AJR 2000; 175:363-370
© American Roentgen Ray Society
The Great Escape
Interfascial Decompression Planes of the Retroperitoneum
Richard M. Gore1,
Dennis M. Balfe2,
Robert I. Aizenstein3 and
Paul M. Silverman4
1
Department of Radiology, Evanston Hospital-Northwestern University, 2650 Ridge
Ave., Evanston, IL 60201.
2
Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology,
Washington University School of Medicine, 510 S. Kingshighway, St. Louis, MO
63110.
3
Department of Radiology, University of Illinois Medical Center, 1740 W.
Taylor, Chicago, IL 60612.
4
Department of Radiology, M. D. Anderson Cancer Center, Department of
Radiology, Box 057, 1515 Holcomb Blvd., Houston, TX 77030.
Received December 9, 1999;
accepted after revision January 24, 2000.
Address correspondence to R. M. Gore.
Introduction
Retroperitoneal fluid collections result from a variety of infectious,
neoplastic, inflammatory, and traumatic causes. In most instances, these fluid
collections remain in their compartment of origin confined by the anterior and
posterior renal fascia, lateroconal fascia, adhesions, or inflammatory closure
of potential outlets [1,
2]. However, when large volumes
of fluid develop rapidly, the capacity of the retroperitoneal space of origin
to accommodate the fluid may be overwhelmed, often causing the recruitment of
laminated, variably fused, and potential expansile retroperitoneal fascial
planes for decompression
[3,4,5].
These fascial planes also serve as a conduit for the spread of fluid,
inflammation, and tumor. This perspective analyzes recent concepts concerning
the origin, location, nature, and significance of fascial planes and their
ability to serve as spaces that can decompress retroperitoneal fluid
collections and infiltrating diseases.
Embryologic Considerations
An understanding of the distribution of fluid in the retroperitoneum is
contingent on an appreciation of the fact that the retroperitoneum forms in
layers and that the retroperitoneal fascia is composed of multiple discrete
layers representing fused leaves of apposed embryonic mesentery
[6,7,8]
(Fig. 1 and Appendix). The
primary body wall, which is the outermost layer of the embryo, is formed by
mesenchyme, which develops in the vertebral bodies, paraspinal muscles, and
the psoas muscle. The body wall is lined with transversalis fascia, which
forms the outer border of the retroperitoneal and peritoneal cavities. Deep in
relation to the transversalis fascia lies a variable amount of properitoneal
fat that forms the posterior pararenal space. This small, almost unoccupied
space is seldom the primary site of abnormality. Two fat pads exist in this
space: one lies posterolateral and one directly ventral to the quadratus
lumborum muscle [9].
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Fig. 1. —Retroperitoneal and interfascial planes. Drawing at level of renal
hila shows that renal and lateroconal fasciae are laminated planes composed of
apposed layers of embryonic mesentery. Thickness of interfascial planes is
exaggerated to illustrate their potentially expansile nature. Note that
perinephric spaces (PRS) are closed medially. Retromesenteric space is
continuous across midline. Retromesenteric anterior interfascial space (RMP),
retrorenal posterior interfascial space (RRS), and lateroconal plane
communicate at fascial trifurcation (arrows). A = aorta, APS =
anterior pararenal space, ARF = anterior renal fascia, DPS = dorsal pleural
sinus, IVC = inferior vena cava, LCF = lateroconal fascia, PP = parietal
peritoneum, PPS = posterior pararenal space, PRF = posterior renal fascia, TF
= transversalis fascia, asterisk = posterior peritoneal recess.
(Reprinted from [3])
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The kidneys form in the pelvis in early embryologic life and then ascend to
their adult position. As a result, the fascia that surrounds each kidney forms
a long tapered cone that fuses at its posterior and lateral aspects to the
surface of the properitoneal fat. At this point of development, two defined
retroperitoneal spaces exist: the perirenal space, which contains the kidneys,
adrenal glands, proximal ureters, and fat; and the posterior pararenal space,
which contains only fat. A potential space is also created between these fused
surfaces, the posterior interfascial or retrorenal plane
[10,
11]. This potential space may
be recruited for the decompression of fluid collections arising in either of
the spaces it bounds.
The perinephric space is divided by thin fibrous lamellae (Fig.
