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There is nothing new under the sun.
Ecclesiastes 1:4-11
To Dee
and
Preface ix
How to access three-dimensional models using QR codes xi
Acknowledgments xiii
PARt 1 1
1 History 3
J. Calvin Coffey and Nicola O’Riordan
2 Mesenteric and peritoneal anatomy 11
J. Calvin Coffey, Peter Dockery, Brendan J. Moran, and Bill Heald
3 Embryologic development of the mesentery, peritoneal reflection, and Toldt’s fascia 41
J. Calvin Coffey, Rishabh Sehgal, and Joep Knol
4 Histology of the mesentery 47
J. Calvin Coffey, Miranda Kiernan, and Leon G. Walsh
5 Toldt’s fascia 57
J. Calvin Coffey and Ravi Kiran
6 Mesenteric physiology 69
J. Calvin Coffey, Rishabh Sehgal, Awad M. Jarrar, and Mattias Soop
7 Pathology of the mesentery 85
J. Calvin Coffey, Jonathon Roddy, Miranda Kiernan, and Shaheel M. Sahebally
8 Radiographic appearance of the mesentery and peritoneum 109
J. Calvin Coffey and Martin Shelly
9 Operative nomenclature 119
J. Calvin Coffey, Bill Heald, and Brendan J. Moran
10 Teaching mesenteric principles 137
J. Calvin Coffey, Deirdre McGrath, and Colin Peirce
11 Gastroenterology 147
J. Calvin Coffey and Manus Moloney
PARt 2 151
vii
viii Contents
Index 351
Preface
This work is intended to furnish the Student and modifi d complete mesocolic excision. As part of these
and Practitioner with an accurate view of the procedures, the surgeon accesses the mesofascial plane in a
Anatomy of the Human Body, and more espe- targeted manner (through division of the peritoneal reflec-
cially the application of this science to Practical tion), then mobilizes an intact mesentery without its disrup-
Surgery. tion. Similarly, the retroperitoneum and covering fascia are
preserved. When the mesentery is sufficiently mobilized,
Henry Gray (1858) the vessels contained within are selected, skeletonized, and
divided, and the mesentery is similarly divided up to the
MESENTERIC-BASED SURGERY DEFINED level of the intestine.
Several terms have been used in reference to nonmesen-
Mesenteric-based surgery is where the surgeon exploits teric-based surgery. These include “conventional” surgery,
mesenteric and associated structures in guiding an intesti- “non-CME surgery, and “non-TME surgery.” Unfortunately,
nal resection. The associated structures are the peritoneal the terms “CME” and “TME” have not been scientifically
refl ction and Toldt’s fascia. Rather than indiscriminately defined in the first instance, and so the related terms also
dissecting through tissue, structures, and planes, the surgeon lack defi ition.
selects certain structures and conducts a particular activity Mesenteric-based surgery has been practiced internation-
related to that structure. For example, during sigmoid mobi- ally for over a century and thus is far from new. However, it
lization for colectomy, the surgeon divides the peritoneal is certainly not universally practiced, and considerable varia-
refl ction at the right side of the base of the mesosigmoid tion has been demonstrated. The variation is explained by
(via a peritonotomy), which exposes the underlying meso- the disparity that has persisted between anatomic and sur-
fascial plane. Th s plane is formed at the interface between gical approaches to the intestine for the past century. While
the mesosigmoid and the underlying Toldt’s fascia. The sur- mesenteric-based surgery is far from new, it is remarkable that
geon then separates the components of this plane to mobilize its anatomic basis has only recently been formally described.
the mesosigmoid. This means that the principles can now be reproducibly
Nonmesenteric-based surgery is one where the surgeon taught and conducted in an entirely standardized manner.
does not adhere to a particular anatomic roadmap. The This book is composed of two parts. In the first part, the
mesentery is divided directly across and dissociated from mesentery, peritoneum, and associated fascia are charac-
the posterior abdominal wall. During dissociation, the ret- terized. In the second part, the data explained in the first
roperitoneum and contained structures are often not recog- are applied to all aspects of resectional colorectal surgery.
nized before being damaged. Surgical anatomy, activities, and operations are carefully
Examples of mesenteric-based surgery now abound defined to enable all surgeons to reproducibly conduct
and include complete mesocolic excision, total mesorectal mesenteric-based surgery.
excision, and total mesocolic excision. Variations are also
emerging, including transanal total mesorectal excision J. Calvin Coff y
ix
How to access three-dimensional models
using QR codes
Each figu e legend in this book will direct the reader to a The reader then will be brought to a three-dimensional
QR code. The QR code to be accessed is specifi d in the fi st model relating to the figu e legend and figu e in question,
number in the following annotation: “QR 2/3.” Th s directs with a series of numbers overlaying the model. By clicking
the reader to QR code 2 and annotation 3. on the number 3, the reader will be brought to a particular
The QR codes are listed below. Using the example above, viewpoint of the model.
the reader should identify QR 2 below and scan the QR code QR codes and models can also be accessed directly at the
with a QR reader (i.e., in a smart phone, lap-top, or tablet). website “www.mpgs.ie.”
