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Mesentery
Mesentery extending from the duodenojejunal flexure to the ileocecal junction
Details
Pronunciation/ˈmɛzənˌtɛri/
SystemDigestive system
Identifiers
Latinmesenterium
MeSHD008643
TA98A10.1.02.007
TA23740
FMA7144
Anatomical terminology

In human anatomy, the mesentery is an organ that attaches the intestines to the posterior abdominal wall, consisting of a double fold of the peritoneum. It helps (among other functions) in storing fat and allowing blood vessels, lymphatics, and nerves to supply the intestines.[1]

The mesocolon (the part of the mesentery that attaches the colon to the abdominal wall) was formerly thought to be a fragmented structure, with all named parts—the ascending, transverse, descending, and sigmoid mesocolons, the mesoappendix, and the mesorectum—separately terminating their insertion into the posterior abdominal wall.[2] However, in 2012, new microscopic and electron microscopic examinations showed the mesocolon to be a single structure derived from the duodenojejunal flexure and extending to the distal mesorectal layer.[2][3] Thus the mesentery is an internal organ.[4][5]

Structure

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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.[6] The study included 109 patients undergoing open, elective, total abdominal colectomy. Anatomical observations were recorded during the surgery and on the post-operative specimens.

These studies showed that the mesocolon is continuous from the ileocaecal to the rectosigmoid level. It was also shown that a mesenteric confluence occurs at the ileocaecal and rectosigmoid junctions, as well as at the hepatic and splenic flexures and that each confluence involves peritoneal and omental attachments. The proximal rectum was shown to originate at the confluence of the mesorectum and mesosigmoid. A plane occupied by perinephric fascia was shown to separate the entire apposed small intestinal mesentery and the mesocolon from the retroperitoneum. Deep in the pelvis, this fascia coalesces to give rise to presacral fascia.[6]

Flexural anatomy

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Flexural anatomy is frequently described as a difficult area. It is simplified when each flexure is considered as being centered on a mesenteric contiguity. The ileocaecal flexure arises at the point where the ileum is continuous with the caecum around the ileocaecal mesenteric flexure. Similarly, the hepatic flexure is formed between the right mesocolon and transverse mesocolon at the mesenteric confluence. The colonic component of the hepatic flexure is draped around this mesenteric confluence. Furthermore, the splenic flexure is formed by the mesenteric confluence between the transverse and left mesocolon. The colonic component of the splenic flexure occurs lateral to the mesenteric confluence. At every flexure, a continuous peritoneal fold lies outside the colonic/mesocolic complex tethering this to the posterior abdominal wall.[2][6]

Mesocolon regions

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The transverse mesocolon is that section of the mesentery attached to the transverse colon that lies between the colic flexures.

The sigmoid mesocolon is that region of the mesentery to which the sigmoid colon is attached at the gastrointestinal mesenteric margin.

The mesoappendix is the portion of the mesentery connecting the ileum to the appendix. It may extend to the tip of the appendix. It encloses the appendicular artery and vein, as well as lymphatic vessels, nerves, and often a lymph node.

The mesorectum is that part attached to the upper third of the rectum.

Peritoneal folds

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Understanding the macroscopic structure of the mesenteric organ meant that associated structures—the peritoneal folds and congenital and omental adhesions—could be better appraised. The small intestinal mesenteric fold occurs where the small intestinal mesentery folds onto the posterior abdominal wall and continues laterally as the right mesocolon. During mobilization of the small intestinal mesentery from the posterior abdominal wall, this fold is incised, allowing access to the interface between the small intestinal mesentery and the retroperitoneum. The fold continues at the inferolateral boundary of the ileocaecal junction and turns cephalad as the right paracolic peritoneal fold. This fold is divided during lateral to medial mobilization, permitting the surgeon to serially lift the right colon and associated mesentery off the underlying fascia and retroperitoneum. At the hepatic flexure, the right lateral peritoneal fold turns and continues medially as the hepatocolic peritoneal fold. Division of the fold in this location permits separation of the colonic component of the hepatic flexure and mesocolon off the retroperitoneum.[2][6]

Interposed between the hepatic and splenic flexures, the greater omentum adheres to the transverse colon along a further band or fold of peritoneum. Dissection through this allows access to the cephalad (top) surface of the transverse mesocolon. Focal adhesions frequently tether the greater omentum to the cephalad aspect of the transverse mesocolon. The left colon is associated with a similar anatomic configuration of peritoneal folds; the splenic peritoneal fold is contiguous with the left lateral paracolic peritoneal fold at the splenic flexure. Division of the latter similarly allows for the separation of the left colon and associated mesentery off the underlying fascia and frees it from the retroperitoneum. The left lateral paracolic peritoneal fold continues distally at the lateral aspect of the mobile component of the mesosigmoid.[2][6]

Microanatomy

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Determination of the macroscopic structure of the mesenteric organ allowed a recent characterisation of the histological and electron microscopic properties.[7] 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.[7]

Development

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Two of the stages in the development of the digestive tube and its mesentery

Dorsal mesentery

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Mesentery in red. Dorsal mesentery is the lower part of the circuit. The upper part is ventral mesentery.
Abdominal part of digestive tube and its attachment to the primitive or common mesentery. Human embryo of six weeks.
Schematic figure of the bursa omentalis, etc. Human embryo of eight weeks.

