Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_699_Библиотеки_им_академика_М_И_Перельмана.pdf
xii How to access three-dimensional models usingQR codes
QR 9 - Splenic flexure in isolation
QR 13 - Mesorec
QR 10 - Splenic region with
flexure removed
QR 11 - Hepatic flexure in isolation
tum and fascia
QR 12 - Hepatic region with
flexure removed
Acknowledgments
We the authors gratefully acknowledge the insight and advice offered by the following individuals:
Ann Brannigan
Consultant Colorectal Surgeon
Mater Misericordiae Hospital
University College Dublin
Dublin, Ireland
John P. Burke
Consultant Colorectal Surgeon
Beaumont Hospital
Dublin, Ireland
Manish Chand
Consultant Colorectal Surgeon
Department of Surgery and Interventional Sciences
University College London
London, United Kingdom
Eoghan Condon
Consultant Surgeon
Department of Surgery
University Hospital Limerick
University of Limerick
Limerick, Ireland
Peter Dockery
Department of Anatomy
School of Medicine
National University of Ireland
Galway, Ireland
Awad M. Jarrar
Department of Cellular and Molecular Medicine
Lerner Research Institute
Cleveland Clinic
Cleveland, Ohio
Mathew Kalady
Department of Colorectal Surgery
Digestive Diseases Institute
Cleveland Clinic
Cleveland, Ohio
Miranda Kiernan
Department of Surgery
Graduate Entry Medical School
University of Limerick
Limerick, Ireland
Ravi Kiran
Department of Surgery
Columbia University Medical Center
Mailman School of Public Health
Center for Innovation and Outcomes Research
Division of Colorectal Surgery
New York Presbyterian Hospital-Columbia
New York, New York
Jonathon Efron
Ravitch Division of GI Surgery
Department of Surgery
The Mark M Ravitch Professor of Surgery and Urology
Johns Hopkins University
Baltimore, Maryland
Bill Heald
Pelican Cancer Foundation
Basingstoke Hospital
Basingstoke, United Kingdom
Joep Knol
Consultant General and Colorectal Surgeon
Jessa Hospital
Hasselt, Belgium
Ian Lavery
Department of Colorectal Surgery
Digestive Diseases Institute
Cleveland Clinic
Cleveland, Ohio
xiii
xiv Acknowledgments
Jeremy Lipman
Associate Professor of Surgery
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Staff Colorectal Surgeon
Cleveland Clinic Foundation
Cleveland, Ohio
Deirdre McGrath
4i Centre for Interventions in Inammation, Infection and
Immunity
Graduate Entry Medical School
University of Limerick
Limerick, Ireland
Manus Moloney
Department of Gastroentrology
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Brendan J. Moran
Peritoneal Malignancy Institute
Basingstoke Hospital
Basingstoke, United Kingdom
James W. Ogilvie Jr.
Department of Colorectal Surgery
Spectrum Health/Ferguson Clinic
Michigan State University
Grand Rapids, Michigan
D. Peter O’Leary
Department of Surgery
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
James O’Riordan
Department of General and Colorectal Surgery
Tallaght Hospital
Dublin, Ireland
Nicola O’Riordan
Department of Surgery
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Colin Peirce
Department of Surgery
University Hospitals Limerick
Limerick, Ireland
Feza Remzi
Professor of Surgery
Director, Inammatory Bowel Disease Center
NYU Langone Medical Center
New York, New York
Jonathon Roddy
Department of Surgery
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Shaheel M. Sahebally
Department of Surgery
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Martin Shelly
Department of Radiology
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Neil J. Smart
Department of Colorectal Surgery
University of Exeter Medical School
Royal Devon & Exeter Hospital
Exeter, United Kingdom
Mattias Soop
Department of Colorectal Surgery
University of Manchester
Manchester, United Kingdom
Salford Royal Hospital
Salford, United Kingdom
David W. Waldron
Department of Surgery
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Leon G. Walsh
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Steven D. Wexner
Digestive Disease Center
Department of Colorectal Surgery
Cleveland Clinic Florida
Weston, Florida
Florida Atlantic University College of Medicine
Florida International University College of Medicine
Miami, Florida
PART 1
1 History 3
2 Mesenteric and peritoneal anatomy 11
3 Embryologic development of the mesentery, peritoneal reection, and Toldt’s fascia 41
4 Histology of the mesentery 47
5 Toldt’s fascia 57
6 Mesenteric physiology 69
7 Pathology of the mesentery 85
8 Radiographic appearance of the mesenteryandperitoneum 109
9 Operative nomenclature 119
10 Teaching mesenteric principles 137
11 Gastroenterology 147
History
J. CALVIN COFFEY AND NICOLA O’RIORDAN
1
Introduction 3
Carl Toldt 3
Sir Frederick Treves 4
Limited support for Toldt’s observations 6
Radiology 6
Renaissance in focus on the mesentery 7
Two roads diverged in a wood, and I—
I took the one less travelled by,
And that has made all the difference.
