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Operative nomenclature
J. CALVIN COFFEY, BILL HEALD, AND BRENDAN J. MORAN
9
Aim 119
Introduction 119
Anatomic terminology 120
In general 120
Pedicles 120
Mesentery 121
Peritoneal reection 125
Fascia 128
Congenital adhesions 128
If the English language made any sense, lackadaisical would have something to do with
A shortage of owers
Doug Larson
AIM
e rst aim is to discuss the general importance of
nomenclature in surgery. e second aim is to summarize the anatomic nomenclature that stems from recent
advancements in our understanding of mesenteric and
peritoneal anatomy. e third aim is to demonstrate how
this is applicable to colorectal surgical procedures and
operations.
INTRODUCTION
Nomenclature is the code used to aid description. An
eective nomenclature comprises elements that are rational and, when combined, have a meaning that is greater
than each element in isolation. In chemistry, the elements
are combined to represent molecules and the combination of these represents chemical interactions. In mathematics, symbols are used to represent concepts and their
combination in equation format becomes a function.
Although gastrointestinal surgery is a science, the associated nomenclature is imprecise. If we are to utilize conventional surgical nomenclature, then an example would
be as follows:
Surgical adaptation of anatomic terminology 131
Resectional nomenclature in colorectal surgery 131
Technical nomenclature 131
Partial or total right mesocolectomy 133
Application of terminology to radiological
nomenclature 134
Future directions 135
Summary 135
References 135
Total mesorectal excision involves mobilization
ofthe mesorectal package conned by the meso-
rectal fascia, by its separation via diathermy, from
extra mesorectal fascial structures.
A further example is
Complete mesocolic excision involves separa-
tion of the parietal and visceral fascia.
Given the confu sion and misconceptions that have sur rounded
mesenteric anatomy, it is not surprising that a broad lexicon
of terminology has been developed by dierent clinical and
scientic disciplines [1–6]. While it is correct to say that surgeons have long recognized the importance of the mesenteric
package, it was not until the development of total mesorectal
excision, the emergence of laparoscopic and robotic colorectal surgery, and the recent demonstration of mesenteric continuity that the mesenteric basis of intestinal surgery gained
prominence [7–10]. Not surprisingly, there has been a lag time
in synchronizing surgical operative and technical nomenclature with these developments [1–4]. Terms “total mesorectal
excision,” “complete mesocolic excision,” and “total mesocolic excision” are relatively new and are increasingly being
adopted into the technical lexicon [1–4,11–26]. ey have yet
to fully substitute terms such as “anterior resection,” “proctosigmoidectomy,” and “ileocolic resection.”
e radiological nomenclature utilized in addressing
the mesentery is also hampered by little overall consensus.
Oentimes, the terms Gerota’s fas cia, the “anterior renal fascia,”
and the “anterior pararenal space” are used interchangeably.
119
120 Operative nomenclature
abdominal wall
Mesenteric root region
Duodenum
Duodenojejunal flexure
Although mesenteric and mesocolic are increasingly used in
radiologic appraisals of intra-abdominal disease, the terms
Toldt’s fascia and peritoneal reections are infrequently used,
and no distinction is made between exural and nonex-
ural components or attached and mobile components of the
mesocolon [27–30]. is stems largely from the diculties
associated with this eld. While it may be possible to readily
identify the right and le mesocolon, as well as the mesorectum, separate regions of the mesosigmoid are more dicult
to categorize. In addition, extension of the mesentery at the
intestinal margin means that there is considerable folding and
overlap at this level. ese properties are extremely challenging for radiologic interpretation and hence for the development of appropriate terminology [1,3,4,30–32].
In the absence of consensus, and in the context of recent
observations, a rule-based nomenclature should be generated
that can universally be applied across scientic and clinical
disciplines [1–4,33,34]. Any such nomenclature should be
transferrable from anatomic to surgical and radiological contexts. It should be simplistic and clear and thus readily adaptable in an intuitive manner. In this chapter, we rst describe an
intuitive and anatomic-based nomenclature to the mesentery,
peritoneal reection, and Toldt’s fascia. We then apply this
nomenclature to surgical and radiological contexts.
