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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_699_Библиотеки_им_академика_М_И_Перельмана.pdf
258 Mesenteric component of rectal resection
Left mesofascial separation
Pe
(a)
(b)
Mesosigmoid
ritonotomy of
left pararectal
reflection
Mesorectal
(Toldt’s ) fascia
Mesorectum
Left
mesorectum
Toldt’s
fascia
Figure 18.6 (a) (See also QR 2d/6.) Laparoscopic view of mobilization of the left mesofascial plane. As this proceeds, the
mesorectal fascia and left lateral aspect of the mesorectum are separated. (b) (See also QR 13/2.) Digital image demonstrating regional anatomy during mesofascial separation in this anatomic location.
e next step is the anterior rectum. e peritoneum of
the anterior midline (in the pouch of Douglas) is deected
anteriorly. e surgeon grasps the anterior surface of the distal rectum with an atraumatic grasper and lis the rectum
upward, o the pelvic oor, and posteriorly toward the sacrum
(Figure 18.10). is places the anterior peritoneal reection
under tension and exaggerates the groove at the reection.
In the female, the anterior peritonotomy is made along the
line of the groove, thereby gaining access to the rectovaginal
septum (Figure 18.10). In the male (Figure 18.11), the anterior
peritonotomy is started 5mm anterior to the groove. In this
manner, the seminal vesicles come into view.
In the male, the seminal vesicles become apparent anteriorly and once identied can be deected anteriorly. One
will note that with adequate anterior retraction and rectal
countertraction (upward and posteriorly) a plane of dissection develops at this location and can be followed posterior
to the seminal vesicles, posterior to the prostate and distally onto the distal rectum (Figure 18.11). is dissection
is done under high magnication, with vapor extraction,
and proceeds in a gradual manner ensuring hemostasis
throughout. e orientation of the prostate is an important consideration when the patient is in the supine or head
down position. e prostate is positioned forward and inferior to the seminal vesicles, as is the membranous urethra.
As a result, once one has developed the plane posterior to
the seminal vesicles, then there is a limited distance only
between this and the distal reaches of the rectum.
Mesorectum
Mesorectal
fascia
(b)
Mesorec
tum
Left mesofascial separation
(a)
Mesorectal
(Toldt’s) fascia
Technique: Laparoscopic/Robotic 259
Peritonotomy of
right pararectal
reflection
Mesosigmoid
Right
mesorectum
Toldt’s
fascia
Figure 18.7 (a) (See also QR 2d/5.) Robotic view of mobilization of the right mesofascial plane. As this proceeds, the
mesorectal fascia and right lateral aspect of the mesorectum are separated. (b) (See also QR 13/1.) Digital image demonstrating regional anatomy during mesofascial separation at this point.
Sometimes in the particularly obese individual, a distinct
plane cannot be readily identied in the anterior midline.
Rather than dissecting directly through here, the anterolateral aspect of the mesorectal package is further mobilized on
either side. e rectum is then retracted upward and posteriorly, and the anterior midline deected further anteriorly.
ese activities mimic those in open surgery where the lipped
pelvic retractor (in the anterior midline) is inserted deep into
the pelvis and countertraction exerted upward and posteriorly
on the rectum. e eects of this combination of traction and
countertraction are to expose the correct plane of dissection in
the anterior midline (even in the massively obese male).
By now, the level of the dissection is deep in the pelvis. e principles of dissection are the same; traction and
countertraction demonstrate the mesofascial plane aer
which separation of whose components leads to further
mobilization. Mesenteric continuity means that dissecting in
a zone-based manner (i.e., posterior, followed by lateral and
then anterior zones) facilitates exposure of the correct plane
in adjoining zones. In other words, the plane of dissection in
one zone becomes apparent following anatomic mobilization
in an adjacent zone. Very occasionally, in the particularly
obese, it may be necessary to dissect directly through fat.
is should be minimized, and every eort should be made
to remain in an anatomic plane.
At the pelvic oor, Waldeyer’s fascia is identied in the
posterior midline (Figure 18.12). is is a condensation
of mesorectal/Toldt’s fascia and is not a separate entity as
260 Mesenteric component of rectal resection
Posterior mesofascial separation
(b)
(T
moid
Right zone of adhesion
(T
of adhesion
Mesorectum
Mesorectal
(Toldt’s) fascial
(a)
Mesosig
Mesorectum
Mesorectal
oldt’s) fascial
Figure 18.8 (a) Robotic view of mobilization of the posterior mesofascial plane. As this proceeds, the mesorectal fascia
and posterior aspect of the mesorectum are separated. (b) (See also QR 13/7.) Digital image demonstrating regional
anatomy during mesofascial separation.
