Anatomical model of large intestine in foetal period and its

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WELLNESS AND HEALTH
CHAPTER XXIV
¹Normal Anatomy Department Wroclaw Medical University
Katedra i Zakład Anatomii Prawidłowej
Uniwersytetu Medycznego im. Piastów Śląskich we Wrocławiu
² Institute of Informatics,Automatics and Robotics,
Wrocław University of Technology
Politechnika Wrocławska, Instytut Informatyki, Automatyki i Robotyki
³Department of Dental Anatomy Wroclaw Medical University
Zakład Anatomii Stomatologicznej
Uniwersytetu Medycznego im. Piastów Śląskich we Wrocławiu
SŁAWOMIR WOŹNIAK¹, ZYGMUNT DOMAGAŁA¹,
RYSZARD KACAŁA¹, HENRYK KORDECKI², MICHAŁ PORWOLIK¹,
WIESŁAW KURLEJ³, PAWEŁ DĄBROWSKI¹, BOHDAN GWORYS¹
Anatomical model of large intestine in foetal period
and its application in endoscopic diagnostic methods
and clinical applications
Budowa anatomiczna jelita grubego w okresie płodowym
i jej wykorzystanie w endoskopowych metodach diagnostycznych
i zastosowaniach klinicznych
Key words: anatomical model, large intestine, mesentery, types of sigmoid colon,
types of transverse colon, foetal period, development
Słowa kluczowe: model anatomiczny, jelito grube, krezka, typy esicy, typy poprzecznicy, okres płodowy, rozwój
INTRODUCTION
Endoscopic investigation of large intestine is very often used and applied all over
the world. In all countries, the colonoscopic examination and sigmoidoscopy performed with flexible endoscopes and rigid tubes – rectoscopy and anoscopy (diagnostic examination of anus). The clinical reasons to perform endoscopic examination are
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as follow: suspection of large intestine cancer, polypes of large intestine, bleeding
from the alimentary tract, inflammatory changes of intestine and others. One to be
mentioned, preventive colonoscopy performed in healthy patients (without any symptoms of the disease of alimentary tract) is very often performed. The anatomical
changes in the abdominal cavity, so called adhesions, after the surgical operations,
interfere with the intestine mobility, and confluence on the course of the examination
and possible complications. Among the complications of the colonoscopy the most
serious are perforation of the intestine and bleeding from the alimentary tract. The
detailed anatomical knowledge of this part of intestine is the key for uncomplicated
examination. The uncomplicated and fast colonoscopy is dependent on anatomical
conditions, such as the course of different parts of intestine, absence of additional
loops, the correct mobility of intestinal loops (dependent on mobility of mesentery),
and obtuse angles of the intestinal inflexions. Incorrect anatomical structure of large
intestine do not allow or interfere with the procedure of colonoscopy. The anatomical
factors are the key for some diseases – such as sigmoid volvulus (the most often occurred disease of this kind) [1, 9]. The great mobility of large intestine may cause the
dislocation of the large intestine into the hernial sac, to create the content of the ventral
hernia.
The large intestine in adults (length 120 – 150 cm, width 5 – 8 cm) is divided in
several parts: cecum (7cm, 7 - 8 cm) with vermiform appendix, colon intestine and
rectum (12 – 20 cm) ended with anus. The beginning of the large intestine is found in
the right iliac fossa, the end in the minor pelvis. Colon intestine is divided into 4 parts:
ascending colon (length 20 cm), without mesentery, transverse colon (40 – 80 cm, 2
parts fixed and mobile) situated on the mesentery, descending colon (20 cm) without
mesentery, situated a little bit laterally than ascending colon, and sigmoid colon (15 –
67 cm) with sigmoid mesentery, situated in the left iliac fossa. The vary range of types
of the transverse colon must be mentioned – it can be U or V shape, and sometimes it
creates two additional loops, to create the letter W. Sigmoid colon is usually composed
of two parts (crures) – colonic and rectal, its whole length range in broad margins,
mostly creates horizontal S letter. The rectum is divided into two parts: pelvical part
(length 12 – 15 cm) and anal (anal canal length about 3 cm ) separated by levator ani
muscle, which built the pelvis diaphragm with others muscles. There is right colic
flexure (hepatic) between the ascending and transverse colon more mobile (hanging
on the hepatocolonic ligament) than the left flexure. The angle of the right flexure is
obtuse or right. In very rare cases no flexure is observed (the angle is close 180 grade).
