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Mesosalpinx

The mesosalpinx is a fold of peritoneum that forms part of the broad ligament of the uterus, specifically serving as the mesentery for the fallopian (uterine) tubes by draping over and enclosing them.^[1] The fallopian tubes, which are enclosed by the mesosalpinx, extend from their fimbriated ends adjacent to the superior pole of the ovary to the cornu of the uterus, with the mesosalpinx providing structural support to the tubes within the pelvic cavity.^[2] Anatomically, the mesosalpinx constitutes the superior portion of the broad ligament, a double-layered peritoneal fold that connects the uterus to the lateral pelvic walls.^[1] It lies between the mesometrium (which supports the uterus) and the mesovarium (which supports the ovary), and its free edge forms the upper border of the broad ligament.^[3] Within its layers, the mesosalpinx houses the fallopian tubes, along with branches of the ovarian and uterine arteries, veins, nerves, and lymphatics that supply these structures.^[1] The fallopian tubes, measuring approximately 10-12 cm in length, course through the mesosalpinx from their fimbriated ends near the ovaries to their openings into the uterine cavity.^[4] The primary function of the mesosalpinx is to anchor the fallopian tubes in position while facilitating their role in gamete transport, as the tubes serve as conduits for oocytes from the ovaries to the uterus and for sperm migration.^[2] It also transmits essential vascular and neural elements to maintain tubal integrity and function.^[1] Clinically, the mesosalpinx is significant in gynecological procedures, such as salpingectomy for ectopic pregnancy or during hysterectomy, where careful ligation of its vascular components is required to avoid complications like hemorrhage or ureteral injury.^[1] Defects or congenital anomalies in the mesosalpinx can lead to herniation of abdominal contents or tubal torsion, potentially necessitating surgical intervention.^[1]

Anatomy

Structure

The mesosalpinx is defined as the superior portion of the broad ligament of the uterus, forming a double-layered fold of peritoneum that drapes over the fallopian tubes and encloses them within its structure.^[1] This peritoneal fold suspends the uterine tubes from the pelvic sidewall, creating a mesentery-like support that integrates the tubes into the pelvic cavity.^[5] Histologically, the mesosalpinx consists of an outer serosal layer formed by a simple mesothelium of flattened to cuboidal epithelial cells, which lines the peritoneal surface and faces the pelvic cavity.^[6] Beneath this lies a layer of loose interstitial connective tissue.^[6] The inner layer mirrors the outer as a continuation of the visceral peritoneum, completing the double-folded enclosure around the fallopian tubes.^[5] Within its folds, the mesosalpinx incorporates vestigial remnants of the mesonephric (Wolffian) duct system, including the epoophoron and paroophoron. The epoophoron, located laterally between the fallopian tube and ovary, comprises 8-20 small tubules that join a common duct, often ending blindly.^[7] Medial to this lies the paroophoron, a rudimentary structure consisting of a few scattered mesonephric tubules.^[7]

Location and relations

The mesosalpinx is a double-layered peritoneal fold that forms the superior portion of the broad ligament within the female pelvic cavity, extending laterally from the uterus toward the pelvic sidewall. It stretches along the length of the fallopian tube, originating from the fimbria ovarica near the ovary and terminating at the uterine cornu where the tube enters the uterus. This structure is present bilaterally, with one mesosalpinx on each side of the uterus, contributing to the intraperitoneal positioning of the reproductive organs.^[1]^[7] In terms of attachments, the superior border of the mesosalpinx adheres directly to the fallopian tube, suspending it within the peritoneal cavity, while its inferior margin connects to the mesometrium, the broader inferior part of the broad ligament that envelops the uterus. Laterally, it adjoins the mesovarium, which extends to cover the ovary, forming a continuous peritoneal sheet that anchors these structures to the pelvic wall.^[1]^[8] The mesosalpinx maintains specific spatial relations to adjacent pelvic structures, lying anterior to the ovary and the underlying ureter, which courses through the base of the broad ligament. Posteriorly, it relates to the round ligament of the uterus, which passes through the broad ligament but remains distinct from the mesosalpinx. Overall, the mesosalpinx envelops the entire length of the uterine tube except for its fimbriated end, which projects freely into the pelvic cavity near the ovary.^[9]^[7]^[8]

