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
188 Appearance of the mesentery during opencolorectal surgery
Mesofascial plane beneath small bowel mesentery
(c)
Legend
(a)
B and C
Small intestinal
mesentery
Small intestinal
peritoneal reflection
Small bowel
mesentery
Small bowel mesenteric
peritoneal reflection
Mesentery
Fascia
Colon
Peritoneum
(b)
Small bowel
mesentery
Toldt’s
fascia
Mesofascial
interface
Figure 14.11 Mesofascial plane generated by the small intestinal mesentery and Toldt’s fascia. (a) (See also QR 3/5.)
Digital overview of the peritoneal reection at the base of the mesentery. (b) Open surgical view demonstrating how the
reection is grasped for division. (c) Open surgical view of the mesofascial plane exposed after division of the reection.
The mesofascial plane is the interface between the fascia and the mesentery.
Right mesofascial plane
)
Legend
(b)
Mesentery
Fascia
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 189
Appendix
Undersurface
of mesentery
Colon
Peritoneum
Right mesofacial
plane (Toldt’s fascia
Peritonotomy
(a)
Toldt's fascia
Right
mesocolon
Mesofascial
interface/plane
Divided ileocecal
peritoneal reflection
Figure 14.12 Mesofascial plane generated at the ileocecal junction between the mesentery and Toldt’s fascia. (a) Digital
image demonstrating peritonotomy of the reection and exposure of the underlying mesofascial plane. (b) Open surgical
view of the mesofascial plane formed by the fascia and mesentery (the thumbnail demonstrates the point of view).
190 Appearance of the mesentery during opencolorectal surgery
Right mesofascial plane
(c)
Legend
Mesentery
Appendix
Undersurface
of mesentery
Fascia
Colon
Peritoneum
Right
mesocolon
(b)
(a)
Right mesofacial
plane (Toldt’s fascia)
Peritonotomy
Right colon
Toldt’s fascia
Undersurface of
right mesocolon
Right mesocolic
fascia still attached
to right mesocolon
Right mesocolic
fascia mobilised o˜
right mesocolon
Figure 14.13 Mesofascial plane generated by the right mesocolon and Toldt’s fascia. (a) Digital view. (b) Open view.
(c)Intraoperative view of the mobilized right mesocolon, Toldt’s fascia and the retroperitoneum. The fascia is still attached
to the right mesocolon on the left of the eld of view. It has been separated from the mesocolon on the right.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 191
Transverse mesocolon and omentum
colon
mesocolon
interface
Greater
omentum
Transverse
Transverse
Omento-mesocolic
Figure 14.14 Upper aspect of the transverse mesocolon after the greater omentum has been mobilized free.
192 Appearance of the mesentery during opencolorectal surgery
Left mesofascial plane/interface
(a)
(b)
mesocolic
) fascia
Legend
Mesentery
Fascia
Descending colon
Colon
Peritoneum
Left mesocolon
(deep surface)
Left mesocolic
(Toldt’s ) fascia
Left mesofacial
plane/interface
Undersurface of
left mesocolon
Left
mesofascial
plane/interface
Left mesocolic fascia
(overlying retroperitoneum)
Left
(Toldt’s
Figure 14.15 Mesofascial plane generated by the left mesocolon and Toldt’s fascia. (a) Digital view. (b) (See also QR 6/2.)
Open view. Themesofascial plane is formed at the interface of the left mesocolon (top of picture) and the fascia beneath.
To generate this view, the left mesocolon is lifted away from the retroperitoneum thus placing the mesofascial interface under tension. The bres of the fascia then become apparent and can be separated from the undersurface of the
mesocolon.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 193
(c)
Mesosigmoidal mesofascial plane
tion
(a)
Sigmoid colon
Mesosigmoid
peritoneal reflection
Mesosigmoid
(b)
Peritoneal
reflection
Mesofacial
interface
Toldt’s fascia
Divided edge
of peritoneal reflec
Figure 14.16 (a) Digital model demonstrating the medial aspect of the mesosigmoid and the technical approach
adoptedin gaining access to the mesofascial plane in this region. (b) Right mesosigmoidal reection prior to division.
(c)Exposure ofmesofascial plane after peritonotomy of reection. The mesofascial plane occurs at the interface between
the mesosigmoid and the underlying mesosigmoidal (i.e., Toldt’s) fascia.
194 Appearance of the mesentery during opencolorectal surgery
Mesofacial plane between mesorectum and fascia
(b)
ostate/seminal
Pr
vesicle retracted
anteriorly
Mesorectal
(Toldt’s ) fascia
(a)
Rectum
deflected
posteriorly
Mesorectum
reflected
anteriorly
Mesofacial
interface
Mesorectal
fascia
Figure 14.17 Mesofascial plane generated by the mesorectum (in front) and the mesorectal (Toldt’s) fascia posteriorly.
In(a) (see also QR 13/3) the rectum is deected posteriorly, and anterior structures anteriorly. The intervening fascia
comes under stretch andcan be visualized. The reverse approach was applied in (b) (see also QR 13/4) deecting the rectum anteriorly. This places the fascia under stretch. As a result the mesofascial interface can be identied and its components separated.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 195
Mesofascial plane between mesorectum and fascia
(b)
Divided edge
m
Mesorectum
of peritoneal
reflection
(a)
Mesofascial
interface
on the left
Mesorectu
Divided
peritoneum
Mesofascial
interface
Mesorectal
fascia
Figure 14.18 Mesofascial plane exposed after division of the left (a) (see also 13/5 and QR 2d/5) and right (b) (see also
QR13/6 and QR 2d/6,7) pararectal peritoneal reections.
196 Appearance of the mesentery during opencolorectal surgery
Ileocolic adipovascular pedicle
r
adipovascular
(a)
(b)
Right colic
adipovascular
pedicle
Ileocolic
pedicle
Mesenterotomy
through avascula
region
Figure 14.19 Ileocolic adipovascular pedicle before (a) (see also QR 1/5) and during (b) isolation for division.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 197
Middle colic adipovascular pedicle
mesocolon
Mesosigmoidal adipovascular pedicle
Skeletonized IMARetroperitoneum
Figure 14.20 Middle colic adipovascular pedicle.
Middle colic adipovascular
pedicle
Transverse
Mesosigmoid
Figure 14.21 Inferior mesenteric adipovascular (IMA) pedicle.