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
278 Mesenteric component of right colectomy
Mesenteric and mesocolic continuity
mesentery
mesocolon
Right mesocolon
Small bowel
Figure 19.1 (See also QR 1 and 7.) Intraoperative image
demonstrating continuity between small intestinal mesentery, right and transverse mesocolon.
Transverse
e small bowel mesentery curves down onto the pos-
terior abdominal wall and extends laterally as the attached
right mesocolon. Toldt’s fascia separates the mesocolon from
the underlying retroperitoneum. As the terminal ileum has
a junction with the cecum at the ileocecal junction, a substantial mesenteric tissue mass occurs at the ileocecal junction. e mesoappendix arises from the undersurface of this
conuence. Depending whether this is short or narrow, the
appendix adopts a retrocecal or a pelvic position [1,4,23,24].
Where the small bowel mesentery curves downward at
the mesenteric base a peritoneal reection is apparent. is
commences at the fourth part of the duodenum and extends
obliquely across the posterior abdominal wall to reach the
ileocecal mesenteric region. Division of the reection (i.e.,
peritonotomy) exposes the mesofascial interface between
small bowel mesentery and underlying Toldt’s fascia. Here,
it can be arbitrarily called the ileocecal peritoneal reection.
e peritoneal reection at the small bowel mesenteric base
has yet to be formally named (despite it’s being an anatomic
constant). e ileocecal peritoneal reection extends around
the inferolateral aspect of the cecum and then proximally as
the right peritoneal reection. Importantly, it “closes o”
access to the colofascial and mesofascial interface in this
region [1,2,4,23,24].
e ileocecal peritoneal reection continues around
the hepatic exure as the peritoneal component of the latter, where it is called the hepatocolic reection. e greater
omentum coalesces to varying degrees with the superior
surface of the hepatocolic reection. Although the right
mesocolon is attached to the retroperitoneum, it is separated from the latter by Toldt’s fascia. Beneath the fascia lie
retroperitoneal structures (i.e., ureters, gonadal vessels, and
duodenum) [1,2,4,23,24].
In describing the activities required for right mesocolectomy, the terms mesofascial and colofascial separation
will be repeatedly used. Mesofascial separation is separation (or detachment) of mesentery from underlying fascia
and colofascial separation is separation of the colon from
underlying fascia. As mentioned previously, a plane is the
interface between two contiguous surfaces. In the case
of the mesofascial plane, the contiguous surfaces are the
mesocolon and fascia. In the case of the colofascial plane,
the contiguous surfaces are the colon and fascia. A further
terminology, retrofascial separation, refers to the separation of the fascia from the underlying retroperitoneum (an
approach adopted in some institutes) [1–4,23,24].
OPEN RIGHT MESOCOLECTOMY
e abdomen is opened via a midline laparotomy and
adequate access obtained using the principles described in
Chapter 16. In keeping with this, the greater omentum (if
attached) is separated from the right colon by division of
adhesions. It may also be necessary to separate the small
bowel and associated mesentery via adhesiolysis. In this
manner, the right colon, mesocolon, terminal ileum, and
ileocecal mesenteric conuence are fully exposed. Special
circumstances arise when the pathology encountered
impedes access to these structures and will be dealt with in
a later section of this chapter.
e lateral-to-medial approach is begun by liing the
right colon o the posterior abdominal wall, placing the right
peritoneal reection under tension. Congenital adhesions
may occur between the right colon and lateral abdominal
wall. ese initially obscure the right peritoneal reection
and must be divided (Figure 19.2). Aer their division,
the right colon is lied away from the posterior wall. is
exaggerates the grove formed by the right peritoneal reection. e groove at the reection is exaggerated, identied,
and divided through. Following peritonotomy, the plane
between the colon and underlying fascia can be identied
(the colofascial interface). If the plane is not readily apparent, then the colon can be lied further away from the retroperitoneum. e traction transmitted to the colofascial
interface is usually sucient to permit its identication and
detachment can be achieved [2].
