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414 A. J. Williamson and J. C. Alverdy
critical in all patients with suspected intestinal volvulus. As many patients are frail
and elderly who present with volvulus, goals of care should be discussed with the
patient and their caregivers.
Suggested Reading
1. https://www.fascrs.org/sites/default/files/downloads/publication/clinical_practice_guidelines_
for_colon_volvulus.pdf.
2. Vogel JD, Feingold DL, Sterward DR, Turner JS, Boutros M, Chun J, Steele SR. Clinical
practice guidelines for colon volvulus and acute colonic pseudo-obstruction. Dis Colon
Rectum. 2016;59:589– 600.
3. Gingold D, Murrell Z. Management of colonic volvulus. Clin Colon Rectal Surg.
2012;25:236–44.
4. Bruzzi M, Lefevre JH, Desaint B, et al. Management of acute sigmoid volvulus: short-and
long-term results. Colorectal Dis. 2015;17:922–8.
5. Mabdida TE, Thomson SR. The management of cecal volvulus. Dis Colon Rectum.
2002;45:264–7.
6. Kuzu MA, Aslar AK, Soran A, Polat A, Topcu U, Hengirmen S. Emergent resection for acute
sigmoid volvulus: results of 106 consecutive cases. Dis Colon Rectum. 2002;45:1085–90.
7. Perrot L, Fohlen A, Alves A, Lubrano J. Management of the colonic volvulus. J Visc Surg.
2016;153(3):183–92.
Embryologic Abnormalities of the Mesentery
Sara Gaines, Thomas Q. Xu, Richard A. Jacobson, and John C. Alverdy
Background
Starting as early as week five of gestation, the intestines of the midgut undergo
three distinct events that are critical to normal intestinal fixation: (1) herniation of
the midgut intestinal loop into the umbilical cord, (2) reduction of the herniated
contents back into the abdomen, and (3) fixation of the intestines to the posterior
body wall. During these three events, counterclockwise rotation around a vascular
axis is completed followed by migration of the proximal and distal portions of the
midgut to their normal adult anatomic positions to fix the intestines on a
broad-based mesentery. As a result, the jejunoileal mesentery extends down obliquely from the ligament of Treitz to the ileocecal valve (Fig. 42.1). For additional
information, see Chap. 2, Embryology of the Mesentery.
42
Malrotations and Indications for Surgery
Embryologic abnormalities of the mesentery that require surgical intervention are
most commonly related to abnormal positioning of the bowel within the peritoneal
cavity resulting from failure of any of the above 3 steps. These abnormalities are
categorized under various forms of malrotation. Malrotation is thought to affect
1:500 live births with the majority becoming symptomatic within the first year of
life. Classic malrotation presents as bilious emesis in infancy from duodenal
obstruction or midgut volvulus, and it is usually associated with abnormal or absent
intestinal fixation by mesenteric bands. The bands, known as Ladd bands, fix the
S. Gaines J. C. Alverdy (&)
Department of Surgery, University of Chicago, 5841 S. Maryland, Chicago, IL 60637, USA
e-mail: jalverdy@surgery.bsd.uchicago.edu
T. Q. Xu R. A. Jacobson
Department of Surgery, Rush University Medical Center, Chicago, IL, USA
© Springer Nature Switzerland AG 2021
E. D. Ehrenpreis et al. (eds.), The Mesenteric Organ in Health and Disease,
https://doi.org/10.1007/978-3-030-71963-0_42
415
416 S. Gaines et al.
Ligament
of Treitz
Ascending
colon
Cecum
Fig. 42.1 Normal oblique fixation of the midgut mesentery at the ligament of Treitz to the cecum
in the right lower quadrant
Descending
colon
cecum to the posterior body which traps the duodenum leading to obstruction. The
duodenojejunal attachment is abnormally short which makes the gut prone to twist
counterclockwise around the superior mesenteric vessels leading a volvulus. An
upper GI series is the standard of care for diagnosis and will show a variation in the
normal positioning of the duodenojejunal junction (Figs. 42.2, 42.3 and 42.4). It has
a sensitivity of 96% to detect malrotation and 79% sensitivity for midgut volvulus.
