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128 Operative nomenclature
Rectosigmoid junction removed
of the intestine
Small intestinal peritoneal reflection
Right mesosigmoidal peritoneal reection: Surface meso-
thelium of the le mesocolon near the midline. It is contiguous above with the mesothelium on the undersurface of the
transverse mesocolon. Below, it is continuous with the right
mesosigmoidal peritoneal reection. Medially, the mesothelium separates from the mesocolon to continue onto the
posterior abdominal wall.
Le mesosigmoidal reection: Distal continuation of the
le peritoneal reection along the le lateral aspect of the
mesosigmoid (Figure 9.22).
Right mesosigmoidal reection: Peritoneal reection at
the medial aspect of the mesosigmoid.
Pararectal reections: Peritoneal reections at either side
of the rectum and mesorectum. e le pararectal reection is a continuation of the le mesosigmoidal reection.
e right pararectal reection is a continuation of right
mesosigmoidal reection (Figure 9.23).
Anterior reection: Peritoneal reection formed by merg-
ing of the right and le pararectal reections in the rectovesical pouch of Douglas, in the anterior midline (Figure9.23).
Flexure extracted
Figure 9.15 Schematic illustration of the region where
the mesosigmoid continues distally as the mesorectum.
This gastromesenteric junction has been conceptually removed from the image to illustrate the mesosigmoid and mesorectum both proximally and distally,
respectively. (Courtesy of CCF. Copyright 2010.)
Jejunum
FASCIA
Waldeyer’s fascia: A condensation of Toldt’s fascia in the
distal pelvis interposed between the distal apex of the
mesorectum and the sacrum posteriorly. e fascia lls
thespace created between the termination of the mesorectum and the surrounding pelvis.
Toldt’s fa scia: Fascia interposed between the mesentery
and the retroperitoneum wherever mesentery is attached
to the latter (i.e., right and le mesocolon, attached component of mesosigmoid and mesorectum). Zones of the fascia
are termed according to the region of mesentery associated.
e fascia around the mesorectum is termed the mesorec-
tal fascia. e fascia interposed between attached mesosigmoid and retroperitoneum is termed the mesosigmoidal
fascia. Gerota’s fascia corresponds to the region of Toldt’s
fascia that surrounds perirenal fat. Waldeyer’s fascia is a ret-
rorectal condensation of the mesorectal fascia in the distal
pelvis.
Although the terms right and le mesocolic fascia are
new, they are intuitive and keeping with the aforementioned
systematized approach to nomenclature.
Small
intestinal
mesentery
Peritoneal reflection
at the base
Figure 9.16 (See also QR 8/1.) View of the medial aspect
of the peritoneal reection at the base of the small intestinal mesentery, in a cadaver.
CONGENITAL ADHESIONS
Mesosigmoidal congenital adhesions: Congenital adhesions
that occur between the lateral aspect of the mesosigmoid
and the parietal peritoneum of the le iliac fossa.
Duodenal congenital adhesions: Adhesions that occur
between the fourth part of the duodenum and the le
mesocolon.
Right congenital adhesions: Congenital adhesions
between the right peritoneal reection and the parietal peritoneum of the right paracolic gutter.
Ileocecal
(b)
Ileocecal peritoneal reflection
Appendix
peritoneal
reflection
Congenital adhesions 129
Terminal
ileum
Legend
Mesentery
Fascia
Colon
Peritoneum
Ileocecal
peritoneal
reflection
(a)
Terminal
ileum
Figure 9.17 (a) Ileocecal peritoneal reection at the inferolateral aspect of the ileocecal junction, as seen in a cadaver.
(b) (See also QR 2/2.) 2.5D snapshot of 3D digital model demonstrating the inferolateral peritoneal reection. An ana-
tomic demarcation is not apparent between this region of the peritoneal reection, and continuous zones (i.e., the right
peritoneal reection and the small bowel mesenteric reection).
