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288 Mesenteric component of right colectomy
Hepatocolic peritoneal reflection
m
(b)
C
Colic
component
of hepatic
flexure
Hepatocolic
peritoneal
reflection
(a)
Toldt’s fascia
overlying
retroperitoneu
Peritonotomy
of hepatocolic
olon
reflection
Figure 19.11 (See also QR 6/7 and 8.) Laparoscopic view of the hepatocolic peritoneal reection before (a) and after (b)
peritonotomy through it. To generate this view of and access to the hepatocolic reection, the patient is placed head up
and the colic component of the exure retracted inferiorly. In obese patients, the reection may be obscured from view by
the omentum.
Right peritoneal reflection
(b)
my
Minimally invasive right mesocolectomy 289
Right
peritoneal
reflection
Toldt’s fascia
on right
Peritonoto
(a)
Right
mesocolon
Mesofacial
interface
Figure 19.12 (See QR 6/3.) (a) Laparoscopic view of the right peritoneal reection during peritonotomy. (b) Mesofascial
plane as seen during laparoscopic right mesocolectomy, following division of the right peritoneal reection. The mesofascial plane is formed by the right mesocolon and underlying right mesocolic (i.e., Toldt’s) fascia.
290 Mesenteric component of right colectomy
Small bowel
Peritoneal reflection at ileocecal junction
Pe
(a
(b)
l
ritonotomy
edge
Ileocecal
peritoneal
reflection
)
Toldt’s
fascia
Ileocecal
peritonea
reflection
Figure 19.13 (See QR 2/1.) Laparoscopic view of the ileocecal peritoneal reection before (a) and after (b) peritonotomy
through it. The mesofascial plane is apparent after peritonotomy and is formed by the mesentery and underlying fascia
(Toldt’s fascia). To obtain this view, the patient is placed head down and the cecum is retracted toward the head.
mobilizes the mesentery in this region. e nal stage of
mesentery
mobilization involves extending the peritonotomy toward
the duodenojejunal exure (Figure 19.14). Further separa-
tion of the mesentery from underlying fascia is eventually
impeded by the root region of the mesentery.
At this point, the complex of intestine and mesentery
and intestine have been fully mobilized. e remaining
attachment is the middle colic adipovascular pedicle and
the root region where the superior mesenteric artery comes
through the pancreas.
A short incision of approximately 4cm is made transversely in the right ank that allows exteriorization of even
the bulkiest mesenteries. e terminal ileum can be divided
between Kocher clamps as can the colon. Most place a suture
Left mesocolon
Peritoneal reflection at base
of small bowel mesentery
on the divided end in case it retracts intraperitoneally.
Figure 19.14 (See QR 3d/3 and QR 8/1.) Laparoscopic view
of the peritoneal reection at the base of the small bowel
mesentery, where this adheres to the posterior abdominal
wall. The small bowel must be retracted to the right upper
quadrant to generate this view of the reection.
SPECIAL CONSIDERATIONS
e mesentery in Crohn’s disease is always thickened and
hypervascular, and many recommend that it is not divided
intraperitoneally. In line with this, most recommend that
References 291
the mesentery and specimen be fully exteriorized to the
abdominal surface, at which point the mesentery can be
divided as previously described. e advantage of this
approach lies in the fact that loss of vascular control of the
adipovascular pedicle is more readily dealt with when it has
been exteriorized in the rst instance.
Rarely, the pathology encountered impedes the development of either the colofascial or mesofascial interface. An
example occurs in a T4 colonic adenocarcinoma that has
invaded locally through the mesentery to involve underlying
fascia. e fascia is noticeably thickened in this context and
its division can lead to fracturing of tumor and intraperitoneal spillage. In these circumstances, one approach is to rst
mobilize circumferentially in the correct anatomic plane but
not to tackle the region in question at rst. Once circumferential mobilization has been achieved, the surgeon is in a better position to assess the true level of local invasion. is is
important as it rst enables one to limit the anatomic extent of
the resection required. Second, it facilitates a more anatomic
and surgical approach to obtaining oncologic clearance.