Mesorectum
Right zone
Mesorectal
oldt’s) fascia
Figure 18.9 Robotic view of the zone of adhesion on the right side.
Technique: Laparoscopic/Robotic 261
The anterior peritoneal reflection
(b)
(T
my
Intact
anterior
re˜ec tion
(a)
Divided
anterior
reflection
Peritonoto
margin
Mesorectum
on right
Mesorectal
oldt’s) fascia
Anterior
mesorectum/
Denonvillier’s
fascia
Figure 18.10 The anterior peritoneal reection I (nonobese female). (a) Laparoscopic view of operative eld seen as
the right pararectal peritonotomy is continued distally onto the anterior peritoneal reection. (b) (See also QR 2d/5-7.)
Regional anatomy after division through the anterior peritoneal reection.
sometimes depicted. Similarities with Toldt’s fascia elsewhere are demonstrated in Figure 18.12. A middle sacral
artery can sometimes occur here and division may cause
troublesome hemorrhage. e vessel is identiable when
dissecting through the fascia under high magnication.
epelvic oor becomes apparent directly in front of view.
With the patient in the lithotomy position, it has a vertical orientation, and slopes diagonally inward as it radially
encroaches on the anal canal. As the mesorectum cones
inward at the distal rectum, the latter can sometimes come
into view suddenly, so careful high-magnication dissection
is again necessary. Dissection in the posterior midline
generally facilitates posterolateral dissection, which in turn
facilitates lateral and thereaer anterolateral dissection.
In completing this sequentially on the le and right, the
entire mesorectum/rectal complex is detached or mobilized
en bloc without disruption. e dissection is only complete
when the red/brown colored bers of the pelvic oor are
seen marking a distal boundary to further dissection.
Where the entire rectum is not bei ng removed (i.e., partial
mesorectal excision), the mesorectum must be divided
across to expose the serosal surface of the rectum. It is
262 Mesenteric component of rectal resection
Anterior peritoneal reflection II
(b)
Pe
Intact
anterior
reflection
Divided right
pararectal
reflection
Divided left
pararectal
reflection
(a)
ritonotomy
of anterior
reflection
Rectum
Mesorectal
fascia
Anterior
mesorectum
Proximal edge
of anterior
reflection
Figure 18.11 (See also QR 2d/5-7.) The anterior peritoneal reection II (obese male). (a) Intraoperative view demonstrat-
ing the intact anterior peritoneal reection prior to peritonotomy here. Both the left and right pararectal reections have
been divided to the level of the anterior peritoneal reection. (b) Regional anatomy evident after division of the anterior
peritoneal reection. Theanterior aspect of the mesorectum is apparent as is the fascia interposed between this and the
seminal vesicles/prostate.
important to take time to do this carefully and thoroughly.
Once the mesorectum has been divided, it retracts distally
and becomes dicult to grasp directly. Its fatty composition
means that it will bleed and tear if directly grasped. In order
to achieve adequate mesorectal division, the mesothelium
overlying the mesorectum is grasped with an atraumatic
grasper. Mesorectal fat can then dissected through using a
tissue sealant device such as the harmonic scalpel. is must
be done under high magnication (with a smoke extractor
or vapor extractor) and in a gradualmanner. esuperior
Waldeyer’s (i.e., Toldt’s) fascia
)
(a)
(b
(c)
Technique: Laparoscopic/Robotic 263
Posterior
mesorectum
Waldeyer’s
(i.e., Toldt’s )
fascia
Rectum
Waldeyer’s
(i.e., Toldt’s )
fascia
)
Rectum and
mesorectum
Waldeyer’s
(i.e., Toldt’s
fascia
Figure 18.12 Waldeyer’s fascia. The fascia is a condensation of Toldt’s fascia in the distal pelvis where it lls the space
created by tapering of the mesorectum away from the surrounding pelvis. Robotic demonstration of Waldeyer’s fascia
posterior to mesorectum (a), lateral to the mesorectum on the left (b), and lateral to the mesorectum on the right (c).
rectal artery and vein should be anticipated and can be
divided using vessel sealant device, clips, or a stapling
device. In general, these vessels are attenuated in the mid to
distal mesorectum and thus more suited to division using
vessel sealant devices such as the Ligasure™, vessel sealer or
harmonic scalpel. e rectum must be repeatedly deected
le and right to demonstrate residual mesorectal tissue on
both sides and in the posterior midline. It is only when
the rectum is fully skeletonized circumferentially that one
should consider dividing it.