When colofascial separation has been completed and
the colon detached, the mesofascial interface is seen
(Figure 19.2). Mesofascial separation involves liing the
colon upward and medially and concurrently displacing
the fascia toward the retroperitoneum. e right peritoneal
reection is divided further, enabling continued mesofascial separation (Figure 19.3). e activities of peritonotomy
and mesofascial separation are continued until further mesenteric detachment is limited by the ileocecal and hepatocolic exures.
At this point, the right colon is still attached at the ileocecal junction and the hepatic exure. To mobilize the former,
the ileocecal peritoneal reflection is divided (Figure19.4).
e fascial interface between the ileocecal mesenteric
(ascending)
Congenital adhesions and right peritoneal re˜ection
Congenital
(b)
peritoneal
adhesions
(a)
Open right mesocolectomy 279
Right
colon
Right
reflection
Figure 19.2 (See also QR 2/3-5.) (a) Congenital adhesions between the right colon and lateral abdominal wall. These
obscure the right peritoneal reection from view. They become apparent after the ascending colon has been retracted
medially. They impede direct access to the right peritoneal reection unless divided. (b) Intraoperative appearance of
right peritoneal reection after division of congenital adhesions. The reection has been divided (i.e., peritonotomy) and
the surgeon has placed his ngers underneath the reection.
exure and underlying retroperitoneum is viewed and components separated (Figure 19.4).
Next, the peritoneal reection at the base of the small
intestinal mesentery is sharply divided. e peritonotomy
is extended proximally to the fourth part of the duodenum (Figure 19.5). e mesofascial interface between
small intestinal mesentery and fascia is identied and
components separated. At this point, the lateral, inferior, and medial planes of dissection meet. e remaining attachments are the mesenteric root region (where the
superior mesenteric vein courses toward and the superior
mesenteric artery emerges from the pancreas) and the
hepatic exure [2].
To mobilize (i.e., detach) the hepatic f lexure, peritonotomy of the right peritoneal ref lection is extended
around the hepatocolic reflection (Figure 19.6). This
exposes the colo- and mesofascial interface so their components can then be separated. The complex formed by
mesentery and intestine can now be medialized as far as
the third part of the duodenum and head of the pancreas
(Figure 19.6).
Not infrequently, the greater omentum coalesces with
the hepatocolic reection. In order to separate the greater
omentum, the omento-colic reection is divided at the midtransverse colon level (Figure 19.7a). is permits access to
the lesser sac and enables the surgeon separate the greater
omentum from the upper surface of the transverse mesocolon. If this activity is continued from the midline toward
the hepatic exure, the hepatocolic peritoneal reection is
exposed.
At this point, the mesentery has been fully mobilized.
e remaining attachment is the mesenteric root region,
where the superior mesenteric artery comes through the
head of the pancreas (Figure 19.7b). If the mesentery has
been fully mobilized, then the head of the pancreas and
second part of the duodenum are clearly seen (Figure19.7b).
Once the mesentery has been mobilized the associated
bowel is by denition fully mobilized. A resection and
Cecum
280 Mesenteric component of right colectomy
(b)
of right mesocolon
Divided edge
Right mesofacial plane and mesofacial separation
Right
peritoneal
re˜ec tion
Divided edge
of peritonotomy
(a)
of right
peritoneal
reflection
Exposed surface
Right mesocolic
(Toldt’s ) fascia
Figure 19.3 (a) (See also QR 6/3.) Right peritoneal reection after division. The ascending colon is retracted medially and
the peritoneal reection brought under stretch. This enables its division without entering underlying structures. (b) Right
mesofascial plane. Toldt’s fascia is interposed between the right mesocolon and retroperitoneum. The plane becomes
apparent after the right colon and mesocolon are lifted away from the posterior abdominal wall.
