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
308 Mesenteric considerations in resection ofthetransverse colon
Isolating the middle colic adipovascular pedicle
root region
(a)
(b)
adipovascular
mesocolon
(b)
Right colic
adipovascular
pedicle
Avascular
mesentery
Figure 21.13 (Continued) (b) Right colic adipovascular pedicle.
Transverse
Mesenteric
Middle colic
vessel
Middle colic
pedicle
Transverse
mesocolon
Transverse
mesocolon
Figure 21.14 (See also QR 1/6-8.) (a) Intraoperative appearance of the avascular mesentery on either side of the middle colic
pedicle. (b)Thefully isolated and skeletonized middle colic pedicle before the point at which it bifurcates into its main branches.
References 309
colic itself as it can be quite short. If too short, then direct
skeletonization and division could lead the surgeon onto
the superior mesenteric trunk and into potential diculty
(Figure 21.14b).
FUTURE DIRECTIONS
e description provided above is a roadmap for anatomic
detachment and disconnection of the transverse mesocolon. is is an essential component of total mesocolic
excision (also called subtotal colectomy), extended right
and le hemicolectomy. Future eorts could utilize the
roadmap provided in the international standardization of
transverse mesocolic mobilization.
SUMMARY
When the transverse mesocolon is operatively approached
based on mesocolic and peritoneal contiguity, its mobilization and division can be fully standardized and thereby
reproduced.
REFERENCES
1. Coffey, J.C., Surgical anatomy and anatomic
surgery—Clinical and scientic mutualism. Surgeon,
2013. 11(4): 177–182.
2. Sehgal, R. and J.C. Coffey, Historical development
ofmesenteric anatomy provides a universally applicable anatomic paradigm for complete/total mesocolic
excision. Gastroenterol Rep, 2014. 2(4): 245–250.
3. Treves, F., Lectures on the anatomy of the intestinal
canal and peritoneum in man. Br Med J, 1885.
1(1264): 580–583.
4. Netter, F.H., Atlas of Human Anatomy.
ElsevierHealth Sciences, Philadelphia, PA, 2014,
pp.267–276.
5. Sinnatamby, C.S., Last’s Anatomy: Regional and
Applied. Elsevier Health Sciences, New York, 2011,
p.257.
6. Standring, S., Gray’s Anatomy: The Anatomical Basis
of Clinical Practice. Churchill Livingstone/Elsevier,
Edinburgh, Scotland, 2008, p. 1137.
7. Coffey, J.C. etal., Mesenteric-based surgery
exploitsgastrointestinal, peritoneal, mesenteric
andfascial continuity from duodenojejunal exure
to the anorectal junction—A review. Dig Surg, 2015.
32(4): 291–300.
8. Coffey, J.C. etal., Terminology and nomenclature incolonic surgery: Universal application of
a rule-based approach derived from updates on
mesenteric anatomy. Tech Coloproctol, 2014. 18(9):
789–794.
9. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
10. 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.
11. Milsom, J.W. etal., Laparoscopic Colorectal Surgery.
Springer, New York, 2006, pp. 203–229.
12. Delaney, C.P., Netter’s Surgical Anatomy and
Approaches. Elsevier Health Sciences, New York,
2013, pp. 277–286.
13. Delaney, C.P. etal., Operative Techniques
inLaparoscopic Colorectal Surgery.
WoltersKluwerHealth, Philadelphia, PA, 2013,
pp.55–64, 109–122.
Mesenteric considerations in small bowel resection
J. CALVIN COFFEY, EOGHAN CONDON, AND DAVID W. WALDRON
22
Aim 311
Introduction 311
Special considerations 313
The fewer the facts, the stronger the opinion.
Arnold H. Glasow
AIM
To demonstrate the mesenteric and peritoneal factors
involved in conducting a small bowel resection.
INTRODUCTION
e small bowel mesentery fans out considerably at the
intestinal margin [1–4]. Where it becomes attached to the
posterior abdominal wall, it is considerably shorter in diagonal extent (i.e., from the duodenojejunal exure to the ileocecal junction) (Figure 22.1). Mesenteric elongation at the
intestinal margin confers a signicant mobility and means
that most small bowel resections can be conducted without
encroaching on the zone of attachment of the mesentery.
at being the case, the primary technical concern in
small bowel resection becomes hemostatic mesenterectomy,
for which there are numerous approaches. By far, the most
dicult mesentery is that seen in active Crohn’s disease
(Figure 22.2). As surgical management of the Crohn’s mesentery has been extensively dealt with in previous chapters,
the current chapter will focus on division of the normal
appearing mesentery.