xi
xii How to access three-dimensional models using QR codes
We the authors gratefully acknowledge the insight and advice offered by the following individuals:
Ann Brannigan Awad M. Jarrar
Consultant Colorectal Surgeon Department of Cellular and Molecular Medicine
Mater Misericordiae Hospital Lerner Research Institute
University College Dublin Cleveland Clinic
Dublin, Ireland Cleveland, Ohio
John P. Burke
Mathew Kalady
Consultant Colorectal Surgeon
Department of Colorectal Surgery
Beaumont Hospital
Digestive Diseases Institute
Dublin, Ireland
Cleveland Clinic
Manish Chand Cleveland, Ohio
Consultant Colorectal Surgeon
Department of Surgery and Interventional Sciences Miranda Kiernan
University College London Department of Surgery
London, United Kingdom Graduate Entry Medical School
University of Limerick
Eoghan Condon
Limerick, Ireland
Consultant Surgeon
Department of Surgery
University Hospital Limerick Ravi Kiran
University of Limerick Department of Surgery
Limerick, Ireland Columbia University Medical Center
Mailman School of Public Health
Peter Dockery Center for Innovation and Outcomes Research
Department of Anatomy Division of Colorectal Surgery
School of Medicine New York Presbyterian Hospital-Columbia
National University of Ireland New York, New York
Galway, Ireland
xiii
xiv Acknowledgments
Brendan J. Moran
Peritoneal Malignancy Institute Neil J. Smart
Basingstoke Hospital Department of Colorectal Surgery
Basingstoke, United Kingdom University of Exeter Medical School
Royal Devon & Exeter Hospital
James W. Ogilvie Jr. Exeter, United Kingdom
Department of Colorectal Surgery
Spectrum Health/Ferguson Clinic
Michigan State University Mattias Soop
Grand Rapids, Michigan Department of Colorectal Surgery
University of Manchester
D. Peter O’Leary Manchester, United Kingdom
Department of Surgery Salford Royal Hospital
University of Limerick Hospitals Group Salford, United Kingdom
University Hospital Limerick
Limerick, Ireland
David W. Waldron
James O’Riordan
Department of Surgery
Department of General and Colorectal Surgery
University of Limerick Hospitals Group
Tallaght Hospital
University Hospital Limerick
Dublin, Ireland
Limerick, Ireland
Nicola O’Riordan
Department of Surgery
University of Limerick Hospitals Group Leon G. Walsh
University Hospital Limerick University of Limerick Hospitals Group
Limerick, Ireland University Hospital Limerick
Limerick, Ireland
Colin Peirce
Department of Surgery
University Hospitals Limerick Steven D. Wexner
Limerick, Ireland Digestive Disease Center
Department of Colorectal Surgery
Feza Remzi Cleveland Clinic Florida
Professor of Surgery Weston, Florida
Director, Inflammatory Bowel Disease Center Florida Atlantic University College of Medicine
NYU Langone Medical Center Florida International University College of Medicine
New York, New York Miami, Florida
PART 1
1 History 3
2 Mesenteric and peritoneal anatomy 11
3 Embryologic development of the mesentery, peritoneal reflection, and Toldt’s fascia 41
4 Histology of the mesentery 47
5 Toldt’s fascia 57
6 Mesenteric physiology 69
7 Pathology of the mesentery 85
8 Radiographic appearance of the mesentery and peritoneum 109
9 Operative nomenclature 119
10 Teaching mesenteric principles 137
11 Gastroenterology 147
1
History
Two roads diverged in a wood, and I— of surgical disease, the emphasis of research shifted away
I took the one less travelled by, from the anatomic-based craft component. More recently,
And that has made all the difference. laparoscopic and robotic surgery have increased focus on
the “craft” component of surgery. In keeping with this,
Robert Frost the fi ld of surgical anatomy has increased in relative sig-
nificance and led to the demonstration of continuity of the
INTRODUCTION mesenteric organ from the small intestinal mesentery to the
mesorectum [4,5]. The following chapter will demonstrate
For centuries, the mesentery and associated peritoneal these shifting trends and clarify the manner in which recent
lining have been regarded as structurally complex. In 1885, demonstrations allow a reconciliation of anatomic and sur-
Sir Frederick Treves provided the fi st comprehensive gical approaches to this important organ. This chapter fin-
description of both, emphasizing that while some mesenteric ishes by demonstrating the opportunities that now occur
regions persisted in adulthood, others regressed and were across a broad array of clinical and non-clinical sciences.
lost [1]. For example, the small intestinal mesentery, trans-
verse, and sigmoid mesocolon were consistently identifiable CARL TOLDT (1840–1920)
in adults, while the right and left mesocolon were identifi-
able in a minority only. Treves’ descriptions were welcome Carl Florian Toldt was born on May 3, 1840, in Bruneck,
at the time, given the apparent complexity of the topic, and Austria. After spending much of his childhood repair-
were subsequently indoctrinated in virtually all anatomic, ing clocks, he received his doctorate in 1864 at St. Joseph’s
embryologic, clinical, and related literature [1–3]. To the University in Vienna and was appointed Professor of
present, the fi st chapter of most reference texts on intestinal Anatomy at the University of Vienna in 1875 (Figure 1.1). He
surgery focuses on anatomy and physiology and is based on became Professor of Anatomy at the German university in
Treves’ descriptions. A review of later chapters dealing with Prague. He subsequently returned to Vienna in 1884 to work
techniques in intestinal removal identifies a remarkable dis- with his colleague, Langer, and together they established
parity. The right and left mesocolon are invariably present the Anatomy Institute of Vienna. Carl Toldt’s best-known
in the adult and must be resected like any other mesenteric anatomic work was Anatomischer Atlas für Studierende
region. Put simply, intestinal surgery has always relied on und Aerzte (An Atlas of Human Anatomy for Students and
the persistence of all regions of the mesentery. Physicians) (Figure 1.2), which was translated into English.
Numerous factors contributed to the divergence of Despite the superb quality of this work, and its anatomic
anatomic and surgical approaches to the mesentery and accuracy, it has been little referenced overall. Toldt died
peritoneum. Since the time of Treves’ anatomic-based from pneumonia in Vienna in November 1920 [6–9].
research, surgeons focused increasingly on cellular aspects Toldt’s descriptions were based on dissection of fresh
of disease. With increasing awareness of the molecular basis cadavers that had not been exposed to corrosive preservative
3
4 History
Tela subserosa
Tunica mucosa
Tela submucosa
Lamina mesenterii
propria Fettgewebe
9/
1
Einstrahlung des Bindegewebes der Lamina
mesenterii propria in die Darmwand Venenzweig
Figure 1.3 The mesentery and adjacent intestine is demonstrated. Toldt drew submesothelial connective tissue as well
as a mesenteric connective tissue lattice. He demonstrated a contiguity between these and the connective tissue of the
outer layers of the intestine. (Taken from Carl Toldt’s Anatomischer Atlas Fur Studirende und Aertze.)
[23]. The theory of Oliphant gained acceptance, while that LAPAROSCOPIC AND ROBOTIC SURGERY:
of Dodd went largely unnoticed until recently (see the THE CRAFT OF COLORECTAL SURGERY
“Anatomic continuity: a simpler principle” section).
More recently still, Charnsangavej et al. exploited During the 1990s, the development of laparoscopic and
vascular markings in order to identify mesenteric regions minimally invasive surgery (and subsequently robotic tech-
on abdominal CT [20,21,24]. This approach is practical and niques) revolutionized intestinal surgery by providing high
readily adopted, which likely explains its widespread use. magnifi ation (greater than 20-fold) and high-resolution
However, the sentiment expressed by Dodd (that the CT anatomic imagery. Just as the principles of laparoscopic
appearance of the mesentery is difficult to correlate with and robotic intestinal surgery emerged, terminologies such
prevailing anatomic concepts) still holds. as “mesocolon” and “Toldt’s fascia” were increasingly uti-
lized. For laparoscopic and robotic colorectal surgery to be
RENAISSANCE IN FOCUS safe and repeatedly successful, the surgeon must adhere to a
ON THE MESENTERY universally reproducible anatomic roadmap. Unfortunately,
the anatomic basis for laparoscopic and robotic intestinal
Interest in the mesentery increased with the realization surgery was also sketchily developed [5,27]. Th s asser-
that when the mesentery associated with the rectum (i.e., the tion may be considered as unexpected, given surgeons for
mesorectum) was fully excised for rectal cancer, the inci- decades practiced technically superb resections in the open
dence of recurrent cancer decreased signifi antly. The con- context. It is not surprising, however, when one considers
cept was termed “total mesorectal excision.” Although total that descriptions of open, laparoscopic and robotic surgi-
mesorectal excision had been conducted worldwide and cal techniques are hallmarked by limited reference to the
for decades, the anatomic basis for its success was a recent mesentery, the associated peritoneum and fascia.
discovery. In 1982, Heald et al. showed that a plane occurs A brief illustration of this point is important at this junc-
between the mesorectum and the pelvis and that dissection ture. The mesofascial plane is a key plane throughout colorec-
in this plane, “the holy plane,” enabled a total mesorectal tal surgery. Access to it is universally gained by division of
excision (Figure 1.7) [25,26]. Th s was a highly signifi ant the overlying peritoneal reflection. Peritonotomy (i.e., divi-
anatomic description as it provided surgeons with a fail- sion) of the reflection and separation of plane components
safe anatomic roadmap, which, if adhered to, led to better are core colorectal activities and are universally required
outcomes for patients with rectal cancer. Initial uptake of for colorectal resection. Despite being centrally important,
the anatomic principle was begrudgingly slow, but it has their anatomic basis has only recently been described.
now gained worldwide acceptance. Surprisingly, Heald and Focus on the anatomic and surgical importance of the
coworkers did not extrapolate the same anatomic basis to mesentery increased further when Werner Hohenberger
the remainder of the colon and mesocolon. described superb results for patients undergoing a “com-
plete mesocolic excision” for colon cancer (Figure 1.8) [28].