Robert Frost
INTRODUCTION
For centuries, the mesentery and associated peritoneal
lining have been regarded as structurally complex. In 1885,
Sir Frederick Treves provided the rst comprehensive
description of both, emphasizing that while some mesenteric
regions persisted in adulthood, others regressed and were
lost [1]. For example, the small intestinal mesentery, transverse, and sigmoid mesocolon were consistently identiable
in adults, while the right and le mesocolon were identiable in a minority only. Treves’ descriptions were welcome
at the time, given the apparent complexity of the topic, and
were subsequently indoctrinated in virtually all anatomic,
embryologic, clinical, and related literature [1–3]. To the
present, the rst chapter of most reference texts on intestinal
surgery focuses on anatomy and physiology and is based on
Treves’ descriptions. A review of later chapters dealing with
techniques in intestinal removal identies a remarkable disparity. e right and le mesocolon are invariably present
in the adult and must be resected like any other mesenteric
region. Put simply, intestinal surgery has always relied on
the persistence of all regions of the mesentery.
Numerous factors contributed to the divergence of
anatomic and surgical approaches to the mesentery and
peritoneum. Since the time of Treves’ anatomic-based
research, surgeons focused increasingly on cellular aspects
of disease. With increasing awareness of the molecular basis
Laparoscopic and robotic surgery: The craft of
colorectal surgery 7
Anatomic continuity: A simpler principle 8
Future directions 8
Summary 8
References 8
of surgical disease, the emphasis of research shied away
from the anatomic-based cra component. More recently,
laparoscopic and robotic surgery have increased focus on
the “cra” component of surgery. In keeping with this,
the eld of surgical anatomy has increased in relative signicance and led to the demonstration of continuity of the
mesenteric organ from the small intestinal mesentery to the
mesorectum [4,5]. efollowing chapter will demonstrate
these shiing trends and clarify the manner in which recent
demonstrations allow a reconciliation of anatomic and surgical approachesto this important organ. is chapter nishes by demonstrating the opportunities that now occur
across a broad array of clinical and non-clinical sciences.
CARL TOLDT (1840–1920)
Carl Florian Toldt was born on May 3, 1840, in Bruneck,
Austria. Aer spending much of his childhood repairing clocks, he received his doctorate in 1864 at St. Joseph’s
University in Vienna and was appointed Professor of
Anatomy at the University of Vienna in 1875 (Figure 1.1). He
became Professor of Anatomy at the German university in
Prague. He subsequently returned to Vienna in 1884 to work
with his colleague, Langer, and together they established
the Anatomy Institute of Vienna. Carl Toldt’s best-known
anatomic work was Anatomischer Atlas für Studierende
und Aerzte (An Atlas of Human Anatomy for Students and
Physicians) (Figure1.2), which was translated into English.
Despite the superb quality of this work, and its anatomic
accuracy, it has been little referenced overall. Toldt died
from pneumonia in Vienna in November 1920 [6–9].