264 Mesenteric component of rectal resection
OPEN TOTAL OR PARTIAL MESORECTAL
EXCISION
Preoperative setup and intraoperative access-related considerations are identical to those for total or partial mesosigmoidectomy so they will be mentioned here in brief
only. It is essential to generate unimpeded access to the
le mesocolon, the mesosigmoid, and the mesorectum. In
all cases, the IMA should be identied clearly and ligated
proximal to the origin of the le colic artery. Although
this is not a requirement in benign disease, it is anatomic,
is mesenteric based, and provides an excellent teaching
opportunity for trainees. Accordingly, many surgeons
routinely mobilize the inferior mesenteric adipovascular
pedicle to skeletonize and expose the vessel for safe ligation and division. Inorder to achieve this safely and reproducibly, one requires unimpeded access to the entire le
mesocolon. us, it may sometimes be necessary to divide
congenital adhesions that can occur between the DJ exure
and the le mesocolon.
Trendelenburg positioning is particularly useful in the
context of rectal dissection deep in the pelvis. is positioning ensures that the greater omentum, small bowel, and
associated mesentery slide out and away from from the pelvis, o the right surface of the mesosigmoid and anterior
surface of le mesocolon. Appropriate instrumentation is
essential in providing adequate access and exposure deep
in the pelvis, and, in this regard, few instruments are better
than the lipped pelvic retractor. e sha of this retractor
has a long stem and is lipped at one extremity, while the arm
of the extractor is at a right angle at the proximal extremity.
Narrower versions are available and some adaptations have
a light source connected along the sha to permit illumination of the distal pelvis. Many would rightly advocate a
headlamp to provide adequate illumination of the distal
pelvis. is simple measure facilitates careful dissection in
anatomic planes at all stages of the dissection. Additional
tips that help with mesorectal access include carefully
spreading the legs upward and outward or placing a large
10 × 10cm swab against the perineum, thereby forcing the
perineum upward and forward.
Video recording of open mesorectal
excision
e development of the concept of TME by Professor Bill
Heald and Mr Brendan Moran was greatly aided by their
insistence on using high magnication and resolution
recordings for demonstration purposes [17–19]. In the recent
past, we adapted the capabilities of the laparoscope and
combined this with an external snake arm in the form of
the UL exoscope (Figure 18.13). While the surgeon and the
assistant perform the procedure, it is our custom to request
a resident or medical student (also scrubbed) to control the
position of the tip of the exoscope as well as the orientation
of the 30° lens. Images are then transmitted in the usual
manner to a television monitor mounted on a stack. In this
manner, the open surgical procedure is readily conveyed
to all theater sta including nursing and anesthetic sta.
Although we do not have quantitative data to support the
following, we have noticed that this transforms the operative environment. Where previously the open dissection
could not be visualized by anybody other than the actual
operating surgeon, images transmitted via the laparoscope
to a laparoscopic stack demonstrate the entire operation to
all in the operating room. Once videos have been obtained,
they are edited in Final Cut Pro (Apple Inc., Cupertino, CA)
and an audio accompaniment established aer which they
are archived (Figure18.13). e University of Limerick (UL)
exoscope adaptation thus overcomes many of the limitations
of previous modalities of video recording and rendition by
transmitting the surgeon’s point of view in a high denition
and high magnication format, to all in the operating room
(Figure 18.13).
Most importantly from a technical perspective, this means
that the subtle fascial planes between mesorectum and the
associated fascia are readily visible, rendered, and depicted.
