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- •Preface
- •Acknowledgments
- •PART 1
- •1: History
- •2: Mesenteric and peritoneal anatomy
- •4: Histology of the mesentery
- •5: Toldt’s fascia
- •6: Mesenteric physiology
- •7: Pathology of the mesentery
- •9: Operative nomenclature
- •10: Teaching mesenteric principles
- •11: Gastroenterology
- •PART 2
- •12: Mesenteric-based colorectal surgery
- •13: Appearance of the mesentery during laparoscopic/robotic colorectal surgery
- •15: Instruments used during mesenteric-based colorectal surgery
- •16: General techniques in mesenteric-based colorectal surgery
- •17: Mesenteric component of sigmoid colectomy
- •18: Mesenteric component of rectal resection
- •19: Mesenteric component of right colectomy
- •22: Mesenteric considerations in small bowel resection
- •25: Mesenteric considerations in reoperative abdominal surgery
- •26: Future directions
- •Appendix A: Operative templates


MESENTERIC PRINCIPLES OF
GASTROINTESTINAL
BASIC AND
SURGERY
APPLIED SCIENCE


MESENTERIC PRINCIPLES OF
GASTROINTESTINAL
BASIC AND
SURGERY
APPLIED SCIENCE

CRC Press
Taylor & Francis Group
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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
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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 innite 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
reection 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
reection 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 modied 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 denition.
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 Coey
ix


How to access three-dimensional models
usingQR codes
Each gure legend in this book will direct the reader to a
QR code. e QR code to be accessed is specied 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
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