Toldt’s descriptions were based on dissection of fresh
cadavers that had not been exposed to corrosive preservative
3
4 History
agents. He rst observed that intestinal mesenteries did not
simply comprise two thin layers of closely apposed cells (i.e.,
the mesothelia) but rather contained vessels, nerves, and fat.
He called the resultant complex of structures the “lamina
mesenteria propria” (Figure 1.3). While Treves described
disappearance of the right and le mesocolon as humans
matured into adults, Toldt maintained they persisted and
attached (i.e., attened against) to the abdominal wall.
Where they attached, Toldt identied a thin seam of connective tissue (Toldt’s fascia) separating mesentery from
abdominal wall, just as two layers of rock might be separated by a seam of rock (see Chapter 2). Toldt suggested that
wherever the mesentery attached to the abdominal wall, the
cellular layer lining both (i.e., the mesothelium) underwent
a “gradual disappearance” to “admit contact and fusion of
their connective tissue laminae.” Toldt also suggested that
the outer cellular layer of the intestine, the tunica serosa,
could undergo a similar process and merge with the covering mesothelium of adjacent mesentery. ere is a striking similarity between current descriptions, and those of
Toldt,and it is remarkable that his work should have been
so infrequently referenced over the past two centuries [6–9].
Figure 1.1 Carl Toldt (1840–1920).
Figure 1.2 Cover illustration of Anatomischer Atlas Fur
Studierende und Aertze.
SIR FREDERICK TREVES
Frederick Treves was born in Dorset, England, in 1853
(Figure 1.4). He received his medical education at the
London School of Medicine and became assistant surgeon
at the London hospital in 1879. In 1883 he was appointed
as surgeon and head of the department of Anatomy. He
famously housed Joseph Merrick, “the Elephant Man,” in his
attic until Merrick died in 1890 [6,10]. Treves was awarded
the Jacksonian prize for dissertations on the pathology,
diagnosis, and treatment of obstruction of the intestine and
numerous Hunterian lectures on the anatomy of the intestinal canal and the peritoneum. He served in the Boer war
in 1899. He was knighted by King Edward VII on whom he
performed an appendectomy in 1902. He was a noted travel
writer and took up nal residence in Geneva (Switzerland)
due to poor health. He died of peritonitis in 1923 [6,10,11].
Treves described the human mesentery as fragmented.
Accordingly, the right and le mesocolic components of
the mesentery are, according to Treves, mostly absent in
the adult human. He described the small intestinal, transverse, and sigmoid mesentery as persisting into adulthood
and attaching directly to the abdominal wall (Figure 1.5).
At the time, his descriptions provided a welcome rationalization of what was, and still is, regarded as a complex anatomic topic (i.e., mesenteric and peritoneal anatomy in the
adult human). Although some aspects of his descriptions of
the mesentery and peritoneum are now regarded as inaccurate, he was correct in describing a “mesenteric root” at the
origin of the superior mesenteric artery. He was also correct in describing the mesentery of the appendix as arising
from the undersurface of the mesentery in the right iliac
fossa. Treves’ stunning descriptions were made at a time
when signicant advances were occurring in anatomic and
Sir Frederick Treves 5
mesenterii propria in die Darmwand
Tunica serosa intestini
a
t
Right colonic
Durchtritt eines Arterienzweiges durch die
Tunica serosa mesenterii
Epithelium
Lamina mesenterii
propria
Einstrahlung des Bindegewebes der Lamina
Fettgewebe
Tunica muscularis
Tela subserosa
Tunica
muscularis
Stratum longitudinale
Stratum circulare
Venenzweig
Tunica mucosa
Tela submucos
9
/
1
Figure 1.3 The mesentery and adjacent intestine is demonstrated. Toldt drew submesothelial connective tissue as well
as a mesenteric connective tissue lattice. He demonstrated a contiguity between these and the connective tissue of the
outer layers of the intestine. (Taken from Carl Toldt’s Anatomischer Atlas Fur Studirende und Aertze.)
