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228 General techniques in mesenteric-based colorectal surgery
Mesosigmoidal
fascia
(c)
Retrofascial plane
Mesocolon
Toldt’s fascia
(b)
Retroperitoneum
(a)
Duodenum
Head of
pancreas
Toldt’s
Iliopsoas muscle
(beneath fascia)
fascia
Figure 16.23 (a) Schematic illustration of retrofascial plane of dissection. (b) Intraoperative (open) example of dissection in
the retrofascial plane. (c) Intraoperative (laparoscopic) view of dissection in the retrofascial plane.
Laparoscopic view of mesofacial plane
l
Mesosigmoid
(a)
(b)
Peritonotomy margin
Closing the mesenteric defect 229
Peritonotomy
exposing
mesosigmoid
and fascia
(i.e., mesofascia
plane)
Peritonotomy
margin
Figure 16.24 Laparoscopic views of (a) peritonotomy and (b) view of mesofascial plane.
Forexample,following a laparoscopic or robotic total meso-
CLOSING THE MESENTERIC DEFECT
colectomy, the entire gastro-mesocolic complex can be eased
through a stoma-sized defect in the abdominal wall.
at is not to say that extraction always proceeds eort-
lessly. Sometimes it can be quite dicult. A number of
approaches can be utilized to facilitate this. In the rst
instance, a nger can be invaginated along the side of
the mesentery through the extraction site into an intraperitoneal location. In this manner, a component of the
mesentery can be digitally eased into an extra-peritoneal
position. is has the eect of releasing an adjoining mesenteric region, allowing more mesentery and associated
colon through. Oentimes, a spiral twisting of the specimen within the extraction site allows the intestinal tract
to disengage through the aperture, bringing the associated
mesentery with it. A nal (somewhat traumatic) approach
is to introduce abdominal retractors to widen an extraction aperture allowing a greater amount of mesentery and
colon through. If these measures fail, then the incision
should be widened.
Although the term “anastomosis” is not generally applied
to the divided margins of the mesentery, it is a legitimate
application of the term. In general, surgeons do not “anastomose” cut ends of mesentery except to prevent internal hernia formation. is is not always required if the mesenteric
fenestration created during a resection is wide enough to
permit small bowel to freely move in and out. It is required,
though, when the mesenteric defect (i.e., the hernia neck)
is narrow in which case there is an increased likelihood of
incarceration or strangulation [65]. Anastomosing mesenteric margins is generally conducted using a running or
interrupted 2-0 absorbable stitch.
A further consideration is the conformation of the
mesenteric anastomosis. Just as an intestinal anastomosis
has end–end or end–side conformation, so too does the
mesentery. By denition, and end-to-side intestinal anastomosis will have an end–side mesenteric anastomosis.
econformation of the mesenteric anastomosis may have
Mesosigmoidal
(Toldt’s ) fascia
230 General techniques in mesenteric-based colorectal surgery
Open view of mesofacial plane
Mesosigmoidal
Mesosigmoid
(b)
Peritonotomy
Mesosigmoid
(a)
fascia
Mesosigmoidal
(i.e., Toldt’s )
fascia
Peritonotomy
margin
Figure 16.25 Open surgical views of (a) peritonotomy and (b) mesofascial plane.
a clinic–pathologic correlate. Data indicate that recurrence
SUMMARY
of Crohn’s disease tends to occur proximal to the intestinal anastomosis, although the reason for this is unknown.
iscould be explained by the conformation of the mesenteric anastomosis. In an end–end anastomosis, two cut ends
of the mesentery are joined. As both have been divided, both
are sources of ongoing inammation. e proximal pole of
the mesenteric anastomosis is rst to encounter the eects
of environmental factors within the intestine. is, coupled
Most operative of time in resectional colorectal surgery is
spent in mobilizing and resecting the mesentery. As a result,
the surgeon must be familiar with approaches to peritonotomy, mesenterotomy, mesofascial separation, mesenterectomy, and vascular skeletonization and division. e
colorectal surgeon must be able to achieve these goals in the
robotic, laparoscopic, and open surgical context.
with the conformation of the mesenteric anastomosis, could
explain the distribution of recurrent Crohn’s disease, proximal to the intestinal anastomosis. It could also explain the
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17
Mesenteric component of sigmoid colectomy
J. CALVIN COFFEY AND MATHEW KALADY
Aims 233
Introduction 233
Preoperative preparation 233
Preparation of the operative eld 234
Techniques: Laparoscopic/robotic partial/total
mesosigmoidectomy 234
Once you have mastered a technique, you hardly
need look at the recipe again and can take off
on your own.
