5: Toldt’s fascia

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48 Histology of the mesentery

operitoneal

(b)

Mesocolon and retroperitoneum

Mesocolon

Toldt’s fascia

(a)

Surface

mesothelium

Mesocolon

Toldt’s fascia

Mesentery

proper

Retroperitoneum

1 mm

Surface

mesothelium

Deep

mesothelium

Retr

mesothelium

Retroperitoneum

Toldt’s fascia

Retroperitoneum

(c)

Figure 4.1 (a) 2.5D snapshot of 3D digital sculpture depicting the histologic structure of the mesentery and underlying fascia. (b) Photomicrograph demonstrating the mesentery, underlying fascia, and retroperitoneum at the level of the left mesocolon. (c) Scanning electron micrograph demonstrating the mesentery, fascia, and retroperitoneum at the level of the right mesocolon.

Wherever mesentery attaches to retroperitoneum, a distinct fascial layer (Toldt’s fascia) occurs between both (Figure4.1b and c) [25–27]. Beneath Toldt’s fascia a further mesothelial layer covers the retroperitoneum itself. Variations occur in the composition of Toldt’s fascia [25,26].

e fascia will be discussed in detail in Chapter 5.

is arrangement of mesothelium and fascia is impor-

tant as it generates the plane that is exploited in good quality

colorectal surgery. A surgical plane is dened as the interface between two contiguous surfaces. Surgical planes provide an anatomic roadmap by which structures may be freed from their normal anatomic attachments to permit safe division and resection. e plane used most oen in colorectal surgery occurs at the interface between the mesothelium on the under surface of the mesentery and Toldt’s fascia, that is, the mesofascial plane. Components of this plane may

Sample

Small intestinal mesentery

20,000 µm

(a) (b)

tive tissue

Transverse mesocolon

(b)(a)

face

Nomenclature: The visceral andparietal peritoneum 49

Mesothelium

Adipocytes

origin

Small

intestinal

mesentery

Figure 4.2 (a) 2.5D snapshots from a 3D digital model of the mesentery demonstrating the location at which full thickness biopsies were taken through the small bowel mesentery. (b) Photomicrograph demonstrating the structure of the small intestinal mesentery.

Connective tissue

septation

Sample from

transverse colon

Adipocyte lobule

Connec

septation

Mesothelium

Upper sur mesothelium

Connective

tissue

Lower surface

mesothelium

Figure 4.3 (a) 2.5D snapshots from a 3D digital model of the mesentery demonstrating the location at which full thickness biopsies were taken through the transverse mesocolon. (b) Photomicrograph demonstrating the structure of the transverse mesocolon.

be separated surgically in a manner that allows complete separation of the mesentery from the posterior abdominal wall[24].

(including the mesentery) [1–3,27]. us, the mesothelial covering on either side of the human mesentery corresponds to “visceral peritoneum” (Figure 4.1). In keeping

20,000 µm

with the above, mesothelium overlying the retroperito-

NOMENCLATURE: THE VISCERAL ANDPARIETAL PERITONEUM

Mesenteric mesothelium is smooth surfaced, highly functional, and comprises a single layer of cuboidalshaped cells [25]. It closely resembles pleural mesothelium and is similar to peritoneum elsewhere within the abdomen. Manyanatomic texts subdivide the abdominal peritoneum into “parietal” and “visceral” regions. Parietal peritoneum lines the inner aspect of the abdominal wall while visceral peritoneum covers the abdominal viscera

neum (i.e.,beneath Toldt’s fascia) corresponds to “parietal peritoneum” (Figure 4.1). It is not uncommon for these to be referred to as the visceral and parietal fascia, respectively [28–36]. As they are not anatomic fascia, this terminology is inaccurate. Moreover, it is also confusing as the only true fascia in this region is Toldt’s fascia, that is, the fascia interposed between the visceral and parietal peritoneum.

roughout this book, the terms “visceral” and “parietal”

peritoneum will be adopted and the term “fascia” will be reserved exclusively for Toldt’s fascia (Figure 4.3) [37].

