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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_699_Библиотеки_им_академика_М_И_Перельмана.pdf
158 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Peritoneal re˜ec tion at base of small bowel mesentery
(c)
Small
intestinal
mesentery
Legend
Mesentery
Fascia
Colon
Peritoneum
(a)
(b)
Jejunum
Small
intestinal
peritoneal
re˜ec tion
Small
intestinal
mesentery
Small
intestinal
peritoneal
re˜ec tion
Small
intestinal
mesentery
Peritoneal
re˜ec tion
at the base of
the intestine
Figure 13.1 Peritoneal reection at the base of the small intestinal mesentery. (a) Laparoscopic view. (b) (See also QR 3/5.)
Digital view. (c)Peritoneal reection at the base of the small intestinal mesentery in a cadaver. Division of the reection
exposes the underlying colo- and mesofascial plane (Figure 13.10).
Ileocecal peritoneal re˜ec tion
Gas
(c)
inÿltration
beneath
peritoneal
mesothelium
Laparoscopic/robotic appearance of the peritoneal reection 159
Cecum
Appendix
Ileocecal
peritoneal
reflection
Needle insufflator placed
beneath surface mesothelium(a)
Legend
Mesentery
Fascia
Colon
Peritoneum
Ileocecal
peritoneal
re°ec tion
Terminal
ileum
Ileocecal
peritoneal
re°ec tion
(b)
Terminal
ileum
Figure 13.2 Peritoneal reection at the ileocecal region. (a) Laparoscopic/robotic view. (b) (See also QR 3/6.) Digital view.
(c)Peritoneal reection at inferolateral aspect of ileocecal junction, in a cadaver. The peritoneal reection is divided to
provide access to the mesofascial plane in this location (see Figure 13.11).
160 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Right peritoneal reflection
(c)
(a)
Ascending colon
Right peritoneal
reflection
Needle for
insufflating beneath
peritoneal reflection
Legend
Mesentery
Fascia
Colon
Peritoneum
(b)
Right
peritoneal reflection
Right
peritoneal reflection
(partially divided)
Figure 13.3 Right peritoneal reection. (a) Laparoscopic view. (b) (See also QR 2/3.) Digital view. (c) Right peritoneal
reection in a cadaver. The peritoneal reection must be divided to provide access to the colo- and mesofascial plane of
dissection (Figure 13.12).
Hepatocolic peritoneal reflection
Colic component
tion
(b)
of hepatic flexure
Laparoscopic/robotic appearance of the peritoneal reection 161
Hepatocolic
peritoneal
reflection
Legend
Mesentery
Fascia
Colon
Peritoneum
Divided hepatocolic
peritoneal reflection
(a)
Transverse
colon
Hepatocolic
peritoneal reflec
Colic component
of hepatic flexure
Figure 13.4 Hepatocolic peritoneal reection. (a) Laparoscopic/robotic view. This view is achieved by placing the patient
head up and retracting the colic component of the hepatic exure toward the left iliac fossa. (b) (See also QR 2/4.)
Digitalview.
162 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Omento-colic peritoneal reflection
olic
T
5. Peritoneal reection between greater omentum and
upper surface of the transverse colon (Figure 13.5).
6. Splenocolic peritoneal reection (Figure 13.6). Dueto
adhesion of the greater omentum to the peritoneal
reection in this location, it can be dicult to demonstrate in isolation intraoperatively.
7. Le peritoneal reection (Figure 13.7).
8. Le peritoneal reection at the base of the mobile
component of the mesosigmoid (i.e., where the latter
curves down and becomes attached to the posterior
abdominal wall) (Figure 13.8).
9. Pararectal peritoneal reection on either side of the
rectum (Figure 13.9).
