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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_699_Библиотеки_им_академика_М_И_Перельмана.pdf
138 Teaching mesenteric principles
(a)
Mesocolon, mesosigmoid, and mesorectum digital model
Le
(b) (c) Inferolateral viewInferomedial view
Attached (i.e. apposed)
mesosigmoid
deep surface
Partially mobilized
ft mesocolon
deep surface
IMA
SRA
Medial view
Mesorectum
Adipovascular
pedicle fold
Fully mobilized
Fully mobilized
Figure 10.1 (a–c) Views of the mesentery from the left mesocolon to mesorectum (including the mesosigmoid) during
successive phases of mesosigmoidal detachment from the retroperitoneum. These are snapshots from a digital sculpture of the mesentery in which the mesenteric regions have been color-coded for recognition. (a) Medial to lateral view
of the medial aspect of the mesentery after the inferior mesenteric adipovascular pedicle has been detached. (b) Medial
to lateral view of the mesentery after complete detachment of the mesosigmoid. (c) Lateral to medial view of stage as
demonstrated in (b). Abbreviations: IMA, inferior mesenteric artery; SRA, superior rectal artery.
Mobilization of the mesosigmoid digital model
mesosigmoid
mesocolon
mesosigmoid
(a)
(b)
Apposed
Left
Intraoperative atlas in open, laparoscopic, and robotic colorectal surgery 139
image on a page to a versatile digital model on either their
Mobile
smartphone or laptop (Figure 10.3). Soware are such that
once the model is accessed (either by smartphone, tablet,
desktop, or laptop), the reader can zoom in or out, rotate the
model, or subtract or add dierent components. is facility
means the student, trainee, and surgeon can appreciate all
aspects of the 3D nature of the structures involved in mesenteric-based surgery.
Apposed
mesosigmoid
In addition, 3D digital models can be imported into augmented reality programs and then viewed as 3D objects as
if in object form in front of the reader. ree-dimensional
environments (theater, the abdomen) can be generated to
provide a virtual reality environment in which the reader
can conceptually enter (Figure 10.4).
Surgical simulation
IMA
SRA
Figure 10.2 Views of the mesosigmoid and mesorectum.
These are snapshots from a digital sculpture of the mesentery in which mesenteric regions have been color-coded
for recognition. (a) Antero-posterior view (from the left)
of the mesentery prior to mobilization (i.e., detachment)
demonstrating the relationship between the apposed and
mobile regions of the mesosigmoid. (b) Similar viewpoint
demonstrating the relationship between the apposed and
mobile regions of the mesosigmoid after full detachment
from the retroperitoneum. Abbreviations: IMA, inferior
mesenteric artery; SRA, superior rectal artery.
Left mesocolon
deep surface
Mobile
mesosigmoid
Apposed
mesosigmoid
deep surface
sculpting, the mobilization process can be captured at any
angle and at any point in time (Figure 10.2). In addition, the
component structures of digital models change in tandem.
us, the surgeon can visualize how an anatomic component changed. Finally, digital models can be subdivided or
sectioned to provide any sectional view required [8,12].
e representation of 3D models in a text book format is
still limited due to the fact that the images are presented in
a attened or 2D plane. is problem can be overcome by
linking digital models to a net-based platform. For example,
a digital model can be archived at a web address and then
accessed from a text-embedded illustration using a simple
QR code. e QR code permits the reader to go from an
e digital models generated for the purpose of illustrating the mesenteric basis of intestinal surgery also serve as
high-delity platforms for postgraduate surgical simulation. It is likely that their application will increase in this
context, given the increasing requirement for simulation
in surgical education in general [13–17]. Future research
in this eld should therefore focus on developing means
of manually reproducing the activities of peritonotomy,
mesofascial separation, vascular skeletonization, and mesenterectomy, in the simulator context.