50 Histology of the mesentery

(a) (b)

face mesothelium

Left mesocolon

100 µm

Sur

Adipocyte lobule

Left mesocolon

biopsy

Connective tissue

lattice

Left mesocolon

Toldt’s fascia

Retroperitoneum

Figure 4.4 (a) 2.5D snapshots from a 3D digital model of the mesentery demonstrating the location at which full thickness biopsies were taken through the left mesocolon. (b) Photomicrograph demonstrating the structure of the left mesocolon.

IMMUNOHISTOCHEMICAL ANALYSIS OFMESENTERIC MESOTHELIUM

Immunohistochemical evaluation of surface mesenteric mesothelium demonstrates expression of markers including D2-40 (podoplanin) and CD-35 [26,38]. Few studies have directly focused on surface marker expression in mesenteric versus nonmesenteric mesothelium. Indeed, no studies have examined

Table 4.1 Immunohistochemical markers expressed in surface mesothelium

Study Year Journal Marker Reference

Satelli etal. 2015 Clin Cancer Res 84-1/vimentin [39] Yokobori etal. 2013 Cancer Res PLS3 [40] Yung etal. 2011 J Biomed Biotechnol Hyaluronan [41] Foroutan etal. 2010 J Biol Sci CD45 [42]

Rosellini etal. 2007 Folia Biol CKAE1-AE3 [43]

Yáñez-Mó etal. 2003 N Engl J Med Cytokeratins [44]

Yang etal. 1999 Perit Dial Int Cytokeratins [45]

Ho-dac-Pannekeet etal. 1997 Adv Perit Dial CA125 [46]

surface marker expression in mesocolic mesothelium (i.e., visceral peritoneum), Toldt’s fascia, nor in mesothelium beneath Toldt’s fascia (i.e., parietal peritoneum). As surface marker expression relates to cellular functionality, this is a key area for future research. Table4.1 provides a summary of the surface markers associated with peritoneal mesothelium in general. Although it is feasible the properties listed can be extrapolated to the mesenteric context, this should be investigated.

CD34 HBME-1 Cytokeratin 18

CK19 p63 Ki-67 Vimentin CD34 HBME-1

ICAM-1

Vimentin

Mesenteric connective tissue lattice 51

tive tissue

Submesothelial connective tissue

connec

MESENTERIC CONNECTIVE TISSUE LAT TICE

A connective tissue layer occurs underneath mesenteric visceral peritoneum. is is the “submesothelial connective tissue layer.” It is highly variable in thickness and composition. In some regions, it is well developed, while in others it is entirely absent (Figure 4.5). For example, it

Submesothelial

tive tissue

(a)

is well developed on the upper surface of the transverse mesocolon, where the latter is adherent to the greater omentum. It is also well developed on the lateral aspect of mesosigmoid. is distribution appears to correlate with the presence of congenital adhesions. For example, congenital adhesions are prominent at the lateral aspect of the mesosigmoid. ey also cause the greater omentum to adhere to the upper surface of the transverse mesocolon.

Surface

mesothelium

Septation

Surface

mesothelium

(b)

Submesothelial connective tissue

Connec

Undersurface

mesothelium

Avascular

interpedicular

mesentery

Ileocolic

adipovascular

pedicle

(c)

Figure 4.5 (a) Photomicrograph demonstrating the mesenteric surface. This is lined with mesothelium beneath which there is a connective tissue layer (arrows) and from which connective tissue septations arise. The latter separate adipocyte compartments. Adipocytes are packaged in a honeycomb-like conformation within compartments. (b)Histologic structure in an avascular interpedicular region of mesentery. Adipocytes are minimal and both mesothelial surfaces are close. Thisgenerates a translucent macroscopic appearance (c).

