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168 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
mesenteric
con˜uence
l
Ileoceacal mesofascial plane
(b)
Cecum
Toldt’s fascia
Peritonotomy
margin
(a)
Legend
Appendix
Terminal
ileum
Mesentery
Terminal ileum
Mesentery
Ileocecal
Fascia
Colon
Peritoneum
Peritonotomy
margin
Figure 13.11 Mesofascial plane generated at the ileocecal junction between the mesentery and Toldt’s fascia.
Mesofascia
interface
Toldt’s
fascia
(a)Laparoscopic/robotic view. (b) Digital view. The mesofascial plane is evident after division of the peritoneal reection in
this region (Figure 13.2).
Right mesofascial plane/interface
operitoneum
Right mesocolic (Toldt’s ) fascia
(b)
Peritonotomy
margins
Laparoscopic/robotic appearanceof adipovascular pedicles 169
Ascending
colon
Right
mesocolon
under
paritoneum
Right
mesofascial
plane/interface
(a)
Legend
Mesentery
Fascia
Colon
Peritoneum
Peritonotomy
margins
Right mesocolic (Toldt’s ) fascia
Cecum
Right
mesocolon
Right
mesofascial
interface/plane
Retr
Figure 13.12 Mesofascial plane generated by the right mesocolon and Toldt’s fascia. (a) Laparoscopic/robotic view.
(b)Digitalview. The colo- and mesofascial plane are evident after division of the peritoneal reection in this region
(Figure 13.3).
170 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Omento-mesocolic plane/interface
interface
Greater omentum
Omento-mesocolic
Transverse mesocolon
(cephalad aspect)
Spleen
Figure 13.13 (See also QR 2/9.) Laparoscopic/robotic view of upper aspect of the transverse mesocolon after the greater
omentum has been mobilized free.
Left mesofascial plane/interface
(overlying retroperitoneum)
Legend
Mesentery
Fascia
Colon
Peritoneum
Left
mesocolon
(deep surface)
Laparoscopic/robotic appearanceof adipovascular pedicles 171
Descending colon
Left mesofascial
plane/interface
Left mesocolic
(Toldt’s ) fascia
(a)
Deep surface
of left mesocolon
Left
mesofascial
plane/interface
Left mesocolic fascia
(b)
Figure 13.14 (See also QR 6/2.) Mesofascial plane generated by the left mesocolon and Toldt’s fascia. (a) Digital view.
(b)Laparoscopic/robotic view.
172 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Mesosigmoidal fascial plane/interface
(lateral aspect)
plane/interface
Mesorectal plane/interface (TME plane)
(a) (b)
plane/interface
Mesosigmoidal
(Toldt’s ) fascia
Mesosigmoid
Mesosigmoidal
Figure 13.15 Laparoscopic/robotic appearance of the mesofascial plane formed by the mesosigmoid and Toldt’s fascia.
Theplane is evident after the peritoneal reection has been divided in this region.
Rectum
Peritonotomy
margin
Pelvic
sidewall
Mesorectal
(Toldt’s) fascia
Right
Mesorectum
Toldt’s
Fascia
Legend
Mesentery
Fascia
Colon
Peritoneum
Mesorectal
Figure 13.16 Mesofascial plane generated by the mesorectum and Toldt’s fascia. (a) Laparoscopic/robotic view. This view
is obtained by retracting the rectum to the left and extending the peritonotomy at the medial aspect of the mesosigmoid.
(b) (See also QR 13/1-7.) Digital view.
Laparoscopic/robotic appearanceof adipovascular pedicles 173
adipovascular pedicle
Ileocolic adipovascular pedicle
Middle colic adipovascular pedicle
adipovascular
root region
Ileocolic
Figure 13.17 (See also QR 1/5.) Laparoscopic/robotic appearance of the ileocolic adipovascular pedicle.
Transverse mesocolon
Transverse
mesocolon
Toward
mesenteric
Middle colic
pedicle
Lesser
sac
Figure 13.18 (See also QR 1/7,8.) Laparoscopic/robotic appearance of the middle colic adipovascular pedicle.
174 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Inferior mesenteric adipovascular pedicle
(c) (d)
adipovascular pedicle
Inferior mesenteric
adipovascular pedicle
Sigmoid colon
Peritoneal
reflection
Mesosigmoid
peritoneal reflection(a) (b)
Inferior mesenteric
Figure 13.19 (See also QR 2/11 and QR 2d/3 and 4.) Laparoscopic/robotic appearance of the inferior mesenteric
adipovascular pedicle. (a) (See also QR 2d/3 and QR 2/11.) Digital model demonstrating the medial aspect of the
mesosigmoid (viewed from below up) after division of the peritoneum and mobilizing of the mesosigmoid from Toldt’s
fascia. (b)Intraoperative view of medial aspect of mesosigmoid as seen during laparoscopic mobilization of the inferior
mesenteric artery vascular pedicle. A peritonotomy has been commenced which exposes the underlying mesofascial
interface between mesosigmoid and underlying Toldt’s (i.e., mesosigmoidal) fascia. (c)Intraoperative view of the medial
aspect of the mesosigmoid and the contained vascular pedicle of the inferior mesenteric artery. The medial (apposed)
mesosigmoid has been mobilized via mesofascial separation from the underlying fascia (Toldt’s or the mesosigmoidal
fascia). (d)Intraoperative view of the fully mobilized and skeletonized inferior mesenteric artery as seen during
laparoscopic mobilization of the mesosigmoid.
