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208 Instruments used during mesenteric-based colorectal surgery
United States) has recently been developed, which maintains pneumoperitoneum while also ltering vapor. is is
increasingly used to prevent rectal billowing in transanal
total mesorectal excision and transanal minimally invasive surgery. Smoke evacuation devices have been shown
to provide a good eld of view and reduce risk of exposure to harmful carcinogens [28]. Devices that maintain
pneumoperitoneum and simultaneously extract vapor are
extremely useful in robotic colorectal surgery.
FUTURE DIRECTIONS
Current instruments are not without limitations. ese provide a basis for future instrument development. For example,
it is not uncommon to experience diculty in retracting the
small bowel and mesentery o the le mesocolon to achieve
unimpeded le mesocolic access. is is because of (1) the
extent to which the small bowel and associated mesentery
elongate and (2) the relatively short zone at which the mesentery attaches to the posterior abdominal wall. at being
the case, future eorts should aim to address these issues
and develop appropriate retraction mechanisms.
SUMMARY
For optimal mesenteric-based colorectal surgery, the
surgeon must have mechanisms that ensure unimpeded
mesenteric access, reliable hemostatic mobilization, and
mesenterectomy. Instruments that are currently available enable the surgeon achieve the these goals, but there
is considerable room for improvement at multiple levels.
Improved mesenteric access, more ecient peritonotomy,
mesofascial access, and separation are clinical needs that
should be addressed in future biodesign.
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2. Acar, H.I. etal., Dynamic article: Surgical anatomical
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5. Quirke, P. etal., Effect of the plane of surgery
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Surgery. Springer International Publishing, Cham,
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16. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
17. 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.
18. Scott-Conner, C.E.H. and C. Henselmann, Chassin’s
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Surgery. W.B. Saunders, Philadelphia, PA, 1994,
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109–123.
21. Beck, D.E. etal., The ASCRS Manual of Colon
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27. Marlicz, W. etal., Various types of stem cells,
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General techniques in mesenteric-based colorectal surgery
J. CALVIN COFFEY AND JEREMY LIPMAN
16
Aim 211
Importance of mesenteric principles 211
Preoperative preparation and patient setup 212
Instruments used in robotic, laparoscopic, and open
colorectal surgery 214
Patient position and mesenteric access 214
Displacing mesentery 216
Preparation of the operative eld 216
Division of mesentery (mesenterotomy) 220
It is sometimes necessary to step backward in
order to go forward.
French saying
AIM
e aim is to demonstrate techniques in peritonotomy,
mesenterotomy, mesofascial separation, mesenterectomy,
and vascular skeletonization and division, in open, laparoscopic, and robotic contexts.
IMPORTANCE OF MESENTERIC
PRINCIPLES
In the past , intestinal surgery focused ma inly on the intestinal
component of surgery, almost to the exclusion of the mesenteric component [1–6]. When considered in totality, one sees
that the most time in colorectal and intestinal procedures
is spent manipulating, dividing, and mobilizing mesentery.
Bowel division and anastomosis can now be safely completed
in a matter of minutes, with current suturing approaches or
stapling devices. In contrast, a signicantly greater proportion of time is spent in gently separating components of the
mesofascial interface, in as bloodless and anatomic a manner as is possible. A comprehensive review of online videos
demonstrating robotic and laparoscopic colorectal surgery
Clearing mesentery from theintestinal margin 222
Greater omentum 225
Colo- and mesofascial interface 226
Gravity 226
Specimen extraction 226
Closing the mesenteric defect 229
Summary 230
References 230
enables subdivision of the duration of the video into mesenteric and intestinal components. On average, the mesenteric
component is 2.5 times longer than the intestinal component.
ere is no doubt that a considerable proportion of intesti-
nal surgery is spent dividing peritoneal reections, mobilizing and div iding mesentery, or skeletonizing the components
of an adipovascular pedicle (Figure 16.1). Surgeons are
increasingly aware of these individual and separate components, a point that can be attributed to an improved understanding of mesenteric, fascial, and peritoneal reection
anatomy in general [7–12]. is was greatly assisted through
the development of the anatomic principles of total mesorectal excision followed shortly aer by total mesocolic excision
(and complete mesocolic excision) [1,13–30]. e central
principles of these approaches are extensive (i.e., complete)
and intact mesenterectomy to improve oncologic outcomes.
It is likely that emphasis on the mesenteric basis of surgery
will increase further given new perspectives and further
improvements in our understanding.
Increasing evidence points toward a role for the
mesentery in driving homeostatic systems. Derangements
in these have long been associated with atherosclerosis,
diabetes mellitus, and metabolic syndrome. Recent identication of mesenteric involvement has shed new light
on the function of the mesenteric organ in general and is
likely to inuence the technical approach to mesenterectomy in the future [31–44].