FUTURE DIRECTIONS
e above description is a universally applicable template
for detachment and disconnection of the mesentery during
ileocolic resection. Such a template is essential in standardization of techniques by which right-sided intestinal lesions
are removed.
SUMMARY
e surgical activities required in open, laparoscopic, and
robotic right mesocolectomy are based on mesenteric, peritoneal, fascial, and intestinal continuity as well as contiguity between these. In keeping with this, all mesenteric stages
(i.e., detachment and disconnection) can be described in
terms of peritonotomy, mesofascial separation, mesenterotomy, and mesenterectomy.
REFERENCES
1. Coffey, J.C., Surgical anatomy and anatomic
surgery—Clinical and scientic mutualism. Surgeon,
2013. 11(4): 177–182.
2. Coffey, J.C. etal., Terminology and nomenclature in
colonic surgery: Universal application of a rule-based
approach derived from updates on mesenteric
anatomy. Tech Coloproctol, 2014. 18(9): 789–794.
3. Culligan, K. etal., Review of nomenclature in colonic
surgery—Proposal of a standardised nomenclature
based on mesocolic anatomy. Surgeon, 2013. 11(1):
1–5.
4. Coffey, J.C. etal., Mesenteric-based surgery exploits
gastrointestinal, peritoneal, mesenteric and fascial continuity from duodenojejunal exure to the
anorectal junction—A review. Dig Surg, 2015. 32(4):
291–300.
5. Coffey, J.C. and P. Dockery, Colorectal cancer:
Surgery for colorectal cancer—Standardization
required. Nat Rev Gastroenterol Hepatol, 2016.
13(5): 256–257.
6. Sehgal, R. and J.C. Coffey, Historical development of mesenteric anatomy provides a universally
applicable anatomic paradigm for complete/total
mesocolic excision. Gastroenterol Rep, 2014. 2(4):
245–250.
7. Sehgal, R. and J.C. Coffey, The development of
consensus for complete mesocolic excision (CME)
should commence with standardisation of anatomy
and related terminology. Int J Colorectal Dis, 2014.
29(6): 763–764.
8. Sehgal, R. and J.C. Coffey, Standardization of the
nomenclature based on contemporary mesocolic
anatomy is paramount prior to performing a complete mesocolic excision. Int J Colorectal Dis, 2014.
29(4): 543–544.
9. Adamina, M. etal., Laparoscopic complete mesocolic excision for right colon cancer. Surg Endosc,
2012. 26(10): 2976–2980.
10. Bertelsen, C.A. etal., Can the quality of colonic
surgery be improved by standardization of surgical technique with complete mesocolic excision?
Colorectal Dis, 2011. 13(10): 1123–1129.
11. Bertelsen, C.A. etal., Disease-free survival after complete mesocolic excision compared with conventional
colon cancer surgery: A retrospective, populationbased study. Lancet Oncol, 2015. 16(2): 161–168.
12. Galizia, G. etal., Is complete mesocolic excision
with central vascular ligation safe and effective in
the surgical treatment of right-sided colon cancers?
Aprospective study. Int J Colorectal Dis, 2014.
29(1):89–97.
13. Hohenberger, W. etal., Standardized surgery for
colonic cancer: Complete mesocolic excision and
central ligation—Technical notes and outcome.
Colorectal Dis, 2009. 11(4): 354–364; discussion
364–365.
14. Kang, J. etal., Laparoscopic right hemicolectomy
with complete mesocolic excision. Surg Endosc,
2014. 28(9): 2747–2751.
15. Killeen, S. etal., Complete mesocolic resection and
extended lymphadenectomy for colon cancer: A systematic review. Colorectal Dis, 2014. 16(8): 577–594.
16. Siani, L.M. and C. Pulica, Stage I-IIIC right colonic
cancer treated with complete mesocolic excision and
central vascular ligation: Quality of surgical specimen and long term oncologic outcome according
to the plane of surgery. Minerva Chir, 2014. 69(4):
199–208.