References 175
SUMMARY
An atlas of the laparoscopic and robotic appearance of the
mesentery, associated peritoneum, and fascia, as seen during mesenteric-based surgery, was developed. is atlas
provides a reference to aid in the performance of mesenteric-based colorectal surgery.
REFERENCES
1. Milsom, J.W. etal., Laparoscopic Colorectal Surgery.
Springer, New York, 2006.
2. Heald, R.J., The “Holy Plane” of rectal surgery. J R
Soc Med, 1988. 81(9): 503–508.
3. 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.
4. Taylor, F.G. etal., Preoperative magnetic resonance
imaging assessment of circumferential resection
margin predicts disease-free survival and local
recurrence: 5-year follow-up results of the MERCURY
study. J Clin Oncol, 2014. 32(1): 34– 43.
5. Chand, M. etal., Laparoscopic surgery for rectal cancer. J R Soc Med, 2012. 105(10): 429–435.
6. Dayal, S. and B. Moran, Extra-levator abdomino-perineal excision in advanced low rectal cancer surgery.
Br J Hosp Med, 2013. 74(7): 381–384.
7. Dayal, S. and B. Moran, LOREC: The English low
rectal cancer national development programme.
BrJHosp Med, 2013. 74(7): 377–380.
8. Coffey, J.C., Surgical anatomy and anatomic
surgery—Clinical and scientic mutualism. Surgeon,
2013. 11(4): 177–182.
9. Coffey, J.C. etal., Terminology and nomenclature
in colonic surgery: Universal application of a rulebased approach derived from updates on mesenteric
anatomy. Tech Coloproctol, 2014. 18(9): 789–794.
10. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
11. Culligan, K. etal., Review of nomenclature in colonic
surgery—Proposal of a standardised nomenclature based on mesocolic anatomy. Surgeon, 2013.
11(1):1–5.
12. 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.
13. Peirce, C. etal., Digital sculpting in surgery:
Anovelapproach to depicting mesosigmoid
mobilization. Tech Coloproctol, 2014. 18(7):
653–660.
14. 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.
15. 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.
16. Standring, S., Gray’s Anatomy:
TheAnatomicalBasisof Clinical Practice. Elsevier
Health Sciences, Edinburgh, Scotland, 2015,
pp.1124, 1136.
17. Coffey, J.C. and P. Dockery, Colorectal cancer:
Surgery for colorectal cancer—Standardization
required. Nat Rev Gastroenterol Hepatol, 2016.
13(5): 256–257.
18. Coffey, J.C. et al., The mesentery in Crohn’s disease:
friend or foe? Curr Opin Gastroenterol, 2016. 32(4):
267–273.
Appearance of the mesentery during
opencolorectal surgery
J. CALVIN COFFEY AND JAMES O’RIORDAN
14
Aim 177
Introduction 177
Methodology 177
Appearance of the peritoneal reection during open
mesenteric-based colorectal surgery 177
Science is the systematic classication of
experience.
George Henry Lewes
AIM
e aim is to demonstrate the appearance of the mesentery,
peritoneum, and fascia as seen during open mesentericbased surgery.
INTRODUCTION
e appearance of the abdomen at open surgery diers
dramatically from that during laparoscopic and robotic surgery. Perhaps the single greatest dierence, apart from the
eects of overhead or natural light on tissues, is loss of the
20-fold magnication and high-denition view aorded by
the laparoscope. e latter is substituted by unaided human
eyesight in the open setting. is means that individual mesenteric and intestinal structures appear more remote, and the
subtle planes used in colorectal surgery are more dicult to
identify. Given (1) dierences between laparoscopic/robotic
and open surgery, (2) most abdominal surgery continues
to be performed open, and (3)the open surgical approach
remains the fallback if laparoscopic (orrobotic) fails or is not
feasible, then it is essential to provide an atlas of the appearance of colorectal surgical anatomy as observed during
mesenteric-based surgery in the open context.
Appearance of the colo- and mesofascial plane
during open mesenteric-based colorectal surgery 178
Appearance of adipovascular pedicles during open
mesenteric-based colorectal surgery 178
Summary 198
METHODOLOGY
e images presented in the following were taken at open
surgery using a laparoscope mounted on a snake arm
(i.e.,the UL Exoscope) (Figure 14.1). is approach meant
the 20-fold magnication and high-resolution imagery
associated with laparoscopic surgery could be replicated
in the open surgical context. In order to orientate the
viewer, corresponding views were generated using a 3D
digital sculpture of the mesentery, gastrointestinal tract,
associated peritoneal reection, and fascia. Cadaveric
images are occasionally used to emphasize a particular anatomic point. efollowing will demonstrate the
appearance of the peritoneal reection, the colon and
mesofascial planes, and adipovascular pedicles, as seen
during open colorectal surgery.
APPEARANCE OF THE PERITONEAL
REFLECTION DURING OPEN
MESENTERIC-BASED COLORECTAL
SURGERY
1. Peritoneal reection at the base of the small intesti-
nal mesentery where it curves onto retroperitoneum
(Figure 14.2).
2. Ileocecal peritoneal reection (Figure 14.3).
3. Right peritoneal reection (Figure 14.4).
4. Hepatocolic peritoneal reection (Figure 14.5).
177