130 Operative nomenclature
Right peritonea
reflec
Right mesocolon
(a)
Toldt’s fascia(b)
Peritonotomy
edge
tion being
l
divided
Small bowel mesentery
Right mesocolon
Peritoneal
reflection
Legend
Mesentery
Fascia
Colon
Peritoneum
Figure 9.18 (a) (See also QR 3/3.) View (from below up) of the divided right peritoneal reection at the lateral aspect of the
right colon in a cadaver. (b) (See also QR 3/3.) 2.5D snapshot of 3D digital model of the right mesocolon and colon. The
model has been sectioned through to demonstrate the anatomic relationships of its components. The viewpoint is from
above (i.e., from the hepatic exure) distally, and the right peritoneal reection can be visualized.
peritoneal reflection
Hepatocolic peritoneal reflection
T
ransverse mesocolon
Hepatocolic
Transverse colon
Right colon
Technical nomenclature 131
RESECTIONAL NOMENCLATURE IN
COLORECTAL SURGERY
In resectional surgery, terminology can be broadly divided
into two categories: the rst category (operative nomenclature) is a code of operative titles (i.e., total mesorectal
excision); the second category (technical nomenclature) is
a code of individual activities that, collectively, combine to
make up an operation. e former has recently undergone a
welcome transformation with the emergence of terms such
as total mesorectal excision and complete mesocolic excision [2]. A further similar term is total mesocolic excision.
In contrast, terminology related to specic activities (i.e.,
peritonotomy, mesenterectomy) is entirely lacking. Both
operative and technical nomenclature can be improved on
in a systemized manner by utilizing the anatomic terminology listed earlier.
Importantly, it should be noted that all nomenclature
will have some limitations. Notwithstanding this, eorts
should continue to develop this aspect of colorectal surgical science. As our understanding of anatomy and surgery
continues to evolve, it is likely that the associated nomenclature will also synchronously develop [34]. To facilitate
this development, we propose the following operative
terminologies (Table 9.1):
●
Figure 9.19 (See also QR 2/4.) 2.5D snapshot of 3D
digital model demonstrating the hepatocolic peritoneal
reection. The view is from above downward. The hepatocolic peritoneal reection is continuous laterally with the
right peritoneal reection.
Small bowel resection could be altered to small intestinal
mesenterectomy and the prex total or partial may be
added to indicate the extent of the mesenterectomy.
“Small intestinal” could be omitted from the terminology
as it is implicit in resection of the associated mesentery.
is is because it is not possible to retain a segment of
small bowel once the associated mesentery has been
SURGICAL ADAPTATION OF ANATOMIC
TERMINOLOGY
removed.
●
Right colic excision is better termed right mesocolectomy
and again the prex total or partial can be introduced to
As mentioned earlier, an eective nomenclature is one comprising elements that, when combined, convey a meaning that
would not be apparent when used in isolation. e examples
indicate the extent of the mesenterectomy.
TECHNICAL NOMENCLATURE
given included nomenclature used in mathematics and chemistry. In both cases, the elements of each nomenclature can be
combined to convey meaning, rules, and functions.
Terminology used in resectional colorectal surgery has
changed little over the past half century. Terms such as ileocolic resection, anterior resection, and proctosigmoidectomy primarily reect the intestinal component of resection
and ignore the mesenteric component. Examination of time
spent in mesenteric mobilization, division, and resection
reveals this comprises a greater component of gastrointestinal resection than heretofore acknowledged. It is reasonable therefore to place a greater emphasis on the mesenteric
component. e anatomic terminology described earlier
consists of individual elements that, when combined, convey the activities required for complete mesenterectomy
[1–4,33]. ey provide the basis of a systemized approach to
surgical nomenclature in general.
is refers to the individual surgical activities that collectively describe the operation in question. e following will
focus on the activities required for mobilization, division,
and resection of the mesentery. e activities required for
intestinal division and anastomosis are beyond the scope of
this chapter.
Mesenteric-based activities are largely targeted toward
the peritoneal reection, the mesentery itself, and the
underlying fascia. As a result, and based on the anatomic
terminology listed earlier, there is now an opportunity to
generate an appropriate technical nomenclature in a systemized manner [1,4]. An example of this principle relates
to peritoneal reections. Peritonotomy is essential to access
the colo- or mesofascial plane. Table 9.2 lists the terms that
describe the individual surgical activities required for mesenteric mobilization, division, and resection.
132 Operative nomenclature
(a)
Greater
Omentocolic peritoneal reflection
y
Peritonotomy of reflection(b)
omentum
Transverse
colon
Peritoneal reflection
Greater
omentum
Peritonotom
margin
Transverse colon
Figure 9.20 (a) Omentocolic reection connecting the greater omentum and underlying transverse colon, as seen in a
cadaver. (b) View of the omentocolic reection in a cadaver following peritonotomy of the reection.