In his 2009 article, he demonstrated that by applying the classic depictions as it meant that the mesenteric organ is
anatomic principles, one could achieve an R0 resection a substantive and continuous structure, and not fragmented
(i.e., clearance of all microscopic disease) in 97% of cases. or discontinuous as was generally described [32,33].
Around the same time, West et al. demonstrated the eff cts The newer appraisal was far simpler than the classic
of anatomic dissection on colon cancer outcomes. Their description. Recognition of continuity led to similar obser-
findings suggested that by adopting a strictly anatomic vations on the peritoneal refl ction and Toldt’s fascia. It is
approach, one could enhance patients’ survival following now accepted that Toldt’s fascia is continuous from the origin
surgery for stage three colon cancer [29,30]. These findings of the mesenteric organ (at the superior mesenteric artery)
went a considerable distance in demonstrating the associa- to its termination at pelvic fl or. Similarly, the peritoneum
tion between anatomic surgery and better cancer-specific is draped in a contiguous manner over intraperitoneal struc-
outcomes. tures from the root region to the so-called anterior refl ction
Remarkably, however, a unifying anatomic principle in the pelvis [32,33].
that could reconcile anatomic with established surgi-
cal approaches to the colon, rectum, and small bowel FUTURE DIRECTIONS
remained elusive.
Anatomic continuity and contiguity of mesentery, fascia,
ANATOMIC CONTINUITY: A SIMPLER peritoneal reflection, and gastrointestinal tract has major
PRINCIPLE implications at numerous levels and across multiple special-
ties (clinical and nonclinical). These form the basis and con-
In 2012, a study was performed involving collaboration tent of this book. For the surgeon, continuity and contiguity
between the Department of Surgery in University Hospital mean that the same anatomic technical elements can be uni-
Limerick, Ireland, and the Department of Colorectal Surgery versally used to perform a safe intestinal resection [33]. For
at the Digestive Diseases Institute at The Cleveland Clinic, in the abdominal radiologist, they enable a clearer understand-
which the anatomic structure of the small and large intestinal ing of the type and extent of intraperitoneal disease [33].
mesentery was formally clarifi d (Chapter 2) [31]. Crucially, Perhaps most importantly, identification of continuity and
the authors demonstrated that the small intestinal and colonic clarification of anatomy now permits the systematic (i.e., sci-
mesenteries are different regions of the same anatomic struc- entific) study of the mesentery and associated structures [33].
ture and that the mesentery itself spans the intestinal tract
from the duodenum to the junction between the rectum and SUMMARY
anus (Figure 1.9). Th s was a considerable departure from
There are numerous incidents in the history of medicine
where an inaccurate understanding of structure was dog-
Transverse matically integrated in literature. William Osler wrote that
Transverse mesocolon “the greater the ignorance the greater the dogma.” Recent
colon clarification of mesenteric structure has presented a far sim-
pler structure than heretofore thought. The following chap-
Left mesocolon ters will describe the scientific opportunities that stem from
this clarification. In addition, it will explain the mesenteric
basis of clinical practice.
Right
mesocolon
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Right Sigmoid colon
colon 1. Treves, F., Lectures on the anatomy of the intesti-
nal canal and peritoneum in man. Br Med J, 1885.
1(1264): 580–583.
Rectum
Mesosigmoid 2. McConnell, A.A. and T.H. Garratt, Abnormalities
of fixation of the ascending colon: The relation of
Anorectal symptoms to anatomical findings. Br J Surg, 1923. 10:
Mesorectum junction
532–557.
3. Netter, F.H., Atlas of Human Anatomy. Elsevier
Health Sciences, Philadelphia, PA, 2014, pp. 263–276.
4. Standring, S., Gray’s Anatomy: The Anatomical Basis
of Clinical Practice. Elsevier Health Sciences, London,
Figure 1.9 (See also QR 1 and 7.) The mesenteric organ. U.K., 2015, Chapter 62, pp. 1098–1111, 1124–1160.
The illustration is of a model of the mesentery generated 5. Coffey, J.C., Surgical anatomy and anatomic
using a 3D printer. Pan-mesenteric continuity is demon- surgery—Clinical and scientific mutualism. Surgeon,
strated (from the duodenum to the anorectal junction). 2013. 11(4): 177–182.
References 9
6. Sehgal, R. and J.C. Coffey, Historical development of 22. Oliphant, M. and A.S. Berne, Computed tomography
mesenteric anatomy provides a universally applicable of the subperitoneal space: Demonstration of direct
anatomic paradigm for complete/total mesocolic spread of intraabdominal disease. J Comput Assist
excision. Gastroenterol Rep, 2014. 2(4): 245–250. Tomogr, 1982. 6(6): 1127–1137.
7. Toldt, C., Bau und wachstumsveranterungen 23. Dodds, W.J. et al., The retroperitoneal spaces revis-
der gekrose des menschlischen darmkanales. ited. Am J Roentgenol, 1986. 147(6): 1155–1161.
Denkschrdmathnaturwissensch, 1879. 41: 1–56. 24. Coffey, J.C. et al., An appraisal of the computed
8. Toldt, C., An Atlas of Human Anatomy: For Students axial tomographic appearance of the human mes-
and Physicians, Vol. 6: Primary Source Edition. entery based on mesenteric contiguity from the
BiblioBazaar, 2013. duodenojejunal flexure to the mesorectal level.
9. Toldt, C. and A.D. Rosa, An Atlas of Human Anatomy Eur Radiol, 2016. 26(3): 714–721.
for Students and Physicians. Macmillan, New York, 25. Heald, R.J., The “Holy Plane” of rectal surgery.
1926. J R Soc Med, 1988. 81(9): 503–508.
10. Cohen, M.M., Jr., Further diagnostic thoughts about the 26. Heald, R.J., E.M. Husband, and R.D. Ryall, The
Elephant Man. Am J Med Genet, 1988. 29(4): 777–782. mesorectum in rectal cancer surgery—The clue
11. Treves, F., Discussion on the subsequent course and to pelvic recurrence? Br J Surg, 1982. 69(10):
later history of cases of appendicitis after operation. 613–616.
