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148 Gastroenterology
When a loop is created, patients experience discomfort
on advancement of the scope. is discomfort is mainly
attributed to colonic stretch, but it is likely it is also contributed to by mesenteric stretch. If the colon stretches then
the attached mesentery must also stretch. Histologic studies
demonstrate numerous nerve endings at the region of intersection between the bowel wall and associated mesentery
[26–28]. Looping is predisposed to by intestinal and mesenteric factors. While the length of both is important, the differential in length between the intestinal and the attached
mesentery is probably more important. is dierential is
greatest in the sigmoid region, followed by the ileocecal and
transverse colonic regions.
Endoscopic mesenteric mapping
More recently, endoscopic identication of the mesenteric pole is gaining attention as a means of negotiating
the colon and minimizing mesenteric tension or looping.
e approach used is referred to as endoscopic mesenteric
mapping (EMM) [29]. It is based on the suggestion that
if the trajectory of the endoscope follows the mesenteric
border of the intestinal tract, this must correspond to the
trajectory of the mesentery, and is thus less likely to create
a loop or stretch. EMM has other potential uses in mapping polyp location [29]. e mucosal or luminal aspect of
the colon is generally homogenous in appearance, and at
present, it is not possible to precisely establish circumferential position. It is reasonable to suggest that if one could
identify the mesenteric pole (i.e., via EMM) this would
provide a reference landmark. ese data, when collated
with distance from the anal verge, could help pinpoint
polyp location.
We recently conducted a study in which a standard
ultrasound probe was applied to the inner surface of intestinal tract that had been opened longitudinally. e probe
was swept around the circumference with a view to determining whether mesentery could be positively identied.
Mesentery was identiable. In addition, a transition was
observed where the mesentery stopped. ese ndings
indicate that mesenteric and nonmesenteric regions of
the intestinal circumference could be dierentiated sonographically. On this basis, it is likely that the mesentery
will be identiable in endoscopic instruments in which an
ultrasound probe is incorporated.
Endoscopic ultrasound using dedicated linear array and
radial echoendoscopes is used for structural evaluation of
the luminal wall and adjacent tissues in the intestinal tract.
Ultrasound probes that go through the accessory channels
of standard endoscopes are commercially available. At present, EUS is widely used in local staging of rectal cancer in
determining the type of surgery required and whether preoperative neoadjuvant chemoradiation is needed [30–33].
Endoanal ultrasound is a well-established technique in
imaging of the anal sphincter. EUS enables the investigator to map out sphincter defects [34–39]. Similarly, EUS can
be used in imaging perianal stulas [40–47]. Fujinon and
Olympus are market leaders in this technology. e current indications for these technologies are for staging and
diagnostic procedures involving lung, upper intestinal,
and rectal malignancies. eir application in delineating
and mapping the anatomical mesocolon and its mesenteric
attachments has yet to be clinically developed but is could
have wide-ranging diagnostic implications in day-to-day
practice.
SUMMARY
Mesenteric stretch is likely a major contributor to discomfort during lower intestinal endoscopy. EMM could provide
a trajectory that would lead to less discomfort for patients
undergoing this procedure. Mapping based on a mesenteric
reference could aid in polyp localization.
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150 Gastroenterology
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PART 2
12 Mesenteric-based colorectal surgery 153
13 Appearance of the mesentery during laparoscopic/robotic colorectal surgery 157
14 Appearance of the mesentery during opencolorectal surgery 177
15 Instruments used during mesenteric-based colorectal surgery 199
16 General techniques in mesenteric-based colorectal surgery 211
17 Mesenteric component of sigmoid colectomy 233
18 Mesenteric component of rectal resection 251
19 Mesenteric component of right colectomy 277
20 Mesenteric component of exure mobilization 293
21 Mesenteric considerations in resection ofthetransverse colon 301
22 Mesenteric considerations in small bowel resection 311
23 Mesenteric considerations in ileal pouch analanastomosis 317
24 Mesenteric considerations in ostomyformationand reversal 323
25 Mesenteric considerations in reoperative abdominal surgery 333
26 Future directions 343
Mesenteric-based colorectal surgery
J. CALVIN COFFEY AND IAN LAVERY
12
Aims 153
Mesenteric-based surgery dened 153
Future directions in colorectal surgery:
Internationalization of the mesenteric standard 154
It is once again the vexing problem of identity within variety; without a solution to this
disturbing problem, there can be no system, no
classication.
