Proximal segmentation of the dorsal mesogastrium reveals new anatomical implications for laparoscopic surgery

Daxing Xie, Chun Gao, An Lu, Liang Liu, Chaoran Yu, Junbo Hu, Jianping Gong, Daxing Xie, Chun Gao, An Lu, Liang Liu, Chaoran Yu, Junbo Hu, Jianping Gong

Abstract

Generally, the gold standard of radical surgery for gastrointestinal (GI) tumors is en bloc resection of primary lesions and their related tissues. For gastric cancer, the ideal surgical treatment should be D2 radical gastrectomy plus complete mesogastrium excision. Complete mesogastrium excision is rarely done or mentioned since little is known about the mesogastrium and its presence is still with controversy. Topographically, the "mesogastrium" refers to a peri-gastric structure composed of "fascia propria", enveloping lymph nodes, blood vessels and adipose tissues, which by connecting to the stomach, suspends from the posterior abdominal wall. In this study, by employing video laparoscopy, a number of proximal segments of dorsal mesogastrium were found being extensively scattered around the pancreas. The structure of the mesogastrium was further identified intraoperatively and then confirmed both grossly and histologically after the operation. Our results demonstrated the existence of mesogastrium (gastric mesentery) and its architecture. We suggest for the first time a "Table model" to describe the relationship between the stomach and gastric mesenteries enveloped by fascia propria, which might provide an improvement in the surgical methods for excision of gastric cancer.

Figures

Figure 1. Left gastroepiploic mesentery and right…
Figure 1. Left gastroepiploic mesentery and right gastroepiploic mesentery.
Pictures of left gastroepiploic mesentery were photographed under laparoscopy before (a) and after dissection (b) during operation. The mesenteric surface could be observed. Left gastroepiploic mesentery was mounted on the stand before fixation (c) and photographed under the microscopy (d, HE 100 x). There exists fascia propria outside the adipose tissue of the mesentery. (e–h) shows the pictures of right gastroepiploic mesentery.
Figure 2. Left gastric mesentery and right…
Figure 2. Left gastric mesentery and right gastric mesentery.
Pictures of left gastric mesentery (a–d) and right gastric mesentery (e–h) were photographed similarly with Fig. 1. We fortunately observed the co-existence of right gastric artery and fascia propria (h).
Figure 3. Posterior gastric mesentery and short…
Figure 3. Posterior gastric mesentery and short gastric mesentery.
(a–d) show posterior gastric mesentery. Two forceps were used to lift up the mesentery in (c), and we were able to observe the same structure of fascia propria in (d). (e) indicates short gastric mesentery.
Figure 4. A proposed “Table Model”.
Figure 4. A proposed “Table Model”.
The difference in the existence of mesothelial cells between serosa (a) and fascia propria (b). (c) shows the “Table Model” we put forward, and (d) indicates “Tri-junction” which is the access point of “D2 plus complete mesogastrium excision” procedure. ((c,d) were drew by Chaoran Yu).
Figure 5. Development of stomach and mesogastrium.
Figure 5. Development of stomach and mesogastrium.
In (a), the stomach was still a tubular “proto-stomach” and its mesentery was continuous. In (b,c), the stomach began to expand and twist towards the left, and gastric mesentery was split into six sections. (d) indicates the process of clustering and coiling of gastric mesentery, and the mesentery were fused with the omentum as the last step.

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