211
212 General techniques in mesenteric-based colorectal surgery
Middle colic adipovascular pedicle
root region
Right mesocolon and Toldt’s fascia
Mass in
mesocolon
right mesocolic fascia
PREOPERATIVE PREPARATION
ANDPATIENT SETUP
Middle colic vessel
Mesenteric
Figure 16 .1 Laparoscopic demonstration of the middle
colic adipovascular pedicle, looking superiorly.
As part of the formal multidisciplinary workup of patients
with colon and rectal cancer, it is important to stage the disease in the context of involvement of the mesorectum or the
mesocolon. is is more readily achieved at the level of the
rectum because of the availability of clear-cut radiologic correlates for the mesorectum. It is more dicult for the colon
as our understanding of the radiographic appearance of the
associated mesentery is less well developed. Moreover, no
studies to date have evaluated the radiologic appearance of the
mesentery in disease states, and in the context of recent developments in our understanding of its anatomy (Figure 16.2).
Increasingly, however, radiologists acknowledge that
the previously referred to “anterior pararenal space” corresponds to the mesocolon and that “anterior renal fascia”
corresponds to Toldt’s fascia (Figure 16.3) [45–48]. at
being the case, the main body of the mesentery and its posterior boundary are readily identied [48].
A problem remains in identifying the anterior boundary. As the small intestinal mesentery continues laterally
to become the right mesocolon, then it follows they are
similar in radiologic appearance. Given this, and given also
that the small intestinal mesentery overlies the right and le
mesocolon, it is dicult to identify the anterior boundary
of the mesocolon. is problem will only be overcome when
cecum
Figure 16.2 Computerized axial tomographic image of a mass in the right colon, with an associated mass in the right
mesocolon. Intraoperatively the patient had a nodal mass in the right mesocolon that was tethered to but had not penetrated Toldt’s fascia.
Toldt’s fascia
Right
Mass in right
mesocolon
Anterior renal
s) fascia
Left
mesocolon
Mesenteric obesity
mesocolon
disrupted
Anterior renal (Toldt’s) fascia
Transverse mesocolon
Preoperative preparation andpatient setup 213
Splenic flexure
mesentery
Descending
colon
(Toldt’
Figure 16.3 Computerized axial tomographic image demonstrating the anterior renal fascia. It is now known that this corresponds to Toldt’s fascia. Fat in the retroperitoneum is separated from the left mesocolon by Toldt’s fascia.
we can reliably and reproducibly dierentiate small intestinal from mesocolic mesentery. For the present, however,
Intact mesentery
wehave to infer the anterior interface [7,48].
ese points are directly relevant to the radiologist and
surgeon as they aid in interpreting radiographic imaging
Obese
transverse
and thus in planning an intestinal resection. Withincreasing recognition of radiographic regions corresponding to
the right and le mesocolon and with increased recognition of the concept of mesocolic continuity, surgeons
and radiologists can better interpret the computer tomographic(CT) appearance of the mesocolon preoperatively
[48]. is aids in determining the extent or stage of disease,
and in preempting intraoperative technical challenges in
achieving a total mesocolic excision. An example of this is
shown in Figure 16.2 where neoplastic extension into the
right mesocolon and thereaer into the underlying fascia was identied prior to operation. Using this approach,
the surgeon could gauge the level of technical diculty
likely to be encountered and make appropriately tailored
preparations.
Surface of mesentery
e radiographic appearance of the mesentery can help in
anticipating intraoperative diculties. e bulky mesentery
presents several challenges not least of which is a so consistency and a tendency to bleed (Figures 16.3 and 16.4). In these
circumstances, minimal traction leads to tearing and troublesome bleeding that can be dicult to control. On the other
hand, the thin mesentery is also challenging. Lack of fat means
that it is dicult to dierentiate mesentery from underlying
fascia and retroperitoneum (Figure16.5). When the fascia is
extremely thin, it is easy to transgress into the retroperitoneum
(Figure 16.6). e ideal case is one where visceral adiposity is
Figure 16.4 Intraoperative demonstration of mesentery in
an obese patient. The mesenteric surface was inadvertently
disrupted in the region demonstrated. This was followed
by localized bleeding from mesenteric vessels.
moderate, can be readily dierentiated from underlying fascia, and does not bleed on gentle retraction.
Preoperative radiologic assessment helps develop a tech-
nical impression of other diculties likely to be encountered.
