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24 C. A. Fleming et al.
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current understanding and mechanisms of attachment. Semin Cell Dev Biol. 2018. pii:
S1084–9521(18)30205–2. https://doi.org/10.1016/j.semcdb.2018.10.004. [Epub ahead of
print].
2. Treves F. Lectures on the anatomy of the intestinal canal and peritoneum in man. Br
Med J. 1885;1(1264):580–3.
3. Standring S. Gray’s anatomy: the anatomical basis of clinical practice. London, U.K.: Elsevier
Health Sciences;2015. pp. 1098–111, 1124–60.
4. Blackburn SC, Stanton MP. Anatomy and physiology of the peritoneum. Semin Pediatr Surg.
2014;23(6):326–30.
5. Sinnatamby CS. Last’s anatomy: regional and applied. London, U.K.: Elsevier Health
Sciences;2011. pp. 234–8, 247–59.
6. Snell RS. Clinical anatomy by regions. Lippincott Williams & Wilkins;2008. pp. 216, 226,
228, 233, 237, 240.
7. Byrnes KG, Walsh D, Lewton-Brain P, McDermott K, Coffey JC. Anatomy of the mesentery:
historical development and recent advances. Semin Cell Dev Biol. 2018. pii: S1084–9521(18)
30204–0. https://doi.org/10.1016/j.semcdb.2018.10.003. [Epub ahead of print].
8. Coffey JC, O’Leary DP. The mesentery: structure, function, and role in disease. Lancet
Gastroenterol Hepatol. 2016;1(3):238–47.
9. Byrnes KG, McDermott K, Coffey JC. Development of mesenteric tissues. Semin Cell Dev
Biol. 2018. pii: S1084–9521(18)30234–9. https://doi.org/10.1016/j.semcdb.2018.10.005.
[Epub ahead of print] Review.
10. Coffey JC. Surgical anatomy and anatomic surgery—clinical and scientific mutualism.
Surgeon. 2013;11(4):177–82.
11. Coffey JC, et al. Mesenteric-based surgery exploits gastrointestinal, peritoneal, mesenteric and
fascial continuity from duodenojejunal flexure to the anorectal junction—a review. Dig Surg.
2015;32(4):291–300.
12. Coffey JC, Lavery I, Sehgal R. Mesenteric principles of gastroinstestinal surgery. CRC Press,
FL, 2017. ISBN 9781498711227.
13. Byrnes KG, McDermott KW, Coffey JC. Mesenteric organogenesis. Semin Cell Dev Biol.
2018. pii: S1084–9521(18)30246–5. https://doi.org/10.1016/j.semcdb.2018.10.006. [Epub
ahead of print].
14. Culligan K, et al. The mesocolon: a histological and electron microscopic characterization of
the mesenteric attachment of the colon prior to and after surgical mobilization. Ann Surg.
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nomenclature based on mesocolic anatomy. Surgeon. 2013;11(1):1–5.
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(9):789–
Part II
Anatomy and Physiology
Vascular Anatomy of the Mesentery
Ahmed Khattab, Saad Hashmi, Eli D. Ehrenpreis, and J. Calvin Coffey
Introduction
To best appreciate the role that the vascular system contributes to the overall
structure of the mesentery, it is essential to first understand the anatomy of the
mesentery itself. The mesentery is a continuous and substantive organ that extends
from the esophagogastric to anorectal junction. The mesentery is connected to all
abdominal digestive organs. In turn, the mesentery affixes these organs centrally in
the within body cavity. This is an important point as conventional models of
abdominal anatomy suggest that the vascular system, (with few exceptions), was
responsible for the bridge between individual digestive system organs and the
musculoskeletal abdominal mainframe.
The mesentery is both directly attached to the body (see Chapter 3 on Mesenteric
Anatomy) via Toldt’s fascia and the peritoneal reflection, while it is indirectly
coupled via the major vascular trunks (celiac, superior mesenteric, and inferior
mesenteric) and also via the hepatic veins. The major arterial trunks are the arterial
inflow of the mesentery (and all contained organs) while the hepatic veins represent
the major venous drainage of the mesentery. These drain into the inferior vena cava.
