Mobilisation of the spleen requires division of the splenorenal ligament. Which structures does this ligament contain?

The splenorenal ligament transmits the splenic artery and splenic vein along with the tail of the pancreas, making option A correct.

Why the splenic vessels and pancreatic tail lie in the lienorenal ligament

The splenorenal ligament, also called the lienorenal ligament, is a double layer of peritoneum that extends from the splenic hilum to the anterior surface of the left kidney. Its contents are defined by embryology: the spleen develops within the dorsal mesogastrium, and the splenic artery and vein must travel through that mesentery to reach the developing splenic hilum. The tail of the pancreas also extends into this same mesenteric fold as the dorsal pancreas elongates during the sixth to seventh week of gestation. Consequently, when the surgeon mobilizes the spleen by dividing the lienorenal ligament, three structures are encountered in the same peritoneal fold: the splenic artery, the splenic vein, and the tail of the pancreas.

The splenic artery, the largest branch of the celiac trunk, follows a highly tortuous course along the superior border of the pancreas before reaching the splenic hilum. The splenic vein runs posterior to the pancreas and joins the superior mesenteric vein to form the portal vein. Because the pancreatic tail lies in immediate proximity to the splenic hilum within the lienorenal ligament, careless clamping or division of this ligament can lacerate the pancreatic tail and produce a postoperative pancreatic fistula. This is the single most important clinical reason the examinee must know the contents of this ligament.

Key anatomical relationships within the lienorenal ligament

Embryological basis: dorsal mesogastrium and its adult derivatives

The lienorenal ligament is a derivative of the dorsal mesogastrium, the embryonic mesentery that suspends the developing stomach and spleen from the posterior abdominal wall. During the fourth week, the spleen appears as a mesenchymal condensation within the dorsal mesogastrium. As the stomach rotates and the greater sac expands, the dorsal mesogastrium is drawn out into several named peritoneal folds. The portion between the stomach and spleen becomes the gastrosplenic ligament. The portion between the spleen and the left kidney becomes the lienorenal ligament. The portion between the spleen and the diaphragm becomes the phrenicosplenic ligament, also called the suspensory ligament of the spleen.

Understanding this embryological framework resolves several common confusions. The lienorenal ligament connects two retroperitoneal structures, the spleen and the left kidney, and therefore its contents are vessels and organs that course between them. The gastrosplenic ligament, by contrast, connects two intraperitoneal structures, the stomach and the spleen, and transmits the short gastric vessels and the left gastroepiploic vessels. The fundus of the stomach is attached to the spleen by this ligament, not by the lienorenal ligament.

Dorsal mesogastrium derivatives in the adult

Clinical application: operative steps in splenectomy

During open or laparoscopic splenectomy, the surgeon mobilizes the spleen by dividing the peritoneal attachments in a predictable sequence. The first step is division of the lienorenal ligament, which brings the splenic hilum into view and allows the splenic artery and vein to be identified and individually ligated. If the lienorenal ligament is divided before the splenic vessels are controlled, the surgeon risks tearing the splenic vein at its junction with the superior mesenteric vein, a hemorrhage that can be difficult to control. After the hilum is secured, the surgeon divides the gastrosplenic ligament, taking care not to avulse the short gastric vessels or injure the greater curvature of the stomach.

The pancreatic tail is the structure most at risk during division of the lienorenal ligament. Anatomical studies using cadaveric dissection report that the tail of the pancreas lies within 1 cm of the splenic hilum in approximately 70 percent of individuals and actually enters the lienorenal ligament in 30 to 40 percent. In inflammatory splenomegaly, as seen in portal hematological disorders, the pancreatic tail may be densely adherent to the splenic hilum, increasing the risk of intraoperative injury. A pancreatic tail injury is managed by oversewing the raw surface and placing a drain, but the injury is best avoided by staying close to the splenic capsule when dividing the lienorenal ligament.

Stepwise mobilization of the spleen in splenectomy

How this question is asked and what separates the correct answer from the distractors

Examiners test the lienorenal ligament in three recurring patterns. The first pattern asks which structures are contained in the ligament, as in this question. The second pattern asks which ligament must be divided first during splenectomy, and the answer is the lienorenal ligament because it gives access to the hilum. The third pattern presents a postoperative pancreatic fistula after splenectomy and asks which structure was most likely injured during mobilization, and the answer is the tail of the pancreas within the lienorenal ligament.