Figure 1.4 Sir Frederick Treves (1853–1923).
attachment
Figure 1.5 Mesenteric attachments and peritoneal anatomy
in the adult human as per Sir Frederick Treves. Themesen-
Left colic
attachmen
tery of the small intestine, transverse, and sigmoid colon are
depicted by Treves as having linear attachments to the posterior abdominal wall. The attachment of the right and left
colon is indicated (arrows). These correspond to the regions
where a right or left mesocolon, if present, would be located.
Laparoscopic and robotic surgery: The craft of colorectal surgery 7
[23]. e theory of Oliphant gained acceptance, while that
of Dodd went largely unnoticed until recently (see the
“Anatomic continuity: a simpler principle” section).
More recently still, Charnsangavej et al. exploited
vascular markings in order to identify mesenteric regions
on abdominal CT [20,21,24]. is approach is practical and
readily adopted, which likely explains its widespread use.
However, the sentiment expressed by Dodd (that the CT
appearance of the mesentery is dicult to correlate with
prevailing anatomic concepts) still holds.
RENAISSANCE IN FOCUS
ON THE MESENTERY
Interest in the mesentery increased with the realization
thatwhen the mesentery associated with the rectum (i.e.,the
mesorectum) was fully excised for rectal cancer, the incidence of recurrent cancer decreased signicantly. e concept was termed “total mesorectal excision.” Although total
mesorectal excision had been conducted worldwide and
for decades, the anatomic basis for its success was a recent
discovery. In 1982, Heald etal. showed that a plane occurs
between the mesorectum and the pelvis and that dissection
in this plane, “the holy plane,” enabled a total mesorectal
excision (Figure1.7) [25,26]. is was a highly signicant
anatomic description as it provided surgeons with a failsafe anatomic roadmap, which, if adhered to, led to better
outcomes for patients with rectal cancer. Initial uptake of
the anatomic principle was begrudgingly slow, but it has
now gained worldwide acceptance. Surprisingly, Heald and
coworkers did not extrapolate the same anatomic basis to
the remainder of the colon and mesocolon.
LAPAROSCOPIC AND ROBOTIC SURGERY:
THE CRAFT OF COLORECTAL SURGERY
During the 1990s, the development of laparoscopic and
minimally invasive surgery (and subsequently robotic techniques) revolutionized intestinal surgery by providing high
magnication (greater than 20-fold) and high-resolution
anatomic imagery. Just as the principles of laparoscopic
and robotic intestinal surgery emerged, terminologies such
as “mesocolon” and “Toldt’s fascia” were increasingly utilized. For laparoscopic and robotic colorectal surgery to be
safe and repeatedly successful, the surgeon must adhere to a
universally reproducible anatomic roadmap. Unfortunately,
the anatomic basis for laparoscopic and robotic intestinal
surgery was also sketchily developed [5,27]. is assertion may be considered as unexpected, given surgeons for
decades practiced technically superb resections in the open
context. It is not surprising, however, when one considers
that descriptions of open, laparoscopic and robotic surgical techniques are hallmarked by limited reference to the
mesentery, the associated peritoneum and fascia.
A brief illustration of this point is important at this juncture. e mesofa scial plane is a key plane throug hout colorectal surgery. Access to it is universally gained by division of
the overlying peritoneal reection. Peritonotomy (i.e., division) of the reection and separation of plane components
are core colorectal activities and are universally required
for colorectal resection. Despite being centrally important,
their anatomic basis has only recently been described.
Focus on the anatomic and surgical importance of the
mesentery increased further when Werner Hohenberger
described superb results for patients undergoing a “complete mesocolic excision” for colon cancer (Figure 1.8)[28].
Figure 1.7 Professor R.J. (Bill) Heald, OBE, MChir,
FRCS(Ed)(Eng).
Figure 1.8 Professor Werner Hohenberger, MD, PhD.