2A,2B,2C)
into multiple compartments that may or may not communicate
[12]. These fibrous lamellae
also form bridging septa that traverse the perinephric fat and interconnect
the renal capsule and anterior and posterior renal fasciae. These bridging
septa are continuous with the anterior and posterior interfascial planes and
may serve as a bidirectional conduit for the spread of blood, fluid, edema,
and infiltrating soft tissue from the perirenal interfascial planes into the
perinephric space.
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Fig. 2A. —Perinephric space bridging septa. Drawing of perinephric space at
level of mid pole of kidney shows that perinephric space contains rich network
of bridging septa (open arrows), lymphatics (solid arrow),
arteries, and veins (arrowhead). Note that perirenal lymphatics
communicate with small lymph nodes at renal hilum, and that these, in turn,
connect with periaortic and pericaval lymph nodes. This lymphatic network
provides potential route of spread for metastatic tumor into perinephric
space. (Reprinted from [3])
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Fig. 2B. —Perinephric space bridging septa. T1-weighted (B) and
T2-weighted fat-suppressed (C) MR images in 47-year-old man with
left-sided pyelonephritis reveal fluid-filled bridging perinephric septa
(arrows).
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Fig. 2C. —Perinephric space bridging septa. T1-weighted (B) and
T2-weighted fat-suppressed (C) MR images in 47-year-old man with
left-sided pyelonephritis reveal fluid-filled bridging perinephric septa
(arrows).
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The next embryologic development key to this discussion is the rotation and
subsequent fusion of the gut and its dorsal mesentery. In this complex
process, the mesentery, which contains the pancreas and duodenum, rotates and
fuses. Under the influence of the rapidly growing liver, the stomach and
duodenum are rotated counterclockwise, so that the left side of this mesentery
becomes anterior. The right side of the mesentery becomes closely apposed to
the body wall, aorta, inferior vena cava, and anterior part of the right renal
fascia. In fusing, the dorsal mesoduodenum forms the pancreaticoduodenal
space, creating another potential space between the fused surfaces of these
fat-containing structures—an anterior interfascial or retromesenteric
plane.
Pari passu, the colon and its mesentery undergo complex rotation and fusion
to form the lateral portions of the anterior pararenal space. The mesentery of
the descending colon rotates in a clockwise direction (as viewed from below)
and its left lateral surface fuses with the anterior renal fascia. Lateral in
relation to the anterior renal fascia, the dorsal mesocolon fuses with the
surface of the posterior pararenal fat to form the lateroconal fascia. The
ascending colon and its mesentery undergo a 180° counterclockwise rotation
(as viewed from the front) so that its original left surface faces right. The
mesentery of the ascending colon rotates counter-clockwise (as viewed from
below) to fuse with the anterior renal fascia (proximally, below the
transverse duodenum) and distally to fuse with the pancreaticoduodenal space.
The lateral part of the right colon fuses with the properitoneal fat to form
the lateroconal fascia. These retromesenteric fusion planes create a potential
space (the anterior interfascial plane) that lies ventral in relation to the
anterior renal fascia and dorsal in relation to the mesenteries of the
ascending and descending colons.
Anatomic Considerations
The existence of the interfascial retroperitoneal planes was recently
documented in a series of cadaveric dissections by Molmenti et al.
[5]. In that study, latex
injected into the tail of the pancreas entered an anterior interfascial
retromesenteric plane that was dorsal in relation to the anterior pararenal
space and ventral in relation to the anterior renal fascia. The plane
continued superiorly in relation to the diaphragm near the esophageal hiatus;
inferiorly in relation to the pelvis along the anterolateral surface of the
psoas muscle; and laterally, posteriorly in relation to the descending colon
and its mesentery. This anterior interfascial retromesenteric plane also
communicated with the posterior interfascial retrorenal plane lying between
the posterior renal fascia and the posterior pararenal space.
The laminated anterior interfascial retromesenteric plane is continuous
across the midline, and it communicates at the fascial trifurcation
(Fig. 3) with the two other
potentially expansile planes, the posterior interfascial and lateroconal
planes.
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Fig. 3. —52-year-old woman with aortic bleeding. CT scan at level of lower
poles of kidneys shows hemorrhage in anterior interfascial plane (straight
open arrow), posterior interfascial plane (curved solid arrow),
and lateroconal interfascial plane (curved open arrow). These
collections meet at fascial trifurcation (straight solid arrow).
