The Mesentery - Past, Present and Future

John Calvin Coffey, BSc, PhD, FRCS

Recent advances in our understanding of the mesenteric organ have significant implications. We now understand that all abdominal digestive organs are directly connected to, and linked by, a single mesentery. This means the adult abdomen is organized into two distinct compartments, the mesenteric and non-mesenteric domains. This is the Mesenteric Model of abdominal anatomy.

This issue is an explanation of why recent advances are important to the colorectal surgeon. In summary they mean that all colorectal surgeries can be simplified to accessing the plane between the two domains (by peritonotomy), then detaching domains by mesofascial separation. The following issue is also important to the general surgeon, and indeed to all visceral surgeons. This is because the principles described apply to all abdominal digestive organs, and not just to the colon, rectum, and anus. Resection of any abdominal digestive organ is thus greatly simplified, if one follows the Mesenteric Model of abdominal anatomy.

The issue commences with an overview of how our understanding of the mesentery has changed and how this has led to significant advances in clinical practice. The issue concludes with a summary of future directions. In between these articles the issue is divided into three sections. The first section explains the development and structure of the mesentery in light of recent advances. The second section is a technical section that explains, in detail, how to operate on the mesentery during complete mesocolic excision, and during robotic colon and rectal surgery. The third section explores emerging topics related to the mesentery. These include the role of the mesentery in Crohn's disease, mesenteric mapping with indocyanine green and other markers, radiological appraisal of the mesentery, and the often confusing topic of mesenteric panniculitis.

The aim of the first section is to provide the anatomical basis for the surgical section that follows. To this end Byrnes et al provide a state-of-the-art review of our current understanding of the development of the mesentery. This leads to an article on the structure of the mesentery in the adult, by Mr. John Bunni. The latter explains how anatomy informs surgical approaches in the excision of colon and rectal cancer.

The second section builds on the anatomical foundation of the first and explains how properties of the mesentery provide the technical basis for techniques in colorectal surgery. Peirce and co-author describe how colorectal surgeons approach the mesentery during robotic colonic surgery. Crolla and co-authors provide a similar technical exposition on how to manage the mesentery during robotic rectal surgery. Danilo Miscovics and co-author summarise key points regarding surgery on the mesentery during complete mesocolic excision of the colon for colon cancer. Joep Knol explains how to approach the mesentery from a transanal perspective. Increasingly, transanal approaches are being adopted as part of the standard armamentarium of the colorectal surgeon.

In the third part of the issue, Manish Chand and co-author describe how mesenteric lymphatics can be mapped. They explain how this technique provides new opportunities for the cancer surgeon. Regan and co-authors explain how the mesentery can be approached from a radiological perspective. This is a nascent field that promises considerable opportunities in the near future. Becker and colleagues discuss the cellular basis of findings in the mesentery in terminal ileitis. This article explores the question as to whether the mesentery exerts a net pathobiological or protective role in Crohn's disease. Antonino Spinelli and co-author explain how surgery may alter mesenteric inputs by either excision of adjoining mesentery or by excluding the mesentery from an intestinal anastomosis. They discuss the paradox associated with stricturoplasty, a procedure associated with excellent outcomes in select patients, but one in which the mesentery is retained. Finally, Ehrenpreis and colleagues discuss the important condition of mesenteric panniculitis. They resolve several issues that have clouded our understanding of this condition in a clear-cut state-of-the-art review of the topic.

The issue finishes with a summary of possible future directions. Recent advances in our understanding of the mesentery and the anatomical foundation of the abdomen are a reminder of the fact that one must always challenge dogma. The erroneous idea that there are multiple mesenteries had its origin early in the 18th century anatomical descriptions and persisted in mainstream literature until 2012. Routine reappraisal of that dogma would have exposed the flaws of the model described. In turn, this would have led to investigation that likely would have uncovered the correct anatomy earlier, and thus greatly accelerated the science and the surgery of the abdomen in general. So, if there is a single major message to be had, it is always question dogma.

Publication History

Article published online:
08 March 2022