Before commencing a mesenterectomy, it is important
to identify the superior mesenteric artery root region. is
is located medial to the duodenojejunal exure at the base
of the transverse mesocolon (Figure 22.3). e middle colic
adipovascular pedicle arises from it. Any dissection of the
small intestinal mesentery must avoid this region unless
Special considerations: Reoperative surgery 314
Summary 314
References 314
absolutely required, as vascular compromise here could
have catastrophic implications (Figure 22.3).
Backlighting the mesentery (Figure 22.4) almost always
provides a vascular road map divisible into adipovascular
and avascular regions (Figure 22.4). Interpedicular areas
can be disrupted using a variety of techniques but many
usethe tip of an artery clip to create an opening on either
side of an adipovascular pedicle. e pedicle itself can be tied
(with 0-0 Vicryl© sutures) or suture ligated. A mesenterotomy is developed by repeating this process. e mesenterotomy is continued from the proximal to distal intestinal
resection margin. ere are several methods of intestinal
division. Ifan end-to-end anastomosis is planned, then simple transection with a straight Mayo scissors is sucient.
If a side/side anastomosis is required, then staple-division
with a stapling division and oversewing of the staple line is
hemostatic. Asoccurs with colorectal resections, the time
spent in intestinal staple-division and anastomosis is oen
less than that involved in mesenterectomy itself.
Currently used tissue sealant devices such as the harmonic
scalpel may reduce the time required to complete mesenterotomy, when used appropriately. ey are not entirely suited
to the bulky mesentery. Many would agree that while they cut
the mesentery eectively, their hemostatic eect is limited in
this context.
Ideally any mesenteric defect should be closed by
approximating the mesenterotomy edges. While some
suggest that it is unnecessary to close a mesenteric defect
greater than 5cm in diameter, most recommend closure
if possible. Mesenteric herniation (see Chapters 7 and 16)
is associated with considerable morbidity and a not insignicant mortality [5]. If mesenteric stumps have been
suture ligated, these may be used as suture anchor points
311
312 Mesenteric considerations in small bowel resection
l
and small bowel mesentery
ry
(a)
(b)
Fat wrapping in Crohn’s disease
bowel and mesentery
Non-intestinal
zone
Ascending
colon
Intestinal
margin
of mesente
Transverse colon
Small bowe
mesentery
Right
mesocolon
Zone of continuity
between right mesocolon
Figure 22.1 Small bowel mesentery.
Fat wrapping
at stricture
Normal
Figure 22.2 Mesenteric changes seen in Crohn’s disease.
In this setting the mesentery is thickened and difcult to
divide through in a hemostatic manner. The mesentery
also extends over the circumference of the intestine as
“fat wrapping” or “creeping fat.”
for interrupted 2-0 Vicryl© sutures. Sutures should not be
placed deep in the mesentery and need only capture the
outer mesothelial layer. e aim is to achieve mesothelial
approximation, which creates a tissue bridge. Deep suture
placement can lead to mesenteric bleeding and hematoma
formation. While the latter is generally self-limiting due
to tamponade, the resultant hematoma can cause vascular compromise and threaten an adjacent anastomosis.
e simplest means of managing a mesenteric hematoma
is to exert focal digital pressure between the index nger
and thumb on the hematoma. If this fails, then the mesentery can be straddled between two 10 × 10cm swabs.
is achieves a greater pressure over a broader region.
Importantly, one should never place sutures in a blind
manner in the mesentery. e net result of that is a worsening of the bleeding and extension of the hematoma.
In open surgery, the entire intestinal and mesenteric
complex from duodenojejunal (DJ) exure to ileocecal level
is relatively easily demonstrated. In contrast, the plicated
and elongated nature of the intestinal margin makes visualization more challenging in the robotic and laparoscopic
setting. ere are several contexts in which it is necessary
to visualize the small bowel and as such the surgeon must
Special considerations 313
Peritoneal reflection at base of small bowel mesentery
reflection
abdominal wall(a)
Mesenterotomy
for hemostasis(b)
Backlighting small bowel mesentery
margin
Small bowel
mesentery
Peritoneal
Small bowel
mesentery
DJ junction
Posterior
Mesenterotomy
margin
Mesenteric vessels
observed on backlighting
Figure 22.4 Backlighting the mesentery during a procedure. This allows differentiation of adipovascular from
nonvascular interpedicular regions.
