Historical development of mesenteric anatomy provides a universally applicable anatomic paradigm for complete/total mesocolic excision

Abstract

Although total mesorectal excision has now become the 'gold standard' for the surgical management of rectal cancer, this is not so for colon cancer. Recent data, provided by Hohenberger and West et al. and others, have demonstrated excellent oncological outcomes when mesenterectomy is extensive (as is implicit in the concept of a 'high tie') and the mesenteric package not violated. Such studies highlight the importance of understanding the basics of the mesenteric organ (including the small intestinal mesentery, mesocolon, mesosigmoid and mesorectum) and of abiding to principles of planar surgery. In this review, we first offer classic descriptions of the mesocolon and then detail contemporary thinking. In so doing, we provide an anatomical basis for safe and effective complete mesocolic excision (CME) in the management of colon cancer. Finally we list opportunities associated with the new anatomical paradigm, demonstrating benefits across multiple disciplines. Perhaps most importantly, we feel that a crystallized view of mesenteric anatomy will overcome factors that have hindered the general uptake of CME.

Keywords: Toldt’s fascia; complete mesocolic excision; mesenteric excision; mesocolon.

Figure 1.

Left: the mesocolic attachment to the posterior abdominal wall is demonstrated as depicted by Carl Toldt, with the arrows indicating the extent of the attachment. Right: the mesocolic attachment as depicted by Frederick Treves, with the arrows indicating the extent of the attachment.