International Journal of Colorectal Disease

, Volume 31, Issue 2, pp 377–384 | Cite as

Anatomy of the transverse colon revisited with respect to complete mesocolic excision and possible pathways of aberrant lymphatic tumor spread

  • Sigmar Stelzner
  • Werner Hohenberger
  • Klaus Weber
  • Nicholas P. West
  • Helmut Witzigmann
  • Thilo Wedel
Original Article



Although lymph node metastases to pancreatic and gastroepiploic lymph node stations in transverse colon cancer have been described, the mode of lymphatic spread in this area remains unclear. This study was undertaken to describe possible pathways of aberrant lymphatic spread in the complex anatomic area of the proximal superior mesenteric artery and vein, the greater omentum, and the lower pancreatic border.


Abdominal specimens obtained from four cadaveric donors were dissected according to the principles of complete mesocolic excision. The vascular architecture of the transverse colon was scrutinized in search of possible pathways of lymphatic spread to the pancreatic and gastroepiploic lymph nodes.


Vascular connections between the transverse colon and the greater omentum at the level of both the hepatic and the splenic flexures could be identified. In addition, small vessels running from the transverse mesocolon to the lower pancreatic border in the area between the middle colic artery and the inferior mesenteric vein were demonstrated. Moreover, venous tributaries to the gastrocolic trunk could be exposed to highlight its surgical importance as a guiding structure for complete mesocolic excision.


The technical feasibility to clearly separate embryologic compartments by predefined tissue planes in complete mesocolic excision was confirmed. However, the vicinity of all three endodermal intestinal segments (foregut, midgut, and hindgut) obviously gives way to vascular connections that might serve as potential pathways for lymphatic metastatic spread of transverse colon cancer.


Complete mesocolic excision Transverse mesocolon Gastrocolic trunk Superior mesenteric vein Superior mesenteric artery Anatomy 



The authors thank Stefanie Gundlach and Merle Winkler for their support in the anatomical dissections and photographing of the macroscopic specimens, Bettina Facompré for her support in the histologic work-up of the microscopic specimens, and Clemens Franke for his assistance in the processing of the figures.

Compliance with ethical standards


NPW is supported by Yorkshire Cancer Research, UK and the Pathological Society of Great Britain and Ireland. All authors declare no conflicts of interest.