Function

Support and protection

The mesosalpinx serves as a key structural component in suspending the uterine tube (fallopian tube) within the pelvic cavity, anchoring it to the broad ligament and preventing sagging or excessive mobility that could lead to torsion.^[10] This suspension is achieved through its double-layered peritoneal fold that drapes over and encloses the tube, maintaining its position relative to the pelvic sidewall during normal movements.^[1] By stabilizing the tube in this manner, the mesosalpinx ensures optimal alignment for ovum transport and reduces the risk of mechanical displacement.^[10] As a protective enclosure, the mesosalpinx acts as a barrier that shields the fallopian tube from mechanical injury arising from pelvic motion.^[1] Its serous membrane wrapping minimizes direct exposure of the tube to surrounding peritoneal surfaces, thereby limiting friction-induced damage.^[11] This encasement also helps preserve the tube's integrity by distributing forces evenly across the broad ligament during physical activity.^[1] The mesosalpinx contributes to the overall stability of the broad ligament complex, which collectively supports the pelvic reproductive organs.^[12] Through its attachment to the superior margin of the broad ligament, it reinforces the ligament's role in countering gravitational and dynamic stresses on the uterus.^[1] This integrative support enhances the resilience of the entire adnexal structure.^[12] Additionally, the mesosalpinx plays a role in containing peritoneal fluid around the fallopian tubes, providing lubrication that reduces inter-organ friction and supports smooth mobility within the pelvic cavity.^[13] As a peritoneal fold, it facilitates the distribution of this serous fluid, which is secreted by mesothelial cells to cushion the tubes against adjacent structures during respiration and locomotion.^[13] This lubricating environment is essential for preventing irritation and maintaining the tubes' functional patency.^[11]

Vascular and neural components

The mesosalpinx encloses anastomoses between the uterine and ovarian arteries, which form part of the ovarian arterial arcade and ensure a dual blood supply to the fallopian tube.^[7] Branches from the uterine artery supply the medial two-thirds of the fallopian tube, while branches from the ovarian artery provide blood to the lateral third, collectively nourishing the tubal walls and supporting physiological functions such as ciliary motility and smooth muscle contraction.^[6] These arterial branches course through the mesosalpinx, forming a rich anastomotic network that maintains tubal vascular integrity.^[14] Venous drainage from the fallopian tube parallels the arterial supply within the mesosalpinx, primarily via the pampiniform plexus that consolidates into the ovarian veins; the medial portion drains additionally through uterine veins.^[15] This venous network facilitates efficient return of deoxygenated blood, with the right ovarian vein emptying into the inferior vena cava and the left into the left renal vein, preventing congestion in the tubal tissues.^[7] Neural innervation of the fallopian tube, embedded in the mesosalpinx, includes sympathetic fibers originating from the hypogastric plexus (via T10-L2 spinal segments) and parasympathetic fibers from the pelvic splanchnic nerves (S2-S4), which join to form the tubal nerve plexus accompanying the vessels.^[16] These autonomic fibers regulate tubal motility, influencing peristalsis essential for ovum transport and fluid secretion.^[7] Lymphatic vessels within the mesosalpinx drain the fallopian tube toward the external and internal iliac nodes, as well as para-aortic nodes, providing immune surveillance and fluid balance for the tubal mucosa.^[17] This drainage pathway integrates with ovarian lymphatics, ensuring comprehensive clearance of interstitial fluid and potential pathogens from the reproductive tract.^[2]

