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MESENTERIC PRINCIPLES OF
GASTROINTESTINAL
BASIC AND
SURGERY
APPLIED SCIENCE
MESENTERIC PRINCIPLES OF
GASTROINTESTINAL
SURGERY
APPLIED SCIENCE
CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742
© 2017 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed on acid-free paper Version Date: 20160812
International Standard Book Number-13: 978-1-4987-1122-7 (Pack - Book and Ebook)
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medi­cal science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibilit y of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers.
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There is nothing new under the sun.
Ecclesiastes 1:4-11
I could be bounded in a nutshell, and count myself a king of innite space.
Hamlet, Act II, Scene 2
To Dee
and
Victor Warren Fazio
Master without peer

Preface

This work is intended to furnish the Student and Practitioner with an accurate view of the Anatomy of the Human Body, and more espe­cially the application of this science to Practical Surgery.
Henry Gray (1858)
MESENTERIC-BASED SURGERY DEFINED
Mesenteric-based surgery is where the surgeon exploits mesenteric and associated structures in guiding an intesti­nal resection. e associated structures are the peritoneal reection and Toldt’s fascia. Rather than indiscriminately dissecting through tissue, structures, and planes, the surgeon selects certain structures and conducts a particular activity related to that structure. For example, during sigmoid mobi­lization for colectomy, the surgeon divides the peritoneal reection at the right side of the base of the mesosigmoid (via a peritonotomy), which exposes the underlying meso­fascial plane. is plane is formed at the interface between the mesosigmoid and the underlying Toldt’s fascia. e sur­geon then separates the components of this plane to mobilize the mesosigmoid.
Nonmesenteric-based surgery is one where the surgeon
does not adhere to a particular anatomic roadmap. e mesentery is divided directly across and dissociated from the posterior abdominal wall. During dissociation, the ret­roperitoneum and contained structures are oen not recog­nized before being damaged.
Examples of mesenteric-based surgery now abound and include complete mesocolic excision, total mesorectal excision, and total mesocolic excision. Variations are also emerging, including transanal total mesorectal excision
and modied complete mesocolic excision. As part of these procedures, the surgeon accesses the mesofascial plane in a targeted manner (through division of the peritoneal reec­tion), then mobilizes an intact mesentery without its disrup­tion. Similarly, the retroperitoneum and covering fascia are preserved. When the mesentery is suciently mobilized, the vessels contained within are selected, skeletonized, and divided, and the mesentery is similarly divided up to the level of the intestine.
Several terms have been used in reference to nonmesen-
teric-based surgery. ese include “conventional” surgery, “non-CME surgery, and “non-TME surgery.” Unfortunately, the terms “CME” and “TME” have not been scientically dened in the rst instance, and so the related terms also lack denition.
Mesenteric-based surgery has been practiced internation­ally for over a century and thus is far from new. However, it is certainly not universally practiced, and considerable varia­tion has been demonstrated. e variation is explained by the disparity that has persisted between anatomic and sur­gical approaches to the intestine for the past century. While mesenteric-based surgery is far from new, it is remarkable that its anatomic basis has only recently been formally described.
is means that the principles can now be reproducibly taught and conducted in an entirely standardized manner. is book is composed of two parts. In the rst part, the mesentery, peritoneum, and associated fascia are charac­terized. In the second part, the data explained in the rst are applied to all aspects of resectional colorectal surgery. Surgical anatomy, activities, and operations are carefully dened to enable all surgeons to reproducibly conduct mesenteric-based surgery.
J. Calvin Coey
ix
How to access three-dimensional models usingQR codes
Each gure legend in this book will direct the reader to a QR code. e QR code to be accessed is specied in the rst number in the following annotation: “QR 2/3.” is directs the reader to QR code 2 and annotation 3.
e QR codes are listed below. Using the example above,
the reader should identify QR 2 below and scan the QR code with a QR reader (i.e., in a smart phone, lap-top, or tablet).
QR 1 - Overview of mesentery
and intestine
QR 2d - Mesentery, peritoneum
and intestine
QR 3d -Sectioned view of right
and left mesocolon
as seen from above II
e reader then will be brought to a three-dimensional model relating to the gure legend and gure in question, with a series of numbers overlaying the model. By clicking on the number 3, the reader will be brought to a particular viewpoint of the model.
QR codes and models can also be accessed directly at the website “www.mpgs.ie.”
QR 2 - Mesentery, peritoneum
and intestine
Sectioned view of right
QR 3 -
and left mesocolon
as seen from above I
QR 4 - Sectioned view of right
and left mesocolon
viewed from below up
QR 5 - Sectioned view of the
mesosigmoid as seen
from above down
QR 7 - Colon and mesocolon
QR 6 - Sectioned right and left
mesocolon viewed
from below up
QR 8 - Medial view of base of small
intestinal mesentery
xi