INTRAOPERATIVE ATLAS IN OPEN,
LAPAROSCOPIC, AND ROBOTIC
COLORECTAL SURGERY
Communication of the anatomic basis of total mesorectal excision (TME) was greatly aided by persistence on the
part of Bill Heald and Brendan Moran in the generation of
high-resolution videos [18–20]. e excellent quality of their
recordings demonstrated, for the rst time, the mesofascial
plane and its components in the pelvis. is required a considerable eort on the part of both these surgeons with insistence
on generating high-quality educational videos and images.
e widespread adoption and development of laparoscopic and robotic colorectal surgery has meant that surgeons can now more readily achieve the same quality images
as those obtained by Heald and Moran [21,22]. Laparoscopic
and robotic imaging provides a 20-fold magnication over
the human eye, and together with high-resolution images,
enable the surgeon record and later demonstrate the planes
utilized in mesenteric-based surgery. In addition, the use of
the laparoscope in open surgery has more recently provided
the same benets in this context (Figure 10.5). e 30° laparoscopic lens, coupled with high magnication and resolution optics, enable the surgeon to demonstrate the planes
exploited in mesenteric surgery in the open context [23].
While the images generated are highly informative, their
combination with digital imagery orientates the reader in
relation to regional anatomy and greatly enhances the educational process (Figure 10.6).
140 Teaching mesenteric principles
Linking text embedded images to online digital models
(b)
rotatable model
Peritoneum, mesentery,
fascia, and intestine
Printed image with
scannable QR code
(a)
Online, digital
The human mesentery
Figure 10.3 (See also QR 2/1.) Flow-chart demonstrating how (a) an image within a text can be linked (through a QR
code) to an (b) online digitalmodel. The reader can then rotate, magnify, and section the model online depending on
the application they view itin. This QR-code capability greatly aids in teaching 3D concepts that are not readily conveyed
through standard text-embedded educational modalities.
Intraoperative atlas in open, laparoscopic, and robotic colorectal surgery 141
Linking text embedded images to online digital models
(c)
Peritoneum, mesentery,
fascia and intestine
Printed image with
scanable QR code
(a)
Virtual reality
walk through
(b)
Figure 10.4 (a–c) Panel demonstrating the manner in which a user can visualize an image in a standard textbook, then
link to anonline virtual reality (VR) model of the digital sculpture, through a QR code. If the application used to visualize
the sculpture is VR based, then the user can visualize it in any VR environment. This approach greatly aids in conveying
threedimensional concepts that are not readily apparent using standard educational modalities.
142 Teaching mesenteric principles
Use of laparscope in open surgery
(a
(d)(c)
adipovascular pedicle
Mesosigmoid
Inferior mesenteric
)
Mesosigmoidal
(Toldt’s) fascia
(b)
Peritonotomy
of peritoneal reflection
Peritonotomy of
medial aspect of mesosigmoid
Peritonotomy
of peritoneal reflection
Mesosigmoidal
(Toldt’s ) fascia
Figure 10.5 (a) 2.5D snapshot of the medial aspect of the mesosigmoid after mobilization. The image is derived from a
3D digital sculpture. (b) The UL Exoscope setup including a malleable snake arm, metal frame, and standard 30 degree
laparoscope. (c) (See also QR 5/3 and QR 2/11.) View of the medial aspect of the mesosigmoid during an open resection,
asseen with the UL Exoscope. Aperitonotomy has been commenced. The mesosigmoidal fascia is apparent. (d) (See also
QR 5/3 and QR 2/11.) View after extension of the peritonotomy seen in (c).