Given that all abdominal digestive organs first connect to the mesentery, and
then to the abdominal wall, their individual vascular, lymphatic and neuronal circuitries are also contained in the mesenteric organ. The celiac trunk and superior
mesenteric artery arise from the anterior surface of the aorta and are relatively
4
A. Khattab S. Hashmi E. D. Ehrenpreis
Department of Medicine, Advocate Lutheran General Hospital, 1675 Dempster St, Park Ridge, IL
60068, USA
J. C. Coffey (&)
School of Medicine and Department of Surgery, University of Limerick Hospital Group,
Raheen, Dooradoyle, Limerick, Ireland
e-mail: Calvin.coffey@ul.ie
© 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_4
27
28 A. Khattab et al.
closely positioned. They almost immediately enter the substance of the mesentery
in which they course towards their anatomical destinations. On this pathway, these
arteries subdivide into respective branches. These branches utilize the mesenteric
frame to travel to and access individual digestive system organs. This concept is
important as the mesenteric frame provides the anatomical platform for both the
arterial supply and venous drainage of abdominal digestive organs.
The venous drainage of the abdominal digestive system is entirely contained
within the mesentery. The inferior mesenteric vein arises in the mesosigmoid,
travels proximally in the left mesocolon and reaches the central region of the
mesentery. Tributaries of the inferior mesenteric vein include the left colic vein,
sigmoid veins, superior rectal vein and rectosigmoid veins. The central or root
region of the mesentery is the location where the small intestinal, right and transverse mesocolic regions of mesentery converge. The superior mesenteric vein is
positioned in the central region where it receives the inferior mesenteric vein. The
right gastro-omental vein, anterior and posterior inferior pancreaticoduodenal veins,
jejunal vein, ileal vein, ileocolic vein, right colic vein and middle colic veins all
drain into the superior mesenteric vein. Alternatively, the inferior mesenteric vein
may enter the splenic vein as it travels from the spleen, within the dorsal mesogastrium, towards the superior mesenteric vein. The superior mesenteric vein and
splenic vein merge to form the portal vein, within the mesoduodenum, posterior to
the head of the pancreas (Fig. 4.1). The portal vein travels towards the liver, in the
mesoduodenum and then enters the portal pedicle (previously called the hepatoduodenal ligament). The portal pedicle is the continuation of the mesentery towards
the liver and contains the portal vein, common bile duct and hepatic artery. The
portal vein travels in the portal pedicle until it reaches the liver.
As mentioned above, the branches of the celiac trunk, the superior and the
inferior mesenteric arteries are all located within the mesentery (Fig. 4.2). There are
many anatomical variations in the pattern of branching of each, but all branches
utilize the mesenteric frame to access their destination organ in the abdominal
digestive system. The following description is a commonly observed pattern. After
entering the dorsal mesogastric region of the mesentery, the celiac trunk divides
into the common hepatic, left gastric and splenic arteries (Fig. 4.3). At first, all of
these divisions are located in the dorsal mesogastrium. The splenic artery remains in
the dorsal mesogastrium throughout its course as it passes laterally towards the
hilum of the spleen. The dorsal mesogastrium is located posterior to the body of the
pancreas. These anatomical observations explain the relationship of the splenic
artery to the pancreas. The left gastric artery enters a mesenteric pedicle at the
4 Vascular Anatomy of the Mesentery 29
Portal vein
(and
tributaries)
Superior
mesenteric vein
(and tributaries)
A
Splenic Vein
(and tributaries)
Inferior
mesenteric vein
(and tributaries)
Portal vein
Superior
mesenteric
pancreatico-
duodenal vien
Middle
colic vein
Right
colic vein
vein
Inferior
B
Splenic vein
Right
gastroepiploic vein
Inferior
mesenteric vein
Left colic vein
Sigmoidal veins
Superior rectal
vein
Jejunal and ileal veins
Fig. 4.1 a Formation of the portal vein from convergence of superior mesenteric, inferior
mesenteric and splenic veins. b Tributaries of the superior and inferior mesenteric veins
30 A. Khattab et al.
Coeliac
trunk
Superior
mesenteric
artery
Abdominal
aorta
Inferior
mesenteric
artery
Fig. 4.2 Celiac trunk, superior mesenteric artery and inferior mesenteric arteries branch points
from the abdominal aorta
esophagogastric junction. It u ses this to access the ventral mesogastrium at the
lesser curvature of the stomach. It travels along the lesser curvature, in the ventral
mesogastrium, distributing branches to the stomach. The common hepatic artery
travels inferolaterally in the dorsal mesogastrium to reach the portal pedicle. Here, it
gives off the right gastric artery and then enters the portal pedicle in which it travels
until it reaches the liver.
