Ligament of TreitzThe ligament of Treitz is a popular eponym that is used for the suspensory muscle of the duodenum. The ligament of Treitz is actually made up of two separate structures according to the description given in 1853 by Dr. Wenzel Treitz (an Austrian physician). While this is a relatively small structure, it has clinical implications in surgical procedures and in rare cases of small bowel obstruction. It is one of several so-called “ligaments” within the abdominal cavity that support the intraabdominal organs.
By formal definition, a ligament is a fibrous connective tissue that connects bone to bone. In the case of the gastrointestinal tract, these ligaments are folds of peritoneum that connect the viscera to adjacent viscera or to the anterior or posterior abdominal wall. While the primary goal of this article is to review the anatomy and function of the suspensory ligament of the duodenum, it will also briefly mention a few other intraabdominal ‘ligaments’ as well.
|Anatomy||Made up of two parts:
- The suspensory muscle of the duodenum
- Hilfsmuskel (accessory muscle)
|Suspensory muscle of the duodenum||Originates from the duodenojejunal flexure
Inserts at the celiac artery
Contains smooth muscle fibers
The lower half of the complex
|Hilfsmukel (accessory muscle)||Originates from the right crus of the diaphragm
Inserts at the celiac artery
Contains skeletal muscle fibers
The upper half of the complex
|Function||A landmark for the duodenojejunal flexure
Marks transition from foregut to the midgut
Helps gastric motility
|Clinical significance||Guide for malrotation syndromes
A rare cause of superior mesenteric artery syndrome
- Other ligaments in the gastrointestinal tract
- Clinical significance
The Hilfsmukel component of the ligament of Treitz (the first part of the ligament) extends from the right crus of the diaphragm and wraps around the esophageal hiatus. It continues down to the celiac artery where it joins the connective tissue around the area. Some anatomists refer to this as the upper part of the ligament.
The second part of the ligament arises as a connective tissue band from the para-aortic connective tissue around the celiac artery. It travels between the pancreas and the splenic vein, as well as the left renal vein. It becomes a triangular structure that inserts at the left lateral aspect of the end of the fourth segment of the duodenum - the duodenojejunal flexure.
Wenzel Treitz described two structures that make up the ligament of Treitz. The first part of the structure arises from the right crus of the diaphragm and loops around the esophagus before inserting as a connective tissue band at the celiac trunk (artery or axis). It is sometimes referred to as Hilfsmukel, which is German for accessory muscle. The Hilfsmukel is roughly the shape of an elongated triangle that is widest at its origin and narrowest at its insertion. Histological assessment of the band reveals that Hilfsmukel is made up of striated skeletal muscle fibers that come from the diaphragmatic end of the muscle.
The second part of the ligament of Treitz is a thin muscular band originating from the celiac trunk as a connective tissue band. It passes between the splenic vein, left renal vein and the pancreas to insert at the duodenojejunal flexure (DJ flexure) and part of the inferior aspect of the transverse duodenum. This segment is referred to as the suspensory muscle of the duodenum. It is a very thin muscle and is roughly triangular at its origin but tapers and becomes narrower toward its fibrous insertion. Histologically, the suspensory muscle of the duodenum is comprised of smooth muscle fibers arising from the enteric end of the muscle.
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Since the ligament of Treitz was discovered, there has been significant discord as to the composition of the suspensory ligament. Some anatomists were only able to identify smooth muscle fibers. Others, however, found just a simple fold of peritoneum that occasionally contained both skeletal and smooth muscle components. One reason for the discord is that there seems to be some degree of variability in the morphology of the structure. Different parts of the ligament of Treitz may either rudimentary or absent.
However, most modern anatomy texts continue to accept Treitz’s initial description of a mixed muscle. This article will continue to honor that convention as well until further definitive evidence is available.
Some anatomists hypothesized that since the ligament of Treitz is a muscle, it should be able to stabilize the duodenojejunal flexure and prevent it from being displaced. However, given the thin nature of the muscle, it has been deemed unlikely to effectively carry out this function.
It does, however, serve as a landmark for surgeons to identify the duodenojejunal flexure. This is the point of transition between the foregut and the midgut. This becomes clinically relevant when discussing gastrointestinal problems such as gastrointestinal bleeding. Bleeding within the gastrointestinal tract that occurs above the level of the ligament of Treitz is called upper gastrointestinal bleeding. However, if bleeding occurs below the level of this ligament, then it is referred to as lower gastrointestinal bleeding.
Other ligaments in the gastrointestinal tract
There are numerous other intra-abdominal ligaments that help to support the abdominal organs. They also help to divide the intra-abdominal cavity into regions and quadrants. While the majority of these peritoneal folds are associated with the liver (and discussed in its own article), there are a few others that are worth mentioning here.
The greater omentum (as well as the lesser omentum) has its origins from the stomach. The greater omentum originates from the greater curvature of the stomach (as opposed to the lesser omentum arising from the lesser gastric curvature). The structure can be described as a double-layered sheet, with the posterior flap inserting along the transverse colon. The segment of the greater omentum that inserts at the transverse colon is known as the gastrocolic ligament or gastrocolic omentum. It forms the anterior boundary of the omental bursa (the lesser sac of the abdomen).
Gastrosplenic (gastrolienal) ligament
A portion of the greater omentum also leaves the greater curvature of the stomach and attaches to the spleen. This is known as the gastrosplenic or gastrolienal ligament. The two layers of the gastrosplenic ligament divide at the hilum of the spleen and envelopes the organ. The layers subsequently re-join to form the lienorenal (splenorenal) ligament, which attaches the spleen to the left kidney. Learn more about the greater and lesser omenta anatomy here to understand everything about these two gastrointestinal ligaments.
The primary dorsal mesentery is an embryonic structure that contributes to the formation of the crura of the diaphragm, the gastrophrenic and gastrocolic ligaments, and the greater omentum. It also plays an important role in the formation of the ligament of Treitz as well. Cells arising from the pleuroperitoneal membrane (one of four embryonic structures that contribute to the formation of the diaphragm) and the retropancreatic fusion fascia (resides between the retroperitoneal organs and the posterior surface of the pancreas) may also contribute to the formation of the ligament of Treitz.
Read more about the development of the gastrointestinal structures here.
The ligament of Treitz is a surgical landmark structure. It divides the gastrointestinal tract into upper and lower portions (foregut and midgut); additionally, it serves as a guide for clinicians who are investigating possible malrotation syndromes observed in pediatric cases of recurrent vomiting without any other obvious cause. The ligament of Treitz is also preserved during Whipple’s Bypass procedures (done to relieve biliary and gastroenteric obstruction in patients with cancer in the head of the pancreas) and utilized during the jejunogastric anastomosis.
The ligament of Treitz has been implicated as a very rare cause of superior mesenteric artery syndrome. Usually, this disorder is characterized by compression of the third part of the duodenum between the superior mesenteric artery and the abdominal aorta. This phenomenon leads to small bowel obstruction, which is characterized by early satiety, vomiting, and obstipation (no passage of feces or gas). In the case of a short and hypertrophic ligament of Treitz, the duodenum can be pulled further into the aortomesenteric angle leading to increased risk of compression and subsequent obstruction. The problem can be rectified by ligating the problematic ligament of Treitz. However, this is a very rare occurrence and should not be entertained as the most likely cause of small bowel obstruction.