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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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below proximal portion of descending colon. B. Note that dissection can reach as far
as the spleen. IMV, inferior mesenteric vein.
Caudate: dissection is continued until the maximum extent of dissection
is achieved (Fig. 24-5).
FIGURE 24-5 Caudal extent of dissection with intact Toldt’s fascia on the
retroperitoneum.
Cephalad: the inferior border of the pancreas is identified (Fig. 24-6).
FIGURE 24-6 Superior extent of dissection showing the inferior border of the
pancreas. The inferior mesenteric vein is shown here perpendicular due to retraction.
FIGURE 24-7 Inferior mesenteric vein and descending mesocolon retracted
showing engorged left gonadal vein lying within intact Gerota fascia.
At any point when it is felt unsafe, one should use an alternative approach
to the splenic flexure, such as moving to a lateral or superior approach.
The IMV is divided high below the inferior border of the pancreas. Care
must be taken to avoid injuring the pancreas and/or the duodenum (Fig.
24-8).
FIGURE 24-8 Dividing the inferior mesenteric vein below the inferior border of the
pancreas.
At this juncture, the aim is to enter the embryologic plane between the
base of the transverse mesocolon and the anterior border of the pancreas in
order to gain access to the lesser sac.
The assistant will lift the dissected descending mesocolon and put it
under appropriate tension. Avoid overtension and tears. The surgeon
grasps the transverse mesocolon and retracts cephalad (Fig. 24-9).
FIGURE 24-9 Transected inferior mesenteric vein (IMV) depicting the correct
intended plane to be entered to the lesser sac. This will require traversing through the
both infra-transverse and supra-transverse mesocolic peritoneal layers.
With a combination of blunt and electrocautery, dissection of the
inferior peritoneal layer at the junction between base of transverse
mesocolon and peripancreatic fat is carried out (Fig. 24-10A).
FIGURE 24-10 A. Inferior mesenteric vein transected. From the previous
dissection, now the inferior body of pancreas is exposed and aim is to enter the plane
between the base of transverse mesocolon and peripancreatic fat. B. Dissection in the
peripancreatic plane leading to the supramesocolic peritoneal layer from below with
stomach shown behind this layer. The transverse colon is on the left side of the image.
C. The supramesocolic peritoneal layer is now traversed, and the lesser sac is
entered. Posterior wall of the stomach can be visualized.
This is then continued cephalad to meet the superior peritoneal layer
covering the transverse mesocolon. Penetrating this layer will gain
access to the lesser sac (Fig. 24-10B and C).
Subsequently, the base of the transverse mesocolon is dissected from the
pancreas with a combination of blunt and electrocautery dissection (Fig.
24-11A and B).
FIGURE 24-11 A. Gradual dissection of the transverse mesocolon from the body and
tail (B) of the pancreas, with continued lateral dissection towards the splenic flexure (C)
and the spleen (D).
PEARLS AND PITFALLS
Maintaining the correct plane is important to avoid injuring the pancreas
and the marginal artery, especially in the case where the mesocolon is
foreshortened. Therefore, at this juncture, we like to reassess and
inspect the mesocolon to ensure its intactness.
Further, it is easy to inadvertently miss the pancreas from the sub-IMV
approach and start to dissect under the pancreas and get into the splenic
vein especially in obese patients.
When starting under the IMV, look “up” as the inferior border of the
pancreas is brought up with the mesentery until it is disconnected.
Dissection is continued laterally until the base of transverse mesocolon
is completely separated from the underlying pancreatic body and tail
(Fig. 24-11C and D).
It is important to realize that the goal is to dissect the mesocolon off
the underlying structure and not the opposite. The latter may mislead
the surgeon to the splenic hilum inadvertently.
Subsequently, lateral attachments of the proximal descending colon are
taken down commencing at the white line of Toldt. This will connect
easily with initially dissected sub-IMV plane, as described earlier (Fig.
24-12A and B).
FIGURE 24-12 Dividing the lateral attachments (A) and meeting the previously
dissected plane (B).
At this point, the attachments between the greater omentum and the
transverse colon are taken down using an energy device, starting
proximally and heading toward the splenic flexure to completely
separate the omentum from the colon (Fig. 24-13A and B).
FIGURE 24-13 Dividing the attachments between the greater omentum and the
transverse colon medially (A) and more laterally (B).
This will leave that last and most challenging portion of the splenic
flexure, which is usually adherently attached to the splenic capsule
and/or the underlying tail of the pancreas relatively easier to navigate
(Fig. 24-14A, B).
FIGURE 24-14 Intra-operative imaging demonstrating how the flexure is initially
(A) and even after dissection (B) adhered to the spleen.
The last attachments can be disconnected in a controlled manner and
with confidence without injuring the colonic conduit, spleen, and/or
pancreas (Fig. 24-15A-D).
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