  1. 1.
    Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S (2009) Standardized surgery for colonic cancer: complete mesocolic excision (CME) and central ligation—technical notes and outcome. Colorectal Dis 11:354–364CrossRefPubMedGoogle Scholar
  2. 2.
    Søndenaa K, Quirke P, Hohenberger W, Sugihara K, Kobayashi H, Kessler H, Brown G, Tudyka V, D’Hoore A, Kennedy RH, West NP, Kim SH, Heald R, Storli KE, Nesbakken A, Moran B (2014) The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery: proceedings of a consensus conference. Int J Colorectal Dis 29:419–428CrossRefPubMedGoogle Scholar
  3. 3.
    Heald RJ (1988) The ‘Holy Plane’ of rectal surgery. J R Soc Med 81:503–508PubMedCentralPubMedGoogle Scholar
  4. 4.
    Heald RJ, Moran BJ (1998) Embryology and anatomy of the rectum. Semin Surg Oncol 15:66–71CrossRefPubMedGoogle Scholar
  5. 5.
    Stelzner F, Friedrichs N, von Mallek D (2009) Homing areas, enveloping fascias, and lymphatic suction vessels confine cancer growth. New MRI, CT, and clinical investigations of colorectal carcinoma. Chirurg 80:216–222CrossRefGoogle Scholar
  6. 6.
    Jamieson JK, Dobson JF (1909) The lymphatics of the colon: with special reference to the operative treatment of cancer of the colon. Ann Surg 50:1077–1090PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    West NP, Hohenberger W, Weber K, Perrakis A, Finan PJ, Quirke P (2010) Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol 28:272–278CrossRefPubMedGoogle Scholar
  8. 8.
    West NP, Kobayashi H, Takahashi K, Perrakis A, Weber K, Hohenberger W, Sugihara K, Quirke P (2012) Understanding optimal colonic cancer surgery: comparison of Japanese D3 resection and European complete mesocolic excision with central vascular ligation. J Clin Oncol 30:1763–1769CrossRefPubMedGoogle Scholar
  9. 9.
    Kobayashi H, West NP, Takahashi K, Perrakis A, Weber K, Hohenberger W, Quirke P, Sugihara K (2014) Quality of surgery for stage III colon cancer: comparison between England, Germany, and Japan. Ann Surg Oncol 21(Suppl 3):S398–S404CrossRefPubMedGoogle Scholar
  10. 10.
    Bertelsen CA, Neuenschwander AU, Jansen JE, Wilhelmsen M, Kirkegaard-Klitbo A, Tenma JR, Bols B, Ingeholm P, Rasmussen LA, Jepsen LV, Iversen ER, Kristensen B, Gögenur I, Danish Colorectal Cancer Group (2015) Disease-free survival after complete mesocolic excision with conventional colon cancer surgery: a retrospective, population-based study. Lancet Oncol 16:161–168CrossRefPubMedGoogle Scholar
  11. 11.
    Kim WK, Kim H, Ahn DH, Kim MH, Park HW (2003) Timetable for intestinal rotation in staged human embryos and fetuses. Birth Defects Res A Clin Mol Teratol 67:941–945CrossRefPubMedGoogle Scholar
  12. 12.
    Culligan K, Coffey JC, Kiran RP, Kalady M, Lavery IC, Remzi FH (2012) The mesocolon: a prospective observational study. Colorectal Dis 14:421–430CrossRefPubMedGoogle Scholar
  13. 13.
    Açar Hİ, Cömert A, Avşar A, Çelik S, Kuzu MA (2014) Dynamic article: surgical anatomical planes for complete mesocolic excision and applied vascular anatomy of the right colon. Dis Colon Rectum 57:1169–1175CrossRefPubMedGoogle Scholar
  14. 14.
    Gillot C, Hureau J, Aaron C, Martini R, Michels NA (1964) The superior mesenteric vein, an anatomic and surgical study of eighty-one subjects. J Int Coll Surg 41:339–369PubMedGoogle Scholar
  15. 15.
    Toyota S, Ohta H, Anazawa S (1995) Rationale for extent of lymph node dissection for right colon cancer. Dis Colon Rectum 38:705–711CrossRefPubMedGoogle Scholar
  16. 16.
    Hasegawa S, Kawamura J, Nagayama S, Nomura A, Kondo K, Sakai Y (2007) Medially approached radical lymph node dissection along the surgical trunk for advanced right-sided colon cancers. Surg Endosc 21:1657CrossRefPubMedGoogle Scholar
  17. 17.
    Sakaguchi T, Suzuki S, Morita Y, Oishi K, Suzuki A, Fukumoto K, Inaba K, Kamiya K, Ota M, Setoguchi T, Takehara Y, Nasu H, Nakamura S, Konno H (2010) Analysis of anatomic variants of mesenteric veins by 3-dimensional portography using multidetector-row computed tomography. Am J Surg 200:15–22CrossRefPubMedGoogle Scholar
  18. 18.
    Yamaguchi S, Kuroyanagi H, Milsom JW, Sim R, Shimada H (2002) Venous anatomy of the right colon. Precise structure of the major veins and gastrocolic trunk in 58 cadavers. Dis Colon Rectum 45:1337–1340CrossRefPubMedGoogle Scholar
  19. 19.