17. Sondenaa, K. etal., The rationale behind complete
mesocolic excision (CME) and a central vascular
ligation for colon cancer in open and laparoscopic
surgery: Proceedings of a consensus conference. Int
J Colorectal Dis, 2014. 29(4): 419–428.
292 Mesenteric component of right colectomy
18. Storli, K.E. etal., Short term results of complete (D3)
vs. standard (D2) mesenteric excision in colon cancer
shows improved outcome of complete mesenteric
excision in patients with TNM stages I-II. Tech
Coloproctol, 2014. 18(6): 557–564.
19. West, N.P. etal., Complete mesocolic excision with
central vascular ligation produces an oncologically
superior specimen compared with standard surgery
for carcinoma of the colon. J Clin Oncol, 2010. 28(2):
272–278.
20. West, N.P. etal., Understanding optimal colonic cancer
surgery: Comparison of Japanese D3 resection and
European complete mesocolic excision with central
vascular ligation. J Clin Oncol, 2012. 30(15): 1763 –1769.
21. Willaert, W. and W. Ceelen, Extent of surgery
in cancer of the colon: Is more better? World J
Gastroenterol, 2015. 21(1): 132–138.
22. Yao, H.W. and Y.H. Liu, Re-examination of the standardization of colon cancer surgery. Gastroenterol
Rep, 2013. 1(2): 113–118.
23. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
24. 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.
20
Mesenteric component of exure mobilization
J. CALVIN COFFEY AND NEIL J. SMART
Aim 293
Introduction 293
Role of digital sculpting 294
Mobilization of the splenic exure 294
Peritoneal component 294
Colic component 294
Mesenteric component 296
Hepatic exure 296
Peritoneal component 296
The characteristic of scientic progress is our
knowing that we did not know.
Gaston Bachelard
AIM
To demonstrate the mesenteric, peritoneal, and fascial
components of exural mobilization.
INTRODUCTION
Mobilization (or detachment) of the exures has traditionally been viewed as a dicult eld in colorectal
surgery, even for the experienced surgeon. is is not surprising given that descriptions of mobilization have had
to rely on the concept of mesenteric discontinuity (see
Chapter2) [1–7]. In keeping with this, surgical texts have
faced a considerable challenge in precisely describing exure mobilization. ree factors have contributed to the
challenge. First, all previous appraisals (with the exception of the most recent edition of Gray’s anatomy) were
based on the principle of mesenteric discontinuity [8–11].
Although “discontinuity” implies the existence of start
and end points, neither has been described. Second, the
small intestinal, transverse, and sigmoid mesenteries were
depicted as “inserting” along a linear “attachment” [1,5].
In keeping with this, the linear attachment of the transverse mesocolon extends from the hepatic to the splenic
exures. Finally, the shape of the mobilized mesentery has
Colic component 296
Mesenteric component of the hepatic exure 296
Ileocolic mesenteric exure 296
Peritoneal component 296
Colic and mesenteric components 298
Duodenal and sigmoidal exures 298
Future directions 298
Summary 298
References 299
little resemblance to that which it adopted in the undisturbed state. is means that it is not possible to infer
structure from the excised organ.
e reader is advised to recapitulate the principle points
outlined in Chapter 2 prior to proceeding. However, a
brief summary of the more important anatomic points will
be provided here. First and foremost, the mesentery and
mesocolon are continuous entities from duodenojejunal
exure to the mesorectum. is means that a mesenteric
conuence occurs at the exures [3–5,7]. For example,
at the hepatic exure, a conuence occurs between right
and transverse mesocolon. At the splenic exure, a conuence occurs between transverse and le mesocolon.