Roman Jakobson
AIMS
e aim of this chapter is to dene mesenteric-based sur-
gery, variants of this, and the outcomes associated. e
second aim is to demonstrate how future resources are
probably best directed at standardizing colorectal surgery worldwide rather than continued attempts at proving
supremacy of one concept over another. A nal aim is to
demonstrate the importance of generating a curriculum to
enable the standardization process.
MESENTERIC-BASED SURGERY DEFINED
Colorectal surgery is divisible into two categories, mesenteric and non-mesenteric based.
Mesenteric-based surgery is where the mesentery is
detached and disconnected along dened anatomic planes.
Non-mesenteric-based surgery is where mesenteric
detachment and disconnection are not guided by dened
anatomic planes.
Subtypes of mesenteric surgery include total mesorectal excision (TME), complete mesocolic excision (CME),
and total mesocolic excision (TMCE), and variants of each.
ese have formed the cornerstone of good quality colorectal surgery for over a century. Remarkably, they are not globally practiced (see following discussion).
Summary 155
References 155
In mesenteric-based surgery, the mesentery is mobilized
intact, allowing a targeted division of contained vessels
and of the mesentery itself [1–4]. e planes involved are
accessed by division through the peritoneal reection.
CME, TME, and TMCE (and variants of each) are mesenteric based. Non-mesenteric-based surgery does not
exploit these planes nor the associated peritoneal reection in gaining access to them. Non-mesenteric-based
surgery does not emphasize careful separation of individual anatomic components of particular planes; it does not
emphasize preservation of the integrity of the mesenteric
lymphatic package. In it, the mesentery is detached from
the posterior abdominal wall in a nonanatomic fashion.
As a result, the retroperitoneum (and contained structures
including the ureters, duodenum, and gonadal vessels) are
threatened. e mesentery is divided across wherever is
rst convenient and this may even include at the junction
between it and the bowel wall [1–4].
Although the principles of TME and CME have formed
the cornerstone of excellent quality colorectal surgery for
over a century, description of the anatomic basis (and hence
surgical basis) was recent [2,4,5]. e anatomic basis for
TME was detailed by Professor Bill Heald in 1982 [6–8]. He
correlated reduced rates of local recurrence in rectal cancer
with dissection in a particular anatomic plane. In setting
down the anatomic basis for TME, Heald set o a renaissance in interest in the anatomic basis of mesenteric-based
surgery. In 2009, a similar phenomenon occurred in a second paper demonstrating a correlation between anatomic
and hence mesenteric-based resection of right-sided colon
cancer. Hohenberger’s paper has rekindled the renaissance
that is mesenteric-based surgery [9]. Many have correctly
argued t hat there is nothing new in the technical approaches
described [10]. Whilethis may be strictly correct to say the
153
154 Mesenteric-based colorectal surgery
fundamental achievements of Heald, Hohenberger, and
their coworkers, must be credited with rearming the relationship between anatomic-based surgery, and improved
outcomes aer cancer surgery.
It may seem remarkable that non-mesenteric-based
surgery continues to be practiced at all. Evidence that it is,
and in fact is widespread, comes from the studies of West
et al. [11–13]. ey developed three terms to address the
plane of surgery utilized and examine the rates at which
each plane was employed. In “mesocolic plane surgery,” the
mesocolon is excised intact, that is, the plane of dissection
is outside the mesentery. In “intramesocolic plane surgery,”
the mesocolon is disrupted and so the plane of dissection is
within the mesentery. In “muscularis propria plane surgery,”
the mesentery is divided at the intestinal margin practically
ush with the colon itself. West etal. examined pathology
specimens and noted the plane of surgery was mesocolic in
32%, intramesocolic in 44%, and muscularis propria based
in 24% [13]. e mean cross-sectional tissue area was signicantly higher in mesocolic plane surgery compared with
other types. e distance from the muscularis propria to
the mesocolic resection margin was greater in mesocolic
plane surgery, compared with both other subtypes. Quirke
etal. reported similar variability in the plane of dissection,
in analyzing mesorectal specimens in 1156 patients, in the
CR07 trial. Surgery was conducted in the mesorectal plane
in 52%, in the intramesorectal plane in 34%, and in the
muscularis propria plane in 13% [14].
e possibility of dierential outcomes associated with
mesenteric and non-mesenteric surgery was rst demonstrated by Heald and more recently supported by the ndings of West, Quirke, Hohenberger, and others. West etal.
found that mesocolic plane surgery was associated with a
15% improved survival on univariate analysis (although
this did not hold on multivariate analysis) [13]. Quirke
etal. found that circumferential resection margin positive
or negative status, as well as 3-year local recurrence rates,
correlated with the plane of surgery utilized [14].