The distractors in this question are deliberately chosen to exploit confusion between the lienorenal and gastrosplenic ligaments. Option B, short gastric vessels and gastric fundus, is the contents of the gastrosplenic ligament. Option C, left suprarenal gland and left crus of the diaphragm, are retroperitoneal structures that lie posterior to the lienorenal ligament, not within it. Option D, left ureter and gonadal vessels, are also retroperitoneal structures located in the pararenal space, separated from the lienorenal ligament by the anterior renal fascia of Gerota.

The discriminating clue in the stem is the word mobilisation. Mobilization of the spleen requires division of the lienorenal ligament to free the spleen from the left kidney and bring the hilum into the operative field. Division of the gastrosplenic ligament is performed later to free the stomach from the spleen. A well-prepared student will therefore select the answer that lists the splenic vessels and the pancreatic tail, the contents of the lienorenal ligament.

Lienorenal versus gastrosplenic ligament: the critical distinction

Why the other options fail

One-glance recall table

Mnemonics

What the exam actually asks

• The lienorenal ligament is the first structure divided in splenectomy to access the hilum, and the gastrosplenic ligament is divided second.
• The tail of the pancreas enters the lienorenal ligament in roughly one third of individuals and is the structure most commonly injured during splenectomy mobilization.
• Postoperative pancreatic fistula after splenectomy is traced to injury of the pancreatic tail within the lienorenal ligament, not to injury of the stomach or the short gastric vessels.
• The suspensory ligament of the spleen, or phrenicosplenic ligament, contains no major vessels and is purely a peritoneal fold connecting the spleen to the diaphragm.
• When the question stem says mobilisation of the spleen, think lienorenal ligament first. When it says freeing the stomach from the spleen, think gastrosplenic ligament.

Traps that cost marks

• Choosing option B because the short gastric vessels are the most commonly discussed vessels in splenectomy, without noticing that they run in the gastrosplenic ligament, not the lienorenal ligament.
• Assuming that the left suprarenal gland lies within the lienorenal ligament because it is adjacent to the spleen in the left upper quadrant, when in fact it lies posterior to the ligament within Gerota fascia.
• Forgetting that the pancreatic tail lies within the lienorenal ligament and therefore selecting an answer that omits it, even though the tail is the structure at greatest risk during mobilization.
• Confusing the phrenicosplenic ligament with the lienorenal ligament and selecting an answer that mentions the diaphragm or the crus, when the phrenicosplenic ligament contains no named vessels.

Frequently asked

What is contained in the lienorenal ligament?

The lienorenal ligament, also called the splenorenal ligament, contains the splenic artery, the splenic vein, and the tail of the pancreas. It is a double layer of peritoneum derived from the dorsal mesogastrium and extends from the splenic hilum to the anterior surface of the left kidney. The pancreatic tail lies within 1 to 2 cm of the splenic hilum in the majority of individuals, making it the structure most vulnerable to injury during surgical mobilization of the spleen.

Which ligament is divided first during splenectomy?

The lienorenal ligament is divided first during splenectomy because it must be opened to bring the splenic hilum into view and allow the splenic artery and vein to be individually identified and ligated. Division of the gastrosplenic ligament, which contains the short gastric vessels and the gastric fundus, is performed only after the hilum has been secured. Dividing the gastrosplenic ligament first risks uncontrolled hemorrhage from the splenic vein.

What is the difference between the lienorenal and gastrosplenic ligaments?

The lienorenal ligament connects the splenic hilum to the anterior left kidney and transmits the splenic artery, splenic vein, and tail of the pancreas. The gastrosplenic ligament connects the greater curvature of the stomach to the splenic hilum and transmits the short gastric vessels and the left gastroepiploic vessels. Both are derivatives of the dorsal mesogastrium, but they connect different structures and contain different neurovascular elements. The lienorenal ligament is divided first in splenectomy; the gastrosplenic ligament is divided second.

References

• Gray's Anatomy, 42nd. Chapter on the posterior abdominal wall and the spleen, peritoneal ligaments
• Bailey and Love's Short Practice of Surgery, 28th. Chapter on the spleen, operative steps in splenectomy
• Robbins and Cotran Pathologic Basis of Disease, 10th. Embryology of the foregut and dorsal mesogastrium derivatives