The primitive gut is suspended from the posterior abdominal wall by the dorsal mesentery. The gastrointestinal tract and associated dorsal mesentery are subdivided into foregut, midgut, and hindgut regions based on the respective blood supply. The foregut is supplied by the celiac trunk, the midgut is supplied by the superior mesenteric artery (SMA), and the hindgut is supplied by the inferior mesenteric artery (IMA). This division is established by the fourth week of development. After this, the midgut undergoes a period of rapid elongation, forcing it to herniate through the navel. During herniation, the midgut rotates 90° anti-clockwise around the axis of the SMA and forms the midgut loop. The cranial portion of the loop moves to the right and the caudal portion of the loop moves toward the left. This rotation occurs at about the eighth week of development. The cranial portion of the loop will develop into the jejunum and most of the ileum, while the caudal part of the loop eventually forms the terminal portion of the ileum, the ascending colon and the initial two-thirds of the transverse colon. As the foetus grows larger, the mid-gut loop is drawn back through the umbilicus and undergoes a further 180° rotation, completing a total of 270° rotation. At this point, about 10 weeks, the caecum lies close to the liver. From here it moves in a cranial to caudal direction to eventually lie in the lower right portion of the abdominal cavity. This process brings the ascending colon to lie vertically in the lateral right portion of the abdominal cavity apposed to the posterior abdominal wall. The descending colon occupies a similar position on the left side.[8][9]

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."[9] In The Developing Human, the author states, "the mesentery of the ascending colon fuses with the parietal peritoneum on this wall and disappears; consequently the ascending colon also becomes retroperitoneal".[10] 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.[9][10]

The portion of the dorsal mesentery that attaches to the greater curvature of the stomach, is known as the dorsal mesogastrium. The part of the dorsal mesentery that suspends the colon is termed the mesocolon. The dorsal mesogastrium develops into the greater omentum.

Ventral mesentery

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The development of the septum transversum takes part in the formation of the diaphragm, while the caudal portion into which the liver grows forms the ventral mesentery. The part of the ventral mesentery that attaches to the stomach is known as the ventral mesogastrium.[11]

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.[11]

In the adult, the ventral mesentery is the part of the peritoneum closest to the navel.

Clinical significance

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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.[12]

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.[13]

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.[2][14]

Surgery

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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.[2][14] Recently, the surgical principles underpinning TME in rectal cancer have been extrapolated to colonic surgery.[15][16] 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%.[17]

Radiology

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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.[18] This is of immediate relevance in the spread of cancer from colon cancer and perforated diverticular disease, and in pancreatitis where fluid collections in the lesser sac dissect the mesocolon from the retroperitoneum and thereby extend distally within the latter.[19]

History

[edit]

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.[20][better source needed] The classical anatomical description of the mesocolon is credited to British surgeon Sir Frederick Treves in 1885,[21] although a description of the membrane as a single structure dates back to at least Leonardo da Vinci.[22] Treves is known for performing the first appendectomy in England in 1888; he was surgeon to both Queen Victoria and King Edward VII.[23] 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.[21][23] These assertions were included in mainstream surgical, anatomical, embryological, and radiologic literature for more than a century.[24][25]

Almost 10 years before Treves, the Austrian anatomist Carl Toldt described the persistence of all portions of the mesocolon into adulthood.[26] 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.[26][27]

In 1942, anatomist Edward Congdon also demonstrated that the right and left mesocolons persisted into adulthood and remained separate from the retroperitoneum—extraretroperitoneal.[28] Radiologist Wylie J. Dodds described this concept in 1986.[18] 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.[18]

Descriptions of the mesocolon by Toldt, Congdon, and Dodds have largely been ignored in mainstream literature until recently. A formal appraisal of the mesenteric organ anatomy was conducted in 2012; it echoed the findings of Toldt, Congdon, and Dodds.[6] 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.[6]

In 2012 it was discovered that the mesentery was a single organ, which precipitated advancement in colon and rectum surgery[29] and in sciences related to anatomy and development.

Etymology

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The word "mesentery" and its Neo-Latin equivalent mesenterium (/ˌmɛzənˈtɛriəm/) use the combining forms mes- + enteron, ultimately from ancient Greek μεσέντερον (mesenteron), from μέσος (mésos, "middle") + ἔντερον (énteron, "gut"), yielding "mid-intestine" or "midgut". The adjectival form is "mesenteric" (/ˌmɛzənˈtɛrɪk/).

Lymphangiology

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An improved understanding of mesenteric structure and histology has enabled a formal characterization of mesenteric lymphangiology.[7] Stereologic assessments of the lymphatic vessels demonstrate a rich lymphatic network embedded within the mesenteric connective tissue lattice. On average, vessels occur every 0.14 mm (0.0055 in), and within 0.1 mm (0.0039 in) from the mesocolic surfaces—anterior and posterior. Lymphatic channels have also been identified in Toldt's fascia, though the significance of this is unknown.[7]

See also

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This article uses anatomical terminology.

Additional images

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  • Mesenteric relation of intestines. Deep dissection. Anterior view.
    Mesenteric relation of intestines. Deep dissection. Anterior view.

