Surgical Anatomy of the Jejunum and the Ileum

Topography and Anatomy

Length of the Jejunu-ileum:

The small intestine, extends from the pylorus to ileo-caecal junction . The small intestine: 3 parts; Retro-peritoneal :Duodenum (20-25cm length); extends from pylorus to D-J flexure Intra-peritoneal : jejunum and ileum (4-6 m length; average 5 m.). . There is some evidence that intestinal length is greater in obese individuals. Upper 40% Jejunum (1.5-2.5 m;average 2 m). Lower 60% ileum ( 2.5-3.5 m; average 3 m). During laparotomy; the tone of intestinal smooth muscles .reduces the length of small intestine(Average length is 3-5 m.). After small bowel resection; assessment of the residual intestinal length is based on as % of the length resected to the total small intestinal length. jejunum begins at the duodeno-jejunal flexure, which is supported by a peritoneal fold known as the ligament of Treitz.(that differentiate duodenum from the jejunum).Ileum ends at the ileo-cacal junction ;which is supported by ileo-caecal fold. The beginning and the end of the small intestine are topographically related to peritoneal pockets or fossae which are usually very shallow. Occasionally, when they are very deep, they may be the cause of internal herniation. At the beginning of the jejunum there are paraduodenal fossae; at the end of the of the ileum ; ileocecal fossae; in the center, there is non-fusion of the mesentric intestinal root to retroperitoneal tissues.(parito-mesentric reces) Differential Characteristics of the Jejunum and Ileum: The jejunum and ileum are completely intraperitoneal; teathered to the post.parietal peritoneum by the root of mesentery. No distinct anatomic landmark demarcates the jejunum from the ileum; the proximal 40% of the jejunoileal segment is arbitrarily defined as the jejunum and the distal 60% as the ileum.The jujenum is demarcated from

the duodenum by ligament of Treitz. The ileum is demarcated from the cecum by the ileocecal valve. There is no good way to identify an isolated loop of small intestine with absolute certainty without following it in one direction to the duodeno-jejunal junction, or in the other direction to the ileo-cecal junction. The clearest guide for distinguishing the jejunum from the ileum is based upon the differences between the topographic features of the blood supply to these two regions of the bowel.

Each typical segment of jejunum characteristically has one or two arterial arcades in the mesentery; with parallel, long vasa recta arising from the arcades (have a length of approximately 4 cm ) then pass to the jejunal wall. A typical segment of the ileum often has three or more arterial arcades in the mesentery, with great numbers of relatively short vasa recta (approximately 1.5 cm in length) passing to the ileal wall. The great number of short vasa recta is related, presumably, to the large role in absorption played by the ileum. Similarly, the increase in the quantity of fat seen in the mesentery of some individuals correlates with the relative significance of the absorption of fatty elements in the ileum, in comparison with that in the jejunum. .

The mucosa of the small bowel : is characterized by transverse folds (plicae circulares), or valvulae conniventes that are visible upon gross inspection. These folds are also visible radiographically and help in the distinction between small intestine and colon, which does not contain them, on abdominal radiographs. These folds are prominent in the distal duodenum and jejunum than in the distal small intestine

Gross examination of the small intestinal mucosa also reveals aggregates of lymphoid follicles. Those follicles, located in the ileum, are the most prominent and are designated Peyer's patches.

. Some Differences between Jejunum and Ileum

Jejunum
Wall thicker Lumen larger

Ileum
Wall thinner Lumen smaller

Fat on mesentery Prominent plicae circulates Single line of arterial arcades

Fat on ileum and mesentery Less prominent plicae Several lines of arterial arcades

Aggregate lymph nodules; sparse Aggregate lymph nodules frequent (Peyer's patches)

Arterial Supply of Jejunum and Ileum:

The superior mesenteric artery; arises from the aorta below the origin of the celiac
trunk.( In about 1% of individuals, there is a combined celiaco-mesenteric trunk.) Then the superior mesenteric artery courses anterior to the uncinate process of the pancreas and the third portion of the duodenum, where it gives branches to supply:

The lower head of pancreas, distal duodenum .Entire small intestine. Ascending and proximal2/3 of transverse colons.