Med Chir Trans, 1905. 88: 429–610. 27. Coffey, J.C. et al., Terminology and nomencla-
12. Congdon, E.D., R. Blumberg, and W. Henry, Fasciae ture in colonic surgery: Universal application of
of fusion and elements of the fused enteric mesenter- a rule-based approach derived from updates on
ies in the human adult. Am J Anat, 1942. 70: 251–279. mesenteric anatomy. Tech Coloproctol, 2014. 18(9):
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fascia of Gerota. Urology, 1976. 7(1): 1–3. Colorectal Dis, 2009. 11(4): 354–364; discussion
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BiblioBazaar, Charleston, SC, 2010. surgical resection and its association with survival:
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Kluwer Health, Philadelphia, PA, 2011, pp. 208–232. observational study. Colorectal Dis, 2012. 14(4):
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2
Mesenteric and peritoneal anatomy
There is pleasure in recognising old things from His descriptions were first presented in a series of classic lec-
a new viewpoint. tures and thereafter integrated in most reference anatomic,
embryologic, surgical, and radiologic texts [1–11]. Treves laid
Richard Feynman down his understanding of mesenteric and peritoneal anat-
omy at a time when anatomic descriptions were providing a
AIM formal basis for safe and anatomic surgery (Figure 2.1) [1,9].
Treves correctly described the small intestinal mesentery
The aim of this chapter is to summarize mesenteric and as having a “mesenteric root” at the origin of the superior
peritoneal structure in light of recent advancements in mesenteric artery. According to his descriptions, the small
our understanding of both. A second aim is to indicate the intestinal mesentery then fans out from the duodenum to
relevance of both to current clinical practice. terminal ileum. At the gastrointestinal margin, the mes-
entery elongates considerably. This contrasts considerably
INTRODUCTION with the length of the “attachment” to the posterior abdom-
inal wall. As per Treves, the mesenteric attachment extends
The magnification aff rded by endoscopic techniques across the posterior abdominal wall from duodenojejunal
coupled with the resolution of modern displays has revolu- flexure to ileocecal level. As it does so, it obliquely traverses
tionized our appraisal of living anatomy. Nevertheless, ref- the aorta and inferior vena cava (Figure 2.2a and b) [1,12].
erence anatomic and embryologic texts continue to present Treves described the right and left mesocolon as being
classic anatomic descriptions. In keeping with this, classic absent in the majority of cases. If an anomalous right or left
descriptions of mesenteric and peritoneal anatomy continue mesocolon was present, then this would be seen to attach
to dominate reference texts. Sir Frederick Treves compre- in regions corresponding closely to the attachment of the
hensively described the human mesentery and peritoneum right or left colon (Figures 2.1 and 2.2a,b). For example, the
in a study spanning 100 cadavers in 1889 (Figure 2.1) [1]. attachment of the right mesocolon corresponds to that of
11
12 Mesenteric and peritoneal anatomy
Attachment
of transverse
mesocolon
Attachment
of right colon
Attachment
of left colon
(i.e., left
mesocolon)
Attachment of
mesosigmoid
Attachment
of small
intestinal
mesentery
Figure 2.1 Schematic demonstrating the attachments of the mesentery as depicted by Treves. The small intestinal
mesentery attaches along a diagonal line crossing the posterior abdominal wall from the fourth part of the duodenum
to the ileocecal junction.
Mesenteric attachments:
classic teaching
Mesentery:
classic teaching Transverse
mesocolon
Right
mesocolon
Left
mesocolon
Vestigial
left mesocolon
Mesosigmoid
Mesosigmoidal
attachment
(a) (b)
Figure 2.2 (a) Schematic summarizing Treves’ descriptions of the attachment of the mesentery and mesocolon (red region).
As per Treves, when an anomalous right mesocolon is present, it attaches along a vertical trajectory from the right iliac fossa
to the hepatic flexure. The transverse mesocolon attaches along a horizontal line that traverses the upper part of the abdo-
men. When an anomalous left mesocolon is present, it attaches along a vertically oriented region, while the mesosigmoid
attaches along a v-shaped line. The attachment of the mesorectum was not defined by Treves. (b) 2.5D snapshot from a
3D digital sculpture of the mesocolon (yellow) as depicted by Treves. The small bowel and associated mesentery have been
conceptually removed for clarity. The right and left mesocolon are vestigial or near absent, while the transverse and sigmoid
regions are substantial. The mesorectum is absent. Overall, the mesentery is fragmented and discontinuous. (Continued)
Introduction 13
Mesenteric attachments:
current teaching
Mesentery:
current teaching Left
mesocolon
Left
Right mesocolic mesocolic
attachment Mesosigmoid
and small bowel
mesenteric
attachment
Mesorectum
Mesosigmoidal
(c) attachment (d)
Figure 2.2 (Continued ) (c) Schematic summarizing the attachment of the mesocolon (yellow region) as described by
Toldt. The right mesocolon is always present and attaches over a broad region on the right side of the posterior abdomi-
nal wall. The left mesocolon is always present and attaches over a similarly broad region on the left side of the abdomen.
The mesosigmoid is a distal continuation of the left mesocolon. (d) (See also QR 1/1.) 2.5D snapshot from a 3D digital
sculpture of the mesocolon (yellow) as it is currently understood. The distal small bowel and associated mesentery have
been retained in the illustration. The right and left mesocolon are substantial and continuous with adjacent regions of mes-
entery. The right mesocolon is continuous with the small intestinal mesentery medially and with the transverse mesocolon
at the hepatic flexure. On the left, the left mesocolon, mesosigmoid, and mesorectum are similarly continuous. Overall,
the mesentery is continuous from root region to the mesorectum.
the right colon, extending along a vertical orientation from A question arises as to how Treves’ generated his fi dings.
the right iliac fossa to the subhepatic region. The attachment His descriptions can be explained if one were to conceptu-
of the left mesocolon corresponds to that of the left colon, ally slice through the posterior region of the abdomen in a
extending from the subsplenic region to the left iliac fossa coronal plane, that is, (1) posterior to the right and left colon
(Figures 2.1 and 2.2a, b) [1]. To the present, many reference and (2) at the level where the small intestinal mesentery
texts continue to describe these regions as the attachments attaches to the posterior abdominal wall (Figures 2.1 and
of the right and left olon or mesocolon [3–5,13,14]. 2.2b). Doing this would generate the impression of a series of
Treves’ description of the transverse and sigmoid meso- mesenteric insertions for the small intestine, transverse, and
colon was similar to that of the small intestinal mesentery. sigmoid mesocolon [10,16,17]. In addition, it would fail to
He described the transverse mesocolon as being “attached” identify the right and left mesocolon as well as the attached
along a horizontal trajectory to the upper part of the posterior region of the mesosigmoid and mesorectum.
abdominal wall (Figure 2.2a and b). He described the meso- In 2012, our group refuted the findings of Treves
sigmoid as attaching to the posterior abdominal wall in the left demonstrating mesenteric continuity from small intes-
iliac fossa. The attachment followed an inverted V shape, with tinal mesentery to mesorectal level (Figure 2.2c and d)
the apex of the “V” providing an important landmark overly- [10]. This led to a general overhaul of our understand-
ing the left ureter (where this crosses the bifurcation of the ing of mesenteric anatomy [2]. We found that the small
common iliac artery) (Figure 2.2a and b) [2,4,6,14,15]. intestinal mesentery attaches to the posterior abdomi-
The mesosigmoid, transverse mesocolon, and small nal wall and extends laterally as the right mesocolon
intestinal mesentery were described as mobile, while the (Figures 2.2c, d, 2.3, 2.4). Along the line of attachment,
right and left mesocolon were described as absent (or vesti- a peritoneal reflection extends from the small intestinal
gial) [4,6,8,9,13,14]. According to this, the mesenteric organ mesentery to the posterior abdominal wall and bridges
is fragmented (present in some regions, absent in others). the gap between the two. The line along which the small
If this description were correct, then one would expect to intestinal mesentery attaches to the posterior abdomi-
identify start and end points for each mesenteric region. nal wall (and continues laterally as the right mesocolon)
These were never described, a point that is explained by extends diagonally from the duodenojejunal junction to
their absence in the first place [10]. the ileocecal level.