Partial or total right mesocolectomy 133
Left peritoneal reflection
Left peritoneal reflection
peritoneal reflection
(descending) colon
Left mesosigmoidal peritoneal reflection
Pararectal peritoneal reflection
Left (descending) colon
Toldt’s fascia
Figure 9.21 Image from cadaver where the viewpoint
is from inferior to superior, along the left peritoneal
reection. The peritoneal reection has been divided
distally to expose the colofascial interface beneath it.
Right mesosigmoidal
peritoneal reflection
Left
pararectal
peritoneal
Right
pararectal
peritoneal
reflection
Figure 9.23 (See also QR 2d/5-7.) Right and left pararectal peritoneal reections demonstrated using a 2.5D
snapshot from a 3D digital sculpture. The reections
coalesce in the anterior midline as the anterior reection
in the pouch of Douglas.
reflection
Left
Sigmoid colon
Left mesosigmoidal
Figure 9.22 (See also QR 2d/1-2.) 2.5D snapshot of 3D
digital model demonstrating the left mesosigmoidal
peritoneal reection from lateral to medial.
Left peritoneal
reflection
PARTIAL OR TOTAL RIGHT
MESOCOLECTOMY
A description of “total” or “partial right mesocolectomy” follows [4]. e description is based on the earlier
nomenclature and aims to illustrate the utility of this
nomenclature.
A peritonotomy of the ileocecal reection is made and
continued laterally to the right peritoneal reection. If the
colon/mesentery complex is lied away from the posterior
abdominal wall, the colofascial and mesofascial planes and
respective components are apparent. Colofascial followed
by mesofascial separation is then conducted. Peritonotomy
of the ileocecal reection is continued medially toward the
duodenojejunal exure along the small bowel mesenteric
reection (i.e., at the base of the small intestinal mesentery).
is exposes the mesofascial interface formed by the right
mesocolon and Toldt’s fascia. Mesofascial separation frees
the right mesocolon from the retroperitoneum without
entering the retroperitoneum proper.
e dissection is then turned to the lateral aspect of the
right/ascending colon where peritonotomy of the right peri-
toneal reection exposes the colofascial or mesofascial interface here. Components of the latter a re then separated. When
this process is continued medially, the small intestinal mesentery, right mesocolon, right colon, ileocecal junction, and
134 Operative nomenclature
Table 9.1 Summary of current terminology, proposed terminology, and abbreviations associated
withproposed surgical terminology
Current terminology Proposed terminology Abbreviation
Right hemicolectomy Right colectomy and mesocolectomy Right mesocolectomy (RMC)
Left hemicolectomy Left colectomy and mesocolectomy Left mesocolectomy (LMC)
Sigmoidectomy Sigmoidectomy and mesosigmoidectomy Mesosigmoidectomy (MSE)
Anterior resection Mesosigmoidectomy and mesorectal excision MSE + TME
Total colectomy Total mesocolectomy TMC
Table 9.2 Summary of various descriptors for conduction mesenteric surgery
Terms Denition
Peritonotomy Division of the peritoneum
Mesenterectomy Resection of part or all of a mesenteric region
Mesenterotomy Line of division of the mesentery
Colofascial plane Interface between colon and the underlying Toldt’s fascia
Mesofascial plane Interface between mesocolon and the underlying fascia
Colofascial separation Separation of components of the colofascial plane
Mesofascial separation Separation of components of the mesofascial interface
Retrofascial interface Interface formed between the retroperitoneum and overlying Toldt’s fascia
Retrofascial separation Surgical separation of the components of the retrofascial interface
mesenteric conuence are fully mobilized. e mesentery is
intact, as is the fascia overlying the retroperitoneum.
A peritonotomy of the hepatocolic reection is performed.
e colic component of the hepatic exure is exposed and
components of the colofascial interface separated. emesenteric component of the hepatic exure must then be separated, via mesofascial separation, from the underlying fascia.