Open right mesocolectomy 281
Mesofacial interface beneath ileocecal peritoneal reflection
(b
Pe
Mesocolon
Peritonotomy
margin
(a)
ritonotomy
margin
Toldt’s
fascia
Small
bowel
mesentery
Mesocolon/small
bowel mesentery
Peritonotomy
margin
)
Figure 19.4 (See also QR 3d/3.) (a) Ileocecal peritoneal reection viewed from above and toward the midline. The reection has been grasped with a forceps and retracted toward the midline. (b) Mesofascial interface beneath the ileocecal
peritoneal reection. The interface is exposed following peritonotomy here. The interface is formed between Toldt’s
fascia and the conuence between small intestinal and right mesocolon. Toldt’s fascia overlies the retroperitoneum. If the
interface is not immediately apparent, then retraction of the mesentery to the right and away from the posterior abdominal wall will demonstrate it.
282 Mesenteric component of right colectomy
Peritoneal reflection at base of small intestinal mesentery
(a)
(b)
Retroperitoneum
Small
intestinal
mesentery
Peritoneal
reflection
at base of
mesentery
Small
intestinal
mesentery
Toldt’s
fascia
Figure 19.5 (See also QR 8/1.) (a) Peritoneal reection at base of the small intestinal mesentery. To generate this view, the
small bowel and mesentery are retracted to the right. This places the reection under stretch. The surgeon is pointing in
the direction of the mesenteric root region. (b) Mesofascial interface beneath the ileocecal peritoneal reection. The interface is exposed following peritonotomy here. The interface is formed between Toldt’s fascia and the conuence between
small intestinal and right mesocolon. Toldt’s fascia overlies the retroperitoneum. In order to demonstrate the interface, the
small bowel mesentery is retracted away from the posterior abdominal wall and to the right. The peritoneal reection is
grasped and retracted to the left.
Hepatocolic
peritoneal reflec
Hepatocolic peritoneal reflection and mesofacial plane
(a)
(b)
Open right mesocolectomy 283
tion
Transverse
mesocolon
Toldt’s
fascia
Mesofacial
plane
Figure 19.6 (See also QR6/7 and 8.) (a) The hepatocolic peritoneal reection. This is demonstrated by retracting the colic
component of the hepatic exure toward the left iliac fossa. (b) The mesofascial interface after peritonotomy of the hepatocolic peritoneal reection. Once the reection has been divided, the fascia and the interface are apparent with continued downward retraction of the colon.
284 Mesenteric component of right colectomy
olic
(b)
(second pa
Omento-colic peritoneal reflection
Omento-colic
reflection
Transverse
colon
(a)
Omentum
Divided edge
of omento-c
reflection
Duodenum
Figure 19.7 (a) Intraoperative view of the peritoneal reection that connects the greater omentum to the underlying
transverse colon (i.e., the omento-colic reection). This must be divided through to expose omentocolic adhesions.
Division of these leads to complete mobilization of the transverse mesocolon and unimpeded access to the lesser sac.
(b)Intraoperative view of the second part of the duodenum and head of pancreas after detachment of the right mesocolon and small intestinal mesentery. The mesentery remains attached only at the root region.
mesenterectomy can then be conducted. Intestinal division
is completed using cutting or stapling techniques and is
Head of
pancreas
rt)
Mesenteric
root region
MINIMALLY INVASIVE RIGHT
MESOCOLECTOMY
followed by exposure of the intestinal margin of the mesentery. As described in previous chapters, the mesentery is
Introduction
divided (and disconnected from adjacent structures) into
As in open right mesocolic excision, the primary goals
avascular interpedicular and adipovascular pedicle regions.
ese can be dierentiated by backlighting the mesentery.
e means by which the mesentery is divided is predicated
on the thickness and consistency, but this can usually be
completed by developing a window in interpedicular areas,
cross- clamping pedicular regions, and dividing between
these. All mesenteric stumps are suture ligated in a hemostatic manner.
e steps in anastomosis can be completed quickly by
attending to the details listed earlier. In contrast, the mesenteric mobilization and division take a signicantly longer
time to complete eectively and safely. In fact, most of the
time spent in operating is spent in detaching and disconnecting the mesentery, and not the intestine.
are (a) mobilization (i.e., detachment) of the intestine and
mesentery back to the mesenteric root region and (b) disconnection of the mobilized intestine and mesentery.