Embryology

Developmental origin

The mesosalpinx originates from the dorsal mesentery associated with the urogenital ridge, a structure derived from intermediate mesoderm that forms along the posterior abdominal wall during the 6th to 8th weeks of gestation. This ridge gives rise to both urinary and genital components, with its peritoneal covering—the urogenital mesentery—serving as the precursor to the broad ligament, including the mesosalpinx portion that envelops the uterine tube. As the urogenital ridge elongates and differentiates, the dorsal mesentery provides the supportive framework for emerging genital structures, connecting them to the body wall before subsequent remodeling.^[18] Closely linked to this process is the development of the paramesonephric (Müllerian) ducts, which arise around the 6th week through invagination of the coelomic epithelium into the underlying mesenchyme lateral to the urogenital ridge. These ducts elongate caudally and fuse in the midline by weeks 8 to 10, forming the uterine tubes, uterus, and upper vagina; the mesosalpinx emerges as the peritoneal fold surrounding the unfused cranial portions of these ducts, which become the fallopian tubes. The coelomic epithelium contributes the serosal lining of the mesosalpinx, while the subjacent mesenchyme differentiates into the connective tissue layers, establishing its double-layered peritoneal structure.^[19]^[5]^[19] Sexual dimorphism in mesosalpinx development becomes evident following gonadal differentiation around week 7. In female embryos, lacking anti-Müllerian hormone (AMH), the paramesonephric ducts persist and induce the maintenance of the associated dorsal mesentery as the mesosalpinx within the broad ligament. In male embryos, AMH secreted by Sertoli cells from week 8 causes regression of the Müllerian ducts and their mesenteries, preventing formation of analogous structures and leaving only vestigial peritoneal folds.^[19]^[18]

Formation process

The formation of the mesosalpinx occurs as part of the broader development of the broad ligament during the differentiation of the female reproductive tract. It begins with the initial reflection of the peritoneum over the cranial portions of the paramesonephric (Müllerian) ducts, which give rise to the uterine tubes, starting around gestational weeks 8 to 12. This peritoneal reflection establishes the double-layered fold that will envelop the developing tubes, coinciding with the elongation of the ducts and the onset of their caudal fusion.^[19]^[20] As the uterine tubes elongate laterally, the broad ligament progressively folds and envelops them, forming the mesosalpinx as its superior portion. This envelopment incorporates remnants of the regressing mesonephric (Wolffian) ducts, such as the epoophoron and paroophoron, which persist within the mesosalpinx as benign vestiges. The folding process integrates these structures into the peritoneal mesentery, providing structural support while the paramesonephric ducts continue to differentiate.^[1]^[21]^[22] Vascular incorporation occurs concurrently, with ingrowth of branches from the ovarian artery (arising from the aorta) and uterine artery (from the internal iliac artery) into the forming mesosalpinx fold around week 10, establishing the tubal blood supply through anastomoses. By the end of the third fetal month (approximately week 12), the mesosalpinx formation is complete, marked by its separation from the adjacent mesovarium along the developing ovarian ligament, a derivative of the gubernaculum that anchors the ovary to the uterus.^[2]^[1]