While the anatomy of the colic component of the exures
is self-evident, that of the peritoneal reections is not and
should also be described. In the case of the hepatic exure,
a peritoneal reection is draped over the right colon as
it approaches the hepatic exure, that is, the “right peritoneal reection.” is continues around the hepatocolic
conuence as the hepatocolic peritoneal reection. Asimilar arrangement occurs at the splenic exure insofar as
the splenocolic peritoneal reection forms the cephalad
aspect of the exure and continues around the colic component as the “le peritoneal reection.” is peritoneal
reection is draped over the descending colon where it
is attached to the posterior abdominal wall across Toldt’s
fascia [3–5].
Each exure can be universally described in terms of
four components. These are the (1) peritoneal, (2) colic,
(3)mesenteric, and (4) fascial.
293
294 Mesenteric component of exure mobilization
A exure arises whenever the intestinal tract changes
from being attached (to the retroperitoneum) to nonattached (and hence mobile) [3,4,7]. In keeping with this, a
exure occurs at the duodenojejunal junction, at the ileocecal junction, at the junction between the descending and
sigmoid colon, and at the rectosigmoid junction. In total,
there are six exures and all can be conceptualized in the
same anatomical manner. Each comprises of exural colon
centered on a mesenteric conuence around which a peritoneal reection helps maintain adherence to the retroperitoneum [3,6,7].
Importantly, the mesenteric component of each exure
should be considered in terms of radial and longitudinal
axes. In the case of the splenic and hepatic exure, the radial
axis extends from a zone of attachment at the middle colic
adipovascular pedicle to a zone of mobility at the intestinal margin. At the hepatic exure, the longitudinal axis
extends from the attached right mesocolon to the mobile
transverse mesocolon. At the splenic exure, the longitudinal axis extends from the mobile transverse mesocolon to
the attached le mesocolon.
As transverse mesocolon anatomy continues to cause
confusion, it is also worthwhile at this point to recapitulate
its composition. At the transverse mesocolon, the mesenteric component of the hepatic and splenic exure coalesce
with the middle colic adipovascular pedicle. At the pedicle,
the mesocolon is attached, whereas at the intestinal margin
it is unattached and mobile.
ROLE OF DIGITAL SCULPTING
e lack of boundaries in the regional anatomy of continuous structures (i.e., mesentery, colon, peritoneum, and
fascia) has greatly hampered the depiction of exural mobilization in general. Recent application of digital sculpting
in surgical education may overcome these challenges. It is
possible to generate high-delity 3D models, which, because
they are digital, can be sectioned, rotated, deformed, and
animated. Digital modeling and associated sowares
vastly expand our ability to explain the mesenteric basis of
colorectal surgery [7,12,13].
In keeping with the above, digital models will be used in
the following to demonstrate anatomic relationships between
mesenteric, peritoneal, colic, and fascial components of the
exures during dierent stages of mobilization. Each exure
will be presented in the form of a panel of images. Each panel
will comprise images demonstrating (1)the intact mesentery as seen from diering angles and (2)sections depicting
the relationship of exural components.
MOBILIZATION OF THE SPLENIC FLEXURE
Peritoneal component
In open surgery, the rst assistant retracts the upper le
abdominal wall to expose the le upper quadrant, while
a second retracts the small bowel, transverse colon, and
greater omentum to the right. is permits the surgeon
to grasp the le colon and retract it medially. Traction is
thus transmitted to the le peritoneal reection which is
divided (i.e., peritonotomy) and as far proximally as possible (Figure 20.1). A complex of transverse oriented adhe-
sions occurs just distal to the splenic exure. When this is
divided through, the lateral peritoneal reection is exposed
and divided. Peritonotomy exposes the colofascial and
mesofascial interface and their components (Figure 20.1).
e colofascial interface is formed by the le colon and
Toldt’s fascia. When the colon is retracted medially, the
interface is exaggerated and the fascia can be peeled o or
separated with diathermy. is results in colonic, but not
mesocolic, mobilization. For mesocolic detachment, the
le colon is lied away from the retroperitoneum. Traction
is then transmitted to the mesofascial interface and components of this separated, either by peeling the fascia back
or by diathermy. Le mesocolic mobilization is continued
as far medially and cephalad as possible. When the conuence between le and transverse mesocolon is freed from
the retroperitoneum, the lesser sac is entered and the pancreas reached.
