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57
5
Toldt’s fascia
J. CALVIN COFFEY AND RAVI KIRAN
The greater the ignorance the greater the dogma.
William Osler
AIM
e primary aim is to demonstrate the nature of Toldt’s fas-
cia at all intestinal levels distal to the duodenojejunal ex-
ure. Asecondary 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)
(Figure5.1) [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 endo-
pelvic 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 sub-
jected 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 dicult to visualize unaided. ese
properties explain why Toldt’s fi dings have yet to be generally
accepted [5,6]. More recently, the development of colorectal
surgery in general and of laparoscopic and robotic technolo-
gies has shown that the fascia is universally present between the
mesentery and retroperitoneum [7–17].
DEVELOPMENT
Toldt suggested that the fascia arose aer the visceral perito-
neum 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 underly-
ing 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 devel-
ops between these. e resultant anatomic arrangement
forms a cornerstone in mesenteric-based gastrointestinal
surgery. Asa 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 com-
prising multiple lamella of collagen [2,3,10]. Beneath the meso-
sigmoid and mesorectum, it is areolar and exquisitely delicate,
a property that has led to its comparison with angel hairs and
candy flo s. As a result, it can oen be quite dicult to identify in
these regions. Variations in composition and appearance make
its identifi ation dicult. Th s represents a signifi ant challenge
to both the novice and experienced surgeon. During colorectal
surgery operating in a plane beneath the fascia threatens retro-
peritoneal structures such as the ureters and gonadal vessels.
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 ofToldt 59
Right mesocolic fascia and the white line ofToldt 61
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
58 Toldt’s fascia
DEMONSTRATION OF TOLDT’S FASCIA
Given variability in fascial composition, the fascia is
best portrayed using a number of modalities. Schematic
diagrams derived from 3D digital sculptures enable
demonstration of the relationship of the fascia to adjacent
structures (Figure 5.1). In the following, schematic dia-
grams are juxtaposed with cadaver-derived screenshots
[1,3,10,11]. Intraoperative images (from both open and lap-
aroscopic cases) are also included as the high magnica-
tion and resolution of these provide unsurpassed views of
living anatomy. Finally, histologic and scanning electron
microscopic photomicrographs are included to complete a
comprehensive visual appraisal of the fascia [2].
TOLDT’S FASCIA: REGIONAL ANATOMY
Mesorectal fascia
Starting in the pelvis, Toldt’s fascia occurs between the meso-
rectum and the bony pelvis. Here, bers are areolar, resem-
bling “angel hair” or “candy oss” (Figure 5.3)[12,13]. Several
Left mesocolic
fascia
Mesosigmoid
fascia
Mesorectal
fascia
Right
mesocolic
fascia
Mesorectal (Toldt’s) fascia
Mesorec
tum
Mesorectal
(i.e
., Toldt’s)
fascia
(a)
(b)
Figure 5.1 (a) Intraoperative photomicrograph demonstrating Toldt’s fascia. (b) 2.5D snapshot of 3D model demonstrat-
ing the fascia (green) associated with mesentery distal to the duodenojejunal exure. The right and left mesocolic fascia,
mesosigmoid, and mesorectal fascia are demonstrated. These represent different regions of the same overall structure,
that is, Toldt’s fascia.
Toldt’s fascia: Regional anatomy 59
terms have been used in reference to the mesorectal region
of Toldt’s fascia. ese include the retrorectal and endopelvic
fascia. Deep in the pelvis, the mesorectum tapers dramati-
cally creating a posterior space in which Toldt’s fascia gath-
ers. In this region, it is referred to as Waldeyer’s fascia [13].
Itoccurs circumferentially at all mesorectal levels. Deep to
the peritoneal reection, it oen coalesces with the anterior
cuff of mesorectum to form Denonvillier’s fascia. As this
component of the mesorectum (i.e., the anterior cu) is not
always well developed, Denonvillier’s fascia is not an ana-
tomic constant. However, the fascia is universally constant.
e fascia is dicult to identify laterally, where the meso-
rectum apposes with the fat of the pelvic sidewall. ese are
the “zones of adherence” or “lateral ligaments” and careful
dissection here may reveal fascia, even in cases of extreme
adiposity. In general however, it seems that at the zone of
adherence the fascia is interrupted and regathers around it.