ANATOMIC TERMINOLOGY
Mesenteric root
Duodenum
Posterior
Figure 9.1 View of the anatomic root of the mesentery
in a cadaver. The mesentery fans out from where the
superior mesenteric artery emerges from underneath the
pancreas. This occurs to the right of the fourth part of the
duodenum as indicated.
Although the anatomic terminology has been dealt with in
detail in Chapter 2, a list of terms and associated descriptions will be outlined here.
Root of mesentery: e root of the mesentery occurs
where the superior mesenteric artery emerges from underneath the pancreas. From this point, the entire mesentery
distal to the duodenojejunal exure fans out. Overall, it is
packaged in a spiral conformation and compactly plicated
at the intestinal margin (Figure 9.1).
IN GENERAL
Attachment: Where the mesentery becomes apposed with the
retroperitoneum. It does not refer to insertion of the mesentery into the posterior abdominal wall. e mesentery does
not insert into the posterior abdominal wall at any point.
Suspension: Where the mesentery is suspended from the
posterior abdominal wall at points of vascular continuity.
Duodenojejunal exure: e region of small bowel and
associated mesentery where the duodenum changes from
attached to the nonattached (Figure 9.2).
Intestinal mesentery: Structure interposed between the
intestinal tract and the posterior abdominal wall and contiguous with both (Figure9.3).
Flexural mesentery: Mesenteric component of a exure
(Figure 9.4).
Nonexural mesentery: Mesentery between two exures.
An example is the small bowel mesentery (between the duodenojejunal and ileocecal exure). Examples include the right
and le mesocolon, the mesosigmoid, and mesorectum.
Duodenojejunal flexure
Figure 9.2 The duodenojejunal exure in a cadaver,
wherethe duodenum changes direction to detach
from the posterior abdominal wall and continues as the
jejunum.
Jejunum
PEDICLES
Adipovascular pedicle: Mesentery surrounding a major vessel. Examples include the superior mesenteric artery (and
its ileocolic extension) and the right, middle, and le colic
arteries. Also included are the inferior mesenteric artery and
its continuation as the superior rectal artery (Figure 9.5).
Mesentery 121
mesorectum
Inferior mesenteric adipovascular pedicle
Intestinal mesentery
Mesosigmoid
Splenic flexure
Adipovascular pedicle
Mesorectum
Left mesocolon
Figure 9.3 View of intestinal mesentery in a cadaver.
Theregion demonstrated is the left mesocolon and
mesosigmoid, as well as the adipovascular pedicle of the
inferior mesenteric artery.
Mesenteric component
Transverse colon
Transverse
mesocolon
of splenic flexure
Mesosigmoid Left mesocolon
Mesorectum
Superior
rectal artery in
Inferior
mesenteric
artery
Figure 9.5 Inferior mesenteric artery adipovascular
pedicle as seen following mobilization in a cadaver.
Theinferior mesenteric artery continues distally as
the superior rectal artery once the left colic vessel has
branched off.
Left mesocolon
Peritoneal reflection
Legend
Mesentery
Fascia
Colon
Peritoneum
Left colon
Figure 9.4 (See also QR 9/1 and 2.) 2.5D snapshot of 3D
digital model of splenic exure. The exure has been conceptually removed to demonstrate its component structures.
Interpedicular (avascular) mesentery: Mesentery between
successive vascular pedicles (Figure 9.6).
MESENTERY
Small bowel mesentery: Mesenteric region associated with
the small intestine.
Intestinal mesenteric margin: Edge of the mesentery
attached to the intestine. Note that a corresponding nonin-
testinal margin is lacking as the mesentery fans out from the
superior mesenteric root region (Figure 9.7).
Ileocecal mesenteric region: Region of mesentery associated with terminal ileum and cecum. In this region,
the confluent small intestinal mesentery and right mesocolon taper toward an apex at the ileocecal junction
(Figure9.8).
Mesoappendix: e mesentery attached to the appendix.
is arises from the under surface of the ileocecal mesen-
teric region (Figure 9.9).
Right mesocolon: Region of mesentery attached to the
right colon. Medially, it is contiguous with the small bowel
mesentery. At the hepatic exure, it continues as the transverse mesocolon. e small bowel peritoneal reection is
the medial limit of the right mesocolon (Figure 9.10).