References

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[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Mesentery

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from Grokipedia
The mesentery is a continuous, double-layered fold of —the lining the —that suspends the and of the from the posterior abdominal wall, while also attaching portions of the , thereby maintaining their position and systemic continuity within the . Historically viewed as fragmented supportive tissues, the mesentery was reclassified in 2016 as a single, distinct organ based on evidence of its contiguous structure spanning from the to the mesorectal level, encompassing all abdominal digestive organs in a unified anatomical unit. This redesignation highlights its role beyond mere attachment, as it forms during embryonic development and persists to integrate the with the body's vascular, neural, and lymphatic systems. Structurally, the mesentery comprises two peritoneal layers enclosing mesenchymal tissue rich in adipose, connective fibers, blood vessels, , and lymphatics, which serve as conduits to nourish and innervate the attached viscera. Its functions extend to mechanical stabilization of the intestines to prevent excessive mobility, facilitation of intestinal , and critical contributions to immune defense through resident lymphoid tissues that monitor for pathogens and regulate . Additionally, the mesentery influences systemic processes, including potential roles in the brain-gut-liver axis via its vascular and immunological networks. Clinically, the mesentery's integrity is vital; disruptions such as mesenteric ischemia or torsion can lead to severe complications like , while its involvement in oncology underscores its importance in for abdominal cancers. Ongoing research continues to elucidate its broader physiological impacts, solidifying its status as a multifunctional organ central to abdominal .

Anatomy

Gross anatomy

The mesentery is defined as a continuous double-layered fold of that attaches the , , and aspects of the colon to the posterior of the . This structure was reclassified as a single organ in based on macroscopic and microscopic analyses demonstrating its continuity throughout the , challenging prior fragmented descriptions. As such, it forms a unifying peritoneal framework supporting the mobile portions of the . The primary components of the mesentery encompass the mesojejunum, which suspends the ; the mesoileum, attaching the ; the transverse mesocolon, supporting the ; and the sigmoid mesocolon, anchoring the . These elements integrate into a cohesive continuum, facilitating overall abdominal organ positioning. The mesentery's flexural anatomy features a root that originates in the left upper quadrant at the (approximately at the level of L2 vertebra) and extends obliquely downward to the right , measuring approximately 15-20 cm in length. From this root, the mesentery distributes in a fan-like manner, with an average width of about 15 cm perpendicular to the intestinal border and a thickness of 1-2 mm in adults, accommodating variable adipose content. Embedded within the mesentery are the and , which provide the primary arterial and venous supply to the small and proximal s via their branching vasa recta and arcades. These vessels course along the root and radiate outward, paralleling the intestinal loops to ensure efficient nutrient and waste transport while maintaining the mesentery's macroscopic integrity.

Regional variations

The mesentery displays distinct regional variations tailored to the anatomical demands of the intestinal segments it supports, particularly in its attachments and mobility. In the , the mesocolon exhibits specialized configurations. The ascending and descending mesocolons are commonly fused to the posterior , positioning these colonic segments as retroperitoneal structures in the majority of adults; complete fusion of the ascending mesocolon is observed in approximately 90% of individuals. In contrast, the transverse mesocolon maintains greater mobility and attaches along the anterior surface of the , facilitating the flexibility of the . The sigmoid mesocolon features an inverted V-shaped attachment to the pelvic wall, allowing for the variable positioning of the within the . For the , the mesentery divides into jejunal and ileal portions, each with characteristic vascular patterns that reflect regional differences in . The jejunal mesentery typically forms 1-2 tiers of arterial arcades from branches of the , accompanied by longer vasa recta vessels that supply the intestinal wall with minimal branching. The ileal mesentery, however, develops 3-5 tiers of arcades with shorter vasa recta, enhancing anastomotic networks and supporting the absorptive demands of the distal small bowel. Common anatomical variations in mesenteric fixation influence intestinal positioning and stability. Incomplete fusion often results in a mobile , present in 10-25% of adults due to persistent mesenteric attachments, which can predispose to rotational issues. These fusion processes primarily occur during fetal development, with the mesocolons adhering to the retroperitoneum by the fifth month of , though incomplete adherence persists postnatally in a minority of cases. Ethnic differences also contribute to variability; for instance, Western populations show higher colonic mobility and sigmoid adhesions compared to Oriental groups, potentially linked to dietary or genetic factors. Clinically, these regional variations, particularly incomplete fixation, can underlie malrotation, where a narrow mesenteric base heightens the risk of and without proper surgical intervention.