Mesosigmoidal fascia
Once it has been identifi d, it is possible to trace Toldt’s
fascia out of the pelvis, proximally under the mesosigmoid
and the left mesocolon and thereaer under the pancreas.
Beneath the mesosigmoid, the mesosigmoidal region of
Toldt’s fascia is areolar (Figure 5.4) [1,13]. As it is extremely
thin here, it is easily disrupted. Not surprisingly, the meso-
sigmoidal fascia is obliterated by solutions used for pres-
ervation. is eff ct may explain its omission from most
reference anatomic texts with the singular exception of the
most recent edition of Gray’s anatomy [2,14–17]. In turn, it
may also explain how the right and left mesocolon could,
with few exceptions, be perceived as absent, obliterated,
or vestigial [10,14–21]. is is explained as follows. If the
fascia is lost, then one has the impression of a single body
of fat. If the fascia is retained, then the mesocolon can be
observed as separate from the retroperitoneum. It is likely
that this phenomenon explains persistence of the concept
that the right and left mesocolon are absent in the adult. It
also explains why the attached component of the mesosig-
moid was not acknowledged up to recently [17]. As demon-
strated in Chapter 2, the mesosigmoid comprises attached
and mobile regions. Toldt’s fascia separates the attached
region from the underlying retroperitoneum [1,3,17].
Left mesocolic fascia and the white line
ofToldt
e composition of Toldt’s fascia changes beneath the proxi-
mal mesosigmoid (i.e., where the mesosigmoid and le
mesocolon are contiguous). Here, the fascia (i.e., the le
Right
mesocolic
fascia
Small intestine
and mesentery have
been removed
Mesorectal
fascia
Mesosigmoid
fascia
Left
mesocolic
fascia
Distribution of Toldt’s fascia
Toldt’s fascia
Transverse colon and
mesocolon have
been removed
Figure 5.2 Schematic illustration showing the distribution of Toldt’s fascia as originally described by Toldt. With minor
exceptions the distribution closely mirrors that seen in Figure 5.1b. (Courtesy of CCF. Copyright 2010.)
60 Toldt’s fascia
mesocolicfascia) comprises multiple lamellae of connective
tissue (Figure5.5). As a result, it loses the areolar appearance
and becomes moredense and somewhat lmy [1]. Th s prop-
erty facilitates its observation, provided of course one is delib-
erately looking for it in the fi st instance. e fascia here can
be excellently demonstrated during laparoscopic and robotic
colorectal surgery, where the surgeon relies on twenty-fold
magnifi ation and high-resolution digital imagery to dier-
entiate it from adjacent structures [22,23]. During this sur-
gery, the mesocolon is detached from the retroperitoneum by
separating it from the underlying fascia. Th s technical activ-
ity exposes a white line at the interface between the fascia and
mesocolon, that is, the white line of Toldt [23]. If this process
of separation is continued underneath the left mesocolon
toward the transverse mesocolon, the inferior border of the
pancreas comes into view. e fascia envelops the pancreas
on both anterior and posterior surfaces [1,4–6].
Laterally, the fascia continues under the left colon and
terminates at the left peritoneal refl ction, where it forms
a white line of Toldt. Although this arrangement can be
demonstrated at open surgery, it is easier demonstrated
with magnifi ation aorded by laparoscopic and robotic
surgery [23]. e white line of Toldt is evident at the le
colic but not at sigmoidal level. Th s is due to dierences in
Mesorectal (Toldt’s) fascia
Posterior
mesorectum
Mesorectal
fascia
Legend
Mesentery
Fascia
Colon
Peritoneum
Rectum
Mesorec
tum
Mesorectum
Toldt’s
fascia
Pe
ritoneal
re˜ec tion
(a)
(b) (c)
Mesorectal fascia
Figure 5.3 (a) Cadaveric example of Toldt’s fascia posterior to the mesorectum (i.e., the mesorectal or endopelvic fascia).
(b) Intraoperative image of Toldt’s fascia surrounding the mesorectum. (c) (See also QR 3/2.) 2.5D snapshot of 3D model
demonstrating the relationship of the fascia, mesorectum, and peritoneal reections.