14 Mesenteric and peritoneal anatomy
Legend
Mesentery Fascia Colon Peritoneum
Figure 2.3 (a) (See also QR 2/1.) 2.5D snapshot from a 3D digital sculpture of the mesentery, associated peritoneal reflec-
tion, and large bowel. Just as the mesentery is contiguous so too is the peritoneal covering and associated large bowel.
(b) Same model as in (a) but with peritoneum removed. (c) Same model as in (b) but with peritoneum and fascia removed.
(d) Same model as in (c) but peritoneum, fascia, and colon removed.
Mesentery in the right iliac fossa Though the base of the small intestinal mesentery (i.e.,
where it continues as the right mesocolon) is short, the intes-
In the right iliac fossa, the mesentery tapers toward an apex tinal margin of the small intestinal mesentery is approxi-
at the ileocecal junction. Th s region of mesentery can be mately 4 ft in length [10,18]. As a result, the mesentery
Mesenteric anatomy 15
Small intestional
mesentery
Right
mesocolon
(a) (b)
Small intestinal
Right mesentery
mesocolon
(c)
Ascending colon
Transverse
Right colon
mesocolon
Small
intestional
mesentery
Figure 2.4 (a) (See also QR 3/1.) 2.5D snapshot of a 3D digital sculpture of the small bowel mesentery and right
mesocolon. The model has been sectioned and the point of view is looking from above downward. The small intestinal
mesentery is continuous with the right mesocolon. (b) (See also QR 4/1.) The model used in (a) has been sectioned
through at the same level, but the point of view now is from below upward. The small intestinal mesentery is continuous
with the right mesocolon. (c) Cadaveric demonstration of continuity between the small bowel mesentery and right
mesocolon. (d) Intraoperative image depicting mesenteric and mesocolic continuity.
16 Mesenteric and peritoneal anatomy
Mesoappendix
Mesoappendix
Small intestinal
mesentery Mesoappendix
Origin of
(a) mesoappendix (b)
Right
mesocolon
Mesoappendix
Small intestinal
(c) mesentery
Figure 2.5 (a) 2.5D snapshot of a 3D digital sculpture of the mesentery at the ileocecal region. The mesoappendix
arises from the undersurface of the mesentery. Given this origin, it is not surprising that the appendix frequently takes
up a retrocecal position. (b) Digital model of mesentery indicating how the mesoappendix arises as an appendage,
from the undersurface of the ileocecal mesenteric confluence. (c) Intraoperative image demonstrating the origin of the
mesoappendix from the ileocecal region of mesentery.
elongates considerably from its base (Figure 2.6). In the that is attached to (i.e., flattened against) the posterior
undisturbed abdomen, it is packed in a concertina-like man- abdominal wall but kept anatomically separate by Toldt’s
ner and readily adopts this position once returned intraperi- fascia (Figures 2.7a,d and 2.8a) [2,10,16]. Although this ana-
toneally [10,18]. The disparity in length between the base of tomic arrangement is exploited in safe colorectal surgery,
the mesentery and the mesenteric border of the intestinal these concepts have been adopted in one reference text, i.e.
tract means that the small intestinal mesentery cannot be Gray’s Anatomy [2].
unfolded and flattened out in its entirety (Figure 2.6).
Adipovascular and avascular
Right mesocolon mesenteric regions
In contrast to the small intestinal mesentery, the right In the region of the ileocolic vessels, increased mesenteric
mesocolon has a smaller surface area and volume. It extends adiposity creates a near constant adipovascular pedicle
from the base of the small intestinal mesentery to the mes- (Figure 2.8b). Similar mesenteric thickening occurs
enteric border of the right (ascending) colon. The right throughout the mesocolon in association with major ves-
mesocolon is a substantive mesenteric region (Figure 2.4) sels such as the right, middle, and left colic vessels and
Mesenteric anatomy 17
Gastrointestinal
mesenteric margin
Region of attachment
(a)
Mesenteric folding
at intestinal margin
Right
mesocolon
Orientation of
the peritoneal reflection
(b)
Figure 2.6 (a) 2.5D snapshot of a 3D digital sculpture of the small bowel and associated mesentery. At the base of the small
bowel mesentery (i.e., where it continues as the right mesocolon) it is short in diagonal extent (dotted line). At the intestinal
margin it elongates extensively in tandem with the small bowel. Together with the associated bowel it is compactly plicated into
a finite intraperitoneal space. (b) (See also QR 1/1.) 2.5D snapshot of a 3D digital sculpture demonstrating continuity between
the small intestinal mesentery and right mesocolon. The small bowel mesentery elongates extensively at its intestinal margin.
also at the inferior mesenteric/superior rectal artery. instrumentation. In contrast, mesenteric fat is soft, friable,
Adiposity increases around the marginal artery and thus and easily bleeds (when denuded of overlying peritoneum)
along the full longitudinal extent of the intestinal mar- and as a result it is not suitable for direct grasping during
gin of the mesentery. Between adipovascular pedicles, the laparoscopic or robotic surgery (if the surgeon wishes to
mesentery thins out considerably and in some instances avoid troublesome bleeding). Importantly, epiploical fat can
adipose tissue is absent (except in obese patients). These be readily diffe entiated from mesenteric fat as it has a lobu-
are the largely avascular interpedicular regions. They lar appearance. In contrast, the surface of the mesentery is
are of surgical importance as they are regions in which smooth and gently contoured.
mesentery can be safely divided with minimal blood loss
(Figure 2.8b) [18–21]. Hepatic flexure
At the intestinal margin of the mesocolon (but not the
small intestinal mesentery), mesenteric fat is similar to that At the hepatic flexure, the right mesocolon narrows, sep-
of appendices epiploicae (Figure 2.9a and b). The latter arise arates from the abdominal wall at its intestinal margin,
from the serosa of the colon and are sufficiently turgid as to and continues as the hepatic component of the transverse
permit grasping and retraction using robotic or laparoscopic mesocolon (Figures 2.7b and 2.10). Thus, the mesenteric
18 Mesenteric and peritoneal anatomy
Small bowel
mesentery
Right
mesocolon
(d)
Figure 2.7 (a–c) (See also QR 1/2 and 3.) 2.5D snapshot of a 3D digital sculpture in which adjacent mesocolic regions are
highlighted in yellow. The mesentery is an adipose structure that lacks distinct boundaries between contiguous zones. As
a result, the optimal means of demonstrating zones is through color coding. In each snapshot, nonhighlighted mesentery
is colored gray and the small intestinal mesentery has been removed to highlight the mesocolon. (d) Cadaveric example of
the right mesocolon after it has been fully mobilized intact, from the retroperitoneum.