Peritoneal relations

The mesentery consists of a double layer of visceral that attaches the and to the posterior via its root, a 15 cm oblique attachment extending from the at the level of L2 to the ileocecal junction at the right . This root crosses anteriorly over the third part of the , , , right , and right , forming key relations that influence vascular and neural pathways within the . The attachment to the parietal along this root integrates the mesentery into the broader peritoneal lining, creating a continuous interface that suspends the intestines while allowing mobility. As a unified structure, the mesentery spans the small and large bowel, providing continuity from the through the to the proximal colon, with peritoneal reflections at the that drape the and appendix against the posterior wall. This continuity, recently reclassified as a single organ, extends mesentery-like folds such as the mesoappendix, which attaches the vermiform appendix to the terminal ileal mesentery, and the , a short peritoneal fold connecting the to the posterior layer of the broad ligament. The broad ligament itself represents an extension of peritoneal folds in the , enclosing the and fallopian tubes while linking to the mesentery via reflections that maintain positional stability. Distinct from omenta, which are peritoneal folds connecting viscera to other viscera—such as the suspending from the to the and the linking the to the liver—the mesentery specifically anchors bowel segments to the posterior via parietal attachments. These relations contribute to the formation of peritoneal recesses, including the paraduodenal fossae near the , where superior and inferior duodenal folds create potential spaces bounded by the mesentery and parietal . By delineating these recesses and reflections, the mesentery compartmentalizes the into distinct regions, such as the supracolic and infracolic compartments, which facilitate organ isolation and fluid distribution. Furthermore, the mesentery's attachments play a critical role in preventing organ torsion by securing the mobile bowel loops against excessive , with its broad fan-shaped base providing a stable anchor that counters twisting forces during or positional changes. This structural integration enhances organization, minimizing the risk of while permitting physiological movement essential for .

Microanatomy

The mesentery exhibits a layered microscopic structure consisting of an outer serosal layer formed by —a that lines both peritoneal surfaces—and an inner core of loose (areolar) . This is composed of a lattice of and fibers, providing flexibility and support, with interspersed whose quantity varies regionally, being more abundant in the jejunal mesentery to accommodate greater vascular and lymphatic demands. The rests on a thin and facilitates smooth peritoneal gliding while acting as a barrier. At the cellular level, fibroblasts predominate in the , synthesizing the of fibers, while resident macrophages and mast cells contribute to immune functions such as and inflammatory responses. Mesothelial cells on the surface exhibit microvilli and express cytokeratins, supporting . Clusters of mesenteric lymph nodes, embedded within the adipose-rich regions, contain lymphoid follicles and sinuses for , underscoring the mesentery's role in localized immunity. Vascular elements include arteries that branch into vasa recta—long, straight arterioles with a muscular media layer embedded in the —supplying the intestinal wall without significant arborization until reaching the serosa. Parallel venous structures, with thinner walls, collect deoxygenated , forming a that drains into the . These vessels are surrounded by supportive fibers. Lymphatic vessels form a hierarchical network, with blind-ended initial lacteals in the intestinal extending into the mesentery as thin-walled, valve-equipped channels that absorb chylomicrons from digested fats. These converge into larger collecting trunks lined by , coursing alongside arteries toward mesenteric nodes for immune processing. Neural components comprise autonomic plexuses of sympathetic and parasympathetic fibers originating from the celiac and superior mesenteric ganglia, distributed along vascular bundles in the . These unmyelinated fibers, often catecholaminergic or Y-positive, innervate vessels and lymphatics, regulating tone and indirectly.

Development

Embryonic formation

The mesentery begins to form during the fourth week of embryonic development from the splanchnic layer of the , which surrounds the primitive gut tube as it arises from endodermal incorporation of the during weeks 3 to 4. This initial dorsal mesentery suspends the primitive gut tube within the coelomic cavity, providing a foundational attachment to the posterior body wall and marking the transition from the undifferentiated primitive gut to the more structured definitive mesentery that supports intestinal looping and vascular supply. As the progresses into weeks 5 through 10, the mesentery elongates in tandem with rapid growth and herniation of the loop, culminating in a 270-degree counterclockwise around the axis upon its return to the . This repositions the mesentery, orienting the and to the left and the and colon to the right, establishing the adult-like mesenteric base and preventing under normal conditions. By weeks 10 to 12, the mesentery undergoes partial fusion with the posterior parietal , leading to retroperitoneal fixation of segments such as the , , and , while the central portion remains mobile to accommodate intestinal motility. Genetic regulation, particularly by expressed in the visceral , directs anteroposterior patterning of the gut and mesentery, ensuring proper rotational alignment and mesenchymal differentiation. Disruptions in function or related pathways can impair this patterning, resulting in with an incidence of approximately 1 in 500 live births.

Dorsal mesentery

The dorsal mesentery originates from the (visceral) that envelops the primitive gut tube during the early stages of embryonic folding, forming a double-layered peritoneal fold that suspends the developing from the posterior body wall. This structure arises dorsal to the gut tube and constitutes the primary mesenchymal support for most of the and derivatives, eventually forming the bulk of the adult mesentery.00179-2) Key derivatives of the dorsal mesentery include the mesentery proper of the small bowel (mesojejunum and mesoileum), which supports the and , as well as portions of the mesocolon for the transverse, descending, and . During development, the dorsal mesentery elongates rapidly in conjunction with the rapid growth of the intestinal tube, particularly in the , where it accommodates the herniation and return of the intestinal loop; by birth, the mesenteric root supporting the small bowel measures approximately 15-20 cm in length, allowing mobility while anchoring vascular structures. The rotational movements of the , facilitated by the dorsal mesentery, play a critical role in positioning key anatomical landmarks. The 270-degree counterclockwise rotation around the axis positions the to the left of the midline at the level of the and relocates the to the right lower quadrant, establishing the normal configuration of the small bowel and proximal colon. In normal development, the dorsal mesentery persists as an intraperitoneal structure for mobile segments such as the , , and , maintaining their suspension within the . For other regions, such as the and ascending/, the mesentery fuses with the posterior parietal during fixation, rendering these organs secondarily retroperitoneal and less mobile. Anomalies in dorsal mesentery development, particularly non-rotation or incomplete rotation of the , can result in abnormal fixation and a narrow mesenteric base, increasing the risk of —a potentially life-threatening twisting that compromises intestinal blood supply.