The left colic flexure (splenic) is situated between the transverse colon and the descending colon. That one inflexion is usually situated higher, more posteriorly and is
attached to the diaphragm with the diaphragm-colonic ligament. The angle of this
flexure is acute. The distance between the right and left flexures is about 30 cm. The
mesentery of the transverse colon is the highest in the middle part, it range from 10
through 16 cm. The sigmoid colon is not attached with the first 10 cm of the sigmoid
colon (10 % of the population is equipped with the mesentery on the whole length of
the sigmoid colon), the maximum height of the mesentery is 9 cm [2, 11, 12]. The
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Woźniak Sławomir, Domagała Zygmunt, Kacała Ryszard, Kordecki Henryk,
Porwolik Michał, Kurlej Wiesław, Dąbrowski Paweł, Gworys Bohdan
Anatomical model of large intestine in foetal period and its application
in endo-scopic diagnostic methods and clinical applications
anatomy of the large intestine in foetal period is rare analyzed in clinical aspects. The
most often of the publications are concerned with the development of this part of alimentary tract [3, 4, 6, 8, 9, 10, 13, 14, 15, 16]. That is urgent necessity to develop the
knowledge about this part of the alimentary tract in clinical applications. That paper
is the continuity of the work performed in Normal Anatomy Department Wroclaw
Medical University. The next papers, concerned with this area, are in progress We
propose the anatomical model of the large intestine helpful in clinical applications.
MATERIAL AND METHODS
The controlled group, used in this paper, consists of 86 human fetuses – 43 male
and 43 female in the CRL (v-tub) range: 110-230 mm and body total length range:
142-330 mm. They aged from 102 days through 213 days of foetal life (IV – VII
months of foetal life). The age was established according to clinical data obtained
from medical interview concerning the date of last menstruation and the date of abortion or immature labour. The age was verify according to own method of establish the
foetal age [5]. The foetuses without complete files or with congenital developmental
abnormalities were not involved in this examination. The procedures were conducted
according to law regulations concerned with the work with foetal specimens and with
the highest ethical attitude. The abdominal cavity was open in typical way, the organs
in this cavity were estimated “in situ”, the metrical date were collected and the freehand drawings, as well photographs were taken. The foetuses with abnormalities and
diseases of the abdominal organs were disclosed. The date measured concerned both,
the large intestine and the mesentery. The length of the parts of the large intestine
were measured. Its topography were establishes. Each measure was done three times
and the mean values were taken. The angles of the inflexions among the parts of the
intestine were measured. The length of the mesenteries of the transverse and sigmoid
colon at the attachment to the posterior abdominal wall, as well the height of the mesenteries (the distance between the attachment and the intestinal wall) were collected.
The position and the arrangement of the part of the sigmoid colon (vertical or horizontal) in the relations with the median and transverse planes were estimated. The
orientation of the part of transverse colon were established. The obtained date were
statistically analyzed with the statistical methods – the Statistica v.10®.
The aim of this paper is to create the basic anatomical model of large intestine in
the foetal period. This model may be used in clinical applications. The obtained results
are not concerned with the diet and feeding habits and the frequency of defecations in
living humans.
RESULTS
The significant (statistically important) differencies between the means values of
measured parameters of males and females were not fund (p<0,05), so the collection
is measured together, without dividing into sex-related and age-related groups. The
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investigation started from the proximal part of the large intestine – caecum and progressed into the distal portion. The mean length of caecum is 6,38 mm (range 2,8 –
10,72 mm). The caecal folds are present. The vermiform appendix is situated in typical positions. No inflexion between caecum and ascending colon is found. The ascending colon is situated in the right half of the abdominal cavity, it ascends straight
up. In 4 foetuses the course of the ascending colon is curved (inflexion in the course
lower than 150 °), in 2 foetuses the additional part of the ascending colon is present
(this part of the intestine is divided into 3 parts). The mean length of the ascending
colon is 15,97 (range 7,73 – 40,38). The mesentery in that part of the intestine is not
found, it is immobile. The right colic flexure (the liver flexure) is flexed in mean angle
107,56° (range 20° - 180°), the angle is obtuse. The range of flexion is very large. The
mean length of transvere colon is 54,22 mm (range 31,98 – 133,11mm). The course
of the transverse colon is straight (without sharp angles) in 57,12%, in 33,78 % single
loop is present, in 4,89 % the course is flexed (the inflexion under right angle), and in
4,19% two loops are present, in that cases the length is lengthen. The mean width of
the transverse colon mesentery (in the attachment to the posterior wall of the abdominal wall) is 20,56 mm (range 10,12 mm - 31,89 mm), and its mean maximal
heigth is 13,01mm (range 4,89 mm – 24,48 mm).
Tab. I Typology of the transverse colon
Nr
Typ of the transverse colon
1
2
3
4
Straight course
Flexed course
Single loop
Two Loops
Frequency
of occuring in %
57,12
4,89
33,78
4,19
The left colic flexure (splenic) is flexed in mean angle 76,12° (range 20 - 110°),
the angle is obtuse. The descending colon runs vertically in the left half of the abdominal cavity, usually straight, but in 8 foetuses the inflexions are present, in that 4
are closer to the sigmoid colon, and 4 closer to the transverse colon, the mean angle
of the inflexion is 111,8 ° (range 90° - 130°). The mean length of the descending colon
is 24,12 mm (range 6,37 mm – 38,97 mm). On this intestine no mesentery is observed.