Techniques
e reader is referred to Chapter 17 and to the open section
of mesosigmoidectomy for details related to mesosigmoidal
and mesocolic mobilization. Certain points will be mentioned
here however. ere is a tendency to commence the mobilization at the mesosigmoidal level. is is particularly the case for
junior surgeons. It is dicult to do, and so should be avoided,
because the fascia in this region is areolar and attenuated. As
a result of these properties, it is dicult to identify the interface formed between fascia and overlying mesosigmoid. Even
experienced surgeons can transgress into nonanatomic planes
in this region, entering either the retroperitoneum posteriorly
or the mesosigmoid anteriorly. Both are associated with bleeding that, although minor, is sucient to obscure the fascial
interface and the plane in which one aims to dissect.
e surgeon begins by liing the proximal sigmoid
upward (away from the retroperitoneum). is places the
mesosigmoid and junction between descending and sigmoid
colon under tension (Figure 18.14). e eect is to transmit
tension to the peritoneal reection and the groove formed at
this is exaggerated. e white line of Toldt will be apparent
at the le peritoneal reection. In general, it is absent at the
mesosigmoidal reection. Beneath the attached component
of the mesosigmoid the fascia is areolar, less dense, and as
such a prominent white line is not apparent where the fascia coalesces with the parietal peritoneum. is is another
reason why the surgeon should not rely entirely on the identication of the white line of Toldt as a landmark for the
commencement of peritonotomy.
e distal le peritoneal reection is divided exposing the underlying colofascial interface. e colon is
retracted anteriorly, placing the interface under stretch,
and exaggerating the bers of Toldt’s fascia (Figure 18.14).
Colofascial separation permits medial mobilization of the
descending colon and brings the mesofascial interface
UL exoscope used during Ileal pouch–anal anastomosis
(c) (d)
anorectal junction
Open total or partial mesorectal excision 265
(a) (b)
Anterior
Mesorectum
Rectum above
anorectal junction
Ileal pouh
Anal
anastomosis
Rectum staple
transected just above
Figure 18.13 (a) UL exoscope. The 30° laparoscope lens is mounted on a snake arm and bracket. The complex is referred
to as the UL exoscope. (b–d) Represent views that can be obtained using the UL-exoscope concept. (b) Intraoperative
view of the distal rectum following its mobilization. The rectum has been retracted posteriorly. (c) Distal rectum following transection just proximal to the anorectal junction. (d) Intraoperative view of ileal-pouch anal anastomosis after the
anastomosis has been completed.
Ileal pouch–anal
stapled anastomosis
266 Mesenteric component of rectal resection
Mobilization of junction between descending and sigmoid colon
(b)
mesocolon
l
Left peritoneal
reflection
Mesosigmoid
(a)
Left
Sigmoid
Mesosigmoid
Mesosigmoidal
(Toldt’s) fascia
Figure 18.14 (See also QR 2d/1-2.) Mobilization of junction between descending and sigmoid colon. (a) Lateral peritoneal
reection prior to peritonotomy and identication of mesofascial plane. A forceps has been used to directly grasp the
reection. The diathermy is then used to divide it without encroaching on underlying structures. (b) Exposure of mesofascial plane following peritonotomy of lateral peritoneal reection.
into view. ecomponents of this plane are separated to
detach the distal le mesocolon from the retroperitoneum
(Figure 18.14).
Given mesenteric continuity, detachment, or mobili-
zation in one region facilitates mobilization in adjacent
regions. Distal mobilization of the le mesocolon brings
the surgeon onto the correct plane of mobilization under
the mesosigmoid. At this point, further mobilization will
be hampered by the peritoneal reection at the le lateral
aspect of the mesosigmoid (Figure 18.15). e reection
is not always readily apparent and frequently obscured
by congenital adhesions that must be divided through
(Figure18.15). ey can be minimal or extensive, in which
case they form a sheetlike structure resembling the peritoneal reection at the base of the mesosigmoid. Even experienced surgeons can be surprised to nd when, aer dividing
Mesosigmoidal mobilization (left/lateral aspect)
congenital
Mesosigmoidal
(a)
(c)
Open total or partial mesorectal excision 267
Left-sided
adhesions
Left lateral
mesosigmoidal
reflection
(b)
Descending
colon
fascia
Mesosigmoid
Figure 18.15 (See also QR 2d/1-2.) Mesosigmoidal mobilization (left/lateral aspect). (a) Intraoperative view of the mesosigmoid
and mesosigmoidal mesofascial plane. (b) The left peritoneal reection has been grasped with a forceps and retracted away
from the mesosigmoid which has been retracted to the right. This places the reection under stretch and facilitates its division.
(c) The reection and underlying mesosigmoidal fascia have been retracted to the left and the mesosigmoid to the right.
This exposes the mesofascial plane and its components can be separated.