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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_699_Библиотеки_им_академика_М_И_Перельмана.pdf
178 Appearance of the mesentery during opencolorectal surgery
UL exoscope
r
laparoscopic camera
Standard
camera stack
Sterile cove
Snake arm
Snake arm
support
Standard
Figure 14.1 Laparoscope mounted on a snake arm. This system captures images that closely approximate to the surgeon’s
point of view. Advantages include the fact that high-magnication and high-resolution images normally obtained during
laparoscopic or robotic surgery can be obtained during open surgery. Similar views cannot be obtained using standard
wall, head, tripod, or theater-light-mounted camera systems. As images are transmitted to a television stack, all theater
personnel can observe the procedure.
5. Peritoneal reection between greater omentumandupper
surface of the transverse colon (Figure14.6).
6. Splenocolic peritoneal reection (Figure 14.7). Due
to adhesion of the greater omentum to the peritoneal
reection in this location, it can be dicult to demonstrate this intraoperatively.
7. Le peritoneal reection (Figure 14.8).
8. Right and le mesosigmoidal peritoneal reection
at the base ofthemobile component of the mesosigmoid (i.e.,where thelatter curves down and
becomes attachedto the posterior abdominal wall)
(Figure14.9).
9. Pararectal peritoneal reection on either side of the
3. Right mesocolon and underlying fascia (Figure 14.13).
4. Transverse mesocolon aer mobilization of the greater
omentum (Figure 14.14).
5. Le mesocolon and underlying fascia (Figure 14.15).
6. Mesosigmoid and fascia beneath mesosigmoidal
peritoneal reection (Figure 14.16). (a) Mesosigmoidal
peritoneal reection prior to peritonotomy. (b)
Exposure of mesosigmoidal fascia aer peritonotomy.
7. Mesorectum and fascia at posterior aspect of mesorectum (Figure 14.17).
8. Mesorectum and mesorectal fascia aer division of
(a)le and (b) right, pararectal peritoneal reection
(Figure14.18).
rectum (Figure 14.10).
APPEARANCE OF ADIPOVASCULAR
APPEARANCE OF THE COLO- AND
MESOFASCIAL PLANE DURING OPEN
PEDICLES DURING OPEN MESENTERICBASED COLORECTAL SURGERY
MESENTERIC-BASED COLORECTAL
SURGERY
1. Ileocolic adipovascular pedicle (Figure 14.19)
2. Middle colic adipovascular pedicle (Figure 14.20)
1. Small bowel mesentery and underlying fascia
(Figure14.11).
2. Ileocecal mesenteric conuence and underlying fascia
(Figure 14.12).
3. Inferior mesenteric adipovascular pedicle
(Figure14.21)
4. Inferior mesenteric vein adipovascular pedicle
(Figure14.22)
(b)(c)
Small intestinal
Peritoneal reflection at the base of the small intestinal mesentery
Legend
Mesentery
Fascia
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 179
mesentery
Colon
Peritoneum
(a)
Small intestinal
mesentery
Small
intestional
peritoneal
re˜e ction
Left
mesocolon
Mesosigmoid
Small bowel
mesentery
Left
mesocolon
Small intestinal
peritoneal reflection
Peritoneal
reflection
Figure 14.2 (See also QR 3/5.) Peritoneal reection at the base of the small intestinal mesentery. (a) Digital model. The
point of view is demonstrated in the thumbnail image. (b) Intraoperative photograph demonstrating the peritoneal
reection at the base of the small intestinal mesentery. (c) Intraoperative image demonstrating increased adiposity in the
peritoneal reection at the base of the small intestinal mesentery (in an obese patient).
180 Appearance of the mesentery during opencolorectal surgery
Peritoneal reflection at the ileocecal junction
(a)
(c)
Appendix
Legend
Mesentery
Fascia
Colon
Peritoneum
ileocecal
peritoneal reflection
Terminal ileum
ileocecal
peritoneal reflection
(b)
ileocecal
peritoneal reflection
Terminal
ileum
Figure 14.3 Peritoneal reection at the ileocecal junction. (a) (See also QR 2/2.) Intraoperative view during open surgery.
The reection has been grasped with a pick-ups and divided with diathermy. (b) Digital view. (c) Ileocecal peritoneal
reection as observed in a cadaver.