The mean angle of the descend-sigmoid inflexion is 110° (range 35° - 180°). The
range is very wide. The mean length of the sigmoid colon is 41,02 mm and range
from 14,02 mm through 106,58 mm. The sigmoid colon is situated horizontaly in the
left iliac fossa in 30,56%, or vertical in 13,88 % or horizonto-vertical in 9,72%. The
central (median – anteriorly to the vertebral column) position of the sigmoid colon is
present in 13,88 % horizontally, in vertical position in 11,11 % and vertico-horizontal
in 11,11 %. In 9,72 % the sigmoid colon is situated mediano-rigth (anteriorly and right
to the vertebrae). The mean width of the sigmoid colon mesentery (in the attachment
to the posterior wall of the abdominal wall) is 10,44 mm (range 3,98 – 43,12 mm) and
mean height 9,67 mm (range 3,12 – 22,28 mm)
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Woźniak Sławomir, Domagała Zygmunt, Kacała Ryszard, Kordecki Henryk,
Porwolik Michał, Kurlej Wiesław, Dąbrowski Paweł, Gworys Bohdan
Anatomical model of large intestine in foetal period and its application
in endo-scopic diagnostic methods and clinical applications
Tab. II. Sigmoid colon typology
Number
of typ
1
2
3
4
5
6
7
Frequency
of occuring
in %
Clasical horizontal
30,56
Clasical vertical
13,88
Clasical vertico-horizontal
9,72
Central horizontal
13,88
Central vertical
11,11
Central vertico-horizontal
11,11
Central-rigth
9,72
The name of the typs
In 2 foetuses the additional loop in the course of the sigmoid colon is present, in
that cases the length is great lengthen. The mean angle of the recto-sigmoid inflexion
is 159° (range 50° - 180°), is so wide open. The range of this inflexion is very wide.
The mean length of the rectum is 23,87 mm and range from 9,2 mm – 41,74 mm. The
course of the rectum is straight, it is situated in the median plane, in the pelvis minor.
No mesentery is observed, the serous membrane (the peritoneum) covers the rectum
anteriorly.
Tab. III. The length of the large intestine (mean)
Name of the part
of the intestine
The mean
length in mm
Cecum
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Large intestine
6,38
15,97
54,22
24,12
41,02
23,87
165,58 mm
The length of the
parts of the large
intestine in %
3,85 %
9,64 %
32,74 %
14,56 %
24,77 %
14,41 %
Using the collected data the anatomical model of the foetal large intestine can be
described (mean parameters are used): the cecum has folds, its length is 6,38 mm. The
ascending colon is situated in the right half of the abdominal cavity, has no mesentery,
mean length is 15,97 mm. The right colic flexure angle is 107,56°. The next part of
the large intestine is transverse colon with mean length 54,22 mm, suspended on the
mesentery with the mean width 20,56 mm and height 13,01 mm. The mean angle of
the left colic flexure is 76,12°, is situated anteriorly to the spleen. The mean length of
the descending colon is 24,12 mm , this part of the large intestine has no mesentery,
is situated in the left half of the abdominal cavity. The angle of the descendo-sigmoid
angle is 110°. The sigmoid colon length is 41,02 mm, the width of sigmoid colon
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mesentery is 10,44 mm, and the heigth is 9,67 mm. The sigmoido-rectal angle is 159°.
The rectum is situated in median position, its length is 23,18 mm.
Tab. IV. Inflexions and angles of the parts of the large intestine
Name of angles/inflexions
Recto-sigmoid inflexion
Sigmoido-descending angle
Left colic flexure
Rigth colic flexure
The value in grades
159°
110°
76,12°
107,56°
Tab. V. Mesentery of sigmoid and transverse colon
Name of mesentery
Transverse colon
Sigmod colon
Weidth (mean) Heigth (mean)
in mm
in mm
20,56
13,01
10,44
9,67
DISCUSSION
The anatomical description of large intestine is worldwide known and described
in anatomical books [2, 11, 12]. Nevertheless there are still doubts, which need to be
resolve and diagnose. The doubts and developmental possibilities were discussed by
Zelikson, which were published in 1966 [15]. The aim of this paper was the development of the sigmoid colon and the different parts of the large intestine and the relations
between the length of the large intestine and the diameters of the abdominal cavity.
The notices are similar to ours. The radiologic investigation of the large intestine were
conducted by Harris in 1976 and this statesments are similar with our thoughts [7].
The next aims of the scientific works were developments of whole large intestine or
right or left half of the colon, as well as ascending and descending colon [4, 13, 16].