52 Histology of the mesentery

Submesothelial

Mesenteric and intestinal connective tissue

Connective tissue branches, or septae, extend from the submesothelial connective tissue into the substance of the mesentery, separating the latter into adipocyte compartments. Adipocytes are packaged in a honeycomb-like conformation (Figure 4.5) and together contribute the main bulk of the mesentery. In certain mesenteric regions, adipocytes are minimal and both mesenteric mesothelial surfaces come into close apposition (Figure 4.5b,c) [23,25,26]. Macroscopically, these regions are identiable as being near translucent. is property is of particular surgical relevance as it enables the surgeon to divide through the mesentery with minimal bleeding (Figure 4.5c).

Taken together, the connective tissue septae and submesothelial connective tissue layer generate a lattice, the “mesenteric connective tissue lattice” (Figure 4.6a and b). is is present throughout the mesentery. At the gastrointestinal margin, it is continuous with connective tissue in outer layers of the gastrointestinal tract (Figure 4.6b and c). Here, the lattice contributes directly to the formation of the intestinal

Mesenteric connective

tissue

connective

tissue

serosa. e serosa in turn contributes connective tissue to the longitudinal and circular smooth muscle layers. Within the mesentery, the lattice encases vessels contributing to the adventitia of these.

Where major vessels enter or leave the mesentery, the

connective tissue of the lattice coalesces with that of the underlying fascia to form a connective tissue cu or adventitia. e perivascular connective tissue cu is also of surgical relevance as it means that the mesentery can be readily cleared from vascular surfaces, with minimal disruption of either vessel or mesentery.

e submesothelial connective tissue layer is largely

acellular. However, cell clusters occur at points where septations arise (Figure 4.7a). Analysis of serial sections demonstrates that on occasion, isolated cell clusters occur. e cells within these clusters have mesenchymal features, resembling broblast and myobroblasts. is is in keeping with earlier ndings suggesting that cells within the submesothelial connective tissue layer have surface markers that are

Intestinal

connective

tissue

Mesenteric connective

tissue

Intestinal

(a) (b)

Mesenteric connective

tissue

Surface

connective tissue

Figure 4.6 (a) 2.5D image from 3D model demonstrating the mesenteric connective tissue lattice and its contiguity with that in the adjacent gastrointestinal tract. (b) All tissue with exception of the connective tissue has been conceptually removed from the model in (a) to depict the extent of the connective tissue lattice. (c) Photomicrograph showing connective tissue contiguity between the mesentery and the gastrointestinal tract. (d) Photomicrograph demonstrating connective tissue contiguity between deep and supercial muscle layers of the intestinal wall.

Connective tissue of

outer muscle layer

connective

tissue

Connective tissue of

outer muscle layer

Connective tissue of

inner muscle layer

Mesenteric connective tissue lattice and lymphatics

Mesenchymal

(b)

(c)

nodes and channels

cell cluster

Mesothelial cell plasticity 53

Surface

mesothelium

(a)

Surface

mesothelium

Connective

tissue lattice

Deep

mesothelium

Figure 4.7 (a) Photomicrograph showing the surface mesothelium of the right mesocolon. At certain points mesenchymal cells clustered as indicated. (b) 3D sculpture demonstrating the connective tissue of the lattice and contained lymphatic channels. (c) Same model as in (b) but with the connective tissue removed.

intermediate between mesothelial and mesenchymal cells [23,25,26]. Itisfeasible that mesenchymal cells within these clusters are derived from overlying mesenteric mesothelium.

e connective tissue lattice also houses a lymphatic network (Figure 4.7b and c). Lymphatic vessels are identiable in the submesothelial connective tissue monolayer as well as in septations. e frequency with which lymphatic vessels are identied varies (though not signicantly) between mesenteric regions. In submesothelial connective tissue, lymphatic vessels measure 10.2 ± 4.1µm in diameter and have an average radius of diusion of 174.72 ± 97.68µm. is means that a lymphatic vessel occurs every 0.17mm (Figure 4.7b and c). Lymphatic vessels also occur in Toldt’s fascia where they measure 4.3 ± 3.1µm in diameter and have a radius of diusion of 165.12 ± 66.26µm. Collectively, a rich lymphatic network occupies all levels of the mesenteric connective tissue lattice and may be vulnerable during surgery [26].