    Jin G, Tuo H, Sugiyama M, Oki A, Abe N, Mori T, Masaki T, Atomi Y (2006) Anatomic study of the superior right colonic vein: its relevance to pancreatic and colonic surgery. Am J Surg 191:100–103CrossRefPubMedGoogle Scholar
  20. 20.
    Ignjatovic D, Spasojevic M, Stimec B (2010) Can the gastrocolic trunk of Henle serve as an anatomical landmark in laparoscopic right colectomy? A postmortem anatomical study. Am J Surg 199:249–254CrossRefPubMedGoogle Scholar
  21. 21.
    Henle FG (1868) Handbuch der systematischen Anatomie des Menschen. Vieweg, Braunschweig, p 371Google Scholar
  22. 22.
    Ignjatovic D, Stimec B, Finjord T, Bergamaschi R (2004) Venous anatomy of the right colon: three-dimensional topographic mapping of the gastrocolic trunk of Henle. Tech Coloproctol 8:19–21CrossRefPubMedGoogle Scholar
  23. 23.
    Voiglio EJ, Boutillier du Retail C, Neidhardt JPH, Caillot JL, Barale F, Mertens P (1998) Gastrocolic vein. Definition and report of two cases of avulsion. Surg Radiol Anat 20:197–201PubMedGoogle Scholar
  24. 24.
    Lange JF, Koppert S, van Eyck CHJ, Kazemier G, Kleinrensink GJ, Godschalk M (2000) The gastrocolic trunk of Henle in pancreatic surgery: an anatomo-clinical study. J Hepatobiliary Pancreat Surg 7:401–403CrossRefPubMedGoogle Scholar
  25. 25.
    Steward JA, Rankin FW (1933) Blood supply of the large intestine: its surgical considerations. Arch Surg 26:843–891CrossRefGoogle Scholar
  26. 26.
    VanDamme JP, Bonte J (1990) Vascular anatomy in abdominal surgery. Georg Thieme, Stuttgart, p 53Google Scholar
  27. 27.
    Yada H, Sawai K, Taniguchi H, Hoshima M, Katoh M, Takahashi T (1997) Analysis of vascular anatomy and lymph node metastases warrants radical segmental bowel resection for colon cancer. World J Surg 21:109–115CrossRefPubMedGoogle Scholar
  28. 28.
    Benedix F, Kube R, Meyer F, Schmidt U, Gastinger I, Lippert H, Colon/Rectum Carcinomas (Primary Tumor) Study Group (2010) Comparison of 17,641 patients with right- and left-sided colon cancer: differences in epidemiology, perioperative course, histology, and survival. Dis Colon Rectum 53:57–64CrossRefPubMedGoogle Scholar
  29. 29.
    Meguid RA, Slidell BM, Wolfgang CL, Chang DC, Ahuja N (2008) Is there a difference in survival between right- versus left-sided colon cancers? Ann Surg Oncol 15:2388–2394PubMedCentralCrossRefPubMedGoogle Scholar
  30. 30.
    West NP, Morris EJ, Rotimi O, Cairns A, Finan PJ, Quirke P (2008) Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study. Lancet Oncol 9:857–865CrossRefPubMedGoogle Scholar
  31. 31.
    Perrakis A, Weber K, Merkel S, Matzel K, Agaimy A, Gebbert C, Hohenberger W (2014) Lymph node metastasis of carcinomas of transverse colon including flexures. Consideration of the extramesocolic lymph node stations. Int J Colorectal Dis 29:1223–1229CrossRefPubMedGoogle Scholar
  32. 32.
    Bertelsen CA, Bols B, Ingholm P, Jansen JE, Jepsen LV, Kristensen B, Neuenschwander AU, Gögenur I (2014) Lymph node metastases in the gastrocolic ligament in patients with colon cancer. Dis Colon Rectum 57:839–845CrossRefPubMedGoogle Scholar
  33. 33.
    Hirono S, Tani M, Kawai M, Okada K, Miyazawa M, Shimizu A, Uchiyama K, Yamaue H (2012) Identification of the lymphatic drainage pathways from the pancreatic head guided by indocyanine green fluorescence imaging during pancreaticoduodenectomy. Dig Surg 29:132–139CrossRefPubMedGoogle Scholar
  34. 34.
    Morikawa E, Yasutomi M, Shindou K, Matsuda T, Mori N, Hida J, Kubo R, Kitaoka M, Nakamura M, Fujimoto K, Inofusa H, Hatta M, Izumoto G (1994) Distribution of metastatic lymph nodes in colorectal cancer by the modified clearing method. Dis Colon Rectum 37:219–223CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Sigmar Stelzner
    • 1
  • Werner Hohenberger
    • 2
  • Klaus Weber
    • 2
  • Nicholas P. West
    • 3
  • Helmut Witzigmann
    • 1
  • Thilo Wedel
    • 4
  1. 1.Department of General and Visceral SurgeryDresden-Friedrichstadt General HospitalDresdenGermany
  2. 2.Department of Surgery, University Hospital ErlangenFriedrich-Alexander University Erlangen-NürnbergErlangenGermany
  3. 3.Pathology and Tumour Biology, Leeds Institute of Cancer and PathologyUniversity of LeedsLeedsUK
  4. 4.Department of Anatomy, Center of Clinical AnatomyChristian Albrechts University of KielKielGermany

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