Medially, in the region of the second part of the duodenum
and head of pancreas, the mesentery thins out to comprise
mainly a mesothelium only (i.e., the base of the transverse
mesocolon).
e greater omentum (which is attached to the upper
surface of the transverse mesocolon) is separated from the
transverse mesocolon, to achieve complete mobilization
of the transverse mesocolon. is is done by rst dividing
(i.e., peritonotomy) the omentocolic reection attaching the
under surface of the greater omentum to the transverse
colon. Next, focal adhesions attaching the under surface of
the greater omentum and upper surface of mesocolon are
divided. is fully exposes the lesser sac. By adopting the
earlier approach, the entire right colon and mesocolon can
be mobilized without disruption of the mesocolic package.
e resultant mobility means that the associated mesenteric
organ can be lied out of the peritoneal cavity for easy identication of contained vessels [4].
e ileocolic adipovascular pedicle is apparent within
the right mesocolon/small bowel mesenteric conuence.
Other vascular pedicles include the right and middle colic
adipovascular pedicles. In these, peritonotomy followed
by adipose clearance skeletonizes the contained vessels and permits their division. Mesenterotomy of interpedicular mesentery separates the region for resection.
Anterograde mesenterotomy up to the intestinal margin
completes the mesenterectomy. Gastrointestinal resection
is completed by division and anastomosis. ese steps,
and the nomenclature associated, are beyond the remit of
the current text.
APPLICATION OF TERMINOLOGY TO
RADIOLOGICAL NOMENCLATURE
Digital imagery provided by the visual human project
enables identication of the mesentery, associated fascial and peritoneal attachments, in full color, and as one
might in a cadaveric dissection [30,33,35–38]. e availability of matching CT and MRI images has meant that
shapes identied on radiologic imaging can be correlated
to corresponding structures in the cadaver [39]. Using this
approach, the structure previously referred to as the “anterior renal fascia” is seen to correspond to Toldt’s fascia, and
the “anterior pararenal space,” to the le mesocolon [30].
us, the anatomic nomenclature detailed in the rst component of this chapter can also be applied to describe structures identied in radiologic appraisals of the abdomen.
References 135
FUTURE DIRECTIONS
e utility of the nomenclatures developed should be
formally tested in a trial setting.
SUMMARY
A functional nomenclature comprises elements that can
be combined in numerous formats to convey meaning that
would not otherwise be apparent. An anatomic nomenclature
was developed based on recent advancements in our understanding of mesenteric and peritoneal anatomy. From this, an
operative nomenclature was developed, which was applied to
colorectal surgery. e nomenclature is universally applicable
(even in non [mal] rotation and situs inversus) and enables the
application of a scientic rigor that heretofore has been lacking.
REFERENCES
1. Culligan, K. etal., Review of nomenclature in colonic
surgery—Proposal of a standardised nomenclature
based on mesocolic anatomy. Surgeon, 2013. 11(1): 1– 5.
2. Sehgal, R. and J.C. Coffey, Standardization of the
nomenclature based on contemporary mesocolic
anatomy is paramount prior to performing a complete mesocolic excision. Int J Colorectal Dis, 2014.
29(4): 543–544.
3. Coffey, J.C., Surgical anatomy and anatomic
surgery—Clinical and scientic mutualism. Surgeon,
2013. 11(4): 177–182.
4. Coffey, J.C. etal., Terminology and nomenclature in
colonic surgery: Universal application of a rule-based
approach derived from updates on mesenteric
anatomy. Tech Coloproctol, 2014. 18(9): 789–794.
5. Coffey, J.C. et al., The mesentery in Crohn’s disease: Friend or foe? Curr Opin Gastroenterol, 2016.
32(4):267–273.
6. Coffey, J.C. and P. Dockery, Colorectal cancer:
Surgery for colorectal cancer—Standardization
required. Nat Rev Gastroenterol Hepatol, 2016.
13(5): 256–257.
7. Heald, R.J., The “Holy Plane” of rectal surgery.
JRSoc Med, 1988. 81(9): 503–508.
8. Heald, R.J., E.M. Husband, and R.D. Ryall, The mesorectum in rectal cancer surgery—The clue to pelvic
recurrence? Br J Surg, 1982. 69(10): 613 – 616.
9. Enker, W.E., Total mesorectal excision—The new
golden standard of surgery for rectal cancer. Ann
Med, 1997. 29(2): 127–133.
10. Delaney, C.P. etal., Operative Techniques in
Laparoscopic Colorectal Surgery. Wolters Kluwer
Health, Philadelphia, PA, 2013, pp. 55–65, 85–96,
109–123, 141–155.
11. Adamina, M. etal., Laparoscopic complete mesocolic excision for right colon cancer. Surg Endosc,
2012. 26(10): 2976–2980.