suggest that mesenteric mesothelium may be plastic and capable of dierentiating into multiple mesenchymal cell types [42,50]. Foroutan etal. examined hematopoietic and mesenchymal stem markers in mesothelial cells in peritoneal dialysate. ese were analyzed by cell culture, ow cytometry, and immunophenotyping for CD45 and CD34 (hematopoietic stem cell markers), HBME-1 (mesothelial cell marker), and cytokeratin 18 (epithelial marker). While mesothelial cells expressed classical mesothelial and epithelial surface markers, they also expressed CD34 (mesenchymal marker) and CD45 (hematopoietic marker) [42]. Both mesenteric mesothelia and lymphoepithelia are known to express podoplanin [38,51–53]. Mesothelia elsewhere (e.g., hepatic and pleural) can undergo mesothelialto-mesenchymal transition [54–56]. Observations such as these support the intriguing suggestion that mesenteric mesothelial cells are not inert and could in fact contribute to the local mesenchymal cellular pool [57–62]. is sug-

Mesenteric lymph

with connective

tissue removed

gestion is supported by our recent observations related to

MESOTHELIAL CELL PLASTICITY

the culture of mesenteric mesothelia. If mesenteric mesothelia are harvested, puried, and cultured, then follow-

A number of studies have demonstrated submesothelial connective tissue cells with surface markers normally observed in cells under transition from one state of differentiation to another (i.e., from mesothelial to mesenchymal cell types) [39,40,47–49]. eseand other ndings

ing 2 weeks a mixture of mesenchymal cell types emerges. is property, when combined with the total surface area of the extensively plicated mesentery, means that mesenteric mesothelium could represent a signicant stem cell reservoir [63].

54 Histology of the mesentery

Derangements of mesenteric mesothelial plasticity may contribute to multiple intraabdominal disease processes. e origin of the cells responsible for adhesion formation is not known. It is not unreasonable to suggest that surgical disruption of mesenteric mesothelium may lead to a localized or widespread mesenchymal response that results in adhesion formation [63,64].

All abdominal wall hernia (out with the acute setting) have a mesothelial component. is could be explained as follows. As mesothelium proliferates an invagination develops. Given the secretery properties of mesothelium, the inner surface of this is highly lubricated and thus permits both entry and exit of abdominal contents. e cumulative eect of persistent mechanical pressures (including positive intraperitoneal pressure) leads to an increase in size of the mesothelial invagination and ultimately to clinical manifestation of the underlying pathology. Perhaps the best invivo model of this phenomenon is the parastomal hernia. Stoma creation requires formation of a defect in the abdominal wall. At formation, the local parietal mesothelium is disrupted. With time, a mesothelial invagination arises that carpets the subcutaneous tissue and is oen associated with herniation of adjacent bowel loops. is is the parastomal hernia.

Mesothelial-to-mesenchymal transformation may also contribute to the development of Crohn’s or diverticular disease [65–69]. In Crohn’s disease, mesenteric lymphangiectasia occurs and correlates with the distribution of mucosal abnormalities [70–73]. In patients with mesenteric adenitis, a pronounced lymphadenopathy occurs at the ileocecal mesenteric conuence. Lymph nodes may also develop in appendices epiploicae [74–76]. is is surprising as classic descriptions indicate that lymph nodes are conned to major vessels. e identication of nodes in appendices epiploices (i.e., remote from major vessels) maybe further evidence of a cellular ux involving nearby mesenteric mesothelium.