Radiotherapy aects the mesentery inamannerthat leads to
214 General techniques in mesenteric-based colorectal surgery
Toldt’s fascia
Toldt’s fascia (open surgery)
Mesentery in thin patient
adipovascular pedicle
Sigmoid vessel
Inferior mesenteric
Figure 16.5 Intraoperative view of extremely thin mesentery. Fat is minimal and contained vessels are thus readily
identiable. There is a relative lack of connective tissue
around these vessels, which means there is an increased
risk of bleeding on minimal retraction.
Mesosigmoid
Superior rectal
adipovascular pedicle
signicant technical challenges. It sometimes causes mesenteric inammation resulting in fusion of planar components
(i.e., mesentery and fascia) [49–55]. A knowledge of mesenteric anatomy enables the surgeon to identify planes and
separate relevant components with minimal damage [7]. e
eects of radiotherapy are patient specic, in some instances
extensive, and in others minimal. Little is known regarding
the histologic and molecular eects of radiotherapy on mesentery, and as such this represents an important avenue for
future research. e radiographic appearance of radiationrelated mesenteric changes should forewarn the surgeon to
particular technical challenges.
INSTRUMENTS USED IN ROBOTIC,
LAPAROSCOPIC, AND OPEN
COLORECTAL SURGERY
Table 16.1 lists some of the instruments useful in achiev-
ing the goals involved in open, laparoscopic, and robotic
mesenteric-based surgery. ese will be referred to in the
descriptions that follow.
Patient position and mesenteric access
Laparoscopic mesenteric-based surgery requires the patient
to be placed in somewhat extreme positions. ese are necessary to permit adequate mesenteric access (Figure 16.7). is,
Toldt’s fascia
Figure 16.6 Intraoperative (open) view of relationship
between mesentery, fascia, and underlying retroperitoneum. The fascia is translucent and provides an extremely
thin barrier to the retroperitoneum.
Right ureter
Right gonadal
vessel
coupled with the duration of laparoscopic procedures, means
that patients may be subjected to prolonged pressure at several
points of neurologic or musculoskeletal vulnerability (i.e., common peroneal nerve). ere are numerous reports of medicolegal cases derived from complications related to positioning
[56–60]. As a result, it is a major concern in mesenteric-based
surgery. In contrast, it may be that extremes of position can be
avoided during robotic colorectal surgery. e versatility of the
wristed instruments may provide capabilities that obviate placing the patient in steep Trendlenberg position.
ere are very few regions of the small intestine and
associated mesentery that themselves are not directly accessible. In contrast, mesocolic access must be developed. Patient
positioning helps enormously in this regard. is applies for
both open and laparoscopic surgery, but given that the mesentery cannot be manually displaced in the laparoscopic
and robotic context, positioning becomes relatively more
important in these. For laparoscopic, but not for robotic,
surgery, it must be possible to place the patient in steep (or
reverse) Trendlenberg position, if required. Prior to starting one must ensure that the patient is adequately secured
to prevent their sliding on the operating table. A sudden
change in position, or the inability to safely generate a particular position, may force a conversion to an open operation, or greatly increase the technical diculty (Figure 16.7).
Instruments used in robotic, laparoscopic, and open colorectal surgery 215
(c)
(d)
Mesocolic access
Table 16.1 Key instrument utilized in open and laparoscopic mesenteric surgery
Open Robotic/Laparoscopic
Metzenbaum scissors Robotic/laparoscopic stack system
Monopolar diathermy 30° camera
Deaver retractor Gas tubing and cables
Hand-held abdominal retractor Ports: 12, 10, 8, 5 mm
Kelly retractor Energy sealant device/monopolar diathermy
Self-retaining abdominal retractor Bipolar fenestrated grasper
Artery clips Monoplar curve tip scissors
Babcock tissue forceps Vessel sealer
Debakey tissue forceps Pencil diathermy
Needle holder Wound protector
Energy sealant device Endoscopic stapling device
Surgical stapling device Endoscopic circular stapler
Suction and irrigation device Smoke extractor
Large-sized swabs/packs Endoscopic suction and irrigation device
(a)
Poor
mesocolic
access
(b)
Left
mesocolon
Excellent
mesocolic
access
Figure 16.7 Examples of adequate and inadequate mesenteric access in the context of the left mesocolon. Where mesen-
teric access is inadequate the small bowel (and associated mesentery) overlie the left mesocolon (a, b). The omentum can
also overlie it as a result of adhesions between the latter and the colon. Where access is adequate there is an unimpeded
access to the mesocolon (c, d).
216 General techniques in mesenteric-based colorectal surgery
Surgical table supports
Surgical table
shoulder supports
Surgical table
lateral support
Arm board
Figure 16.8 Patient positioning is crucial to obtain access.