Ventral mesentery

The ventral mesentery originates from the and splanchnic located ventral to the during the fourth week of embryonic development, remaining restricted to the proximal regions of the including the , , and . This structure forms a double-layered peritoneal fold that connects the developing gut tube to the ventral body wall, providing early support without extending caudally like its dorsal counterpart. As the protrudes from the and expands into the ventral mesentery around Carnegie stage 13 (28–32 days post-fertilization), the liver bud invades and differentiates the mesentery into specialized components. The primary derivatives of the ventral mesentery include the , , and , which collectively anchor the liver to adjacent structures. The , comprising the hepatogastric and hepatoduodenal ligaments, connects the liver to the and , respectively, and transmits precursors of the , hepatic artery, and . The represents the remnant connecting the liver to the anterior and contains the obliterated in its free edge. The , along with the right and left triangular ligaments, attaches the liver's posterior surface to the diaphragm, stabilizing its position in the upper abdomen. Unlike the dorsal mesentery, the ventral mesentery maintains a fixed position without involvement in gut rotation or elongation, adhering directly to the anterior and later integrating laterally with the posterior by Carnegie stage 23 to form a continuous fascial layer. This stability ensures consistent ventral attachments, facilitating the incorporation of the liver and supporting vascular structures like the precursors within the hepatoduodenal ligament. Anomalies of the ventral mesentery are rare but can include cysts within the or absence of ligaments such as the falciform and coronary in congenital syndromes like hepatic malrotation (wandering liver). These defects may arise from disrupted hepatic expansion or abnormal mesenchymal folding, potentially leading to associated visceral malpositions, though they are infrequently reported compared to dorsal mesentery variations.

Functions

Structural support

The mesentery serves as a critical anchorage for the abdominal digestive organs, securing them to the posterior while permitting limited mobility essential for physiological processes such as . By suspending the small and large intestines, it prevents excessive displacement that could lead to or other mechanical complications, yet its elastic composition allows coordinated wave-like contractions to propagate along the without undue restriction. Elastic fibers within the mesentery contribute to this balanced support, providing the necessary tensile stiffness to maintain organ positioning during dynamic movements. In terms of load distribution, the mesentery bears the weight of the , which measures approximately 7 meters in length in adults, along with the contents accumulated during . This supportive role involves distributing mechanical forces across its broad attachment to the , mitigating localized stress on individual organs and facilitating efficient peristaltic activity. Although specific tension values during vary, the mesentery's design accommodates the gravitational and contractile loads inherent to intestinal function. The mesentery also contributes to the compartmentalization of the peritoneal cavity, with components such as the transverse mesocolon delineating the supracolic compartment (containing the stomach, liver, and spleen) from the infracolic compartment (housing the small intestine, ascending and descending colons). This division organizes abdominal contents, reduces inter-organ friction, and directs the flow of peritoneal fluid, enhancing overall structural integrity. Communication between these spaces occurs via the paracolic gutters, preserving functional connectivity without compromising separation. Adaptive changes in the mesentery occur in response to systemic conditions, including of its adipose component in , where mesenteric fat accumulation leads to enlarged adipocytes and increased tissue mass to accommodate excess . Conversely, in , the mesentery undergoes , characterized by wasting and overall reduction in supportive volume, which exacerbates organ vulnerability due to diminished mechanical buffering. These alterations reflect the mesentery's plasticity in maintaining structural amid metabolic shifts. Biomechanically, the mesentery's tensile strength derives primarily from fibers in its , which provide resistance to stretching and ensure durability under load, while imparts flexibility, allowing reversible deformation during organ . This composite structure enables the mesentery to withstand both static gravitational forces and dynamic peristaltic tensions, optimizing support without rigidity. Studies on its elastic components highlight how specifically enhances in tensile directions, crucial for long-term organ stabilization.