Intraoperative atlas in open, laparoscopic, and robotic colorectal surgery 143
Digital models and intraoperative images
t
and descending colon
Digital model
Sigmoid colon
Left mesosigmoidal
peritoneal reflection
Left (descending) colon
Left lateral
peritoneal reflection
Intraoperative (open) view
Left iliac fossa
Junction between sigmoid
Distal
Proximal
Intraoperative (open) view
Descending colon
Divided lef
peritoneal
reflection
Edge of
peritonotomy
Figure 10.6 (See also QR 2d/1,2.) The top image is a 2.5D snapshot from a 3D digital sculpture demonstrating the
peritoneal reection lateral to the mesosigmoid and left mesocolon. The bottom left imaged demonstrates the divided
peritoneal reection viewed from above down (at open surgery). The bottom right image is the divided peritoneal
reection looking from below up (laparoscopic view). This combination of images conveys three dimensional concepts
required to understand the operative anatomy involved in dividing the peritoneum and gaining access to surgical planes.
144 Teaching mesenteric principles
Application of visible human project
(c)
mesocolon
(a)
Toldt’s fascia
Left mesocolon
Retroperitoneum
Peritoneal
reflection
Left mesocolon
Peritoneal
(b)
reflection
Toldt’s fascia
Toldt’s fascia
Retroperitoneum
Retroperitoneum
Peritoneal
reflection
Left
Figure 10.7 (a) Appearance of Toldt’s fascia, the left mesocolon, and left peritoneal reection in the full-color data set
of the Visible Human Project. (b) Computerized axial tomographic image (axial plane) corresponding to the region in (a).
Structures corresponding to Toldt’s fascia, the mesocolon, and peritoneal reection are evident. Bottom image demonstrates the corresponding region in 3D, after importing the CT data set into Osirix (c). Toldt’s fascia, the left mesocolon,
and the peritoneal reection can be visualised in 3D.
References 145
RADIOLOGIC ATLAS
Although it is crucial that the surgeon be able to interpret
the operative eld in terms of mesenteric and peritoneal
parameters, it is equally important that he/she be able to
plan an operation according to the same parameters. To
facilitate this, a radiologic atlas of mesenteric anatomy was
recently developed (Chapter 8) [9]. e atlas serves numer-
ous functions; in the rst instance, it is a reference against
which the computerized axial tomographic appearance of
the normal mesentery can be compared in general. Second,
this provides a means for reappraising the appearance of
the mesentery in disease states. From the surgical perspective, the radiologic atlas provides an important tool that
helps in the preoperative preparation of patients and in
deciding on intraoperative strategies. By way of example,
radiologic evidence of disease progression outside of with
the normal mesenteric, peritoneal, and fascial planes is a
sign of advanced disease that is usually reected in a technically challenging operation.
VISIBLE HUMAN PROJECT
e generation of a radiologic atlas would not have been
possible without the data provided by the visual human
project (VHP) [9,24–26]. In the latter, human anatomy can
be observed in full color format and cross-checked against
corresponding computerized axial tomographic (CT) and
magnetic resonance imaging (MRI) (Figure 10.7). As a
result, exures can be identied insitu in the full color dataset and corresponding regions identied in CT and MRI
images [9]. e resolution of images in the VHP is such that
fascial planes can be identied, extracted, and then reconstructed. Similarly, undisturbed peritoneal reections can
be identied, traced, exported, and reconstructed [9,24–26].
Images taken from the VHP full color dataset were essential in providing proof of concept in relation to mesenteric,
peritoneal, and fascial continuity, as well as the technical
implications thereof. As an extension of this, images from
the VHP help demonstrate the planes that form the cornerstone of mesenteric-based surgery.
FUTURE DIRECTIONS
Many of the educational modalities described above were
recent developments generated from the need to convey
complex three dimensional concepts. ese now require
formal validation in trial contexts.
SUMMARY
Mesenteric-based surgery is founded on the principles of
mesenteric, peritoneal, fascial, and intestinal continuity and
their contiguity. In order to convey these principles in the
robotic, laparoscopic, and open context, a number of educational instruments were developed. ese capture the three
dimensional and contiguous nature of these structures.
ey overcome the limitations arising from the lack of anatomic demarcation between continuous mesenteric zones.
ey are used interchangeably in the following chapters.