Mesenterotomy
Kocher clamps on
mesenteric stumps
Figure 22.3 (a) The small bowel peritoneal reection
at the base of the small bowel mesentery, in a cadaver.
(b)Division of a thickened mesentery in Crohn’s disease.
have a strategy to deal with the mesentery and intestinal
tract safely. One approach is the small bowel walk in which
the intestine is grasped (using an atraumatic grasper) and
then grasped further proximally with a second grasper.
e graspers are spread apart in an action that splays open
the intervening gastromesenteric region for examination. Toprogress proximally, the distal grasper is placed
just distal to the proximal grasper, which is then replaced
more proximally. e intervening intestine and mesentery
between is again exposed by spreading the graspers.
is technique is particularly important in the setting
of a normal appendix where one is obliged to out rule the
presence of a Meckel’s diverticulum. It is also important in
laparoscopic ileal pouch anal anastomosis where it is critical
to generate sucient intestinal and mesenteric reach to permit a tension free ileoanal anastomosis. In the latter case,
the small intestinal mesentery should be fully mobilized
up to the superior mesenteric artery (SMA) root region.
To achieve this, surgeon and assistant are positioned at
the patient’s le iliac fossa and the monitor at the patient’s
right shoulder. Optimum patient position is head and right
shoulder down, the eect of which is for the small intestine
to gravitate into the right upper quadrant and away from
the mesenteric base.
SPECIAL CONSIDERATIONS
Not infrequently the colorectal surgeon is requested to harvest a mesenteric lymph node for biopsy purposes. Although
the laparoscopic approach is feasible, it is hazardous and
many would recommend an open approach. Alimited midline laparotomy is usually sucient as intestinal and mesenteric mobility allow delivery of the mesentery into the
wound. Careful preoperative assessment is crucial to determine the position of the target node relative to the mesenteric base and the root region of the mesentery. Excision
commences by supercial division of the surrounding
314 Mesenteric considerations in small bowel resection
Carcinoid and mesenteric metastasis
Carcinoid
(a) (b)
Small
bowel
Isolated
lymphatic
metastasis
in mesentery
Figure 22.5 (a) Small intestinal carcinoid. (b) Metastatic lesion in the small bowel mesentery. The lesion arose from the
carcinoid in (a).
mesothelium, which sometimes has the eect of rendering the node more prominent. e dissection is then carried directly down on to the surface of the node, which is
shelled from its mesenteric basin. Appropriate sized clips
are placed on associated vessels. Importantly, blind dissection of the mesentery in the hope that an impalpable node
will be encountered should be avoided. If the target node is
not palpable, then it is unlikely that mesenteric excavation
will proceed in an uncomplicated manner.
A similar situation sometimes arises in small intestinal
threatened. Examples of settings in which this occurs include
reoperative surgery for Crohn’s disease or ileal pouch excision surgery [6–9]. Oentimes, the small intestinal mesentery
must be separated from the associated mesocolon, retroperitoneum, and anterior abdominal wall. It is only when one has
a crystallized view of normal mesenteric anatomy that one
can proceed in a manner that enables dierentiation of mes-
enteric, mesocolic, omental, and retroperitoneal fat. e latter
is crucial as it ensures that one does not violate or transgress
anatomic planes and cause trauma.
carcinoid with associated metastatic disease (Figure 22.5)
and in the case of mesenteric desmoid disease. e same
principles apply in so far as the root region must be avoided.
In general, preoperative CT evaluation establishes proximity of the mesenteric mass to the superior mesenteric artery
and vein.
SUMMARY
e anatomic properties of the small intestinal mesentery
are such that it is suciently mobile at the intestinal margin,
to permit most resections. e root region, that is, where it
emerges to fan out and span the intestinal tract distal to the
SPECIAL CONSIDERATIONS:
duodenojejunal exure, should be avoided.
REOPERATIVE SURGERY
REFERENCES
Anatomic and mesenteric considerations of reoperative
abdominal surgery will be dealt with in detail in Chapter25.
Given the relevance of particular points to the current chapter,
a brief discussion of the small bowel mesenteric-based principles of reoperative surgery will be included here. Reoperative
surgery requires a clear understanding of mesenteric anatomy
for several reasons. Given that the retroperitoneum and fascial
interface may have been excavated during initial surgery, these
are oen pulled up onto the lateral surface of the small intestine to which they can adhere. In keeping with this, retroperitoneal structures such as the gonadal vessels and ureters are
1. Coffey, J.C., Surgical anatomy and anatomic
surgery—Clinical and scientic mutualism. Surgeon,
2013. 11(4): 177–182.
2. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
3. 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.
References 315
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. Steele, S.R. etal., Complexities in Colorectal Surgery:
Decision-Making and Management. Springer,
NewYork, 2014, p. 504.
6. de Buck van Overstraeten, A., A. Wolthuis, and
A.D’Hoore, Surgery for Crohn’s disease in the era
of biologicals: A reduced need or delayed verdict?
World J Gastroenterol, 2012. 18(29): 3828–3832.
7. Garrett, K.A. etal., Outcome of salvage surgery
for ileal pouches referred with a diagnosis of
Crohn’s disease. Dis Colon Rectum, 2009. 52(12):
1967–1974.
8. Mallick, I.H. etal., Management and outcome of
pouch-vaginal stulas after IPAA surgery. Dis Colon
Rectum, 2014. 57(4): 490–496.
9. O’Riordan, J.M. etal., Long-term outcome of colectomy and ileorectal anastomosis for Crohn’s colitis.
Dis Colon Rectum, 2011. 54(11): 1347–1354.
Mesenteric considerations in ileal pouch
analanastomosis
J. CALVIN COFFEY AND JAMES W. OGILVIE JR.
23
Aims 317
Introduction 317
Process makes you more efcient.
Steve Jobs
AIMS
To demonstrate the importance of mesenteric and peritoneal factors in constructing and anastomosing an ileal
pouch to the anal canal.
INTRODUCTION
Ileal pouch anal anastomosis (IPAA) is generally performed
in two or three stages. In the two-stage procedure, a total
mesocolectomy, proctectomy, ileal pouch formation and
loop ileostomy are rst conducted. e stoma is reversed ata
later time point. e three-stage procedure usually follows
emergency subtotal colectomy. In the second stage, the rectum is removed, an ileal pouch and covering loop ileostomy
constructed. Most surgeons currently do not advocate a
one-stage total mesorectal and mesocolic excision followed
by IPAA without covering loop ileostomy [1–7]. Proceeding
chapters have described total mesocolic and mesorectal
excision and so the reader is referred to these as an introduction to the present chapter.
A number of mesenteric principles should be adapted
in ileal pouch formation and anastomosis (Figure 23.1).
First, it is absolutely required that the intestinal and mesenteric complex of ileum and mesentery be able to reach
the pelvic oor comfortably without mesenteric tension.
is is an important early consideration as it is preferable
to identify problems with reach before pouch formation.
Some bowstringing is inevitable following ileal pouch–
anal anastomosis but this does not appear (as yet) to
impair pouch function. In order to reach the divided distal
Summary 321
References 321
rectum (Figure 23.2), the small bowel mesentery must be
mobilized o the retroperitoneum, as far proximally as
the root region of the mesentery. As a result, the reection at the base of the small intestinal mesentery must be
divided up to the fourth part of the duodenum. Division
of the reection exposes the mesofascial interface enabling
separation of its components and detachment of the mesentery from the retroperitoneum, without disruption of
either. Itmay also be necessary, at the fourth part of the
duodenum, to divide congenital adhesions between this
and residual le mesocolon.
Problems with reach can persist despite the above
measures. One means of overcoming these is to carefully
divide the ileal mesentery between vessels. is should be
done aer rst back-lighting the mesentery to identify the
vessels. Any mesenteric windows should be created away
from the intestinal margin of the mesentery. Positioning
them in this manner helps increase mesenteric reach.
Although the right mesocolon should also be absent
(assuming a total mesocolectomy was conducted in the rst
instance), residual mesocolon can still be present in some
cases. A problem arises here in so far as the small intestinal mesentery is continuous with the right mesocolon. is
means the residual right mesocolon must be mobilized o
the retroperitoneum for complete mesenteric mobilization.
Adhesions from previous surgery can render this technically challenging. Some surgeons divide the small bowel
mesentery as close to the ileocecal junction as possible
while others divide the mesentery high-up on the ileocolic vascular pedicle. It is not known whether this preference
is associated with dierential rates of adhesion formation.
Notwithstanding the above considerations, and provided
the surgeon identies and follows the mesofascial interface,
then it is usually possible to safely and quickly mobilize the
entire mesentery.
317