LAPAROSCOPIC/ROBOTIC APPEARANCE
OF THE COLO- AND MESOFASCIAL PLANE
1. Small bowel mesentery and underlying fascia
(Figure13.10)
2. Ileocecal mesenteric conuence and underlying fascia
(Figure 13.11)
3. Right mesocolon and underlying fascia (Figure 13.12)
4. Transverse mesocolon aer mobilization of the greater
omentum (Figure 13.13)
5. Le mesocolon and underlying fascia (Figure 13.14)
6. Mesosigmoid and underlying fascia (Figure 13.15)
7. Mesorectum and associated fascia (Figure 13.16)
LAPAROSCOPIC/ROBOTIC
APPEARANCEOF ADIPOVASCULAR
PEDICLES
1. Ileocolic adipovascular pedicle (Figure 13.17)
2. Middle colic adipovascular pedicle (Figure 13.18)
3. Inferior mesenteric adipovascular pedicle (Figure 13.19)
Omento-c
reflection
ransverse
colon
Greater
Figure 13.5 Laparoscopic/robotic view of the peritoneal reection connecting the greater omentum and transverse colon.
omentum
Splenocolic peritoneal re˜ec tion
Spleen
t
of splenic ˜exure
Divided edge
of splenocoli
(b)
Laparoscopic/robotic appearanceof adipovascular pedicles 163
peritoneal
re˜ec tion
(a)
Legend
Mesentery
Fascia
c
Transverse colon
Splenocolic
peritoneal
re˜ec tion
Colon
Peritoneum
Colic componen
Descending colon
Figure 13.6 Splenocolic peritoneal reection. (a) Laparoscopic/robotic view. (b) (See also QR 2/5.) Digital view.
Demonstration of the reection in isolation of the greater omentum is difcult given the variable degree to which the
omentum fuses with the reection.
164 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Left peritoneal re˜ec tion
y
Descending
(b)
Descending
colon
(a)
colon
Divided left
peritoneal
re˜ec tion
Edge of
peritoneotomy
Legend
Mesentery
Fascia
Colon
Peritoneum
Left
peritoneal
re˜ec tion
Edge of
peritoneotom
Figure 13.7 Left peritoneal reection. (a) Laparoscopic view. (b) (See also QR 2d/1-2.) Digital view. Division of the reec-
tion is required in order to access the colo- and mesofascial planes of dissection (Figure 13.14).
Laparoscopic/robotic appearanceof adipovascular pedicles 165
Left peritoneal reflection at base of mesosigmoid
Descending
d
(b)
(a)
colon
Mesosigmoi
Divided left
peritoneal
reflection
Figure 13.8 Left peritoneal reection at the base of the mesosigmoid. (a) Laparoscopic/robotic view. (b) (See also
QR2d/1-2.) Digital view.
166 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Pararectal peritoneal re˜ec tion
pararec
tal
(a)
colon(b)
Anterior
re˜ec tion
Left
tal
re˜ec tion
Right
pararec
re˜ec tion
Rectum
Left
pararectal
re˜ec tion
Sigmoid
colon
Rectum
Anterior
peritoneal
re˜ec tion
Right
pararectal
re˜ec tion
Sigmoid
Figure 13.9 Pararectal peritoneal reections. (a) Laparoscopic/robotic view. (b) (See also QR 2d/5-7.) Digital view.
e
Toldt’s fascia
Pe
Cecum
Mesofascial plane/interface
(b)
Laparoscopic/robotic appearanceof adipovascular pedicles 167
Small bowel
mesentery
Toldt’s fascia
over
retroperitoneum
(a)
ritonotomy
margin
Legend
Mesentery
Region of
mesofascial
plane/interface
Small bowel
mesentery
Fascia
Colon
Peritoneum
Mesofascial
plane/interfac
Figure 13.10 Mesofascial plane generated by the small intestinal mesentery and Toldt’s fascia. (a) Laparoscopic/robotic view.
(b)Digital view. The mesofascial plane is evident after division of the peritoneal reection at the base of the small intestinal
mesentery (Figure 13.1).