When mobilization is complete, only the root region and
the middle colic adipovascular pedicle remain as points of
suspension. Mobilization can be conducted via medial-tolateral or lateral-to-medial approach. Most recommend that
the approach be tailored to the intraoperative ndings. e
medial-to-lateral approach requires that the adipovascular
pedicle be exposed and surgically divided in order to permit
access beneath the right mesocolon. e lateral-to-medial
approach does not require adipovascular pedicle ligation.
Once intestinal and mesenteric mobilization are completed,
Minimally invasive right mesocolectomy 285
Ileocolic adipovascular pedicle—Medial view point
(b)
r
the right colon and mesocolon can be easily exteriorized
and all vascular pedicles directly ligated. e following will
address the ileocolic adipovascular pedicle and medial-tolateral mobilization rst. It is followed by a description of
the key steps involved in lateral-to-medial mobilization.
Medial-to-lateral mesenteric detachment
e patient is then placed in a gentle head down position with
the right shoulder raised. e small bowel will gravitate away
from the right mesocolon. Access to the latter is sometimes
impeded by the greater omentum that must be separated from
it. Adequate right mesocolic access is a requirement in laparoscopic right mesocolectomy. A further assistant port (5mm)
placed in the right iliac fossa is oen useful. e assistant
places a toothed grasping device through this port, grasps an
appendices epiploicae, and places it under tension toward the
right side. e eect is to transmit tension to the right mesocolon (without tearing it), which in turn exaggerates the ileocolic adipovascular pedicle (Figures 19.8 and 19.9a).
e avascular interpedicular region on either side can
be quickly divided through until the mesofascial plane is
identied. e mesofascial plane is developed by inserting
an instrument into the window created, liing the right
mesocolon upward, and displacing the fascia posteriorly
(Figure 19.9b). Separation of Toldt’s fascia detaches the right
mesocolon (i.e., mesofascial separation). is is completed
as far laterally as possible aer which attention is turned to
the adipovascular pedicle (Figure 19.9b).
e adipovascular pedicle is skeletonized under high
magnication with a “chimney” for smoke evacuation. e
fat of the adipovascular pedicle is divided in a stepwise and
gradual manner using an harmonic scalpel. In this manner,
the fat on the anterior, anterolateral, and posterolateral aspect
is dealt with. However, mesenteric fat on the far side of the
pedicle cannot be directly cleared given the limitations of the
30° laparoscope lens. To overcome this, a curved retraction
device (see below) can be gently inserted to generate a mesenteric window on the opposite side of the pedicle (Figure 19.9c).
One such retractor has a retractable and blunt tipped blade
that is curved. is combination of features makes it suited
for gentle introduction immediately posterior to the vessel.
ere are numerous means by which ileocolic ves-
sels may be divided. One includes insertion of a stapling
device in the le upper quadrant port. Under direct view,
the stapling device is articulated to allow placement of the
narrow blade behind the vessel prior to closure. Ideally, one
should keep the jaws of the stapler closed for approximately
To right
mesocolon
To small
bowel
mesentery
Figure 19.8 (See also QR 1/5.) Laparoscopic view of the ileocolic adipovascular pedicle. The cecum is retracted toward the
right and anterior abdominal wall. This lifts the pedicle away from the retroperitoneum and exaggerates the pedicle. (a)
Intraoperative view of the ileocolic adipovascular pedicle in a thin individual as seen during laparoscopic right mesocolectomy (i.e., hemicolectomy). Continuity is apparent between the small intestinal mesentery on the near side of the mesentery, and the right mesocolon on the far side. (b) Similar view of the ileocolic adipovascular pedicle as observed during
laparoscopic surgery in a patient with an elevated BMI.
(a)
To small
intestinal
mesentery
Ileocolic
adipovascular
pedicle
5
Ileocolic
adipovascula
pedicle
286 Mesenteric component of right colectomy
Medial to lateral approach—The ileocolic adipovascular pedicle
(c)
my
(a)
Ileocolic
adipovascular
pedicle
Ileocolic
pedicle
Toldt’s
fascia
Figure 19.9 Laparoscopic view of ileocolic adipovascular pedicle before (a) and after (b) (see also QR 6/4) dissection through
the mesentery to enter the mesofascial plane. In (a) the mesentery is intact. The ileocolic pedicle is visible after the cecum has
been retracted toward the right. In (b) the mesentery on the near side of the pedicle has been divided through. The fascia is
visible draped onto the under surface of the mesentery. (c) Isolation of the ileocolic pedicle using a curved retraction device.