component of the hepatic flexure is a confluence between extends longitudinally from the right mesocolon to the
right and transverse mesocolon [18,20]. transverse mesocolon. At the right mesocolic pole of the
The mesenteric component of each flexure is best longitudinal axis, the mesentery is fully attached across its
described in terms of radial and longitudinal axes. The breadth. At the transverse mesocolic pole of the longitudi-
radial axis of the hepatic flexure extends radially from the nal axis, the mesentery is attached centrally but mobile at
middle colic vascular pedicle to the intestinal margin of the intestinal margin. Thus, the mesenteric component of
the mesentery. As it does so, the mesentery changes from the hepatic flexure undergoes considerable conformational
attached (to the posterior abdominal wall) to nonattached changes. These have implications for surgical mobilization
and thus mobile (Figure 2.12a). The longitudinal axis and resection of the hepatic flexure.
Mesenteric anatomy 19
Right mesocolon
Small intestional
mesentery
Peritoneal
reflection
White line
of Toldt
Legend
Mesentery
Fascia
Colon
Peritoneum
(a)
Right colic
adipovascular
pedicle
Ileocolic
adipovascular
pedicle
Avascular
interpedicular
(b) regions of mesentery
Figure 2.8 (a) (See also QR 3/1.) 2.5D snapshot of a 3D digital sculpture showing continuity between the small intestinal
mesentery and the right mesocolon (viewed from above). In addition, the fascia that occurs between the right mesocolon
and retroperitoneum (Toldt’s fascia) is apparent. The fascia extends beneath the colon to form the colofascial plane and
stops at the right peritoneal reflection, where it gives rise to the white line of Toldt (circle). The fascia also extends medi-
ally until it stops at the small bowel mesenteric peritoneal reflection. (b) Overview of the right mesocolon demonstrating
adipovascular pedicles and avascular interpedicular areas. Adipose tissue is minimal in the interpedicular regions leading
to their near translucent appearance.
20 Mesenteric and peritoneal anatomy
Appendices
Appendices epiploicae
epiploicae
Mesenteric
fat
Figure 2.9 (a) 2.5D snapshot of a 3D digital sculpture demonstrating appendices epiploicae along the surface of the
ascending colon. (b) Intraoperative photograph of appendices draped along the surface of the right colon. They are vari-
able in shape and similar in color to nearby right mesocolon. They can be differentiated from nearby mesentery due to
their lobular appearance.
Hepatic flexure
Hepatic
flexure
Legend
Mesentery
Colon
Mesenteric root
Peritoneum
Hepatic Transverse
flexure mesocolon
Hepatic
flexure
Figure 2.10 2.5D snapshots of a 3D digital sculpture showing how the right mesocolon narrows toward the hepatic
flexure. (a) Anterior view. (b) (See also QR 1/4.) Posterior view from above. (c) Posterior view looking from medial to lateral.
(d) Posterior view looking lateral to medial.
flexure). The full extent of the left mesocolon (i.e., from also between the colon and the retroperitoneum (Figure
nonintestinal to intestinal margin) is attached (i.e., flat- 2.13b). Unlike the transverse mesocolon, the left meso-
tened against) to the posterior abdominal wall (Figures 2.7 colon does not undergo elongation at the intestinal mar-
and 2.13a through c). Toldt’s fascia is interposed between gin. Distally, the left mesocolon continues as the attached
it and the retroperitoneum (Figure 2.13a through c) and component of the mesosigmoid [10,18].
22 Mesenteric and peritoneal anatomy
(a) (b)
(c) (d)
Figure 2.11 (a–d) (See also QR 1/2.) 2.5D snapshot of a 3D printed model of the mesocolon and colon demonstrating
contiguity throughout its length from ileocecal junction to mesorectal level. The transverse mesocolon is colored green to
demonstrate its appearance from different viewpoints.
Transverse mesocolon
Mesenteric
component of Middle colic
hepatic flexure adipovascular
pedicle
(a)
Mesenteric
component of
splenic flexure
Translucent
peritoneum,
i.e., region of
translucent zone
(b)
Figure 2.12 (a) (See also QR 1/6-8.) 2.5D snapshot of a 3D digital model in which the mesenteric components of the
(a) hepatic and (b) splenic flexures converge on the middle colic adipovascular pedicle.
24 Mesenteric and peritoneal anatomy
Left mesocolon
Legend
Mesentery
Fascia
Colon
Peritoneum
Left mesocolon
White line
Toldt’s fascia of Toldt
Retroperitoneum
(a)
Descending colon
Peritoneal
reflection
Toldt’s fascia
(b)
Descending
colon
Peritoneal
reflection
(c)
Figure 2.13 (a) (See also QR 4/2.) 2.5D snapshot of a 3D digital model demonstrating the left mesocolon. (b) Cadaveric image
demonstrating Toldt’s fascia posterior to the colon. This relationship becomes apparent after division of the overlying perito-
neal reflection. (c) Once the colon has been separated from Toldt’s fascia, the mesocolon and underlying fascia are exposed.
Mesenteric anatomy 25
Mesocolic continuity
Transverse
mesocolon Left mesocolon
Mesosigmoid
Inferior mesenteric
vascular pedicle
Figure 2.14 Cadaveric images of continuous transverse, left mesocolon, and mesosigmoid. Vascular pedicles and avascular
interpedicular areas are apparent. A small window was inadvertently created in the transverse mesocolon.
observed whenever an interface occurs between perito- the posterior abdominal wall. In between these junctions,
neal mesothelium and Toldt’s fascia. For example, it can the sigmoid elongates and leaves the posterior abdomi-
be observed beneath the right and left mesocolon. Thus, it nal wall, taking the mesosigmoid with it. This means that
is inaccurate to suggest that it is confined to the right and the transverse axis is attached medially and mobile later-
left peritoneal reflections. As will be seen in the chapters on ally (Figure 2.16a and b) [10,16,20,21]. Where the mobile
right and left mesocolectomy, the white line represents an component detaches from the posterior abdominal wall a
anatomic landmark that may help the surgeon in deciding peritoneal reflection bridges the gap between the two. The
where to commence peritonotomy (i.e., peritoneal inci- line along which the mesosigmoid detaches has a diagonal
sion) (Figures 2.15 and 2.16) [18]. orientation along the left iliac fossa. The associated perito-
neal reflection has a similar orientation and extends from
Mesosigmoid the junction between the descending and sigmoid colon to
that between the sigmoid colon and rectum (Figure 2.16a
The mesosigmoid is continuous distally with the meso- and b) [9,10].
rectum and proximally with the left mesocolon. It is best The mobile component of the mesosigmoid fans out in
considered in terms of longitudinal and transverse axes. a manner similar to that of the transverse mesocolon and
The longitudinal axis extends from the left mesocolon to small bowel mesentery. In keeping with this property, the
the mesorectum and spans the attached region of the meso- intestinal margin of the mobile component is considerably
sigmoid. The transverse axis extends from the midline longer than the base region at which it is attached [9,10].
laterally. This diffe ential in length is exaggerated in some individuals
and predisposes to volvulus formation, where the sigmoid
Mesosigmoid: Transverse axis twists on its mesentery (see Chapter 7).