Clinical significance

Surgical considerations

During salpingectomy or hysterectomy, the mesosalpinx serves as a key structure for accessing the fallopian tube, with surgeons typically grasping the ampullary or fimbriated end of the tube using a Babcock clamp and elevating it to expose the mesosalpinx for dissection. An incision or transection is made parallel to the tube along the mesosalpinx, starting from the fimbriae and proceeding medially toward the uterine cornua, ensuring complete removal of the tube while preserving adjacent ovarian tissue. This approach, applicable in open, laparoscopic, or vaginal routes, involves fenestrations or electrosurgical dissection of the mesosalpinx to isolate and transect vascular pedicles close to the tubal side.^[23]^[24] Opportunistic salpingectomy, recommended by organizations such as the American College of Obstetricians and Gynecologists (ACOG) and the International Federation of Gynecology and Obstetrics (FIGO), involves removal of the fallopian tubes during other pelvic surgeries (e.g., hysterectomy or tubal ligation) to reduce the risk of epithelial ovarian cancer. This procedure targets the mesosalpinx to excise the tubes, as emerging evidence indicates that many high-grade serous ovarian cancers originate in the fimbriated ends of the fallopian tubes. Studies show a 42-65% reduction in ovarian cancer risk following salpingectomy, without significantly impacting ovarian function. As of 2024, this approach is increasingly adopted in benign gynecologic surgeries for prevention in average-risk women.^[25]^[26] To control bleeding, ligation targets the tubal branches arising from the uterine artery, which course through the mesosalpinx and anastomose with ovarian artery branches to supply the fallopian tube. Small clamps, such as Kelly or tonsil clamps, or vessel-sealing devices are applied across these vessels within the mesosalpinx, favoring the tubal margin to minimize disruption to ovarian blood supply, followed by transection and suture ligation if needed. This segmental vascular organization in the mesosalpinx necessitates meticulous hemostasis to prevent avulsion or excessive bleeding from the delicate pedicles.^[15]^[23]^[27] Due to the ureter's proximity within the base of the broad ligament, dissection of the mesosalpinx carries a risk of ureteral injury, particularly during adnexal procedures where the ureter lies medial and inferior, sometimes as close as 5 mm to key vascular structures. Careful retroperitoneal or intraperitoneal visualization and minimal skeletonization are essential to avoid clamping, transection, or kinking, with injury rates reported at 0.5-2% in hysterectomies and up to 2% in laparoscopic gynecologic surgery. Intraoperative ureteral stents may aid identification in high-risk cases.^[28]^[29] In laparoscopic oophorectomy, the mesosalpinx acts as an anatomical landmark for isolating ovarian vessels within the infundibulopelvic ligament, guiding transection parallel to the fallopian tube remnant after initial salpingectomy to delineate the plane between tubal and ovarian structures. This facilitates safe coagulation and division of the ovarian pedicle while avoiding distortion from adhesions, enhancing precision in minimally invasive approaches.^[24]^[30]

Associated pathologies

Endometriosis can involve the mesosalpinx through ectopic endometrial tissue implantation, leading to the formation of adhesions that distort the normal anatomy and contribute to infertility by impairing tubal function and ovarian reserve.^[31] In such cases, the mesosalpinx may become adherent to surrounding structures like the ovary or pelvic sidewall, exacerbating inflammatory responses and chronic pelvic pain.^[32] Studies indicate that mesosalpinx involvement in endometriomas is associated with a significant postoperative decline in anti-Müllerian hormone (AMH) levels, suggesting long-term damage to ovarian function and reduced fertility potential.^[31] Defects in the mesosalpinx, whether congenital or iatrogenic, are rare but can result in internal hernias where loops of small bowel or the ovary herniate through the gap, potentially causing strangulation and ischemia.^[33] These defects often present with acute abdominal pain and signs of bowel obstruction, as seen in cases of gangrenous ileum herniation requiring emergent laparotomy.^[33] Congenital openings in the mesosalpinx have also been linked to simultaneous ovarian torsion and gangrenous strangulation, mimicking intestinal pathology and necessitating prompt surgical repair to prevent necrosis.^[34] Rare tumors arising from the smooth muscle components of the mesosalpinx include leiomyosarcomas and lipoleiomyomas, which typically manifest as pelvic masses causing pain or discomfort. Leiomyosarcomas originate from the smooth muscle surrounding adnexal vessels and present as large, solitary masses with hemorrhagic necrosis, often detected incidentally during imaging for nonspecific lower abdominal symptoms.^[35] Lipoleiomyomas, benign variants composed of smooth muscle and adipose tissue, may occur in the mesosalpinx or adjacent fallopian tube structures and can degenerate, leading to acute pain from mass effect, as in cases of hydropic degeneration mimicking ovarian tumors.^[36] Hydrosalpinx, characterized by fluid accumulation in the fallopian tube due to distal occlusion, often stretches the mesosalpinx as the distended tube increases in bulk, potentially leading to adhesions or torsion.^[37] This condition frequently follows pelvic inflammatory disease from infections like chlamydia or gonorrhea, resulting in chronic tubal distension that impairs the mesosalpinx's supportive role and contributes to infertility by creating a toxic environment for embryos.^[38] The mechanical strain on the mesosalpinx can exacerbate pelvic pain and complicate fertility treatments, with surgical intervention often required to mitigate these effects.^[39]

References

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