The superior mesenteric artery enters the mesentery soon after it arises from the
anterior surface of the aorta. It is incorporated into the substance of the mesentery in
which it travels towards the right iliac fossa. It sequentially gives off jejunal and
ileal branches and also the ileocolic artery (Fig. 4.4). The jejunal and ileal arteries
4 Vascular Anatomy of the Mesentery 31
Coeliac trunk
Left gastric a.
Common
hepatic a.
Splenic a.
Fig. 4.3 Branches of the celiac trunk
are numerous arteries that form anastomotic arcades which lead to multiple smaller
arteries called vasa recta supplying the ileum and jejunum. The jejunum has long
and few vasa recta while the ileum has numerous, short vasa recta. The ileocolic
artery is virtually an anatomical constant and travels, within the mesentery, to the
ileocaecal junction. In the region of the junction, it sometimes gives off the
appendicular artery which enters the mesoappendix and passes towards the
appendix. The mesoappendix is a posterior appendage of the main body of the
mesentery. Another branch of the superior mese nteric artery is the inferior pancreaticoduodenal artery which supplies the head and uncinate process of the pancreas along with the ascending and inferior duodenum.
32 A. Khattab et al.
Middle
colic artery
Right
colic artery
Ileocolic
artery
Superior
mesenteric
artery
Jejunal and
ileal arteries
Fig. 4.4 Branches of the superior mesenteric artery. Note the inferior pancreaticoduodenal artery
is not depicted in this image
The middle colic arterial pedicle is important. It arises from the upper surface of
the superior mesenteric artery, in the central region of the mesentery. It subdivides
into branches that also travel in the transverse mesocolon to the colon. A right colic
artery, when present, arises from either the main trunk of the middle colic artery, or
a branch of this. It exploits mesenteric continuity to travel in the mesentery and
access the ascending colon.
4 Vascular Anatomy of the Mesentery 33
Sigmoid
arteries
Superior
rectal artery
Left colic
artery
Fig. 4.5 Main branches of the inferior mesenteric artery
The inferior mesenteric artery arises from the anterior surfa ce of the aorta and
immediately enters the mesentery at a mesenteric pedicle termed the inferior
mesenteric arterial pedicle. Soon after, this artery gives off the left colic branch
which enters the left mesocolon and travels in the latter towards the descending
colon. Once the left colic artery has been given off the inferior mese nteric artery is
called the superior rectal artery. It travels in the mesosigmoid and thereafter in the
mesorectum, and branches in each region to supply these components of the
intestine (Figs. 4.5 and 4.6).
34 A. Khattab et al.
Transverse colon
Ascending branch
of left colic artery
Left colic artery
Abdominal aorta
Descending
colon
Duodenum
Inferior
mesenteric
artery
Superior
rectal artery
Sigmoid
Rectum
arteries
Sigmoid colon
Fig. 4.6 Detailed view of the branches of the inferior mesenteric artery
Suggested Reading
1. https://teachmeanatomy.info/abdomen/vasculature/arteries/superior-mesenteric/.
2. https://teachmeanatomy.info/abdomen/vasculature/arteries/superior-mesenteric/.
3. https://teachmeanatomy.info/abdomen/vasculature/arteries/inferior-mesenteric/.
4. https://www.earthslab.com/anatomy/superior-mesenteric-vein/.
5. https://teachmeanatomy.info/abdomen/vasculature/venous-drainage/.
6. https://s3.amazonaws.com/teachmeseries/tmanatomy/wp-content/uploads/20171222215727/
Inferior-Mesenteric-Artery-arising-from-the-Abdominal-Aorta-1024x622.jpg.
7. https://slideplayer.com/slide/4356935/14/images/22/Inferior+mesenteric+artery.jpg.