The continuation of that work were conducted by very few authors [3, 6, 8, 9, 10, 14].
The very few papers concern the clinical points of view – except the volvulus of the
sigmoid colon [1]. There is urgent need for analyzing the large intestine and its angles
and inflexions in applying to the colonoscopy and sigmoidoscopy. Similar to
Bhatnagar we observe the great range of measured parameters of the sigmoid colon
and the sigmoid colon mesentery, we do not confirm the necessity of measure the
width of the mesentery on different levels of the mesentery. The parameters of descending colon , and the shape of the parts of the large intestine are the same as written
by Gworys and Ziółkowski. The proposal made by Haris, and next by Malas to divide
the large intestine into two parts – proximal and distal, with the border on the left
colic flexure is not correct and ought to be forgotten. The typology of the sigmoid
colon reflects the complicated anatomical structure of this part of large intestine and
its mesentery. In the paper of Rigoard – the development of the right colon is discussed
(but very few members of the examined group – 3 cadavers and 17 foetuses impact
the validity of this study, as well the theory of peritoneal fusion and the theory of
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Woźniak Sławomir, Domagała Zygmunt, Kacała Ryszard, Kordecki Henryk,
Porwolik Michał, Kurlej Wiesław, Dąbrowski Paweł, Gworys Bohdan
Anatomical model of large intestine in foetal period and its application
in endo-scopic diagnostic methods and clinical applications
sliding. The author support the theory of the fusion, our notices are the same. In the
papers of Mandiba the great attention is paid to the shape of the sigmoid colon, its
mesentery at the attachment to the posterior wall of the abdominal cavity – we think,
that too little attention is paid to the position and arrangement of this part of the large
intestine in the abdominal cavity. The shape of the attachments of the sigmoid colon
mesentery – straight, diverted U-shape, and diverted V-shape is similar to our analysis. In our paper we propose the very simple typology of sigmoid colon. This typology
is based on the position in the abdominal cavity and arrangements of the parts of the
sigmoid colon (vertical or horizontal). In that typology the mobility of mesentery is
involved. The transverse colon is grouped according to the orientation of the part of
transverse colon and presence of additional loops. We hope our anatomical model will
be useful in clinical applications.
CONCLUSIONS
The analysed parameters of the large intestine lead us to create the anatomical
model of large intestine in the foetal period, during development. We hope our model
will be useful in clinical applications, among them the endoscopic examinations. The
observed variability in the course of large intestine is the cause of complications observed during the examination and the failed examinations (stoped before caecum)
Acknowledgments
The paper could be written thanks to financial support of Medical University
Wroclawa.
We would like to thank to: Alina Proniewicz, Agnieszka Perlicka-Łukaszun and
Miroslaw Lukaszun for help during preparatory study.
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ABSTRACT
The anatomical structure of the large intestine is still the subject of interest for
anatomists and clinicists. The most important part of this study is the mobility of the
large intestine concerned with the parameters of the mesentery. The aim of this paper
is to create the foetal anatomical model of large intestine which can be applied in
clinical applications. The examined group is composed of 86 human fetuses – 43
male and 43 female in the CRL (v-tub) range: 110-230 mm and body total length
range: 142-330 mm. They aged from 102 days through 213 days of foetal life (IV –
VII months of foetal life). The length of the whole intestine is collected, as well the
width and height of the mesenteries of transverse colon and sigmoid colon and angles
and inflexions of the large intestine, and left and right colic flexures. The mean length
of the large intestine is 165,58 mm.
336
Woźniak Sławomir, Domagała Zygmunt, Kacała Ryszard, Kordecki Henryk,
Porwolik Michał, Kurlej Wiesław, Dąbrowski Paweł, Gworys Bohdan
Anatomical model of large intestine in foetal period and its application
in endo-scopic diagnostic methods and clinical applications
STRESZCZENIE
Budowa anatomiczna jelita grubego nadal stanowi przedmiot zainteresowania
anatomów i klinicystów. Szczególnie istotna jest ruchomość jelita związana z parametrami jego krezki. Celem pracy jest stworzenie modelu anatomicznego jelita grubego na materiale płodowym w celu wykorzystania go do celów klinicznych i diagnostycznych. Materiał badany stanowiło 86 płodów (43 męskie i 43 żeńskie): z wymiarami v-tub 110-230 mm i długością ciała 143 – 330 mm, w wieku od 102 do 213
dnia (IV – VII miesiąc życia płodowego). Zmierzono długość poszczególnych odcinków jelita, szerokość i wysokość krezek poprzecznicy i esicy oraz kąty między poszczególnymi odcinkami jelita i zgięć okrężniczych prawego i lewego (wątrobowego
i śledzionowego). Średnia długość jelita wynosi 165,55 mm.
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