Ileocecal exure: Complex of intestinal, mesenteric, and
peritoneal structures where the ileum continues as the cecum.
122 Operative nomenclature
Large intestine and associated mesentery
(a) (b)
Mesosigmoid
Adipovascular pedicles and avascular interpedicular regions
M
(a)
iddle colic pedicle
Color code
Right colic pedicle
Ileocolic
pedicle
(b)
Red, adipovascular pedicle
Yellow, avascular interpedicular region
Figure 9.6 (a) Postoperative specimen following a total mesocolic excision. Adipovascular pedicles and avascular interpe-
dicular areas are clearly seen. Both regions are highlighted in red and yellow, respectively, in (b).
Transverse mesocolon
Splenic flexure
Left
mesocolon
Mesorectum
Mesoappendix
Figure 9.7 (a) (See also QR 7/3.) 2.5D snapshot of 3D digital model of large bowel and mesentery. (b) The intestinal
tract has been conceptually removed from the model used in (a), in order to demonstrate the intestinal margin of the
mesentery.
Mesoappendix(a)
Mesoappendix
Small intestinal mesente
ry
Right mesocolon
Ileocecal mesenteric region
Figure 9.8 (See also QR 1/1.) 2.5D snapshot of 3D digital
model of right mesocolon and small intestinal mesentery.
These are continuous and represent different regions of
the same structure.
Hepatic exure: Complex of intestinal, mesenteric, and
peritoneal structures where the ascending colon continues
as the transverse colon (Figure 9.11).
Transverse mesocolon: Mesentery attached to transverse
colon. It is formed by merging of the mesenteric components of the hepatic and splenic exure, and the middle colic
Mesentery 123
adipovascular pedicle. e mesenteric component of the
hepatic and splenic exure coalesce with the adipovascular
pedicle of the middle colic vessel. e transverse mesocolon is suspended at the origin of the middle colic artery and
extends toward its intestinal margin.
Splenic exure: Complex of intestinal, mesenteric, and
peritoneal structures where the transverse colon continues
as the descending colon (Figure 9.12).
Le mesocolon: Mesenteric region attached to the le
colon. e le colon provides a lateral limit. e medial
limit is formed by le medial peritoneal reection.
Proximal sigmoid exure: Complex of intestinal tract,
mesentery, and peritoneal reection where the descending
colon continues as the sigmoid colon (Figure 9.13).
Distal sigmoid exure: Complex of intestinal tract, mesentery, and peritoneal reection where the sigmoid colon
continues distally as the rectum (Figure 9.13).
Mesosigmoid: Mesentery attached to sigmoid. It is contiguous above and below with the le mesocolon and mesorectum, respectively (Figure 9.14).
Mobile mesosigmoid: Mobile region of mesosigmoidal
mesentery attached to the sigmoid. It converges on the
attached region of the mesosigmoid (Figure 9.14).
Attached mesosigmoid: Region of mesosigmoidal
mesentery attached to (i.e., attened against) the retroperitoneum. It is a medial extension of the mobile mesosigmoid and the caudal extension of the le mesocolon
(Figure9.14).
Rectosigmoid junction: e transition between sigmoid
colon and upper rectum (Figure 9.15).
Mesorectum: e mesentery associated with the rec-
tum (Figure 9.15). It is a downward extension of the
mesosigmoid.
Crohn’s disease
Figure 9.9 (a) Postoperative demonstration of the origin of the mesoappendix from the undersurface of the ileocecal
mesenteric conuence. (Continued)
124 Operative nomenclature
Right mesocolon
(a)
l
Mesoappendix
(b)
Small intestiua
mesentery
Right
mesocolon
Figure 9.9 (Continued ) (b) View of the mesoappendix and its origin from the nearby mesenteric conuence after
mobilizing this from the posterior abdominal wall.
Section cut
See below
Legend
Mesentery
Colon
Peritoneum
Figure 9.10 2.5D snapshot of 3D (a) (See also QR 2/1.) digital model demonstrating the mesentery. (Continued)
ry
Left mesocolon
Right mesocolon(b)
of hepatic flexure
of hepatic flexure
Hepatic flexure
Figure 9.10 (Continued ) 2.5D snapshot of 3D (b) (See also QR 4/1.) right mesocolon.