FUTURE DIRECTIONS IN COLORECTAL
SURGERY: INTERNATIONALIZATION
OFTHE MESENTERIC STANDARD
As is oen the case with surgical approaches, diculties arise when it comes to applying scientic techniques.
Oentimes, it is found that surgery cannot be characterized
using the same scientic techniques as are readily applied
in other sciences. For example, there has never been, nor
will there ever be, a randomized control trial comparing
laparoscopic versus open cholecystectomy. Many cite the
example of the parachute in explaining this phenomenon.
Not many individuals would willingly sign up to the control
arm of a study examining the ecacy of parachute versus
no parachute in jumping from an airborne plane. Similar
issues arise in respect of mesenteric-based surgery and the
subtypes involved.
Unfortunately, it is not possible to prove supremacy of
mesenteric over non-mesenteric-based surgery. Proof would
involve a randomized trial in which surgeons credentialed
as being capable of mesenteric-based surgery are required
to conduct a non-mesenteric-based procedure on randomized patients. In order to obtain ethical approval, one needs
to demonstrate that the patient is protected at all points.
Extracting the colon and mesentery from the abdomen,
without attention to anatomic planes, is equivalent to simply wrenching it out and hoping for the best. As a result, it
would be unethical to conduct a trial comparing mesenteric
and non-mesenteric-based surgery.
A second and perhaps greater issue arises in that CME and
TME, and TCME are dicult (if not impossible) to precisely
dene. Similarly their corollary, non-CME, non-TME, and
non-TCME-based surgeries (collectively referred to as “conventional” surgery) are equally dicult to dene, if not more
so. e reasons for this are anatomic. Mesenteric, peritoneal,
intestinal, and fascial continuity mean there are no anatomic
boundaries delimiting separate regions of each. For example,
there are no boundaries separating the right mesocolon from
the small intestinal mesentery or transverse mesocolon (they
are separate regions of the same entity). Similarly, it is not possible to anatomically dene the commencement of the rectum
and the end of the sigmoid colon. By extension of this argument, it is not possible to conduct a randomized trial comparing CME with non-CME or TME with non-TME.
In the absence of randomized clinical trials, one is
required to rely on lower levels of evidence to support a
hypothesi s. e literature now abounds wit h studies comparing CME and historic non-CME groups [15–17]. esame
holds for TME and non-TME historic groups [6]. In surgery, historic comparisons suer because one can never be
assured that a procedure falls into one category of surgery
or another. Overlaps will occur meaning that homogenous
groups ideally suited to statistical comparison are not available. Notwithstanding this, historic comparisons that followed the introduction of TME-based surgical principles in
several countries demonstrate vast improvements in surgical, pathological, and outcome-related parameters [6]. ey
are compelling argument for the feasibility of international
standardization in colorectal surgery, when this emphasizes
a mesenteric based approach.
Emerging evidence indicates that eorts at standardization must be increased [18]. e recent results of the
OSTRiCh group demonstrate wide variability in circumferential resection margin positivity rates. ey concluded
that rates of margin positivity remain high in the United
States. is is mirrored by the ndings of recent comparisons between laparoscopic and open surgery in which
circumferential resection positivity rates were 11.1% and
7.7% for laparoscopic and open resection of the rectum,
respectively [19–22].
It has been proposed that the answer to the issues
highlighted lie in either increased centralization or better standardization. In a recent editorial, Susan Galandiuk
References 155
commented that when patients take risks involving their
own lives, they prefer to do so close to their family and community supports [23]. In other words, many patients who
will require colorectal surgery will not wish to (orindeed
cannot) travel to centers of excellence. In this context, the
need for a standardization, rather than centralization,
increases further.