42 Embryologic Abnormalities of the Mesentery 417
Fig. 42.2 This fluoroscopic image from a patient with malrotation is a single-contrast upper-GI
exam. The exam shows dense barium within the stomach and proximal small bowel loops in the
right upper abdomen (arrow) with a lack of the expected course of the duodenum to the ligament
of Treitz in the left upper quadrant (asterisk). Note that, by convention, fluoroscopic images have
the grey-scale inverted compared with regular X-ray
Fig. 42.3 Radiographs from
a different patient during a
small bowel examination
again demonstrate the atypical
course of the duodenum
(arrows) with duodenojejunal
junction positioned to the
right of midline. With
permission from Dr. Abraham
Dachman and Dr. Justin
Ramirez
418 S. Gaines et al.
Fig. 42.4 A radiograph
obtained later in the
examination demonstrates
progression of barium
contrast into the remainder of
the small bowel (oval) which
is positioned entirely to the
right of midline.
Non-opacified, air-filled colon
(asterisk) can be seen within
the left abdomen. With
permission from Dr. Abraham
Dachman and Dr. Justin
Ramirez
Mesocolic hernias may also occur when the right or left mesocolon fail to fixto
the posterior body wall. These hernias carry a risk of small bowel obstruction,
incarceration or strangulation. A less common cause of an embryologic mesenteric
abnormality relates to an intrauterine vascular accident leading to atresia of the
intestine and shortening of the mesentery. Intestinal atresia is caused by an ischemic
event early in the developing gut. In a rare variant known as the “apple peel”, there
is atresia of the proximal jejunum and absence of the distal SMA and mesentery.
The apple peel appearance results from a spiraling of the intestine around its vascular supply (Fig. 42.5). Infants born with this condition may suffer from necrotizing enterocolitis shortly after birth.
Surgeries for Malrotations and Mesocolic Hernias
Malrotation or hernias that cause obstruction are treated with an urgent laparotomy
to reduce the chance of ischemic injury. Midgut volvulus that has progressed to
complete infarction is rapidly lethal. Malrotation is treated with the Ladd procedure.
The first step is to relieve the volvulus by rotating the bowel in a counterclockwise
direction (Fig. 42.4). The peritoneal attachments between the cecum and the
42 Embryologic Abnormalities of the Mesentery 419
Fig. 42.5 Ladd procedure demonstrating counterclockwise detorsion of midgut volvulus
abdominal wall are then released. The duodenum is then completely mobilized
(Kocher maneuver) to divide any remaining attachments. An appendectomy is
performed prior to closing to avoid any potential confusion from acute appendicitis
in the future.
Right mesocolic hernias are treated with division of the lateral peritoneal
attachments of the cecum and right colon. Left mesocolic hernias are treated by
mobilization of the inferior mesenteric vein to allow reduction of the small bowel
from the hernia. The hernia is then closed to prevent recurrence.
Intestinal atresia that causes obstruction requires operative intervention to restore
continuity. The goal is to preserve as much of the intestinal length as possible. This
is achieved through short segmental bowel resection with end-end or end-oblique
420 S. Gaines et al.
anastomosis. The apple peel jejunal atresia may require multiple serial anastomoses,
and the ileocecal valve is preserved if possible to allow for toleration of enteral
nutrition.
Complications
Complications include recurrence of the volvulus or duodenal obstruction. Small
bowel obstruction due to adhesions is thought to occur in 1–10% of patients following the Ladd procedure.
Summary
Malrotation that causes an intestinal obstruction is a surgical emergency; a high
index of suspicion is needed so as to not miss the diagnosis. Swift identification of
malrotation prevents extent of intestinal necrosis and unnecessary bowel resection.
Recurrence of volvulus or obstruction is rare with a technically complete Ladd
procedure.
Suggested Reading
1. Soffers JHM, Hikspoors JPJM, Mekonen HK, Koehler E, Lamers WH. The growth pattern of
the human intestine and its mesentery. BMC Dev Biol. 2015;15:31.
2. Berrocal T, Lamas M, Gutierrez J, Torres I, Prieto, del Hoyo ML. Congenital anomalies of the
small intestine, colon, and rectum. RadioGraphics. 1999;19:1219–36.
3. Applegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving
approach to the upper gastrointestinal series. Radiographics. 2006;26:5.