The left side of the superior mesenteric artery gives origin to five intestinal arteries above the origin of the ileocolic artery, and 11 arteries below that level. Eight more arteries arise from the ileal branch of the ileocolic artery. A few centimeters from the mesenteric border of the intestine, these intestinal vessels branch to form a series of arterial arcades; connecting the intestinal arteries with one another Proximally, in the jejunum, 1-3 arcades are present; distally, in the ileum, there is an increased number of arcade; (3-4 arcades) connecting the intestinal arteries with one another These vascular arcades form the primary anastomoses of the small intestinal arterial supply. A complete channel may exist from the posteroinferior pancreaticoduodenal artery and is parallel to the mesenteric border of the small intestine and joins the marginal artery (of Drummond) of the colon. In some individuals, this anastomotic pathway is incomplete, usually at the end of the ileum. From the arches of the arcades, numerous straight arteries (the vasa recta) arise, then pass (without cross-communication) to enter the intestinal wall. They may bifurcate to supply each side, or they may pass singly to alternate sides of the intestine. The vasa recta branch beneath the serosa without anastomosing, then piercing the muscularis externa. (There is no collateral circulation between the vasa recta or their branches in the sub-serosal surface of the intestines. ).This configuration provides the best blood supply to the mesenteric side of the intestine, and the poorest supply to the ante-mesenteric border. So there is no collateral circulation beyond the terminal arcades (in other words, no communication between the vasa recta and/or within the intramural network), then the blood supply of the ante-mesenteric border of the small bowel is probably relatively poor. Therefore, during surgery, the bowel ought to be opened halfway between the mesenteric and the ante-mesenteric border. Within the intestinal wall, the arteries form a large

anastomosing plexus in the submucosa. From this plexus, short vessels reach the lamina propria to supply a network of capillaries around the intestinal crypts, while longer arteries supply the cores of the intestinal villi

Thus, there are two regions of anastomoses of intestinal arteries: the extramural arches between intestinal arteries, and the intramural submucosal plexus.

Venous Drainage: One or more small veins originate near the tip of each intestinal villus and travel outward, receiving contributions from a plexus of veins around the intestinal glands. They enter the submucosal plexus, which is drained through the muscular layer by larger veins traveling with the arteries in the mesentery, to reach the superior mesenteric vein. These intestinal veins are interconnected by venous arcades that are similar to, but less complex than, the accompanying arterial arcades. The superior mesenteric vein belongs to the portal system, which drains the intestinal blood into the liver.

Lymphatic Drainage:Lymphatic vessels (lacteals) arise in the cores of the intestinal villi. They form plexuses at the base of the villi, the base of the crypts, in the muscularis mucosa, in the submucosa, and between the circular and longitudinal layers of the muscularis externa. This series of plexuses is drained by large lymphatics that pierce the muscle wall and travel in the mesentery with the arteries and veins.Then the lymph flows to nodes residing between the leaves of the mesentery. Over 200 small mesenteric nodes lie near the vasa recta (along mesenteric border of the bowel) and along the intestinal arterial arcades. Drainage from the mesenteric nodes is finally to the large, superior mesenteric lymph nodes at the root of the mesentery along superior mesenteric vessels. Efferent vessels from these and the celiac nodes form the intestinal lymphatic trunk. This trunk passes beneath the left renal artery and ends in the left lumbar lymphatic trunk (70 percent) or in cisterna chylli (25%) and then up the thoracic ducts, ultimately to empty into the venous system located in the neck.(Lt.Subclavian V.)

In summary, the pathways of small bowel lymphatics are as follows

Intramural:

Lacteals to mucosal vessels to submucosal plexus

to

subserosal plexus TO LNs along the mesenteric arterial arcades TO lymph

Extramural: Vasa recta lymph nodes (Along mesenteric border of bowel)

nodes along the superior mesenteric artery and celiac artery TO cisterna chyli

The lymphatic drainage of the small intestine constitutes a major route for transport of absorbed Fat into the circulation and similarly plays a major role in immune defense and also in the spread of neoplastic cells arising from cancers of the gut.

Innervation of the small intestine:

I. External: Autonomic Nerves

Parasympathetic: Derived from vagusN. via coliac branch. Parasympathetic stimulation: lead to increase intestinal motility and secretion Sympathetic: Derived from greater&lesser splanchicNs. (They have their ganglionic cells in superior mesenteric plexus) Sympathetic stimulation lead to: decrease motility and secreation of the small bowel. Also sympathetic fibres distributed in the adventia of mesenteric B.V.are motor to B.V.(causing mesenteric vasoconstriction). Pain from the intestine is mediated through general visceral afferent fibers in the sympathetic system

II. The enteric nervous system(ENS) (Meissner's) plexus (nerve fibers and ganglionic cells):present in the submucosa Myenteric (Auerbach's) plexus (nerve fibres and ganglion cells) present in the muscle layer in interface between longitudinal and circular muscle layer. ENS : is an independently functioning network,(neural plexus and ganglionic cells) which is connected to the central autonomic neural network in the central nervous system by parasympathetic and sympathetic nerves. The enteric nervous system may influence the effector system in the gut directly,(through excitatory and inhibitory stimuli) : The predominant excitatory transmitters are acetylcholine and substance P. The inhibitory transmitters include nitric oxide, vasoactive intestinal peptide(VIP),

adenosine triphosphate(ATP); serotonine and somatostatine or indirectly through its actions on intermediate cells, which include endocrine cells and cells of the immune system.

Mesentery of Small Intestine:-

50,51