White line
of Toldt
White line
of Toldt
Toldt’s fascia
(a)
Legend
Mesentery
Fascia
Colon
Peritoneum
Peritoneal
reflection
White line
of Toldt
Left mesocolon
(b) Toldt’s fascia
Figure 2.15 (a) (See also QR 6/5.) 2.5D snapshot of a 3D digital model demonstrating the left mesocolon (viewed from
above) and descending colon, sectioned in such a manner as to permit identification of the mesocolon. (b) (See also
QR 6/6.) 2.5D snapshot showing a section through the left mesocolon, viewed from below up. Toldt’s fascia is shown as it
extends from beneath the mesocolon, to beneath the colon, and thereafter to reach the left peritoneal reflection.
distal mesosigmoidal angle. These angles are of surgical and focal congenital adhesions. While in some individuals
endoscopic significance (Figure 2.17). these adhesions are absent, in others they are plentiful
and form a band resembling the peritoneal reflection. It is
Congenital adhesions this band that surgical trainees (and indeed sometimes
highly experienced colorectal surgeons) can mistake as the
Frequently, the lateral aspect of the mesosigmoid is adher- starting point for lateral to medial mobilization of the
ent to the parietal peritoneum of the left iliac fossa across mesosigmoid.
Mesenteric anatomy 27
Mesosigmoid
Sigmoid colon
Attached
mesosigmoid
Mobile
mesosigmoid
Toldt’s fascia
Legend
Mesentery
(a) Fascia
Colon
Mobile Peritoneum
mesosigmoid
Peritoneal
reflection
White line
of Toldt
Peritoneal
reflection
Attached
mesosigmoid
(b)
Figure 2.16 (a) (See also QR 5/1.) 2.5D snapshot of a 3D digital model demonstrating the mesosigmoid viewed from above
down and demonstrating attached and mobile regions. Toldt’s fascia is observed beneath the attached mesosigmoid,
between it and the retroperitoneum. The fascia continues laterally as far as the peritoneal reflection where the attached
region of mesosigmoid continues laterally as the mobile region. (b) (See also QR 6/1.) Same model as in (a) sectioned and
viewed from below up to illustrate the same mesofascial relationships beneath the attached mesosigmoid. The fascia con-
tinues laterally until limited by the lateral peritoneal reflection.
28 Mesenteric and peritoneal anatomy
Distal
mesosigmoid
angle Proximal
mesosigmoid
angle
Figure 2.17 Panel of 2.5 D images presenting sigmoid and rectum from multiple viewpoints. These enable demonstration of
the proximal and distal mesosigmoidal angles. The proximal mesosigmoidal angle occurs at the junction of the descending
and sigmoid colon. The distal mesosigmoidal angle occurs at the junction between the sigmoid and the rectum.
Mesosigmoid
Mesorectum
Mesosigmoid Legend
Mesentery
Mesorectum Fascia
Colon
Peritoneum
(a) (b)
Sigmoid
colon
Mesorectal
fascia
Denonvillier’s
fascia
Waldeyer’s
fascia
(c) (d)
Figure 2.18 (a) (See also QR 7/1.) 2.5D snapshot of a 3D digital model demonstrating continuity between the mesosig-
moid and mesorectum from a posterior and left-sided viewpoint. (b) (See also QR 7/2.) 2.5D snapshot of a 3D digital
model demonstrating continuity between the mesosigmoid and mesorectum from a posterior and right-sided view-
point. (c) 2.5D snapshot of a 3D digital model demonstrating continuity between the mesosigmoid and mesorectum
with Toldt’s fascia included. (d) 2.5D snapshot of a 3D digital model demonstrating continuity between the mesosig-
moid and mesorectum and fascia included.
making the anatomic arrangement in this location difficult The cephalad aspect of the splenic flexure is also
to defi e. A further refl ction is always evident beneath the obscured from view by the splenocolic reflection. Just as
greater omentum bridging the space between this and the occurred for the hepatic flexure, coalescence of the greater
transverse mesocolon [10,11,16,20,21]. Th s has been arbi- omentum with the splenocolic reflection makes it difficult
trarily called the omento-colic refl ction. to diffe entiate anatomic structures at this location
30 Mesenteric and peritoneal anatomy
Small bowel
mesentery
Legend
Mesentery
Fascia
Small bowel
peritoneal reflection
(b) (c)
Figure 2.19 (a) Cadaveric view of the peritoneal reflection at the base of the mesentery and continuing around the ileoce-
cal junction. (b) (See also QR 4/1.) 2.5D snapshot from 3D digital model that has been sectioned through the mesentery
and right mesocolon. This enables demonstration of the peritoneal reflection at the base of the small intestinal mesentery.
The view is from below up. (c) (See also QR 3/1.) Same model as in (b) but with view from above down. The small intestinal
mesentery is continuous with the right mesocolon and at the base of the former, the peritoneal reflection is apparent.
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that the only papers of Oudney’s placed in his hands, were “an
itinerary from Mourzuk to Bornou,” and “An excursion to the
westward of Mourzuk.” The latter is printed at the end of the
“Introductory Chapter;” but of the former, only a few mineralogical
notes are given. There is not a doubt, however, but that a vast mass
of materials illustrative of the districts visited, were collected by Dr.
Oudney, although it is now impossible to say what has become of
them. Mr. Barrow asserts that he was labouring under a pectoral
complaint when he left England; and that the disorder was increased
by this journey to Ghaat, and he would thereby insinuate that, during
the greater part of the time he lived in Africa, he was rendered unfit,
by bodily weakness, for keeping regular journals. Now, none of his
most intimate friends had the least suspicion that he was troubled
with any disease of the breast. His chest, instead of being
contracted, was broad and ample; and, in ascending the hills of his
native land, and the equally difficult common stairs of Edinburgh, the
lightness of his figure, and the activity of his habits, always enabled
him to outrun the longest-winded, and the supplest-jointed of his
companions; and certainly nothing mentioned in the letters which we
have published would lead to the inference that he did not enjoy the
most perfect health till after he had been a considerable length of
time in Bornou. It is likewise quite clear that he was not of a
character to neglect any duty which the situation in which he was
placed imposed upon him; and so we repeat, that a great deal of
valuable information must have been collected by him, although it is
to be feared it is now irrecoverably lost. It is to be regretted,
moreover, that his premature death rendered the term of his service
too short to warrant government to make some provision for his
sisters, now orphans, and one of them in a bad state of health.
MEMOIR
OF
AFRICAN TRAVELLER.
MEMOIR
OF
AFRICAN TRAVELLER.