Right peritoneal reflection
(b)
(a)
Legend
Mesentery
Fascia
Colon
Peritoneum
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 181
Right peritoneal
reflection
Right
(ascending) colon
Right
peritoneal reflection
Divided edge
of peritonotomy
Figure 14.4 Right peritoneal reection. (a) (See also QR 6/3.) Digital view. (b) Intraoperative view of the right peritoneal
reection during division. It is being divided using diathermy. The colon is retracted to the right which transmits tension to
the right peritoneal reection.
182 Appearance of the mesentery during opencolorectal surgery
Hepatocolic peritoneal reflection
(c)
Legend
Mesentery
Fascia
Colon
Peritoneum
Hepatocolic
peritoneal reflection
(a)
Hepatocolic
peritoneal reflection
Transverse
colon
Colic component
of hepatic flexure
Liver under retraction
Liver edge
Colic component
of hepatic flexure
(b)
Colic component
of hepatic flexure
Hepatocolic
peritoneal
reflection
Liver under retraction
Liver edge
Divided edge of
reflection
Divided edge of
reflection
Figure 14.5 Hepatocolic peritoneal reection. (a) (See also QR 2/4.) Digital view. (b) and (c) The hepatocolic peritoneal
reection as seen during open surgery, In (c) a nger has been placed beneath the reection which is being divided using
diathermy.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 183
Omento-colic peritoneal reflection
(b)
Transverse colon
Omento-colic
peritoneal reflection
(a)
Greater omentum
Transverse
colon
Peritoneal
reflection
Omentum
Figure 14.6 Peritoneal reection connecting the greater omentum and transverse colon. (a) View from above down.
(b)View from upper left quadrant medially. By placing traction on the colon and counter-traction on the omentum
thereection becomes apparent under stretch. This enables its safe division using diathermy.
184 Appearance of the mesentery during opencolorectal surgery
Splenocolic peritoneal reflection
(b)
(a)
Transverse
colon at flexure
Splenocolic peritoneal reflection
Splenocolic
peritoneal
reflection
Peritonotomy
of splenocolic
peritoneal
reflection
Figure 14.7 Splenocolic peritoneal reection, (a) medial to lateral view and (b) (See also QR 2/5.) lateral to medial view.
The reection was divided through using a Ligasure. The greater omentum fuses with the splenocolic peritoneal reection
and so it is difcult to demonstrate the reection in isolation.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 185
Descending colon
(b)
Left peritoneal reflection
Sigmoid
colon
Legend
Mesentery
Fascia
Colon
Peritoneum
peritoneal
reflection
(a)
Transverse
colon
Left
Descending
colon
Left peritoneal
reflection
Sigmoid
colon
Figure 14.8 Left peritoneal reection. (a) (See also QR 2d/1,2.) Digital view. (b) Intraoperative view of the left peritoneal
reection. The reection has been grasped using a pick-ups. The colon is retracted medially, thereby bringing the reection under tension and enabling its division. The view is from the left upper quadrant downward.
186 Appearance of the mesentery during opencolorectal surgery
(a
(c)
Mesosigmoidal peritoneal reflections
Sigmoid colon
)
Medial aspect
of mesosigmoid
Inferior mesenteric
adipovascular pedicle
Right medial
mesosigmoidal reflection
(b)
Legend
Mesentery
Fascia
Colon
Peritoneum
(d)
Figure 14.9 Peritoneal reections at either side of the base of the mesosigmoid. (a) (See also QR 2d/3,4.) Reection
at right (medial) side of the mesosigmoid. (b) (See also QR 2d/3,4.) Magnied view of the reection as seen in (a). (c)
Intraoperative view of this region of the reection. Thesigmoid and mesosigmoid are retracted to the left. This lifts the
mesosigmoid away from the retroperitoneum and brings the right mesosigmoidal reection into view. (d) (See also QR
2d/8,9.) Digital view of the lateral aspect of the mesosigmoid. A peritonotomy through the left mesosigmoidal reection has been included to demonstrate the mesosigmoid as it curves onto and becomes attached to the posterior
abdominalwall.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 187
Pararectal peritoneal reflections
reflec
(c)
Rectum
Anterior
peritoneal reflection
Left
pararectal
tionz
(a)
Divided left
pararectal
peritoneal
reflection
(b)
Right
pararectal
reflection
C
B
Sigmoid colon
Mesorectum
Divided edge of
right pararectal
reflection
Mesorectum
Figure 14.10 Pararectal peritoneal reections. (a) (See also QR 2d/5.) Digital view from above. (b) Open surgical view of
the left pararectal reection undergoing division (thumbnail demonstrates the point of view). (c) (See also QR 2d/6,7.)
Open surgical view of the right pararectal reection undergoing division (thumbnail demonstrates the point of view).