Julia Child
AIMS
To demonstrate the mesenteric and peritoneal basis of
sigmoidal resection.
INTRODUCTION
e term “sigmoidectomy” is similar to right hemicolectomy and anterior resection insofar as it omits reference to
that component of the procedure that requires most time
(i.e.,detachment and disconnection of the mesosigmoid)
[1,2]. It has been suggested that the term “sigmoidectomy” be
substituted by “total” or “partial mesosigmoidectomy” [1,2].
Total mesosigmoidectomy directly references the mesenterectomy, and given that removal of the sigmoid is implicit
(it is not possible to retain the sigmoid in the absence of a
mesosigmoid), the word “sigmoidectomy” could be justiably substituted by “mesosigmoidectomy.” is is analogous
to total mesorectal excision, complete mesocolic excision,
and total mesocolectomy.
PREOPERATIVE PREPARATION
Preoperative radiographic imaging provides numerous
opportunities for preparation prior to surger y. Assessmentof
Open mesosigmoidectomy 239
Special considerations: Unable to identify the
correctanatomic plane for mobilization 249
Future directions 249
Summary 249
References 249
visceral adiposity (i.e., mesenteric adiposity) provides the
surgeon with an indication of the level of technical diculty likely to be encountered. is is particularly important in inammatory conditions such as diverticulitis where
the mesentery can be grossly inamed and edematous.
In these cases, the mesentery diers considerably (from
normal) in terms of consistency and vascularity. Some correctly argue that the diverticular mesentery resembles that
seen in Crohn’s disease [3,4]. Although mesenteric thickening occurs in both, fat wrapping (creeping fat) is unique to
Crohn’s disease [5–7]. Surgical management of the mesentery in both settings can be quite challenging.
e identication of an abscess on preoperative imaging is technically important. An abscess is a walled-o
collection of pus. In the case of an intraperitoneal abscess
derived from a sigmoidal process, the “walling o” eect, or
compartmentalization, generally involves multiple organs
including bladder, small bowel (and associated mesentery),
sigmoid, and mesosigmoid. In this setting, it is particularly
important to have clear understanding of mesenteric and
peritoneal reection anatomy as it is imperative to accurately dierentiate individual structures [8]. If dissection
proceeds indiscriminately then mesenteric injury is inevitable, bleeding extensive, and the surgeon may be compelled
to resect bowel that could otherwise have been retained.
Although the general rule is to avoid operating in the
setting of a phlegmon, this may not be possible in patients
who failed conservative management, or in emergencies.
Most prefer to separate phlegmon components under
direct vision and although this can be done via minimally
invasive means (bycareful and anatomic separation), the
233
234 Mesenteric component of sigmoid colectomy
commonest approach is via open laparotomy. Some adopt
a hybrid approach where splenic exure and le colon/
mesocolon are rst mobilized using minimally invasive
means (i.e., robotically or laparoscopically). Separation of
phlegmon components is then done via a short (lower midline) incision. is approach has been used to good eect in
the setting of a diverticular colovesical stula [9–13].
Two additional points are important in diverticular sur-
gery. Oentimes, either the bladder or ureter can be involved.
Ideally, this should be preempted on review of preoperative
imaging and not encountered unexpectedly during an operation. Urologic support may be required and should be organized preoperatively, and consideration should be given, in
advance, to ureteric stent placement [14–16].
PREPARATION OF THE OPERATIVE FIELD
As with most colorectal surgery, it is imperative to set up
the operative eld correctly. e primary aim is to develop
unimpeded mesocolic access from the mesosigmoid to the
splenic exure. In laparoscopic and robotic settings, this
can beachieved placing a 10/12mm port in the right lower
quadrant and a 5 mm (or 8 mm in the case of robotic surgery) port in the right upper quadrant as well as a 5 mm
(or8 mm) port in the le lower quadrant, to assist in retrac-
tion. Port placement may be adjusted based on overall body
habitus and intraperitoneal anatomy. e optimal scope
has a 30° lens. Patient positioning in Trendelenburg with
the right side down, allows the small bowel (and associated mesentery) and greater omentum to fall away from the
le mesocolon and mesosigmoid. When this is technically
dicult and it is not possible to remove the small bowel
and mesentery from the pelvis, it is likely due to adhesions
between the small bowel mesentery and mesosigmoid.