FUTURE DIRECTIONS

e characterization of mesenteric histology has raised several suggestions that prompt investigation. ese could involve a characterization of the role of mesenteric mesothelium in several disease processes including adhesion formation, hernia development, and Crohn’s disease. e concept of connective tissue contiguity should be explored in broader terms. As has been demonstrated to date, the mesenteric connective tissue lattice is contiguous with that of adjacent intestine. e mesenteric connective tissue lattice also contributes adventitia to contained vessels. ese ndings suggest that a systemic connective tissue platform occurs, which receives inputs from mesenteric and intestinal sources and which could provide a novel route of disease spread (Figure 4.6).

SUMMARY

e cellular and extracellular composition of the mesentery is similar from the root region to the anorectal junction. Multiple levels of continuity (including connective tissue,

vascular, neurologic, and lymphatic) occur between mesentery and adjacent intestinal tract and between mesentery and associated vessels. Characterization of mesenteric histology provides opportunities to refresh approaches to several disease processes including those involving systemic manifestations.

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Toldt’s fascia

J. CALVIN COFFEY AND RAVI KIRAN

Aim 57 Introduction 57 Development 57 Composition 57 Demonstration of Toldt’s fascia 58 Toldt’s fascia: Regional anatomy 58

Mesorectal fascia 58 Mesosigmoidal fascia 59 Left mesocolic fascia and the white line ofToldt 59 Right mesocolic fascia and the white line ofToldt 61

The greater the ignorance the greater the dogma.

William Osler

AIM

e primary aim is to demonstrate the nature of Toldt’s fascia at all intestinal levels distal to the duodenojejunal exure. Asecondary aim is to highlight the clinical relevance of the fascia.

INTRODUCTION

Toldt’s fascia is the connective tissue layer that occurs between attached regions of mesentery and retroperitoneum (or pelvis) (Figure5.1) [1–4]. Several terms have been used in reference to it. At the mesorectal level, the fascia is referred to as Waldeyer’s fascia, the retrorectal fascia, Denonvillier’s fascia, and the endopelvic fascia. Surrounding the kidney Toldt’s fascia is termed Gerota’s or the anterior pararenal fascia. Toldt’s characterization of the distribution of the fascia was remarkably accurate and closely mirrors current descriptions (Figure 5.2) [5]. Fortunately, Toldt worked with cadavers that had not been subjected to corrosive preservatives. As the fascia is exquisitely thin in particular regions, preservatives obliterate it, leading to the erroneous impression that it is absent in that region. In normal circumstances, the fascia is dicult to visualize unaided. ese properties explain why Toldt’s ndings have yet to be generally accepted[5,6]. Morerecently, the development of colorectal

Fascial continuity 62

Histology 62 Function of Toldt’s fascia 63 Surgical implications of Toldt’s fascia 66 Toldt’s fascia and radiologic implications 66 Adhesions and Toldt’s fascia 66 Future directions 67 Summary 67 References 67

surgery in general and of laparoscopic and robotic technologies has shown that the fascia is universally present between the mesentery and retroperitoneum [7–17].

DEVELOPMENT

Toldt suggested that the fascia arose aer the visceral peritoneum of the mesentery fused with the parietal peritoneum of the retroperitoneum [4–6]. He suggested that during this process epithelial monolayers were lost and the underlying connective tissue fused to generate the fascia. It is now known that the visceral mesenteric and parietal peritoneal layers are retained into adulthood and that the fascia develops between these. e resultant anatomic arrangement forms a cornerstone in mesenteric-based gastrointestinal surgery. Asa result, it is the focus of the current chapter.

COMPOSITION

e composition (and hence appearance) of Toldt’s fascia is variable. Beneath the right mesocolon, it is well developed comprising multiple lamella of collagen [2,3,10]. Beneath the mesosigmoid and mesorectum, it is areolar and exquisitely delicate, a property that has led to its comparison with angel hairs and candy oss. As a result, it can oen be quite dicult to identify in these regions. Variations in composition and appearance make its identication dicult. is represents a signicant challenge to both the novice and experienced surgeon. During colorectal surgery operating in a plane beneath the fascia threatens retroperitoneal structures such as the ureters and gonadal vessels.

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