Mesentery

The mesentery of the small intestine arises from the root of the mesentery (or mesenteric root) and is the part connected with the structures in front of the vertebral column. The root is narrow, about 15 cm long, 20 cm in width, and is directed obliquely from the duodenojejunal flexure at the left side of the second lumbar vertebra to the right sacroiliac joint. The root of the mesentery extends from the duodenojejunal flexure to the ileocaecal junction. This section of the small intestine is located centrally in the abdominal cavity and lies behind the transverse colon and the greater omentum. The mesentery becomes attached to the colon at the gastrointestinal margin and continues as the several regions of the mesocolon. The parts of the mesocolon take their names from the part of the colon to which they attach. These are the transverse mesocolon attaching to the transverse colon, the sigmoid mesocolon attaching to the sigmoid colon, the mesoappendix attaching to the appendix, and the mesorectum attaching to the upper third of the rectum. The mesocolon regions were traditionally taught to be separate sections with separate insertions into the posterior abdominal wall. In 2012, the first detailed observational and histological studies of the mesocolon were undertaken and this revealed several new findings. The microscopic structure of the mesocolon and associated fascia is consistent from ileocecal to mesorectal levels. A surface mesothelium and underlying connective tissue is universally apparent. Adipocytes lobules within the body of the mesocolon are separated by fibrous septa arising from submesothelial connective tissue. Where apposed to the retroperitoneum, two mesothelial layers separate the mesocolon and underlying retroperitoneum. Between these is Toldt's fascia, a discrete layer of connective tissue. Lymphatic channels are evident in mesocolic connective tissue and in Toldt's fascia. During these topographic changes, the dorsal mesentery undergoes corresponding changes. Most anatomical and embryological textbooks say that after adopting a final position, the ascending and descending mesocolons disappear during embryogenesis. Embryology—An Illustrated Colour Text, "most of the mid-gut retains the original dorsal mesentery, though parts of the duodenum derived from the mid-gut do not. The mesentery associated with the ascending colon and descending colon is resorbed, bringing these parts of the colon into close contact with the body wall." To reconcile these differences, several theories of embryologic mesenteric development—including the "regression" and "sliding" theories—have been proposed, but none has been widely accepted. The lesser omentum is formed, by a thinning of the mesoderm or ventral mesogastrium, which attaches the stomach and duodenum to the anterior abdominal wall. By the subsequent growth of the liver, this leaf of mesoderm is divided into two parts – the lesser omentum between the stomach and liver, and the falciform and coronary ligaments between the liver and the abdominal wall and diaphragm. In the adult, the ventral mesentery is the part of the peritoneum closest to the navel. ==Clinical significance==