Adhesions frequently occur between greater omentum and
le mesocolon. ese should be divided to ensure unimpeded mesocolic access as far medially as the duodenojejunal exure. Although it is feasible to conduct a total or
partial mesosigmoidectomy without full direct access to
the le mesocolon, this increases the possibility of intraoperative complications and should ideally be avoided.
TECHNIQUES: LAPAROSCOPIC/ROBOTIC
PARTIAL/TOTAL MESOSIGMOIDECTOMY
e rst major component of “medial to lateral” mesosigmoidectomy is mobilization of the inferior mesenteric
adipovascular pedicle from the posterior abdominal wall
(Figure 17.1a). is commences with peritonotomy of the
right mesosigmoidal peritoneal reection. To facilitate this,
the mesosigmoid must be lied away from the retroperitoneum, thereby exaggerating the groove created by the peritoneal reection. Peritonotomy in the correct location may
be followed by inltration of the mesofascial plane with CO2.
is “CO2 dissection” can greatly aid in the identication of
the correct plane of dissection and in facilitating mesofascial separation. In sequentially separating the mesosigmoid
from underlying fascia, the adipovascular pedicle is gradually mobilized. Given the importance of these steps they
will be described in further detail in the following.
e sigmoid colon is grasped at an appendices epiploicae using a grasper (placed through a le iliac fossa
5mm port). It is then lied toward the anterior abdominal wall. is has the eect of liing the mesosigmoid o
the retroperitoneum. In so doing, the peritoneal reection
at the base of the mesosigmoid is exaggerated providing
an anatomic landmark for the commencement of dissection (Figure 17.1). e surgeon grasps the medial aspect of
the mesosigmoid with an atraumatic grasper and places
it under further tension. Using the tissue sealant device,
such as the Harmonic scalpel, the mesothelium is divided
(i.e., peritonotomy) along a number of centimeters. It
is important to limit the depth of the peritonotomy as
digression into the mesosigmoid at this location leads to
bleeding that obscures the mesofascial plane.
e mesosigmoidal fascia resembles the mesorectal
fascia and is areolar in appearance [17–19]. As a result,
it is not uncommon for the surgeon to experience some
diculty in immediately identifying the mesofascial
plane at this point in the operation. Cautious dissection
here is usually successful in this context as the mesofascial interface is a plane of minimal resistance that emerges
with traction and dissection in the correct orientation. If
one is clearly in the mesosigmoid then dissection should
stop, and a separate peritonotomy created closer to the
posterior abdominal wall. Importantly, the surgeon
should never proceed with mobilization of the adipovascular pedicle, until the mesofascial interface has been
identied and developed. ere are occasions (albeit rare)
when this is not possible despite all eorts. In this setting,
one is best advised to develop the mesofascial interface
elsewhere rst. is approach is encapsulated in Victor
Fazio’s term “Circle the enemy.”
e 30° lens is exceptionally useful at this stage in the
procedure. Once a window has been made, and the beginnings of the mesofascial interface separated (Figure 17.2),
the lens face is reoriented to look “underneath” the mesosigmoid. is permits further mesofascial separation
from medial to lateral. Gradually, further medial to lateral
mesofascial separation becomes easier (compared with
the starting mobilization). e focus of dissection returns
to the medial aspect of the mesosigmoid where mesothelium is divided proximally (thereby extending the initial
peritonotomy). As the overall aim is to free the inferior
mesenteric artery (IMA) adipovascular pedicle from the
retroperitoneum, extension of the peritonotomy should
proceed cephalad, back up along the origin of the IMA,
toward the le mesocolon.
Mesosigmoidal fat is divided under high magnication
(with a vapor extractor in use), thereby separating the
adipovascular reection o the retroperitoneum. In so
doing, the 30° lens is repeatedly reoriented to visualize
the under surface of the mesosigmoid and the mesofascial
interface (Figures 17.1 and 17.2).
