, it can
volumes can also spread to the left paracolic gutter. travel to any of the peritoneal recesses.
From the paracolic gutters, blood can accumulate in the
dependent rectovesical recess of the pelvis.
Since the peritoneum forms the serosa of bowel,
Summary
bowel perforations can result in blood, air and bowel The two spaces of the abdomen are separated by the
contents such as endoluminal contrast spilling into the peritoneum (Table 1).
peritoneal cavity. The mesenteric vessels lie in sub- The peritoneal cavity is a potential space between the
peritoneal fat between 2 layers of visceral peritoneum. visceral and parietal layers of the peritoneum. This po-
Blood from a mesenteric hematoma can therefore tential space normally contains only a small amount of
traverse the visceral peritoneum to enter the peritoneal peritoneal fluid and is not seen on transaxial imaging of
cavity and appear as intraperitoneal hemorrhage. normal patients. The peritoneal cavity is distinct from the
Similarly, hemorrhage in tissues around extraperi- subperitoneal space and contains no organs or structures.
toneal organs such as the pancreas and kidney can The spread pattern in the peritoneal cavity follows the flow
cross the posterior peritoneum to enter the peritoneal of peritoneal fluid.
cavity. The subperitoneal space is a continuous intercon-
In the pelvis, the peritoneum reflects over the bladder necting space beneath the peritoneum containing the
dome. A rupture of the bladder dome results in in- extraperitoneal space, the ligaments and mesenteries, and
traperitoneal spill of urine and administered bladder their suspended organs. Individual mesenteries and
contrast into the paravesical, paracolic, and inframeso- ligaments are identified by the vessels that course
colic recesses. Intraperitoneal bladder rupture is less through them. The subperitoneal space provides the av-
common than extraperitoneal bladder rupture. enues for bidirectional spread of disease.
2722 H. K. Pannu, M. Oliphant: The subperitoneal space and peritoneal cavity

Transperitoneal spread occurs when disease spreads appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
from the subperitoneal space to the peritoneal cavity by made.
crossing the peritoneal lining.

Acknowledgment. The authors would like to thank Ms Terry Helms from

the Medical Graphics department at Memorial Sloan Kettering Cancer
Center for her invaluable help and expertise in creating the illustrations for References
this paper. 1. Meyers MA, Charnsangavej C, Oliphant M (2011) Meyers’ dynamic
radiology of the abdomen: normal and pathologic anatomy, 6th edn.
Open Access. This article is distributed under the terms of the Creative Berlin: Springer Science + Business Media, LLC
Commons Attribution 4.0 International License (http://creative- 2. Standring S, Ellis H, Berkovitz BKB (2005) Gray’s anatomy: the
commons.org/licenses/by/4.0/), which permits unrestricted use, dis- anatomical basis of clinical practice, 39th edn. Amsterdam: Elsevier
tribution, and reproduction in any medium, provided you give Churchill Livingstone