Vascular and lymphatic roles

The mesentery serves as the primary conduit for arterial supply to the structures, primarily through branches of the (SMA). The SMA gives rise to 4–6 jejunal arteries and 8–12 ileal arteries, which course between the layers of the mesentery and form complex anastomotic arcades; these arcades give off straight vasa recta vessels that directly perfuse the and . Additionally, the SMA branches into arteries, including the right , middle , and ileocolic arteries, which supply the ascending and via similar arcading patterns within the mesenteric . The 2016 reclassification of the mesentery as a continuous organ highlighted its integrated vascular axis, where these arterial structures form a cohesive network spanning from the to the mesorectum, ensuring uninterrupted blood flow to abdominal digestive organs. Venous drainage from the mesentery converges into the (SMV), which collects blood from the , , , and before uniting with the to form the at the pancreatic neck. This arrangement directs nutrient-rich blood from the into the portal system for hepatic processing. In conditions of , such as , elevated pressure can lead to the development of mesenteric , which pose a risk of due to dilated submucosal veins in the mesentery. The mesenteric lymphatic system facilitates the absorption and transport of dietary , with approximately 100–150 lymph nodes distributed throughout its structure serving as key filtration sites. Lacteals, the blind-ended lymphatic capillaries within intestinal villi, uptake chylomicrons—lipoprotein particles assembled from absorbed long-chain fatty acids—via transcellular and paracellular mechanisms, propelling them through collecting vessels in the mesentery. flow rates in the human intestine typically range from 1 to 2 L per day during fat absorption, accommodating the transport of approximately 100–200 g of dietary daily. These mesenteric lymph nodes play a critical role in immune surveillance by filtering antigens from the gut lumen and serving as activation sites for T and B lymphocytes, where dendritic cells present microbial and food-derived antigens to initiate adaptive immune responses. Post-2016 studies recognizing the mesentery as a distinct organ have advanced understanding of its contributions to , revealing how mesenteric and lymphatics mediate release and immune cell trafficking in response to gut-derived signals, linking local intestinal perturbations to broader inflammatory disorders.

Neural integration

The mesentery serves as a conduit for autonomic nerves that innervate the , integrating sympathetic and parasympathetic inputs to regulate gut function. Sympathetic innervation arises primarily from the superior mesenteric plexus, which derives postganglionic fibers from the celiac and superior mesenteric ganglia to supply the structures suspended by the mesentery, including the and proximal colon. Parasympathetic innervation is provided via the , which extends through the mesentery to the and proximal colon, promoting digestive processes such as motility and secretion. Extensions of the (ENS) within the mesentery facilitate intrinsic control of intestinal function by connecting the (Auerbach's) and (Meissner's) plexuses through mesenteric nerve fibers. The , located between the longitudinal and circular muscle layers, coordinates and gut tone, while the regulates and blood flow; these plexuses are linked bidirectionally via interconnecting neurons and glial cells that traverse the mesenteric tissue. Mesenteric nerves thus enable the ENS to operate semi-autonomously, integrating local sensory inputs with extrinsic autonomic signals for coordinated neural activity.01086-3) Sensory fibers embedded in the mesentery detect mechanical stimuli such as stretch and traction, contributing to perception. These unmyelinated C-fibers and thinly myelinated Aδ-fibers transmit signals via spinal and vagal pathways, where mesenteric distension or activates nociceptors to produce poorly localized, cramping . This mechanism underlies , in which mesenteric irritation projects sensations to somatic dermatomes, such as the midline or back, due to convergence of visceral and somatic afferents in the . Neurovascular bundles within the mesentery organize autonomic alongside arteries and veins, ensuring synchronized delivery of neural signals to support gut . These bundles, running to the superior mesenteric artery and its branches, allow sympathetic inhibition and parasympathetic excitation to modulate contraction in a region-specific manner, thereby facilitating peristaltic waves and segmental mixing. The spatial arrangement in the mesentery promotes efficient neurovascular coupling, where neural impulses adjust local flow to match demands. In pathophysiological contexts, the mesentery's neural components exhibit vulnerability and adaptability. During intestinal transplantation, extrinsic occurs as mesenteric s are severed, leading to temporary loss of autonomic regulation and impaired until partial reinnervation may develop over months. In (IBD), neural plasticity in the ENS manifests as structural and functional remodeling of mesenteric fibers and plexuses, including axonal and altered expression, which can perpetuate dysmotility and even after subsides. This plasticity highlights the mesentery's role in chronic gut disorders, where enteric and neurons adapt to inflammatory cues to influence disease progression.

Clinical significance

Surgical considerations

Surgical mobilization of the mesentery is a critical step in various abdominal procedures to facilitate access and resection of underlying organs. Kocherization, for instance, involves incising the peritoneal attachments along the lateral border of the to mobilize the second and third portions, allowing better exposure during or right . This technique minimizes traction injury to the superior mesenteric vessels while preserving the blood supply to the . Similarly, in procedures, ligation of the mesentery is performed at the vascular pedicle to ensure ; for example, in right hemicolectomy, the ileocolic and right colic vessels are divided after high ligation at their origins to achieve oncologic clearance. Vascular control during mesenteric requires meticulous handling to prevent ischemia, a common intraoperative challenge. Clamping of the or vein is often employed temporarily during reconstruction or resection, but prolonged occlusion can lead to bowel ischemia, with reported complication rates ranging from 5% to 10% in major vascular procedures. Surgeons mitigate this risk through techniques like staged clamping or the use of shunts, guided by intraoperative to assess flow. Management of mesenteric defects is essential in procedures addressing congenital or acquired anomalies. In Ladd's procedure for , the mesentery is widened by dividing congenital bands and closing any paraduodenal defects to prevent , thereby reducing long-term risks through reinforcement with sutures or if needed. This approach has significantly lowered recurrence rates to under 5% in pediatric cases. In oncologic surgery, mesenteric involvement necessitates extensive to achieve adequate staging and . For , central mesocolic excision during aims to harvest at least 12 lymph nodes from the mesentery for pathologic evaluation, correlating with improved 5-year survival rates up to approximately 85% in stage III . This technique emphasizes en bloc resection to avoid spillage and ensure complete removal of potential micrometastases. Recent advances in mesenteric have shifted toward minimally invasive laparoscopic approaches, which reduce postoperative adhesions and shorten recovery times. Post-2020 guidelines from the American Society of Colon and Rectal Surgeons recommend laparoscopic mesentery mobilization as the standard for elective colectomies, with adhesion-related complications dropping by 30-50% compared to open in randomized trials. These methods incorporate enhanced recovery protocols to further optimize outcomes.