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In the iliac fossa, the anterior and posterior renal fascia fuse to form a
single multilaminar fascia, the combined interfascial plane. This combined
interfascial plane continues in the pelvis along the anterolateral margins of
the psoas muscle contiguous with the pelvic retroperitoneal perivesical and
presacral spaces. Therefore, this plane can serve as a decompressing conduit
to the pelvis for interfascial fluid originating in the retroperitoneum. The
inferior blending of Gerota's fascia also seals the inferior aspect of the
perinephric space. This prevents the extension of perinephric fluid from the
abdominal retroperitoneum into the pelvis. Because the retroperitoneal fascial
planes traverse the midline and are continuous with the pelvic
retroperitoneum, interfascial fluid collections can spread from the abdominal
retroperitoneum across the midline or into the pelvis.
The concept of recruitable planes surrounding the renal fascia can help
resolve several conflicting, recently published cadaver studies that have
investigated the extension of retroperitoneal fluid into the pelvis and across
midline. Mindell et al. [13],
Kneeland et al. [14], and
Mastromatteo et al. [15] have
concluded that the cone of the renal fascia is open, allowing fluid to extend
across the midline and into the pelvis
[16]. In two different
studies, Raptopoulos et al.
[17,
18] used latex injections of
subsequently dissected cadavers and concluded that the cone of renal fascia is
closed, preventing fluid from crossing the midline and extending into the
pelvis. The interfascial plane concept acknowledges that although the renal
fascia do indeed form an enclosed space, fluid can leak through bridging
perinephric septa [12] and
extend into the interfascial planes. From there, the fascia can descend into
the pelvis via the combined interfascial plane and cross the midline via the
anterior interfascial retromesenteric plane.
Clinical and Imaging Observations
The concept that the previously described lines of fusion are expandable
planes in which rapidly growing fluid collections may accumulate is also
supported by clinical and imaging observations.
Surgical Anatomy
When performing a right or left hemicolectomy, the surgeon mobilizes the
ascending and descending colons by dissecting through the anterior and
lateroconal fusion planes beginning at the "white line of Toldt"
[19]. This dissection is
usually quite easy, nearly bloodless, and does not compromise the viability of
the bowel, allowing the ascending and descending colons to be mobilized
freely. Similarly, when transabdominal surgical exposure of either kidney or
ureter is required, the procedure is facilitated by the medial reflection of
the overlying colon. Again, this task is readily accomplished without the need
for sharp dissection. However, these dissecting planes may be difficult to
develop in patients with a history of pancreatitis
[20].
Anatomic Variants
The site of fusion between the anterior and posterior laminae of the
posterior renal fascia normally is lateral in relation to the kidney. If this
fusion occurs more dorsally than usual, then fluid in the posterior sulcus of
the peritoneal cavity can reside in the posterior interfascial retrorenal
plane (Fig. 4). Additionally,
peritoneal fluid can accumulate in the anterior interfascial retromesenteric
planes in patients in whom the mesenteries of the ascending and descending
colons have not completely fused (Fig.
4) to the retroperitoneum.
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Fig. 4. —59-year-old man with fulminant ulcerative colitis in whom incomplete
fusion of fascial planes has permitted retromesenteric and retrorenal
extension of peritoneal fluid. CT scan shows that ascending (A) and descending
(D) mesocolons have not completely fused with renal fascia, permitting ascites
(straight arrows) to enter anterior interfascial retromesenteric
plane. Posterior renal fascia has also not fused, allowing peritoneal fluid to
extend into retrorenal posterior interfascial planes (curved arrows).
These anterior interfascial planes are easily surgically dissected during
hemicolectomy. Posterior interfascial planes are readily dissected during
nephrectomy.
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Pancreatitis
In patients with pancreatitis, inflammatory fluid most commonly extends
into the anterior pararenal space, lesser sac, and subperitoneal spaces of the
small bowel mesentery and transverse mesocolon. In some individuals, fluid and
inflammatory tissue may accumulate in the retroperitoneal interfascial planes,
dissecting posteriorly (Fig. 5)
to involve the posterior interfascial retrorenal plane, traversing the midline
in the anterior interfascial retromesenteric plane
(Fig. 6), or spreading
inferiorly in the combined interfascial plane to reach the pelvic
retroperitoneum or superiorly along the diaphragm to enter the
mediastinum.