Techniques: Laparoscopic/robotic partial/total mesosigmoidectomy 235
(d)
(b
s fascia
Mesosigmoidectomy
Sigmoid colon
Mesosigmoid
peritoneal
reflection
(a)
) Toldt’
PeritonotomyMesosigmoid
Extension of peritonotomy
Retroperitoneum(c)
Inferior
mesenteric
artery
Extension of
peritonotomy
Mesosigmoidal
(Toldt’s ) fascia
Retroperitoneum
Figure 17.1 Panel demonstrating the right (lateral) aspect of the base of the mesosigmoid and the peritoneal
reection in this location. (a) Image of digital model demonstrating the reection here. (b) Intraoperative appearance of mesosigmoidal peritoneal reection as seen at the commencement of a laparoscopic mesosigmoidectomy.
A peritonotomy has been commenced. (c) The peritonotomy in (b) has been lengthened, exposing the underlying fascia
(Toldt’s or the mesosigmoidal fascia) and the overlying mesosigmoid. (d) When the peritonotomy is lengthened further
proximally, the inferior mesenteric artery comes into view.
236 Mesenteric component of sigmoid colectomy
Medial to lateral mesosigmoid mobilization (robotic surgery)
(mesosigmoidal)
undersurface of mesocolon)
(b)
(a)
itoneum
Inferior mesenteric
adipovascular pedicle
Mesosigmoid
Toldt’s fascia
Mesosigmoid
Toldt’s fascia (pulled up onto
Figure 17.2 (a) Robotic view demonstrating the mesofascial plane formed between mesentery above and mesosigmoidal
fascia below. The curved line follows the path of the inferior mesenteric adipovascular pedicle within the mesosigmoid.
(b) In this photograph, the mesosigmoid has been further mobilized off the retroperitoneum. Themesosigmoidal (Toldt’s)
fascia overlies the retroperitoneum. To the right of the eld of view, it is pulled onto the undersurface of the mesosigmoid
where the latter has not yet been mobilized.
Mesosigmoidal mobilization proceeds in a “zigzag”
manner, that is, in transverse and craniocaudal directions.
Eventually, further mobilization will be impeded as the
IMA curves toward the aorta. Here, bers of Toldt’s fascia
coalesce with mesosigmoidal connective tissue.
At this stage in the procedure, some surgeons promptly
divide the IMA with a tissue sealant device. Others use linear
stapling devices to divide the pedicle, sometimes including
part of the avascular interpedicular region proximal to it
(Figure 17.3). Clips can also be placed across and the IMA
divided between these (Figure 17.3). Some prefer to fully
skeletonize the artery. is has advantages in that it facilitates gaining control of any residual bleeding following
vascular division. To fully skeletonize the vessel, the 30°
lens is reoriented to visualize the avascular interpedicular
mesentery cephalad to the adipovascular pedicle. e latter
Fascia overlying
retroper
Mesosigmoid
(b)
mesenteric ar
Mesentery
Inferior mesenteric adipovascular pedicle (robotic surgery)
proximal
to IMA pedicle
Skeletonised
inferior
mesenteric artery
Mesosigmoid
mesenterotomy
(a)
Techniques: Laparoscopic/robotic partial/total mesosigmoidectomy 237
Clips on inferior
prior to division
Figure 17.3 (a) Robotic view during division of the mesocolon above the inferior mesenteric adipovascular pedicle. The
mesenteric region being divided is the avascular interpedicular area. (b) Fully skeletonized inferior mesenteric artery after
being clipped using hemolock clips. The mesosigmoidal (Toldt’s) fascia is evident in the background. The left ureter and
ileopsoas muscle faintly visible beneath the fascia.
is divided through with tissue sealant devices. iscan proceed quickly as it is an avascular mesentery. Itis important
however as it helps in further skeletonizing and isolating the
adipovascular pedicle.
Next, mesenteric fat on the far side of the vessel (i.e.,
out of direct view) remains to be freed from the vessel
surface. A blunt-tipped curved retractor can be employed
in thissetting. is form of retractor has a gently curved
blade with a blunt rubber tip. As it is retractable, one can
vary thelength of the blade exposed. e curvature means
tery
Left ureter
beneath
fascia
that it can be gently introduced behind a vessel and used
to tease open a gap between the vessel surface and adjacent tissue. is retractor may not be necessary in robotic
colorectal surgery when the wristed tips of the instruments
mean the tips can be gently introduced behind the vessel
in question.
Linear staplers can generally be can be inserted through
the 10/12mm port in the right iliac fossa, articulated so
that the thin blade inserts posterior to the vessel and closed
on the vessel for 1 minute for extrusion of residual edema.