Radiological evaluation

Computed tomography (CT) serves as the primary imaging modality for evaluating the mesentery, providing detailed visualization of its fan-shaped structure, vascular supply, and associated lymph nodes. With intravenous contrast enhancement, CT angiography facilitates precise mapping of mesenteric vessels, including the superior and inferior mesenteric arteries and veins, essential for assessing patency and anomalies. Mesenteric lymph nodes are typically resolved on CT, with a short-axis exceeding 5 mm indicating potential enlargement requiring further evaluation. Magnetic resonance imaging (MRI) offers complementary soft-tissue contrast to CT, particularly in assessing mesenteric fat and inflammation without ionizing radiation. Contrast-enhanced MRI sequences, such as T1- and T2-weighted imaging, delineate the mesenteric root and attachments, while MR angiography supports vessel evaluation similar to CT. The normal mesenteric appearance on MRI includes a hypointense fibrous root with surrounding hyperintense fat, aiding in the identification of subtle abnormalities. Ultrasound, including Doppler techniques, provides a non-invasive initial assessment of mesenteric vascular patency, detecting flow velocities and directions in the and vein. Color Doppler can reveal engorged or hyperemic vessels indicative of , such as in via the comb sign. However, ultrasound utility is limited by overlying bowel gas, which obscures deeper mesenteric structures, making it less reliable for comprehensive evaluation compared to cross-sectional imaging. Key radiological signs include the whirlpool sign on CT, characterized by swirling of mesenteric vessels and fat around the , diagnostic of . Engorged mesenteric vessels, appearing as dilated vasa recta, signal active inflammation in conditions like or ischemia. These signs enhance diagnostic accuracy for acute mesenteric disorders. Quantitative metrics, such as mesenteric fat thickness measured on CT or , serve as indicators for obesity-related risks, with values exceeding 10 mm correlating with . This measurement quantifies visceral adiposity within the mesentery, providing prognostic insights beyond body mass index. Advances in imaging post-2016 include 3D reconstructions from CT and MRI datasets, enabling detailed mesenteric root mapping and vascular modeling for preoperative planning. These volume-rendered techniques improve visualization of complex , such as vessel branching, with applications in oncologic and .

Pathological conditions

Mesenteric ischemia refers to a reduction in blood flow to the intestines supplied by the mesenteric arteries, leading to tissue damage. Acute mesenteric ischemia (AMI) arises suddenly from causes such as , , or nonocclusive hypoperfusion, presenting with severe out of proportion to physical findings, , , and bloody . It carries a high of 50-70%, primarily due to delayed and bowel . Chronic mesenteric ischemia (CMI), often resulting from , manifests as postprandial , weight loss, and fear of eating, with risk factors including , , , and . Unlike AMI, CMI progresses gradually and has a better prognosis with , though untreated cases can lead to acute events. Inflammatory conditions of the mesentery include mesenteric and mesenteric . Mesenteric , also known as sclerosing mesenteritis, is a rare idiopathic disorder characterized by chronic , fat , and of the mesenteric , often presenting with , , and . It affects middle-aged adults and may be associated with autoimmune diseases or prior surgery, with a benign course in most cases but potential for . Mesenteric , common in children, involves of mesenteric lymph nodes typically secondary to viral infections like , causing right lower quadrant pain, fever, and tenderness mimicking . It is self-limiting and resolves without specific treatment. Tumors of the mesentery are predominantly metastatic, with primary neoplasms being rare. Primary mesenteric tumors, such as , account for about 1% of all sarcomas and arise from mesenchymal tissues, presenting as abdominal masses with pain, obstruction, or weight loss. in the mesentery are exceptionally uncommon, with fewer than 50 reported cases, and exhibit a propensity for local recurrence despite low metastatic potential in well-differentiated forms. Metastatic involvement often occurs via lymph nodes from gastrointestinal or ovarian primaries, complicating staging; the 2016 reclassification of the mesentery as a distinct organ has refined TNM staging by emphasizing its continuous structure in assessing tumor and nodal spread. Congenital anomalies predisposing to mesenteric include defects leading to internal hernias and . Internal hernias through congenital mesenteric defects allow bowel loops to protrude, causing obstruction or strangulation, with an overall incidence of 0.2-0.9% in the general population, though transmesenteric types represent 5-10% of cases. These are often asymptomatic until adulthood but can present acutely with severe pain and . Small bowel , frequently associated with mesenteric defects or malrotation, has an annual incidence of 1.7-5.7 per 100,000 adults in Western countries and may result in ischemia if untreated. Recent reports highlight emerging pathological associations, including post-COVID-19 mesenteric thrombosis and fibrosis in systemic sclerosis (scleroderma). Studies from 2020-2023 document cases of superior mesenteric artery or venous thrombosis in COVID-19 patients, attributed to hypercoagulability and endothelial dysfunction, often presenting as acute ischemia even in mild infections. In scleroderma, mesenteric fibrosis manifests as sclerosing mesenteritis-like changes, leading to inflammation and scarring that can cause bowel dysmotility or ischemia, particularly in limited cutaneous forms. These fibrotic alterations contribute to gastrointestinal complications in up to 50% of scleroderma patients.