REFERENCES
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3. Culligan, K. etal., The mesocolon: A prospective
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4. Culligan, K. etal., Review of nomenclature in colonic
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5. Culligan, K. etal., A detailed appraisal of meso-
colic lymphangiology—An immunohistochemical
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6. Culligan, K. etal., The mesocolon: A histological
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mesenteric attachment of the colon prior to and
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7. Sehgal, R. and J.C. Coffey, Historical develop-
ment of mesenteric anatomy provides a universally
applicable anatomic paradigm for complete/total
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anorectal junction—A review. Dig Surg, 2015. 32(4):
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11. Coffey, J.C. et al., The mesentery in Crohn’s disease:
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Tech Coloproctol, 2014. 18(7): 653–660.
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Gastroenterology
J. CALVIN COFFEY AND MANUS MOLONEY
11
Aim 147
Introduction 147
Pain during endoscopy 147
Sometimes one has to go a very long distance
out of his/her way, to come back a short distance correctly.
Edward Albee
AIM
e rst aim is to discuss the association been mesenteric
related events and discomfort experienced by patients during lower intestinal endoscopy. e second aim is to discuss
the emerging concept of endoscopic mesenteric mapping
(EMM) and the clinical opportunities presented.
INTRODUCTION
Pain during endoscopy
Colonoscopy is one of the most commonly performed endoscopic procedures worldwide with over 500,000 performed
annually in the United States alone [1–4]. Colonoscopy
training programs are required to assess competency of
trainees performing colonoscopies [5–11]. A cecal intubation rate of 90% is one of the competency criteria set down
by the joint advisory group (JAG) on intestinal endoscopy.
JAG requires 200 procedures be performed prior to assessing
for competency [12–16]. Colonoscopy training programs
currently rely on the Halstedian apprenticeship model [17].
Competency in colonoscopy is assessed on a range of factors
including adenoma detection rate, polyp retrieval and cecal
intubation rates, and, crucially, patient comfort levels. e
competent colonoscopist is one who can reach the cecum
with minimal patient discomfort. is ability becomes
more important, when multiple intubations are required in
order to resect and retrieve right-sided lesions.
Endoscopic mesenteric mapping 148
Summary 148
References 148
It is feasible (though unproven) that mesenteric factors
contribute to abdominal discomfort patients experience
during colonoscopy. Pain during endoscopy is multifactorial, but classic arguments suggest it mainly relates to colonic
stretch [18]. Although there is a subgroup of patients in
whom simple insertion of the scope into the rectum triggers
signicant pain, these are in the minority. It is suggested that
this pain is contributed to by preexisting psychologic factors
[19–22]. e dimensions of the colon are such that considerable insuation would be required to cause colonic stretch.
It is widely recognized that patients can perceive pain with
minimal insuation, as the endoscopist rounds a exure.
In the absence of colonic stretch, it is likely that mesenteric
stretch (or tension within the mesentery) leads to discomfort and pain. As there are six exures in total (including the
rectosigmoid), the opportunities for placing the mesentery
under stretch are frequent. us, it is not unreasonable to
argue that pain during endoscopy is contributed to by mesenteric factors such as stretch and tension [18,23].
Tension can be placed in the mesentery in a number of
dierent locations. Generally speaking, these correspond to
where the intestinal tract changes from being mobile to being
attached to the abdominal wall, or vice versa (i.e., the exures). Examples include the exure between the rectum and
sig moidand between sigmoid and descending colon. e latter can be associated with a particularly acute angulation. is
becomes even more angulated aer insuation of the sigmoid.
Further examples of acute angulation include the splenic,
hepatic, and ileocecal exure. ere are numerous approaches
to negotiating these in as ecient a manner as possible; these
include suctioning as one advances, maintaining the endoscope as straight as possible, having the patient adopt position in which gravity alters the conformation of the exure,
and direct manual abdominal pressure (altering the conformation of the colon) [24,25].
147