A variety of barriers can be used (including side T-bars
and shoulder pads) to facilitate adequate positioning and
prevent the patient from slipping.
Knee and body strap
In placing a patient in a steep right or le lateral position,
some use side T-bars to prevent lateral slide (Figure16.8).
So padded gamgees are inserted between T-bars and bony
prominences to minimize risk of nerve injury. is is further aided by positioning the patients hands with thumbs
in the upright position. To prevent the patient from sliding
superiorly (when in Trendelenburg position), so cushioned
shoulder pads can be placed immediately above the shoulders with gamgee padding interposed between shoulders
and pads. Some institutes utilize an inatable rubber mat
that does not slip if placed directly onto rubber. However,
this is not a fail-safe mechanism particularly in the obese
patient. To prevent the patient from sliding inferiorly (i.e.,
when in steep reverse Trendelenburg), a half-bottom table
and overlying wedge support can be used.
Prior to beginning any procedure patient position is tested
to ensure that the patient is secure in all positional extremes.
e patient should be carefully examined to ensure all pressure points are padded and gaps are lled with supports. Only
then should the patient be draped. Safesetup for mesentericbased surgery can be quite time consuming and it is always
preferable that an experienced operating team is involved.
Displacing mesentery
In open, laparoscopic, and robotic colorectal surgery, the
surgeon must be able to mobilize mesocolon and mesentery
without damaging surface mesothelium. Minor bleeding is
inevitable following mesothelial breech, as there are small
blood vessels located immediately beneath. Although this
bleeding is usually minimal, it renders anatomic planes
indistinct. Mesofascial and retrofascial planes are easily
obscured by even the smallest amount of blood. If the mesothelium must be disrupted (i.e., during peritonotomy), this
is best done with a hemostatic sealant device that divides in
an hemostatic manner.
During mesenteric-based surgery, it is important to have
strateg ies that permit mesenteric retr action without mesothelial damage. One approach is to grasp appendices epiploicae
using a a grasper with serrated jaws (Figure16.9). ese are
excellent in grasping and holding epiploicae without causing
bleeding. As they are attached to the colon, their retraction
is transmitted to the colon and mesocolon. In addition, epiploicae are generally attached at a narrow pedicle, meaning
that they can be retracted in numerous directions.
Another means of retracting the mesentery is to utilize
an atraumatic tissue grasper placed directly on the mesothelium of the mesentery. is enables a more focused
retraction of the mesothelium but without tearing and
has the added advantage of permitting ne dissection
(Figure 16.10). Mesentery denuded of mesothelium should
never be directly grasped, as adipose tissue is so and will
bleed extensively.
ere are several other methods to safely retract
the mesentery. Some tack appendices epiploicae to the
anterior abdominal wall. Other laparoscopic retractors
areavailable that can be placed underneath the mobilized
le mesocolon, used to li this up, and expose the mesofascial interface. e mesentery can be maintained separate from the underlying fascia using the open jaws of a
grasper or by placing a swab between the two.
PREPARATION OF THE OPERATIVE FIELD
Too oen, the junior or inexperienced surgeon hastily
plunges toward the operative eld intent on completing
the intestinal component of a resection. is invariably
leads to time wastage and can be damaging as, in an eort
to eect a resection, structures are hastily displaced in the
hope of identifying “something familiar.” It is essential,
particularly in mesenteric-based surgery, to fully prepare the operative eld. e strategy used depends on the
region in question.
In the case of the rectum/mesorectum, it is important
to place the patient in Trendelenburg so that the small
bowel and associated mesentery fall away from the pelvis
(Figure 16.7). e same applies for a long redundant sigmoid and mesosigmoid. In itself, the intestinal component
of a redundant sigmoid is not dicult to technically manage (it can be retracted by grasping an epiploica). Diculty
arises because of the associated mesosigmoid. As described
in Chapter 2, the base of the mesosigmoid is considerably
shorter than the intestinal margin. As a result, the mesentery must narrow considerably from the intestinal to the
Grasping appendices epiploicae
T
ransverse colic
Atraumatic
(c)
appendices
epiploicae
Preparation of the operative eld 217
Greater
omentum
(a)
Toothed
grasper on
epiploicae
(b)
Toothed, ratcheted grasper
Lesser sac
grasper to
stabilize
epiploicae
Figure 16.9 (a) Intraoperative view of the retraction afforded by grasping an appendices epiploicae using a toothed
grasper. Although the latter is traumatic, the consistency of the epiploicae means that it will not tear or bleed. The
same cannot be said for the mesentery and any attempt to directly grasp the mesentery with a traumatic grasper will be
followed by hemorrhage. (b) Grasper being used to grasp an appendices epiploicae. (c) Blades of traumatic grasper.