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Fig. 5. —45-year-old woman with interfascial fluid spread in acute
pancreatitis and retrorenal dissection of fluid in lumbar triangle. Note fluid
in left anterior interfascial space (straight open arrow),
lateroconal interfascial space (curved open arrow), and posterior
interfascial space (curved solid arrow). Fluid extends to and
thickens transversalis fascia (straight solid arrow), dissecting
quadratus lumborum muscles and posterior pararenal fat (arrowhead).
This is source of Grey Turner's sign of pancreatitis.
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Fig. 6. —58-year-old man with pancreatitis and inflammatory fluid spread into
interfascial planes. CT scan shows fluid extending into anterior interfascial
space (open arrow), right fascial trifurcation (solid
arrow), and subsequently lateroconal and posterior interfascial spaces.
Note that fat in anterior pararenal space adjacent to ascending colon (AC) is
spared.
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Perirenal fluid collections related to pancreatitis can access the
posterior interfascial plane and extend into the transversalis fascia through
a cleft between the medial border of the posterior pararenal space and the
lateral border of the quadratus lumborum fat pad, the lumbar triangle. The
relatively low position of flank discoloration associated with pancreatitis
(Grey Turner's sign) is attributable to this lumbar triangle pathway.
Perirenal Hematomas
Subcapsular and perinephric hematomas result from a number of traumatic
(biopsy, lithotripsy, or blunt abdominal injury) and neoplastic (renal cell
carcinoma or angiomyolipoma) causes
[21]. The hematomas can gain
access to the anterior and posterior interfascial planes via numerous bridging
perinephric septa that consist of fibrous lamellae, which traverse the
perirenal space (Fig.
7A,7B,7C).
Conversely, these septa may be a conduit of hemorrhage or other rapidly
accumulating fluid collections that recruit the interfascial planes and from
there, spread into the perinephric space
[12].
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Fig. 7A. —65-year-old man with spontaneous subcapsular renal hemorrhage
decompressing along perinephric bridging septa and retroperitoneal
interfascial planes. CT scan at level of mid kidney shows both subcapsular and
perinephric hemorrhage. Note thickened perinephric bridging septa
(arrows).
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Fig. 7B. —65-year-old man with spontaneous subcapsular renal hemorrhage
decompressing along perinephric bridging septa and retroperitoneal
interfascial planes. CT scan at level slightly lower than that of A
shows perinephric blood decompressing in anterior (open arrow) and
posterior (curved arrow) interfascial planes. Note that descending
colon (straight solid arrow) and fat in anterior pararenal space are
uninvolved.
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Fig. 7C. —65-year-old man with spontaneous subcapsular renal hemorrhage
decompressing along perinephric bridging septa and retroperitoneal
interfascial planes. CT scan at level of iliac crest shows that blood
extending down anterior and posterior interfascial planes lies in caudal
continuation of these structures—the combined interfascial plane
(arrows).
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Urinomas
Encapsulated collections of urine that lie outside the renal collecting
system and ureters most commonly result from obstructive uropathy and less
frequently from abdominal trauma, surgery, or diagnostic instrumentation
[22]. Most urinomas reside in
the perinephric space. This fluid can access the interfascial planes via the
bridging perinephric septa or by direct extension occurring with ureteral
disruption. Disruption of the ureteropelvic junction characteristically fills
both the anterior and posterior interfascial planes
[23,24,25]
(Fig. 8).
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Fig. 8. —Ruptured calyceal fornix with urine decompressing into anterior and
posterior (curved arrow) interfascial spaces in 60-year-old woman
with obstructive uropathy caused by adenopathy resulting from stage IV
cervical cancer. CT scan at level of mid pole of right kidney shows
hydronephrosis and urine dissecting into bridging perinephric septa. Multiple
calcified gallstones are present. Note posterior perinephric (Zuckerkandl's
body) fascia (straight arrow) is separated from posterior pararenal
space by this urinoma.
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Duodenal Perforation and Pneumoretroperitoneum
Blunt abdominal trauma, peptic ulcer disease, and endoscopic sphincterotomy
(Fig. 9) are the major causes
of duodenal perforation and the pathologic gas and fluid that may decompress
into the anterior interfascial space. Extravasated gas, bile, and pancreatic
juice may extend into the pancreaticoduodenal space and subsequently cross the
midline via the anterior interfascial retromesenteric plane. Similar to
retroperitoneal fluid, retroperitoneal gas readily dissects preestablished
interfascial planes (Fig.
10).
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Fig. 9. —Interfascial dissection of gas. CT scan shows ERCP-related duodenal
perforation resulting in dissection of gas in anterior interfascial plane
(straight arrow) in 63-year-old man. Scan also shows gas and fluid in
posterior interfascial plane (curved arrow).