4. Mulholland MW, Lillemoe KD, Doherty GM, Maier RV, Simeone DM, Upchurch GR, editors.
Greenfield’s surgery. Philadelphia, PA: Lippincott Williams & Wilkins.
5. Sizemore AW, Rabbani KZ, Ladd A, Applegate KE. Diagnostic performance of the upper
gastrointestinal eries I the evaluation of children with clinically suspected malrotation. Pediatr
Radiol. 2008;38:518–28.
Mesenteric Hernia
Richard A. Jacobson, Robert C. Keskey, and John C. Alverdy
Background
Defects in the mesentery capable of permitting small bowel herniation can be
congenital or acquired after surgery. Based on autopsy studies, congenital mesenteric defects exist in less than 2% of the American population. However, only a
fraction of these become symptomatic over the course of a lifetime. Congenital
hernias can occur through enlarged natur al openings such as the foramen of
Winslow, or due to abnormal rotation and fusion of the peritoneum creating
paraduodenal fossae, pericecal folds, or spaces in the transverse or sigmoid
mesocolon (Fig. 43.1). Hernias occur in the foramen of Winslow in 8%,
paraduodenal (left and right) in 53%, transmesenteric in 8%, transomental in 1–4%,
pericecal in 13%, intersigmoid in 6% and supravesical and pelvic in 6%. A large
and growing portion of the population is at risk for mesenteric hernia through
surgically acquired defects, especially those undergoing a Roux-en-Y gastric
bypass procedure. Similar to congenital hernias, there are specific anatomic locations where internal hernias can occur following intestinal surgeries. In order to
appreciate where these hernias can arise, it is important to understand intestinal
anatomy following bypass surgery. In gastric bypass surgery, a gastric pouch is
created and anastomosed to a distal limb of jejunum, referred to as a ‘Roux’ limb.
The Roux limb is used to bypass 75–150 cm of small bowel before it is anastomosed to the biliopancreatic limb; the proximal jejunum carries biliary and pancreatic secretions (Fig. 43.2). The areas at risk for the development of mesenteric
hernias are: (1) the space between the Roux limb mesentery and the transverse
mesocolon (Petersen’s space), (2) The mesenteric opening at the biliopancreatic
43
R. A. Jacobson
Department of Surgery, Rush University Medical Center, Chicago, IL, USA
R. C. Keskey J. C. Alverdy (&)
Department of Surgery, University of Chicago, 5841 S. Maryland, Chicago, IL 60637, USA
e-mail: jalverdy@surgery.bsd.uchicago.edu
© Springer Nature Switzerland AG 2021
E. D. Ehrenpreis et al. (eds.), The Mesenteric Organ in Health and Disease,
https://doi.org/10.1007/978-3-030-71963-0_43
421
422 R. A. Jacobson et al.
limb, (3) The opening through the transverse mesentery when the bypass is retrocolic (Fig. 43.3). Any patient who has had a bowel resection is technically at risk,
however this is particularly true following bariatric surgery since there is an
ongoing loss of mesenteric fat that occurs over a long time period. When mesenteric
hernias become symptomatic, they are more likely than to contain closed loop
obstructions than external hernia. This increases the likelihood that mesenteric
hernias will require operative intervention.
A
B
C
D
F
G
E
Fig. 43.1 Potential sites of internal hernias. A = foramen of Winslow, B = left paraduodenal,
C = right paraduodenal, D = transmesenteric hernia, E = pericecal hernia, F = transomental
hernia, G = intersignmoid hernia
43 Mesenteric Hernia 423
Biliopancreatic
limb
Gastric
pouch
Proximal
anastomosis
Roux
(alimentary)
limb
Distal anastomosis
Common channel
Fig. 43.2 Anatomy following Roux-en-y gastric bypass. The stomach is stapled to form a gastric
pouch. A piece of jujenum is anastomosed to the neostomach and forms the “Roux” or alimentary
limb. Of note, the roux limb can be placed overtop of the colon referred to as antecolic or through
the transverse mesocolon referred to as retrocolic. The proximal jejunum draining bile acids and
pancreatic enzymes is referred to as the ‘biliopancreatic’ limb and is connected to the Roux limb as
shown. The intestine distal to this connection is referred to as the common channel