12. Bertelsen, C.A. etal., Can the quality of colonic
surgery be improved by standardization of surgical technique with complete mesocolic excision?
Colorectal Dis, 2011. 13(10): 1123–1129.
13. Bertelsen, C.A. etal., Disease-free survival after
complete mesocolic excision compared with conventional colon cancer surgery: A retrospective,
population-based study. Lancet Oncol, 2015. 16(2):
161–168.
14. Feng, B. etal., Laparoscopic complete mesocolic
excision (CME) with medial access for right-hemi
colon cancer: Feasibility and technical strategies.
Surg Endosc, 2012. 26(12): 3669–3675.
15. Galizia, G. etal., Is complete mesocolic excision
with central vascular ligation safe and effective in
the surgical treatment of right-sided colon cancers?
Aprospective study. Int J Colorectal Dis, 2014.
29(1):89–97.
16. Hohenberger, W. etal., Standardized surgery for
colonic cancer: Complete mesocolic excision and central ligation—Technical notes and outcome. Colorectal
Dis, 2009. 11(4): 354–364; discussion 364–365.
17. Kang, J. etal., Laparoscopic right hemicolectomy
with complete mesocolic excision. Surg Endosc,
2014. 28(9): 2747–2751.
18. Killeen, S. etal., Complete mesocolic resection
and extended lymphadenectomy for colon cancer:
A systematic review. Colorectal Dis, 2014. 16(8):
577–594.
19. Sondenaa, K. etal., The rationale behind complete
mesocolic excision (CME) and a central vascular
ligation for colon cancer in open and laparoscopic
surgery: Proceedings of a Consensus Conference.
IntJ Colorectal Dis, 2014. 29(4): 419– 428.
20. Storli, K.E. etal., Short term results of complete (D3)
vs. standard (D2) mesenteric excision in colon cancer
shows improved outcome of complete mesenteric
excision in patients with TNM stages I–II. Tech
Coloproctol, 2014. 18(6): 557–564.
21. West, N.P. etal., Complete mesocolic excision with
central vascular ligation produces an oncologically
superior specimen compared with standard surgery
for carcinoma of the colon. J Clin Oncol, 2010. 28(2):
272–278.
22. West, N.P. etal., Understanding optimal colonic
cancer surgery: Comparison of Japanese D3 resection and European complete mesocolic excision with
central vascular ligation. J Clin Oncol, 2012. 30(15):
1763–1769.
23. West, N.P. etal., Pathology grading of colon cancer
surgical resection and its association with survival:
A retrospective observational study. Lancet Oncol,
2008. 9(9): 857–865.
24. Yao, H.W. and Y.H. Liu, Re-examination of the standardization of colon cancer surgery. Gastroenterol
Rep, 2013. 1(2): 113–118.
136 Operative nomenclature
25. Sehgal, R. and J.C. Coffey, Historical development of
mesenteric anatomy provides a universally applicable anatomic paradigm for complete/total mesocolic
excision. Gastroenterol Rep, 2014. 2(4): 245–250.
26. Sehgal, R. and J.C. Coffey, The development of
consensus for complete mesocolic excision (CME)
should commence with standardisation of anatomy
and related terminology. Int J Colorectal Dis, 2014.
29(6): 763–764.
27. Charnsangavej, C. etal., CT of the mesocolon.
Part1. Anatomic considerations. Radiographics,
1993. 13(5): 1035–1045.
28. Charnsangavej, C. etal., CT of the mesocolon.
Part2. Pathologic considerations. Radiographics,
1993. 13(6): 1309–1322.
29. Ramachandran, I. etal., Multidetector computed
tomography of the mesocolon: Review of anatomy
and pathology. Curr Probl Diagn Radiol, 2009. 38(2):
84–90.
30. Coffey, J.C. etal., An appraisal of the computed
axial tomographic appearance of the human mesentery based on mesenteric contiguity from the
duodenojejunal exure to the mesorectal level. Eur
Radiol, 2016. 26(3): 714–721.
31. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
32. Culligan, K. etal., The mesocolon: A histological
and electron microscopic characterization of the
mesenteric attachment of the colon prior to and
after surgical mobilization. Ann Surg, 2014. 260(6):
1048–1056.
