posted on 2022-11-21, 15:15authored byKevin G. Byrnes
Introduction
Recent advances in our understanding of mesenteric anatomy clarify its
shape distal to the duodenojejunal flexure. Investigation of mesenteric anatomy has
raised several questions about its overall shape. These include the shape of the
mesentery proximal to the duodenum, its anatomical relationship with fascia at this
level, the distribution of the peritoneal reflection, and how the overall structure of the
mesentery arises from its embryological forerunner. This thesis aimed to characterise
embryological development and anatomical form of the abdominal mesentery in
humans.
Methods
An appraisal of mesenteric development was performed. As part of this
appraisal, three-dimensional models and dynamic models of the mesentery at
consecutive stages of development were generated. Next, a dissection was performed using cadavers to comprehensively investigate mesenteric shape in adulthood. This
dissection applied a mesenteric-based approach that is commonly used in oncologic
surgery rather than a peritoneal-based one. A comprehensive appraisal of the cross
sectional appearance of mesenteric anatomy and reconstruction of its in situ
anatomical shape was performed. To overcome the innate challenges in
communicating the mesenteric model of abdominal anatomy, digital sculpting
techniques and three-dimensional printing were used to generate virtual and physical
models of the mesentery.
Results
The mesentery (in its ex vivo and in situ state) is continuous from
oesophagogastric junction to mesorectal level. In most cases, abdominal digestive
organs are connected to the mesentery, rather than the abdominal wall. Moreover, the
peritoneal landscape is explained by the mesenteric landscape. The human mesentery
remains a continuous structure throughout development and does not become
fragmented. The mesentery develops according to a set developmental program during which a foundation shape is acquired (primary mesenteric organogenesis) and
undergoes subsequent alterations at a sub-regional level (secondary mesenteric
organogenesis). Hence, the abdomen is organised along mesenteric lines, into two
principal compartments: the mesenteric and non-mesenteric domain. This system of
organisation is referred to as the mesenteric model of abdominal anatomy. Digital
sculpting and three-dimensional printing were used to communicate results relating
to mesenteric anatomy and development.
Conclusions
The findings reported in this thesis identify a new level of organisation of
abdominal contents that may reconcile embryological, anatomical and surgical
approaches to the abdomen. The classic model of mesenteric anatomy, which is
complex and fragmented, may be replaced with a mesenteric-based model in which
digestive organs are organised around a single mesentery that attaches to the posterior
abdominal wall. Limitations were present in each arm of this study. For example, the
anatomical study required excision of the mesentery and so its shape was altered. The embryological study required interpolation between stages. Lastly, some structures
were challenging to identify during cross-sections analysis. However, collectively,
findings from embryological, foetal, anatomical and cross-sectional analysis of the
mesentery provide an opportunity to propose a definition for the mesentery: the organ
that, in the embryo, supports development of all abdominal digestive organs, and
following birth, maintains all abdominal digestive organs in position and in
continuity with other systems. This system, which may be more broadly applied to
mammalian species in general, requires further investigation.