Clarifications of the mesenteric anatomy have facilitated a clearer understanding of diseases involving the mesentery, examples of which include malrotation and Crohn's disease (CD). In CD, the mesentery is frequently thickened, rendering hemostasis challenging. In addition, fat wrapping—creeping fat—involves extension of mesenteric fat over the circumference of contiguous gastrointestinal tract, and this may indicate increased mesothelial plasticity. The relationship between mesenteric derangements and mucosal manifestations in CD points to a pathobiological overlap; some authors say that CD is mainly a mesenteric disorder that secondarily affects the GIT and systemic circulation. Thrombosis of the superior mesenteric vein can cause mesenteric ischemia also known as ischemic bowel. Mesenteric ischemia can also result from the formation of a volvulus, a twisted loop of the small intestine that when it wraps around itself and also encloses the mesentery too tightly can cause ischemia. The rationalization of mesenteric and peritoneal fold anatomy permits the surgeon to differentiate both from intraperitoneal adhesions—also called congenital adhesions. These are highly variable among patients and occur in several locations. Congenital adhesions occur between the lateral aspect of the peritoneum overlying the mobile component of the mesosigmoid and the parietal peritoneum in the left iliac fossa. During the lateral to the medial approach of mobilizing of the mesosigmoid, these must be divided first before the peritoneum proper can be accessed. Similarly, focal adhesions occur between the undersurface of the greater omentum and the cephalad aspect of the transverse mesocolon. These can be accessed after dividing the peritoneal fold that links the greater omentum and transverse colon. Adhesions here must be divided to separate the greater omentum off the transverse mesocolon, thus allowing access to the lesser sac proper. Surgery While the total mesorectal excision (TME) operation has become the surgical gold standard for the management of rectal cancer, this is not so for colon cancer. Recently, the surgical principles underpinning TME in rectal cancer have been extrapolated to colonic surgery. Total or complete mesocolic excision (CME), use planar surgery and extensive mesenterectomy (high tie) to minimise breach of the mesentery and maximise lymph nodes yield. Application of this T/CME reduces local five-year recurrence rates in colon cancer from 6.5% to 3.6%, while cancer-related five-year survival rates in patients resected for cure increased from 82.1% to 89.1%. Radiology Recent radiologic appraisals of the mesenteric organ have been conducted in the context of the contemporary understanding of mesenteric organ anatomy. When this organ is divided into non-flexural and flexural regions, these can readily be differentiated in most patients on CT imaging. Clarification of the radiological appearance of the human mesentery resonates with the suggestions of Dodds and enables a clearer conceptualization of mesenteric derangements in disease states. == History ==

The mesentery has been known for thousands of years, however it was unclear whether the mesentery is a single organ, or whether there are several mesenteries. The classical anatomical description of the mesocolon is credited to British surgeon Sir Frederick Treves in 1885, although a description of the membrane as a single structure dates back to at least Leonardo da Vinci. Treves is known for performing the first appendectomy in England in 1888; he was surgeon to both Queen Victoria and King Edward VII. He studied the human mesentery and peritoneal folds in 100 cadavers and described the right and left mesocolons as vestigial or absent in the human adult. Accordingly, the small intestinal mesentery, transverse, and sigmoid mesocolons all terminated or attached at their insertions into the posterior abdominal wall. Almost 10 years before Treves, the Austrian anatomist Carl Toldt described the persistence of all portions of the mesocolon into adulthood. Toldt was professor of anatomy in Prague and Vienna; he published his account of the human mesentery in 1879. Toldt identified a fascial plane between the mesocolon and the underlying retroperitoneum, formed by the fusion of the visceral peritoneum of the mesocolon with the parietal peritoneum of the retroperitoneum; this later became known as Toldt's fascia. In 1942, anatomist Edward Congdon also demonstrated that the right and left mesocolons persisted into adulthood and remained separate from the retroperitoneum—extraretroperitoneal. Radiologist Wylie J. Dodds described this concept in 1986. Dodds extrapolated that unless the mesocolon remained an extraretroperitoneal structure—separate from the retroperitoneum—only then would the radiologic appearance of the mesentery and peritoneal folds be reconciled with actual anatomy. The single greatest advance in this regard was the identification of the mesenteric organ as being contiguous, as it spans the gastrointestinal tract from duodenojejunal flexure to mesorectal level. and in sciences related to anatomy and development. Etymology The word "mesentery" and its Neo-Latin equivalent '' () use the combining forms mes- + enteron'', ultimately from ancient Greek ('), from (', "middle") + ('''', "gut"), yielding "mid-intestine" or "midgut". The adjectival form is "mesenteric" (). Lymphangiology An improved understanding of mesenteric structure and histology has enabled a formal characterization of mesenteric lymphangiology. Stereologic assessments of the lymphatic vessels demonstrate a rich lymphatic network embedded within the mesenteric connective tissue lattice. On average, vessels occur every , and within from the mesocolic surfaces—anterior and posterior. Lymphatic channels have also been identified in Toldt's fascia, though the significance of this is unknown. ==See also==

File:Small intestine dissection.jpg|Mesenteric relation of intestines. Deep dissection. Anterior view. ==References==