Given the aforementioned, it may be proposed that
the surgical community move away from trying to prove
the impossible (i.e., the supremacy of CME or TME or
mesenteric-based surgery over non-CME, non-TME,
and non-mesenteric-based surgery) and focus instead on
establishing a universally reproducible standard by which
colorectal surgery can be safely conducted [1,2,5]. Such a
standard should be entirely anatomic based, universally
reproducible, and easily conveyed from one individual to
another. To achieve this, a formal curriculum should be
established, agreed, and then disseminated internationally.
SUMMARY
e terms CME and TME cannot be precisely dened.
Similarly, non-CME and non-TME or conventional surgery cannot be precisely dened and rigorous comparisons between both types are not possible. In contrast, the
terms mesenteric and non-mesenteric based can be dened.
Notwithstanding this, clinical trials proving ecacy of one
standard over another are not ethical and thus will not be
conducted. In this context, future resources may be best
directed toward further consolidating the standardization
(rather than proving the supremacy of) mesenteric-based
surgery. Numerous international programs have already
achieved this in relation to TME.
e non-mesenteric standard of colorectal surgery
cannot be universally reproduced because it is not anatomic
based. e mesenteric-based standard can be universally
reproduced because it is founded on universally applicable principles (anatomic, histologic, physiologic), which
are described in the rst half of this book. e second half
describes how surgeons adopt these principles to reproducibly achieve the standard of mesenteric-based colorectal
surgery. e second half thus serves as a surgical foundation
by which the principles of mesenteric-based surgery can be
universally taught and thus achieved.
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156 Mesenteric-based colorectal surgery
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Appearance of the mesentery during laparoscopic/robotic colorectal surgery
J. CALVIN COFFEY AND MANISH CHAND
13
Aim 157
Introduction 157
Laparoscopic/robotic appearance of the peritoneal
reection 157
Laparoscopic/robotic appearance of the colo- and
mesofascial plane 162
Always remember that you are absolutely unique.
Just like everybody else.
Margaret Mead
AIM
e aim of this chapter is to demonstrate the appearance
of the structures utilized in mesenteric-based surgery from
duodenojejunal exure to mesorectal level, as seen during
laparoscopic and robotic surgery.
INTRODUCTION
e development of laparoscopic and robotic colorectal
surgery meant an instrument was interposed between surgeon and patient, and the surgeon could no longer directly
grasp tissue. In open surgery, tissue can be directly grasped
by the surgeon, and if one encountered unexpected bleeding or contamination, it could be directly dealt with.
Asthis is clearly not the case for laparoscopic or robotic
surgery, it was imperative that surgeons minimized the
possibility of unexpected events. is led to an increased
interest in surgical anatomy and individuals such as Jeery
Milsom, Bartholomäus Böhm, and Kiyokazu Nakajima
must be congratulated in their development of an anatomic and safe basis for laparoscopic colorectal surgery
[1]. From the outset, these authors emphasized the importance of a clear understanding of anatomy. e clinical
community is indebted to Prof. Bill Heald and Brendan
Laparoscopic/robotic appearance of adipovascular
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Summary 175
References 175
Moran, who demonstrated the importance of the surgical
anatomy in the open context in total mesorectal excision
[2–7]. ey also set a standard of video presentation that
greatly advanced the surgical educational process. e discoveries of these clinical investigators laid the foundation
for recent investigations into mesenteric and fascial as well
as peritoneal reection structure.
e identication of mesenteric continuous showed that
mesenteric structure is far simpler than previously suggested.
Once this became apparent, then the structure of the contiguous peritoneal reection, greater omental attachments, and
congenital adhesions intuitively fell into place [8–18].
e following chapter will demonstrate the appearance of
the mesentery, associated peritoneal reections, and underlying fascia as seen during laparoscopic and robotic surgery.
Images are presented with 3D models adjacent [8,13]. e3D
models depict regional anatomy in a schematic format and aid
in interpretation of the corresponding laparoscopic/robotic
image. e following presents the appearance of the peritoneal
reection, the mesentery and the fascia, as they are encountered
during laparoscopic and robotic mesenteric-based surgery.
LAPAROSCOPIC/ROBOTIC APPEARANCE
OF THE PERITONEAL REFLECTION
1. Peritoneal reection at the base of the small intesti-
nal mesentery where it curves onto retroperitoneum
(Figure 13.1).
2. Ileocecal peritoneal reection (Figure 13.2).
3. Right peritoneal reection (Figure 13.3).
4. Hepatocolic peritoneal reection (Figure 13.4).
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