At this stage, the exure is still attached by the splenocolic peritoneal reection. In the past, this was sharply
divided (in a somewhat blind manner) aer which the le
upper quadrant was packed to tamponade inevitable bleeding. While the reection itself is not well vascularized, the
overlying greater omentum is. At the exure, the omentum
fuses to varying degrees with the peritoneal reection. Asa
result, sharp division through this complex is invariably followed by generous hemorrhage.
e complex of splenocolic peritoneal reection and
greater omentum can be divided in an anatomic and hemostatic manner. e surgeon begins in the midline where the
greater omentum is retracted vertically and countertraction
placed on the transverse colon. e reection between both
stretches and can be hemostatically divided. is exposes
adhesions between greater omentum and transverse mesocolon. ese are divided until the lesser sac is fully opened.
e surgeon can now place a hand into the lesser sac,
under the greater omentum, and divide through this toward
the splenic exure (Figure 20.1). At the exure, it is possible
to insinuate the index nger of the le hand under the splenocolic peritoneal reection, between it and the mesenteric
conuence. In this way, the splenocolic reection is separated enough to hemostatically divide it, without injuring
the underlying mesentery. Continuing this process laterally,
the surgeon reaches the divided margin of the le peritoneal
reection, thus completing division of the peritoneal component of the exure.
Colic component
As the transverse colon is already mobile, only the
descending colon and colic component of the exure must
be mobilized or detached. On the le, division of the le
peritoneal reection exposes the colofascial interface.
Mobilization of the splenic exure 295
Splenic flexure
(e)
(a)
l
separation
Intact
Intestinal
component
of flexure
(b)
Colofascia
Fascial
component
of flexure
Peritoneal component
of flexure
Peritoneal
component
Peritoneal
component
Mesenteric
(c) (d)
component
Mesenteric
component
of flexure
Figure 20.1 (See also QR 9 and 10.) (a) 2.5D image derived from a 3D digital model of the splenic exure. (b) The exure
(including all components) has been slightly displaced from adjacent structures to demonstrate continuity of each and
contiguity between each. (c)Section through the exure demonstrating the splenocolic reection and its relationship
to underlying colic and mesenteric exural components. (d) Section through the descending colon where it has been
separated from the underlying fascia (i.e., colofascial separation). (e) Demonstration of mesenteric component of splenic
exure in terms of longitudinal and radial axes.
296 Mesenteric component of exure mobilization
Separation of the colon from underlying fascia continues
along the descending colon toward the colic component
of the exure. Colofascial separation here completes colic
detachment (Figure 20.1d).
To achieve colofascial separation, the colon may be
peeled or stripped o the underlying fascia. is is associated with some bleeding that stops with packing and
tamponade. Alternatively, the interface between colon
and fascia may be diathermy separated or sharply separated using dissecting scissors. Once the colic component
is fully mobilized, it can be medialized to demonstrate the
mesofascial interface.
Mesenteric component
e mesenteric component of the exure (i.e., the splenic
mesenteric conuence) is best conceptualized in terms of
longitudinal and radial axes. e longitudinal axis occurs
from the transverse to le mesocolon (or vice versa). e
radial axis extends from the nonintestinal (attached) zone to
the intestinal (nonattached) zone of mesentery (Figure 20.1e).
As described earlier, the transverse mesocolon is par-
tially mobilized once the greater omentum and splenocolic reection have been separated from it. ese activities
address the longitudinal axis of the exure. Continuing the
process of le mesofascial separation as far medially and
cephalad as possible fully separates or detaches the mesocolon across its radial axis (i.e., from attached to nonattached
zones). Aswith colofascial separation, mesofascial separation can be conducted either by stripping the mesentery o
the retroperitoneum or diathermy division at the mesofascial interface. Mesofascial separation has been completed
when the middle colic adipovascular pedicle is encountered
and further mobilization impeded by this.
