Ligament of Treitz

Location

The phrenicoceliac part (a.k.a Hilfsmuskel component, superior part) of the ligament of Treitz extends from the right crus of the diaphragm and wraps around the esophageal hiatus. It continues down to the celiac artery where it joins the connective tissue around the area. Some anatomists refer to this as the upper part of the ligament.

The celiacoduodenal (inferior) part of the ligament arises as a connective tissue band from the paraaortic connective tissue around the celiac artery. It travels between the pancreas and the splenic vein, as well as the left renal vein. It becomes a triangular structure that inserts at the left lateral aspect of the end of the fourth segment of the duodenum - the duodenojejunal flexure.

Anatomy

Wenzel Treitz described two structures that make up the ligament of Treitz. The phrenicoceliac part of the structure arises from the right crus of the diaphragm and loops around the esophagus before inserting as a connective tissue band at the celiac trunk (artery or axis). It is sometimes referred to as Hilfsmuskel, which is German for accessory muscle. The phrenicoceliac part is roughly the shape of an elongated triangle that is widest at its origin and narrowest at its insertion. Histological assessment of the band reveals that it is made up of striated skeletal muscle fibers that come from the diaphragmatic end of the muscle.

The celiacoduodenal part of the suspensory ligament of the duodenum is a thin muscular band originating from the celiac trunk as a connective tissue band. It passes between the splenic vein, left renal vein and the pancreas to insert at the duodenojejunal flexure (DJ flexure) and part of the inferior aspect of the transverse duodenum. This segment is sometimes referred to as the suspensory muscle of the duodenum proper. It is a very thin muscle and is roughly triangular at its origin but tapers and becomes narrower toward its fibrous insertion. Histologically, the suspensory muscle of the duodenum is comprised of smooth muscle fibers arising from the enteric end of the muscle.

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Since the suspensory ligament of the duodenum was discovered, there has been significant discord as to the composition of the suspensory ligament. Some anatomists were only able to identify smooth muscle fibers. Others, however, found just a simple fold of peritoneum that occasionally contained both skeletal and smooth muscle components. One reason for the discord is that there seems to be some degree of variability in the morphology of the structure. Different parts of the ligament of Treitz may either rudimentary or absent. 

However, most modern anatomy texts continue to accept Treitz’s initial description of a mixed muscle. This article will continue to honor that convention as well until further definitive evidence is available.

Function

Some anatomists hypothesized that since the suspensory ligament of the duodenum is a muscle, it should be able to stabilize the duodenojejunal flexure and prevent it from being displaced. However, given the thin nature of the muscle, it has been deemed unlikely to effectively carry out this function.

It does, however, serve as a landmark for surgeons to identify the duodenojejunal flexure. This is the point of transition between the foregut and the midgut. This becomes clinically relevant when discussing gastrointestinal problems such as gastrointestinal bleeding. Bleeding within the gastrointestinal tract that occurs above/proximal to the level of the suspensory ligament of the duodenum is called upper gastrointestinal bleeding. However, if bleeding occurs below/distal to the level of this ligament, then it is referred to as lower gastrointestinal bleeding.

Other ligaments in the gastrointestinal tract

There are numerous other intraabdominal ligaments that help to support the abdominal organs. They also help to divide the intra-abdominal cavity into regions and quadrants. While the majority of these peritoneal folds are associated with the liver (and discussed in its own article), there are a few others that are worth mentioning here.

Development

The primary dorsal mesentery is an embryonic structure that contributes to the formation of the crura of the diaphragm, the gastrophrenic and gastrocolic ligaments, and the greater omentum. It also plays an important role in the formation of the ligament of Treitz as well. Cells arising from the pleuroperitoneal membrane (one of four embryonic structures that contribute to the formation of the diaphragm) and the retropancreatic fusion fascia (resides between the retroperitoneal organs and the posterior surface of the pancreas) may also contribute to the formation of the ligament of Treitz. 

Read more about the development of the gastrointestinal structures here.