Toldt’s fascia: Regional anatomy 61
the composition of the fascia at both levels. e left meso-
colic fascia is dense and forms a discrete line where it fuses
with the peritoneal refl ction. In contrast, the mesosigmoi-
dal fascia is areolar and does not form a distinct line where
it meets the peritoneal refl ction. Th s is clinically relevant
as it is oen easier to commence mobilizing the left colon
by identifying the white line of Toldt. As the white line is
not present at the sigmoidal level, commencement of mobi-
lization here is more dicult [22,23].
Right mesocolic fascia and the white line
ofToldt
On the right side, Toldt’s fascia occurs between the right
mesocolon and underlying retroperitoneum. Here, it is
thicker than on the left side, which reects increases in
collagen lamellae (Figure 5.6). As on the le, the fascia
continues under the right colon (forming a colofascial
plane) until it reaches the right peritoneal reection with
Mesosigmoid fascia
Mesosigmoid
Mesosigmoid
fascia
(a)
Legend
Mesosigmoid
fascia
Mesosigmoid
(c)
Mesosigmoid
Mesosigmoid
fascia
(b
)
Mesentery
Fascia
Colon
Peritoneum
Figure 5.4 (a) Cadaveric example of Toldt’s fascia beneath the mesosigmoid (i.e., the mesosigmoidal fascia). Here, the
fascia is areolar and easily disrupted or missed. (b) Intraoperative image of Toldt’s (mesosigmoidal) fascia interposed
between the mesosigmoid and underlying retroperitoneum. (c) (See also QR 2d/1.) 2.5D snapshot of 3D model demon-
strating the relationship of the fascia to the mesosigmoid. Note that the lateral limit of the fascia occurs where the meso-
sigmoid changes fromattached to mobile (i.e., at the peritoneal reection).
62 Toldt’s fascia
which it coalesces at the white line of Toldt. Medially, the
right mesocolon is contiguous with the small intestinal
mesentery. In keeping with this, Toldt’s fascia continues
medially until the small intestinal peritoneal reection, at
which its distribution again ceases [3].
Fascial continuity
Although the fascia is contiguous, it is interrupted at points
where vessels enter or leave the mesentery. Here, it coalesces
with mesenteric connective tissue, to form a perivascular col-
lar of connective tissue. e latter contributes to the adventitia
of the vessel in question, a property that has been discussed in
Chapter 4. e fascia also interrupted at the peritoneal refl c-
tion, the dierent regions of which serve as a mechanical bar-
rier to its further spread (see Chapter2). Finally, the fascia is
disrupted at the zones of adherence around which it regathers.
HISTOLOGY
e fascia is comprised of collagen, with occasional cell bod-
ies interspersed between collagen bundles [2]. Lymphatic
vessels are present in one-third of individuals. ey have a
Left mesocolic fascia
Left mesocolon
Left mesocolic fascia
Le
ft mesocolon
(undersurface)
White line
of Toldt
Left mesocolic
fascia
Left mesocolic fascia
(Toldt’s fascia)
Left
mesocolon
Mesentery
Legend
Fascia
Colon
Peritoneum
(a)
(b) (c)
Figure 5.5 (a) Cadaveric example of Toldt’s fascia beneath the left mesocolon (i.e., the left mesocolic fascia). Here, the fas-
cia is lamellated, thick, and thus more easily identied compared with beneath the mesosigmoid. (b) Intraoperative image
of Toldt’s (mesocolic) fascia interposed between the left mesocolon and underlying retroperitoneum. (c) (See also QR 6/2.)
2.5D snapshot of 3D model demonstrating the relationship of the fascia to the mesocolon.
Function of Toldt’s fascia 63
radius of diusion of 174.72 ± 97.68 µm. is means a lym-
phatic vessel can be expected every 174 µm [24]. e origin
of these, as well as their termination, is as yet unknown and
could be of oncologic signicance.
At points of vascular contiguity (i.e., the origin of the
middle colic or inferior mesenteric vessels), the fascia
coalesces around vessels where it encases these. From these
points, the connective tissue of the fascia continues into the
body of the mesentery as the mesenteric connective tissue
lattice [1,2]. e relevance of this relationship, in relation
to disease spread, is discussed in Chapter 7 (i.e., diseases
involving the mesentery).