At this stage, the mesenteric, colic, and peritoneal com-
ponents of the exure have been fully mobilized.
HEPATIC FLEXURE
e principles of hepatic exural mobilization are identical
to those of splenic exure mobilization and likewise can be
detailed in terms of anatomic components.
Peritoneal component
In general, the greater omentum does not extend to overlie the hepatocolic reection but it can do in patients with
considerable visceral adiposity. In these patients, the omentum fuses with the hepatocolic peritoneal reection. In this
context, the omentum should rst be separated from the
transverse colon medially (see splenic exure).
As with the splenic exure, peritonotomy permits access
to the colofascial interface. Following completion of the
peritonotomy of the right peritoneal and hepatocolic peritoneal reection, the hepatic exure remains attached by its
colic and mesenteric components.
Colic component
When the right colon is retracted medially the colofascial
interface comes under tension, and the interface between
colon and fascia is exaggerated (Figure 20.2d). e right
colon can be peeled from the fascia by gentle traction with
countertraction on the fascia. Alternatively, the fascial
interface can be diathermy divided. is process is then
continued proximally up to the colic component of the
hepatic exure. e hepatic exure now remains attached
at the mesentery.
Mesenteric component of the hepatic
exure
As with the splenic exure, the hepatic mesenteric component is best considered in terms of its longitudinal (i.e., the
conuence between right and transverse mesocolon) and
radial axis (spanning from the attached mesentery to nonadherent intestinal margin) (Figure 20.2e). Mobilization
along the longitudinal axis involves extending right mesocolonic mobilization as far cephalad and medial as possible. Care is taken during the medial component, where
the second and third parts of the duodenum (and head
of the pancreas) are encountered. With these maneuvers,
the mesenteric conuence at the hepatic exure is fully
detached along both longitudinal and radial axes. Further
mobilization is limited by the middle colic adipovascular
pedicle. By now, however, one will notice that the hepatic
exure is fully mobile and the right colon can be fully
medialized.
Mobilization of the hepatic exure will be described in
terms of its peritoneal, colic, and mesenteric components
(Figure 20.2a and b). When the right colon is retracted medially, traction is transmitted to the right peritoneal reection, which can then be divided sharply (i.e., peritonotomy)
(Figure 20.2c). e index nger of the le hand can be placed
beneath the right peritoneal reection and directed toward
the hepatic exure. e peritonotomy is then extended
onto the nger as far as the hepatocolic peritoneal reection (Figure 20.2c). Some surgeons use hemostatic sealant
devices to divide the hepatocolic peritoneal reection, while
others advocate sharp division and tamponade by packing.
ILEOCOLIC MESENTERIC FLEXURE
e central principles are based on peritoneal, intestinal,
and mesenteric continuity and are identical to those for
splenic and hepatic exure mobilization (Figure 20.3a).
Peritoneal component
e rst step is to divide (i.e., peritonotomy) the ileocecal peritoneal reection at the inferior aspect of the ileocecaljunction (Figure 20.3b). is reection is an extension
of the peritoneal reection at the base of the small intestinal
Hepatic flexure
(e)
(a)
t
Intact
Ileocolic mesenteric exure 297
Colic
component
(b)
Mesenteric
component
Right peritoneal
reflection
(c) (d)
Peritoneal
component
Fascial
component
Mesenteric
component
Peritoneal
componen
Fascial
component
Mesenteric
component
Figure 20.2 (see also QR 11 and 12) (a) 2.5D image derived from a 3D digital model of the hepatic exure. (b) The exure
(including all components) has been slightly displaced from adjacent structures to demonstrate continuity of each and
contiguity between each. (c)Sectionthrough the exure demonstrating the right peritoneal reection and its relationship
to underlying colic andmesenteric exural components. (d) Section through the ascending colon (after peritonotomy) it
has been separated from the underlying fascia (i.e., colofascial separation). (e) Demonstration of mesenteric component of
hepatic exure in terms oflongitudinal and radial axes.