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Supravesical and Pelvic Hernias
膀胱上疝和盆腔疝
The peritoneum follows the surfaces of the pelvic viscera and walls (Fig 2) with differences between the sexes.
覆盖于盆腔脏层和壁层的腹膜（图2）因性别而存在差异。

Anatomy of the Lesser Pelvis in Males
男性小骨盆的解剖
The peritoneum leaves the junction of the middle and lower third of the rectum and passes forward to the upper poles of the seminal vesicle and the superior aspect of the bladder. Between the rectum and bladder, the peritoneum forms a retrovesical pouch. Lateral to the rectum, the peritoneum forms right and left perirectal fossae, anterior to which is the retrovesical pouch. The anterior peritoneum covers the superior surface of the bladder, forming a paravesical fossa on each side (9).
腹膜覆盖在直肠的中下三分之一，向前覆盖精囊腺上极和膀胱的上方。在直肠和膀胱间，腹膜形成膀胱后隐窝。直肠侧方形成左右直肠旁隐窝，其前方为膀胱后隐窝。前侧的腹膜覆盖膀胱的前面，两侧形成膀胱旁窝。

Supravesical Hernia
膀胱上疝
The supravesical fossa is the area of the abdominal wall between the remnants of the median and the left or right umbilical ligaments (49). The sac may remain above the pelvis and form an external supravesical hernia or pass downward and form an internal supravesical hernia. Internal supravesical hernias are divided into the following three categories: (a) anterior, (b) right or left lateral, and (c) posterior, which are based on whether the course is in front of, beside, or behind the bladder (50).
膀胱上窝是位于脐内韧带和脐左或脐右韧带残迹之间的腹壁区。疝囊位于骨盆上形成膀胱外上疝，或者向下形成膀胱内上疝。内上疝根据疝是位于膀胱的上方、两侧还是后方分为三种：（a）前；（b）左侧或右侧和（c）后。

Anatomy of the Lesser Pelvis in Females
女性小骨盆的解剖
Perirectal and paravesical fossae also appear in females. At the lateral limit of the paravesical fossae, the peritoneum invests the mesosalpinx, round ligament, and broad ligament of the uterus. The rectovesical pouch is divided by the uterus and vagina into the vesicouterine pouch and rectouterine pouch (pouch of Douglas). The broad ligaments extend from the sides of the uterus to the lateral pelvic walls (Fig 16). The superior extent of the broad ligaments contains the fallopian tubes. Immediately below the fallopian tubes, the anterior and posterior peritoneal folds condense to form the mesosalpinx. The mesosalpinx is bounded by the fallopian tube superiorly, the uterus medially, the ovary laterally, and the ovarian ligament inferiorly. The lateral extent of the broad ligament covers the ovarian vessels, forming the infundibulopelvic ligament, which suspends the ovary. The anterior leaf of the broad ligament covers the round ligament of the uterus and forms the mesoligamentum teres (9,51).
直肠旁隐窝和膀胱旁隐窝也存在与女性，在膀胱旁隐窝的侧方腹膜包绕输卵管系膜、子宫圆韧带和阔韧带。直肠膀胱陷凹被子宫和阴道分成膀胱子宫陷凹和直肠子宫陷凹（Douglas窝）。阔韧带从子宫一侧向骨盆侧延伸（图16）。阔韧带向上包绕输卵管。输卵管内下方，前后腹膜皱襞汇合形成输卵管系膜。输卵管系膜位于输卵管上方，子宫外侧，卵巢侧方及卵巢韧带的上方。阔韧带侧方区域有卵巢血管，形成漏斗骨盆韧带，供应卵巢。阔韧带前叶覆盖有子宫圆韧带形成系膜韧带圆肌。

Figure 16. Drawing (coronal view) shows the anatomy of the broad ligament (B) and various defects. F = fallopian tube, M = mesosalpinx, O = ovary, R = round ligament. (Adapted and reprinted, with permission, from reference 7.)
图16 示意图（冠状面）显示阔韧带（B）解剖和各种缺损。F，输卵管；M，输卵管系膜；O，卵巢；R，圆韧带。

Hernia through the Broad Ligament阔韧带疝

Hernias through a defect of the broad ligament account for only 4%–5% of all internal hernias (1,3,52). The herniated viscus is the small intestine in more than 90% of cases. The typical patient with this hernia is a middle-aged woman who has been pregnant and has no history of abdominal surgery. More than 85% of these hernias have occurred in parous women (51).
阔韧带疝仅占所有腹内疝的4%–5%，90%以上病例的疝内容物是小肠。发生阔韧带疝的病人多是曾孕和无腹部手术史的中年妇女。经产妇占85%以上。