33. Coffey, J.C. etal., Mesenteric-based surgery exploits
gastrointestinal, peritoneal, mesenteric and fascial
continuity from duodenojejunal exure to the anorectal junction—A review. Dig Surg, 2015. 32(4): 291–300.
34. Standring, S., Gray’s Anatomy: The Anatomical Basis
of Clinical Practice. Elsevier Health Sciences, London,
U.K., 2015, pp. 1083–1098.
35. Ackerman, M.J., The visible human project.
JBiocommun, 1991. 18(2): 14.
36. Johnson, P.T., K.M. Horton, and E.K. Fishman,
Nonvascular mesenteric disease: Utility of multidetector CT with 3D volume rendering. Radiographics,
2009. 29(3): 721–740.
37. The National Library Of Medicine’s Visible Human
Project. https://www.nlm.nih.gov/research/visible/
visible_human.html, N.p., 2016. Web April 10, 2016.
38. Juanes J.A. et al., Application of the “Visible Human
Project” in the eld of anatomy: A review. Eur J
Anat, 2003. 7: 147–159.
39. Li, Y. and K. Hauenstein, New imaging techniques
in the diagnosis of inammatory bowel diseases.
Viszeralmedizin, 2015. 31(4): 227–234.
Teaching mesenteric principles
J. CALVIN COFFEY, DEIRDRE McGRATH, AND COLIN PEIRCE
10
Aim 137
Introduction 137
Digital atlas and demonstration of mesenteric principles 137
Novel approach to depicting living anatomy 137
New dimensions in surgical education 137
Surgical simulation 139
An investment in knowledge pays the best interest.
Benjamin Franklin
AIM
e second half of this book focuses on the application of
the scientic principles described in the preceding chapters, to mesenteric-based surgery. Before commencing, it is
appropriate to describe the educational modalities that will
be used to convey the principles involved.
INTRODUCTION
e following chapters detail the mesenteric basis for intestinal surgery distal to the duodenojejunal exure. e concepts
involved are largely 3D and cannot be conveyed adequately
using conventional educational modalities. To overcome this
challenge, several novel educational instruments were developed
including digital, operative (open, laparoscopic, and robotic),
cadaveric, and radiologic atlases of the mesenteric organ.
Collectively, these generate a curriculum that facilitates an
understanding of mesenteric-based surgery [1–11]. e following chapters describe these educational modalities as well as the
opportunities that now are present in the educational context.
Intraoperative atlas in open, laparoscopic, and
robotic colorectal surgery 139
Radiologic atlas 145
Visible human project 145
Future directions 145
Summary 145
References 145
mesenteric continuit y and contiguity mea ns that peritonotomy,
mesofascial separation, and mesenterectomy are key activities
required for excision, at any level distal to the duodenojejunal
exure. However, continuity presents an educational challenge
in that there are no boundaries delimiting continuous regions
of the peritoneum, the colon, and the associated mesentery.
Moreover, when the gastromesenteric complex is resected
intraoperatively, the shape it adopts bares little if any resemblance to the shape it had in the abdomen [2,8]. Digital sculpting provides an opportunity to overcome these issues. Using
digital methodologies such as ZBrush (Pixologic, Los Angeles,
Unites States), Cinema 4D (Maxon Computer Ltd., Bedford,
United Kingdom), Maya (Maya Digital Studios, Mumbai,
India), and RenderMan (Pixar, California, United States), it is
possible to generate high-delity mesenteric models that can be
regionally colored, deformed, and sectioned (Figure 10.1)[12].
In keeping with this, a digital atlas of the mesentery, colon,
and peritoneum was generated (Chapter2). e educational
value of these models is illustrated in the chapter on exures
(Chapter20), where the exures were conceptually excised to
demonstrate the relationships between anatomic components
(i.e.,peritoneal reection, colon, and mesentery).
New dimensions in surgical education
DIGITAL ATLAS AND DEMONSTRATION
OF MESENTERIC PRINCIPLES
Novel approach to depicting living anatomy
e principles of anatomic continuity form the cornerstone
of modern-day colorectal surgery [8]. Peritoneal, colonic, and
As technology became integral to the twenty-rst century educational environment, several opportunities in
undergraduate and postgraduate surgical education arose.
Traditional surgical texts present operations as a series of 2D
snapshots (oen in grayscale or black and white). e reader
is required to interpolate the changes in shape that occur in
the peritoneum, mesentery, and intestinal tract. With digital
137