History

Etymology

The term "mesentery" originates from the word mesenterion, a compound of mesos ("middle," from the medhyo-) and enteron ("intestine," from enter-, related to "internal"). This nomenclature reflects its anatomical position as a central supportive for the intestines. Early references to the appear in Aristotle's Historia Animalium (4th century BCE), where he described the "mesenterium" as a broad, membranous, and fatty entity uniting the intestines and attached midway to the . Although attributed to early anatomists like Herophilus (c. 335–280 BCE), who pioneered systematic human dissections in and advanced intestinal terminology, the precise coining of mesenterion aligns with Hellenistic Greek medical rather than a single inventor. The term was adopted into Latin as mesenterium by the Roman physician (c. 129–c. 216 CE), who integrated it into his comprehensive anatomical writings, portraying the mesentery as a vascular hub supporting intestinal nutrition and distinguishing it from adjacent peritoneal folds. This Latin form influenced medieval and anatomy, entering English as "mesenterie" by the early via medical texts. In the 16th century, refined these descriptions in De humani corporis fabrica (1543), emphasizing the mesentery's continuity and correcting Galenic inaccuracies about its attachments, thereby standardizing its role in modern nomenclature. A significant terminological shift occurred in 2016 when the mesentery was reclassified as a distinct organ based on evidence of its continuous, membranous structure, prompting updates in anatomical and surgical glossaries to reflect its systemic integrity rather than fragmented parts. Related terms include "mesocolon," denoting the colonic portion of the mesentery, with its developmental framework outlined by Václav Treitz in 1857 as part of peritoneal fold analyses. The omentum, by contrast, refers to separate derivates like the (a descending peritoneal ) and (), historically differentiated from the mesentery to avoid conflation in visceral attachments. Linguistic variations persist, such as the French mésentère (from Latin mesenterium), while contemporary usage in reports employs "mesenteric" for descriptors like "mesenteric fat stranding" or "misty mesentery" in imaging diagnostics.

Key discoveries

The earliest descriptions of the mesentery date back to , where (c. 335–280 BC) and (c. 304–250 BC) identified it as a supportive structure containing mesenteric veins filled with a clear or milky fluid, interpreted as , which provided vascular nourishment to the intestines. In the 2nd century AD, of Pergamum expanded on these observations, describing the mesenteric lymph nodes as glandular structures involved in processing nutrients and contributing to the body's vascular network, though his views were influenced by humoral theory. During the , revolutionized anatomical understanding through direct human dissections, publishing detailed illustrations and descriptions of the mesentery in his 1543 work De Humani Corporis Fabrica, portraying it as a double-layered peritoneal fold anchoring the to the posterior and correcting several Galenic inaccuracies regarding its extent and attachments. In 1622, Italian physician Gaspare Aselli discovered the lacteals—milky lymphatic vessels in the mesentery of a well-fed —demonstrating their role in transporting from the intestines, marking a key advancement in understanding mesenteric lymphatics and lipid absorption. In the 1660s, Marcello Malpighi advanced microscopic anatomy by examining frog mesentery, revealing the capillary network that connects arteries and veins, thus providing early histological insights into the mesentery's and contributions to nutrient exchange and absorption. The 19th century saw significant progress in understanding mesenteric fixation and lymphatics. In 1857, Wenzel Treitz described the suspensory muscle of the duodenum (ligament of Treitz), a fibromuscular band that stabilizes the duodenojejunal junction and contributes to the overall fixation of the root of the small bowel mesentery, influencing intestinal positioning and preventing excessive mobility. Concurrently, Marie Philibert Constant Sappey pioneered lymphangiology through mercury injection techniques, mapping the distribution of lymphatic vessels within the mesentery in works like his 1885 Traité d'anatomie descriptive, which delineated pathways from intestinal lacteals to mesenteric nodes and emphasized their segmental organization. In the , radiological advancements illuminated the mesentery's dynamic functions. The introduction of barium contrast studies, such as small bowel follow-through, enabled visualization of intestinal loops and their mesenteric attachments, demonstrating the organ's role in facilitating bowel mobility while maintaining vascular integrity during . By the 1940s, clinical recognition of mesenteric ischemia emerged, with reports like those by (1940) linking mesenteric venous occlusion to acute , underscoring the mesentery's vulnerability to vascular compromise and its centrality in abdominal emergencies. Modern insights culminated in 2016 with J. Calvin Coffey's systematic cadaveric dissections, published in The Lancet Gastroenterology & Hepatology, which redefined the mesentery as a single, continuous, helically structured organ enveloping all intraperitoneal digestive structures, overturning the longstanding fragmented model and integrating it into official anatomical nomenclature like . In the 2020s, emerging research has connected the mesentery to the and chronic inflammation, particularly in , where dysbiotic in mesenteric promote lymphatic remodeling and immune activation, as evidenced by studies identifying microbial signatures in altered mesenteric fat that exacerbate intestinal pathology.

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