FUNCTION OF TOLDT’S FASCIA
It is likely that the fascia assists in maintaining attachment
between the overlying mesentery and underlying retroperi-
toneum. e elucidation of function in general is aided by
the identication of states in which the structure in ques-
tion is absent and extrapolation of related observations.
Right mesocolic fascia
Right colon
Right
mesocolon
Toldt’s
fascia
(a)
Mesentery
Legend
Fascia
Colon
Peritoneum
Undersurface of
right mesocolon
Right mesocolic fascia
still attached to
right mesocolon
Right mesocolic fascia
mobilized o˜ right
mesocolon
Right mesocolic fascia
(Toldt’s fascia)
Right
mesocolon
(b) (c)
Figure 5.6 (a) (See also QR 2/4.) Intraoperative example of Toldt’s fascia beneath the right mesocolon (i.e., the right mesocolic
fascia). (b)Intraoperative image of Toldt’s (mesocolic) fascia interposed between the right mesocolon and underlying retro-
peritoneum. (c) (See also QR 6/4.) 2.5D snapshot of 3D model demonstrating the relationship of the fascia to the mesocolon.
64 Toldt’s fascia
isincludes nonrotation of the intestinal tract. In nonrota-
tion (see below), the small intestinal mesentery is fully mobile
and positioned in the right paracolic gutter (Figure 5.7). e
right mesocolon and foreshortened transverse mesocolon are
adherent to the retroperitoneum. e absence of attachment
of the small intestinal mesentery can be associated with a dev-
astating volvulus around the mesenteric root region, at the
superior mesenteric vascular pedicle. is is the commonest
life-threatening abdominal emergency in the rst year of life.
In adulthood, incomplete attachment of the right mesocolon
is associated with volvulus of the ileocecal region (Figure5.7).
Similarly, incomplete attachment of the mesosigmoid is
associated with volvulus of this. Finally, it is suggested that
incomplete xation of the left and right mesocolon may cause
diculty during endoscopic negotiation of the colon [25–28].
Toldt’s fascia may also provide a barrier function. Rarely
in colorectal cancer does one observe spread of a colon can-
cer through the fascia into the retroperitoneum. Even where
the mesocolon has been directly involved, spread through
the fascia is unusual (Figure 5.8a) [13].
A further function may relate to uid absorption. In
patients with uid overload, the fascia increasesdramatically
Appendix
Mesoappendix
Normal gastromesenteric confirmation Confirmation as seen in malrotation model
(a) (b)
Intraoperative nonrotation
(c)
Figure 5.7 (a) Overview of normal gastromesenteric anatomy. (b) Overview of gastromesenteric anatomy in mal or nonro-
tation. The small intestine and associated mesentery are positioned to the right. The left colon and mesentery are to the
left and the right gastromesenteric complex is located between. (c) Given the central positioning of the right colon in mal
or nonrotation, the appendix can occupy variable positions.
Function of Toldt’s fascia 65
in width (Figure 5.8b). Th s suggests that it provides a means
of uid absorption and retention [29].
Elucidation of the function of Toldt’s fascia is dicult in
view of the absence of appropriate animal models. In general in
experimental science, animal models used are either murine,
porcine, or rodent in nature. In these, the intestinal tract is
highly mobile and the associated mesentery does not become
apposed to the abdominal wall. At present, a species has yet
to be identifi d for which the mesenteric attachment equates
with to that observed in Homo sapiens. e identifi ation of
Right mesocolon and Toldt’s fascia
Right
mesocolon
Mass in right
mesocolon
Splenic ˜exur e
mesentery
Descending
colon
Anterior
renal
(Toldt’s )
fascia
Anterior renal (Toldt’s) fascia
Transverse mesocolon
Left
mesocolon
Toldt’s fascia
Right mesocolic fascia
Mass in
cecum
(a)
(b)
Figure 5.8 (a) Axial computerized tomography demonstrating a lesion in the right colon. There is a right mesocolic lesion
with involvement of the underlying fascia. Intraoperatively the patient has a T4 adenocarcinoma that had invaded locally
through the mesentery and into the underlying fascia. (b) Axial computerized tomography demonstrating fascial thicken-
ing in a patient with congestive cardiac and renal failure.