Duodenojejunal flexure: anatomy and topography

Q: What forms the suspensory ligament of Treitz?

It is formed by a peritoneal fold covering the muscle (m. suspensorius duodeni). The muscle originates from the circular muscular layer of the intestine at the flexure, passes posterior to the pancreas, and blends into the fascia and muscular bundles of the left crus of the diaphragm.

Q: What is the Treitz recess and why is it clinically significant?

This is a peritoneal depression (recessus duodenojejunalis) bounded anteriorly by the peritoneal fold, posteriorly by the parietal peritoneum of the posterior abdominal wall, superiorly by the transverse mesocolon, and inferiorly by the upper margin of the flexure. When enlarged, it can form a hernial sac for a true internal hernia.

Location and borders

The flexure is located to the left of the vertebral column at the level of the II–III lumbar vertebrae, inferior to the root of the transverse mesocolon (mesocolon transversum).

Topographically, the flexure is closely related to the following structures:

Root of the mesentery of the small intestine (radix mesenterii) begins at the flexura duodenojejunalis and runs obliquely from superior to inferior and from left to right toward the right iliac fossa, crossing anterior to the terminal duodenum, abdominal aorta, inferior vena cava, right ureter, and psoas major muscle.
Inferior mesenteric vein (v. mesenterica inferior) runs to the left of the flexure beneath the body of the pancreas and drains into the splenic vein.

Ligamentous apparatus and Treitz recess

Fixation of the flexure is provided by the suspensory ligament of Treitz (lig. suspensorium duodeni), formed by a peritoneal fold covering the muscle of the same name (m. suspensorius duodeni). The muscle originates from the circular muscular layer of the intestine at the flexure, ascends posterior to the pancreas, expands in a fan-like manner, and blends into the fascia and muscular bundles of the left crus of the diaphragm.

A peritoneal recess—the duodenojejunal recess (recessus duodenojejunalis, or Treitz recess)—forms near the flexure. Its walls are formed by:

Anteriorly — plica duodenojejunalis (a peritoneal fold between the flexure and the root of the mesocolon transversum).
Posteriorly — parietal peritoneum of the posterior abdominal wall.
Superiorly — transverse mesocolon.
Inferiorly — superior border of the flexure.

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Blood supply

The flexura duodenojejunalis receives blood supply from:

Anterior inferior pancreaticoduodenal artery (a. pancreaticoduodenalis inferior anterior).
Posterior inferior pancreaticoduodenal artery (a. pancreaticoduodenalis inferior posterior).
First jejunal artery.

Clinical and surgical significance

The flexure serves as an anatomical landmark during abdominal surgeries:

Locating the initial segment of the small intestine (Gubarev maneuver): To locate the flexure, the surgeon grasps the greater omentum and transverse colon with the left hand, elevates and retracts them upward. Then, using the fingers of the right hand, the surgeon slides along the transverse mesocolon toward the spine, slips to the left, and grasps the first fixed loop of the small intestine.
Intestinal revision: Examination of the small intestine begins at the flexura duodenojejunalis, inspecting each loop sequentially along its free and mesenteric borders. If a wound is identified, it is not sutured immediately; instead, the loop is wrapped in a sponge, secured with a soft elastic clamp, and the revision is continued.
Witzel jejunostomy: In cases of advanced gastric cancer or chemical burns of the stomach where gastrostomy is impossible, a jejunal loop is selected 40–50 cm distal to the duodenojejunal flexure.
Treitz hernia: Pathological enlargement of the Treitz recess (recessus duodenojejunalis) can form a hernial sac for a true internal hernia.

Class and exam questions

How do surgeons locate the duodenojejunal flexure?

This is achieved using the Gubarev maneuver. The greater omentum and transverse colon are grasped, elevated, and retracted upward; the fingers slide along the transverse mesocolon toward the spine, then slip to the left to grasp the first fixed loop.

What forms the suspensory ligament of Treitz?

It is formed by a peritoneal fold covering the muscle (m. suspensorius duodeni). The muscle originates from the circular muscular layer of the intestine at the flexure, passes posterior to the pancreas, and blends into the fascia and muscular bundles of the left crus of the diaphragm.

What is the Treitz recess and why is it clinically significant?

This is a peritoneal depression (recessus duodenojejunalis) bounded anteriorly by the peritoneal fold, posteriorly by the parietal peritoneum of the posterior abdominal wall, superiorly by the transverse mesocolon, and inferiorly by the upper margin of the flexure. When enlarged, it can form a hernial sac for a true internal hernia.

Which arteries supply blood to this flexure?

Blood supply is provided by the anterior and posterior inferior pancreaticoduodenal arteries, as well as the first jejunal artery.

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What else to study on this topic

Duodenum
Root of the mesentery of the small intestine (radix mesenterii)
Inferior mesenteric vein (v. mesenterica inferior)
Pancreas

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Duodenojejunal flexure