15–30 seconds before activating the stapling mechanism,
to reduce residual edema (Figure 19.10a). Once red addi-
tional pedicular bleeding is managed by placing clips
obliquely across the staple line.
e staple line (on the mesocolic side) can be grasped
using a traumatic grasper and retracted upward away from
the retroperitoneum. is places the mesofascial interface
under tension and facilitates further mesofascial separation (Figure 19.10b). Separation is best done under high
magnication as fascial bers tend to ride up onto the
undersurface of the mesocolon. It is possible to dissect
directly through the fascia, although there is a danger of
entering the retroperitoneum. e latter is frequently associated with bleeding, which, although minor, can obscure
(b)
ones view of the mesofascial interface. It is preferable to
gently sweep the fascia posteriorly, in as hemostatic a manner as possible (Figure 19.10b).
Mesofascial separation (and hence mesenteric detach-
ment) continues laterally until the right peritoneal reection
is reached. Oen the right colon is encountered before the
right peritoneal reection. e colon is lied upward and the
fascia at the colofascial interface swept posteriorly (Figure
19.10c). e right peritoneal reection is reached in this man-
ner. It should not be divided just yet as it suspends the colon
from the abdominal wall, preventing it falling into the
operative eld and impeding progress (Figure19.10c). Once
the peritoneal reection is reached, the patient’s position is
changed to permit direct access to and allow peritonotomy of
Mesenteroto
Skeletonized
ileocolic
vessel
(a)
(c)
Medial to lateral approach—The ileocolic adipovascular pedicle
m
(b)
Minimally invasive right mesocolectomy 287
Staple
division
of pedicle
Undersurface
of right
mesocolon
Toldt’s
fascia
Fascia overlying
retroperitoneu
Figure 19.10 (See also QR 6/4.) Laparoscopic view of division of the ileocolic pedicle using stapling device (a). Once the
pedicle has been divided, the right mesofascial plane becomes evident (b). The plane is the interface between the right
mesocolon (above) and the fascia (beneath). (c) Mesofascial separation involves sweeping the mesocolon away from the
underlying fascia to mobilize the mesentery.
the peritoneal reection. e positional changes and actions
are identical to those conducted during the lateral-to-medial
approach and will be described next.
Lateral-to-medial mesenteric detachment
e patient is placed right shoulder and head up. e colic
component of the hepatic exure is retracted toward the
right iliac fossa, thereby exposing the hepatocolic peritoneal reection (Figure 19.11a). is can then be directly
divided through (i.e., peritonotomy) to expose Toldt’s fascia and the underlying retroperitoneum (Figure 19.11b).
e colic and mesenteric components of the hepatic exure can then be swept away from the underlying fascia and
retroperitoneum. As the mesentery is separated from the
posterior abdominal wall, the duodenum and pancreas
come into view. e process of separation is continued
Undersurface
of right
mesocolon
Toldt’s fascia
overlying
retroperitoneum
medially until further mobilization is impeded by the
root region of the mesentery.
e patient is then placed head down and right shoulder
up. e lateral extremity of the colon is then retracted toward
the le iliac fossa, thereby exposing the right peritoneal reection (Figure 19.12a). e peritonotomy is continued through
this structure. is exposes the colofascial and mesofascial
interface (Figure 19.12b). By sweeping the colon and thereaer the mesocolon medially, the interface components are
separated and the mesocolon detached. At this point, the
intestine and mesentery are still attached at the small intestinal mesentery and associated peritoneal reection.
e patient is placed further head down and the ileocecal junction visualized from below. is exposes the ileocecal
component of the peritoneal reection (Figure 19.13a), which,
following division, exposes the underlying mesofascial plane
(Figure 19.13b). Sweeping the mesentery away from the fascia