Broad ligament defects are classified as congenital or acquired. Congenital cases have an embryologic basis due to a developmental peritoneal defect around the uterus. Acquired defects are due to surgical trauma, pregnancy and birth trauma, perforations following vaginal manipulation, and prior pelvic inflammatory disease (52). A classification for the broad ligament has been proposed on the basis of the anatomic position of the defect: type 1 = defect caudal to the round ligament, type 2 = defect above the round ligament, and type 3 = defect between the round ligament and the remainder of the broad ligament through the mesoligamentum teres (53).
阔韧带缺损分先天性的和获得性的，先天性缺损的病人其胚胎学基础是子宫周围的腹膜发育缺损。获得性缺损的病人则是由外伤、妊娠、产伤、阴道手术的穿孔和盆腔炎症性疾病引起的。根据阔韧带缺损解剖位置的不同，分成3种类型：Ⅰ型　圆韧带尾侧缺损，Ⅱ型　圆韧带上部缺损，Ⅲ型　圆韧带和阔韧带残余部分之间缺损。

On the other hand, Hunt (54) classified two types of hernia through the broad ligament. One is the fenestra type, through a defect in the broad ligament, and the other is the pouch type, with herniation into an anterior or posterior aperture of the broad ligament. The fenestra type, with complete defects, may allow passage of small bowel loops with potential hernial strangulation. These are the most common cases. The pouch type, with single-layer defects, may allow visceral structures to enter and become entrapped in the parametrial tissue (54,55). The following are the characteristic CT appearances (56): (a) a cluster of dilated small bowel loops with air-fluid levels in the pelvic cavity and (b) bowel loops compressing the rectosigmoid dorsolaterally and the uterus ventrally (Fig 17). 此外，Hunt把阔韧带疝分布两型：其一是窗型　疝囊穿过阔韧带内的缺损，其二是囊袋型　疝囊进入阔韧带前面或后面的孔隙。窗型是阔韧带完全缺损，小肠肠襻可穿入缺损，发生肠绞窄的潜在风险高。囊袋型是单层缺损，内脏可疝入宫旁组织。CT的特征表现如下：（a）盆腔内见含气液平面的簇状扩张的小肠肠襻，（b）肠襻压迫腹侧的子宫和背外侧的直肠乙状结肠。

Figure 17. Hernia through the broad ligament in a 51-year-old woman, gravida 2, para 2, with acute lower abdominal pain of 24 hours duration. She had no significant medical history. (a) Contrast-enhanced CT scan of the pelvis shows dilated small bowel loops (S) and a cluster of dilated bowel loops with air-fluid levels (arrow) between the uterus (U) and rectum (R). Stenosis of an incarcerated bowel loop (arrowheads) can be visualized because of the fat layer around the uterus; the C-shaped configuration of the bowel loop suggests a closed-loop obstruction. (b) CT scan obtained 10 mm below a shows that the rectum (R) and sigmoid colon (S) are compressed dorsolaterally and the uterus (U) is compressed ventrally. Arrow = cluster of dilated bowel loops. (c) Image obtained with enteroclysis performed through a long intestinal tube shows an SBO (arrowhead). Laparotomy was performed 11 days after CT. (d) Laparoscopic photograph shows viable distal ileal loops (I) herniated from anterior to posterior through a defect in the left broad ligament (arrows). Resection was not performed. 图17a.　一例51岁女性阔韧带疝，孕2产2，急性下腹痛24小时，无有意义的疾病史。（a）盆腔CT增强扫描显示扩张的小肠肠襻（S）和子宫（U）直肠（R）之间簇状扩张的含气液平面的小肠肠襻（三角形箭头）。由于子宫旁脂肪层的衬托，可见C形结构的闭襻型肠梗阻的狭窄处。（b）10cm下方CT扫描显示直肠（R）和乙状结肠（S）被推移到背外侧，子宫被推移到腹侧。长箭头所指处是簇状扩张的小肠肠襻。（c）通过长导管灌肠造影显示小肠梗阻（SBO，三角形箭头所指处），CT检查11天后进行了剖腹手术。（d）腹腔镜照片显示末段回肠从前向后疝入左侧阔韧带（长箭头）缺损处。由于肠道尚有活力，所以没有行切除术。