Peritoneal reection 125
Transverse
mesocolon
Small
intestinal
mesente
Colic component
of hepatic flexure
Legend
Mesentery
Fascia
Colon
Peritoneum
Peritoneal component
Figure 9.11 (See also QR 11/1,2.) 2.5D snapshot of 3D digital
model of hepatic exure. The exure has been conceptually
removed to demonstrate its component structures.
Mesenteric component
PERITONEAL REFLECTION
e following description is not meant to indicate that
there are separate reections. e peritoneal reection is
continuous and distinct anatomic demarcations are not
apparent between regions. e following are the regions of
the peritoneal reection as they are currently understood.
Small bowel peritoneal reection: Peritoneal reection at
the base of the small intestinal mesentery where it curves onto
and becomes attached to the retroperitoneum (Figure 9.16).
Ileocecal peritoneal reection: Continuation of the small
intestinal peritoneal reection at the ileocecal exure where
it attaches exural regions to the posterior abdominal wall
(Figure 9.17).
Right peritoneal reection: Cephalad continuation of the
ileocecal peritoneal reection along the right paracolic gutter and toward the hepatic exure (Figure 9.18).
Hepatocolic peritoneal reflection: Continuation of the
right peritoneal ref lection around the hepatic f lexure
where it attaches to the colic component of the flexure
(Figure 9.19).
Omentocolic reection: Peritoneal reection interposed
between the greater omentum and the upper surface of the
transverse colon (Figure 9.20).
Le peritoneal reection: Distal continuation of splenocolic reection along the le paracolic gutter (Figures 9.21
and 9.22).
126 Operative nomenclature
Descending colon(b)
Splenic flexure
Transverse
colon
Legend
Mesentery
Flexure removed
Descending colon
Transverse
mesocolon
Fascia
Colon
Peritoneum
(a)
Transverse
Mesenteric
component of
splenic flexure
Left
mesocolon
Colic component
of splenic flexure
colon
Peritoneal
component of
splenic flexure
Figure 9.12 (See also QR 9 and 10.) (a) Digitized view of the splenic exure with the exure itself removed. The remaining
anatomic structures and their relations are apparent. (b) Digital view of the splenic exure removed from related anatomic
structures. The relations between the colon, mesentery, fascia, and peritoneum are apparent.
Lateral mesosigmoidal
Mobile mesosigmoid
(a) (b)(c)
Mesosigmoid
(a)
(d)
mesosigmoid(c)
peritoneal reflection
Distal sigmoidal flexure
Mobile region
of mesosigmoid
Proximal
sigmoidal flexure
Congenital
adhesions
Lateral aspect of
mobile region
of mesosigmoid
Lateral peritoneal
reflection after
division of
congenital
adhesions
Peritoneal reection 127
Proximal
sigmoidal
flexure
Figure 9.13 (See also QR 7/4-6.) (a) Schematic 2.5D image demonstrating the mesosigmoid as one might encounter it
intraoperatively in the undisturbed format. The divided line is the line of the left mesosigmoidal peritoneal reection that
is obscured from view at rst. (b) The mesosigmoid has been partially mobilized by dividing congenital adhesions and the
line of the left mesosigmoidal peritoneal reection is exposed distally. (c) When congenital adhesions are fully divided, then
the mobile component of the mesosigmoid is free and, when medialized, exposes the full extent of the left mesosigmoidal
peritoneal reection. This represents the true starting point of mesosigmoidal mobilization in colorectal surgery. (Courtesy
of CCF. Copyright 2010.)
Left mesocolon
Attached
mesosigmoid
Attached
mesosigmoid
(b)
Distal
sigmoid
Mobile mesosigmoid
Sigmoid
proximal to
rectosigmoid
junction
Mobile
Figure 9.14 (See also QR 5/1.) Schematic illustrations of the axial sections through the mesosigmoid at successively more
distal levels. The mesosigmoid comprises attached and mobile regions. The attached component is the distal continuation
of the left mesocolon. Both the attached and mobile regions’ margins converge at the rectosigmoid junction where the
mesosigmoid continues distally as the mesorectum.