The life of Captain Hugh Clapperton, who died in his second attempt
to explore the interior of Africa, was short, but very eventful. Not only
did he possess a frame and constitution, both of body and mind, well
fitted for a career of active exertion and romantic enterprise; but from
the day of his birth to that of his death, it was his lot to endure, with
almost no interruption, a painful succession of hardships and
privations, or to be engaged in scenes and pursuits of a nature so
perilous as to put existence itself in constant and imminent jeopardy.
And had any record of these things been kept, either by himself or by
any one else, who might chance to know even a tithe of the manifold
dangers to which he was exposed, and the bold, and sometimes
rash enterprises in which he was engaged, a narrative might thence
have been composed, all true to the letter, and yet as full of
wonderful and diversified incident, as well as of fearless and daring
action, as ever flowed from the pen of the most creative genius in
fictitious history—all modified by the child-like simplicity and
generous nobleness of heart, combined with unbending integrity,
unshrinking courage, and indomitable fortitude, in the character of
him, whose fortunes in life they formed, and whose achievements in
the discharge of duty they exhibited. But no such record was kept,
except, while he lived, in our hero’s own retentive memory; and
therefore, now that he is dead, some of the most marvellous
passages of his life must remain in the deep oblivion in which they
have been buried. We are assured by the friends with whom he lived
in the closest intimacy, that when, like Othello, he was questioned
respecting the story of his life from year to year; the battles, sieges,
fortunes, that he had past; he would, with a fine flow of good humour,
and an interesting detail of particulars, run it through even from his
boyish days, down to the time when he was desired to tell it; and
then, like the enamoured Moor, it was his hint to speak of most
disastrous chances,
He was born in the year 1788, and was, as we have seen, soon
after placed under the charge of a stepmother, by whom it is said he
was not only neglected, but treated with harshness and cruelty; and
hence throughout his life stepmothers were regarded by him with a
feeling of unconquerable horror.[4] The accounts which he
occasionally gave his companions of the sufferings of his youth,
arising from the causes which have been specified, were appalling.
In reference to them, an enemy, who, however, seems to have been
in possession of accurate information on the subject, says, that while
a schoolboy, “the climate of Lapland and that of Timbuctoo
alternated several times in the course of a day—a species of
seasoning, or rather case-hardening, that must go far to render him
invulnerable on the sultry banks of the Joliba.” And one of the most
intimate of his friends thus speaks of them in a letter now before us:
“How can the hardships and privations of his early life be touched
upon without hurting the feelings of relatives? These had much
better be buried in oblivion, although they tended to form the man
hardy and self-denying.” When he was a boy, he was nearly
drowned in the Annan; and on that occasion he used to say, that he
felt as if a calm and pleasing sleep was stealing over his senses, and
thought that gay and beautifully painted streamers were attached to
his legs and arms, and that thereby he was buoyed out into the sea;
but he always declared that he experienced no pain until efforts were
making to restore him to a state of animation. At this time he was an
expert swimmer, having been previously taught that useful art by his
brothers; but he had exhausted his strength by continuing too long in
the water. When the alarm of his danger was given by some one to
his father, he hastened to the spot, plunged in, and found his son in
a sitting posture in very deep water.
Among the injuries of his early life, that of a neglected education
was none of the least. He was taught the ordinary acquirements of
reading, writing, and arithmetic, which are generally imparted to the
lowest classes of the Scottish youth; but he was never initiated into a
knowledge of the classic authors of Greece and Rome. Under Mr.
Bryce Downie, however, a celebrated teacher of geometry in the
town of Annan, he acquired a practical knowledge of mathematics,
including navigation and trigonometry, and afterwards, by means of
his own application, he acquired many other branches of useful and
ornamental knowledge, and excelled especially in drawing.[5]
He very early discovered a strong propensity for this latter
accomplishment, so that, with the aid of a few instructions from his
father, who excelled in the knowledge of geography, he could sketch
a map of Europe, while still a child in frocks, with chalk on the floor.
His love of foreign travel and romantic adventure, were likewise very
soon manifested in the delight which he took in listening to his father,
while he pointed out the likely situation of the “North West passage”
to him and his brothers on the globe; in the enthusiasm which he
displayed, when told by his father that he might be the destined
discoverer of that long sought for route from Europe to Eastern Asia;
and also in the avidity with which he devoured books of voyages and
travels of all descriptions whenever they fell in his way.
The circumstance of his entering upon a seafaring life is variously
reported. By one account we are assured that his situation at home
being so unpleasant, he became so thoroughly disgusted with his
father’s house, that he left it clandestinely, and went on board the
first vessel in the harbour of Annan that was willing to receive him.
By his anonymous and unfriendly biographer, it is said that he was
promoted to the rank of an apprentice to a coasting sloop of
Maryport, commanded by Captain John Smith, and that soon
afterwards he was again promoted to the rank of cook’s mate on
board his majesty’s tender in the harbour of Liverpool. His uncle’s
account, in the sketch of his life prefixed to the Journal of his Second
African Expedition, is, that on leaving Mr. Downie, at the age of
thirteen, he was, by his own desire, bound an apprentice to the
owner of a vessel of considerable burden trading between Liverpool
and North America: that after making several voyages in that vessel,
he either left her or was impressed into his Majesty’s service, and
put on board the tender lying at Liverpool. It is clear, from all these
accounts, that Captain Clapperton commenced his naval career as a
common sailor boy—a situation which implies hard duty and rough
usage; yet, as is testified by the following well authenticated
anecdote, this, with all he had previously endured, was unable to
break his spirit, or to subdue the dignified feelings of a noble nature.
As soon as he had joined the trading vessel in which he first sailed,
he was told that one piece of duty which he had to perform on board
was to brush his captain’s boots and shoes. This he positively
refused to do, adding, that he was most willing to take his full share
of the hardest work which belonged to the loading, the unloading, or
the working of the ship; but to the menial drudgery of cleaning boots
and shoes he certainly would not submit. After he had for a short
time served on board several trading vessels, he was impressed into
his Majesty’s service at Liverpool; and in 1806 he was sent to
Gibraltar in a navy transport.[6] The idea, however, of having been
placed on board a man-of-war by force, and retained there as a
prisoner, was so galling to his nature—to a spirit panting and
struggling to be free—that he formed the resolution (one most
difficult to be put in practice) of deserting whenever the opportunity
of doing so should occur: and such was the reckless daring of his
disposition, that, watching the time when he was least observed by
his messmates before the mast, he actually threw himself headlong
overboard, and swam towards a Gibraltar privateer—a vessel of that
class which, during the late war, were usually called rock scorpions
by our sailors. He was taken on board the privateer, and so for a
short time he was the associate of an abandoned and a lawless set
of robbers. But he was soon disgusted with their regardless, savage
and brutal manners, and so embraced the first opportunity of leaving
them, and of going again into the merchant service. While, however,
he was on board the Rock Scorpion, she had sustained an
engagement, in which our hero was severely wounded by a grape-
shot—an accident by which his body was seamed and scarred in a
frightful manner, and which, had it happened to his face or his limbs,
must have rendered him deformed or lame for life.