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Fig. 10. —Intraperitoneal and retroperitoneal gas is present on this CT scan
of 61-year-old man with chronic obstructive pulmonary disease, pneumothorax,
and retroperitoneal and peritoneal extension of air. Note how gas has easily
dissected anterior (straight arrow) and posterior (curved
arrow) interfascial planes. Intramural dissection of gas has also
occurred in colon.
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Colonic Diseases
As previously stated, the ascending and descending mesocolons fuse
posteriorly with the anterior renal fascia and laterally with the anterior
surface of the posterior pararenal fat. Accordingly, the laminated lateroconal
and anterior interfascial planes partly comprise variably fused layers of
mesocolon that have become retroperitoneal. Because the anterior interfascial
and lateroconal planes are so intimately associated with the
retroperitonealized ascending and descending mesocolons, the edema and
inflammation associated with diverticulitis, ischemic
(Fig. 11) and infectious
(Fig. 12) colitis, retrocecal
appendicitis, and infiltrating colonic neoplasms can spread into the
interfascial planes.
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Fig. 11. —CT scan of 57-year-old man with schemic colitis shows edema
extending into anterior interfascial plane (open arrow), fascial
trifurcation (solid arrow), and pericolic fat in anterior pararenal
space. Note marked colonic mural thickening and submucosal edema.
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Fig. 12. —CT scan of 49-year-old man with pseudomembranous colitis shows mural
thickening of ascending (AC) and descending (DC) colons. Note inflammation of
fat of anterior pararenal spaces bilaterally. Also note that fluid has
extended in anterior (straight arrow) and posterior (curved
arrows) interfascial spaces bilaterally.
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Abdominal Aortic Aneurysm Rupture
Hemorrhage caused by abdominal aortic aneurysm rupture or disruption of the
inferior vena cava can communicate with the retroperitoneum via a number of
pathways [26]. Most abdominal
aortic aneurysms bleed posteriorly and are confined by the psoas space or
extend into the posterior interfascial plane behind the left kidney. The
inferior vena cava often bleeds directly into the right posterior interfascial
plane [26]. Hemorrhage is
often present in one or both perirenal spaces as well. The anterior
interfascial planes are less commonly involved
(Fig. 13). These observations
suggest that the abdominal aorta and inferior vena cava may be continuous with
or actually reside in the medial aspect of the posterior interfascial
plane.
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Fig. 13. —Aortic aneurysm rupture with interfascial spread of retroperitoneal
hematoma (straight arrows) in 73-year-old man. CT scan obtained at
level of lower pole of left kidney reveals hyperdense hematoma extending
across midline in anterior interfascial (retromesenteric) plane bilaterally.
On right, hematoma also decompresses in posterior interfascial plane
(curved arrow).
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Aortic hemorrhage can also dissect the pelvis in the combined interfascial
plane and present as a groin mass or in the anterior interfascial plane to
cause obstructive jaundice or duodenal or colonic obstruction
[27].
Metastatic Disease
Metastatic tumors can spread to the perinephric spaces and interfascial
planes by several mechanisms. Most commonly, paraaortic and pericaval
retroperitoneal lymph nodes communicate with small lymph nodes near the renal
sinus, and these, in turn, connect with small lymph nodes and a rich network
of lymphatics in the perinephric space
[1]
(Fig. 14). Pleural and
transdiaphragmatic lymphatics communicate with the superior aspect of the
perinephric space, providing a pathway of disease spread to the perinephric
space that may subsequently involve the interfascial planes
[28].
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Fig. 14. —Metastases to perinephric and interfascial spaces from carcinoma of
pancreas in 70-year-old woman. CT scan shows marked retroperitoneal
lymphadenopathy (curved arrow) with tumor spread into anterior
interfascial plane (open arrow). Tumor has also infiltrated
perinephric lymphatics (straight solid arrow).
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Summary
In this perspective, we have presented embryologic, anatomic, clinical, and
imaging evidence that fluid collections originating in a retroperitoneal space
may exit the space by entering easily dissectable planes that result from the
embryologic fusion of dorsal mesenteries. These planes extend from the
diaphragm to the pelvic floor and appear to be an important means by which
rapid accumulating fluid collections and infiltrating diseases extend into the
retroperitoneum.
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Introduction
Embryologic Considerations
