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338 Mesenteric considerations in reoperative abdominal surgery
Omental adhesions to small bowel
omentum
manner, as this would traumatize tissue and could worsen
bleeding. An approach in this circumstance is to gently place
a 4 × 4cm swab in the region and then tackle bleeding at
a later point. e sponge may have a hemostatic and tamponade eect. If blood continues to ooze through the swab
then the region may be overlain by hemostatic pads and supported by an additional swab. If bleeding continues despite
these measures then it must be directly controlled via suture
ligation at that point, rather than later.
It is not dicult to damage the mesentery in reoperative intestinal surgery and so the surgeon must have operative strategies to deal with the variable situations that arise.
Perhaps the most important is avoidance of dissection close
to the superior mesenteric artery. is requires that one
have a clear understanding of mesenteric and mesocolic
anatomy. Reoperative contexts in which this danger occur
include any in which the small bowel mesentery was fully
mobilized (i.e., as part of ileo-pouch anal anastomosis, and
Crohn’s related resections).
Variations in surgical techniques have been demonstrated
by several investigators. ese are associated with variations in early and long-term postoperative outcome [9–13].
Recognition of the incidence of variation led to the development of the terms mesocolic, intramesocolic, and muscularis
propria plane surgery [14]. e surgeon engaged in reoperative surgery needs to bear such variations in mind. Lack of
recognition of mesofascial planes has, in the past, led surgeons to dissect into the retroperitoneal planes. On reoperation, lack of recognition of this has in turn led surgeons to
inadvertently damage the ureters or gonadal vessels.
Just as the retroperitoneal fat can be displaced into
an abnormal location so too can the greater omentum
(Figure25.8). Again, it becomes important to be able to
dierentiate omental from mesenteric and retroperitoneal fat. Neomesothelialization can increase this diculty
but almost always it is possible to safely and fully separate
omental from mesenteric or retroperitoneal fat.
As can be seen earlier, the overall target in reoperative
surgery is to achieve a complete and intact separation of
the entire intestine and mesentery up to the fourth part
of the duodenum. Only when this has been fully achieved
should one commence any resectional component.
Reoperative surgery: Miscellaneous areas
oftechnical difculty
Other areas of technical diculty include the distal le
and right iliac fossa, the posterior surface of the bladder,
and the anterior surface of the sacrum deep in the pelvis
(Figure 25.9). Neomesothelialization in the le and right
iliac fossa can be quite dense and particularly dicult to
dissect through safely. As a result, it is important to practice
the principles explained and emphasized earlier in order to
prevent damage to the ureter and (in the anterior midline)
to the dome of the bladder. Bladder injury may be inevitable and as such one should have a strategy for managing
these injuries (i.e., beyond the remit of the current volume).
Greater
Figure 25.8 The greater omentum is often adherent to
underlying gastromesenteric structures. Separation of the
greater omentum requires a careful adhesiolysis.
e anterior surface of the sacrum and the pelvic oor
can present signicant technical challenges. Adhesions to
these surfaces can be extensive, and dense, involving both
intestine and associated mesentery. Excellent illumination,
retraction, irrigation, and suction are of the utmost importance in identifying mesofascial planes in these regions.
Reoperative surgery and postoperative
complications
Reoperative colorectal surgery is oen carried out as
part of management of postoperative complications. e
commonest examples occur with a postoperative leak, or
hematoma, or abscess formation. In these settings, the
small bowel and mesentery, and omentum tend to coalesce
around the pathology, generating a phlegmon, walling it o
from the remainder of the peritoneal cavity. A crystallized
view of mesenteric and peritoneal structure is again essential, in order to (1) access to the pathology in question and
(2) manage the pathology surgically. In order to gain access
to the pathology, the surgeon must be able to dierentiate
separate fatty compartments and tease these apart without
disturbing structural integrity. Where fusion of separate
structures is too dense, dissection should continue elsewhere, eventually coming back to the same region.
Troublesome bleeding must oen be tackled in the
reoperative context. For example, separation of the greater
omentum o the mesentery or mesocolon is frequently followed by supercial bleeding from both surfaces. A further
example occurs between apposed mesenteric structures
(a)
(b)
Adhesions
dome of bladder
Special considerations 339
Adhesions in
left iliac fossa
Dome of bladder
Adhesions to
Figure 25.9 (a, b) Adhesions also occur between the dome of the bladder (and/or uterus) and must be divided without
entering the latter.
340 Mesenteric considerations in reoperative abdominal surgery
Incorrect plane surgery I
In
(b)
(e.g., when the small bowel mesentery adheres to the right
surface of the mesosigmoid). Unfortunately, the inammatory response leads to a weakening of the supercial
mesothelium, which can become denuded and which
again predisposes to bleeding from both mesenteric surfaces. Asthis originates from supercial vessels (located
within the mesenteric connective tissue lattice), it is generally short lived.
In the setting of postoperative pelvic abscess following
an appendectomy, one must proceed cautiously in separating anatomic components of the abscess. e goal is
to fully unravel all adhesional complexes and to examine
the mesentery in its entirety. is ensures that there are no
residual interloop or intermesenteric abscesses. is procedure should only be conducted by a surgeon familiar with
all aspects of mesenteric and mesocolic anatomy (intra- and
extrapelvic) as it is necessary to mobilize all loops from the
duodenojejunal exure to the pelvis.
Reoperative surgery: Finding oneself
unexpectedly in the wrong plane
As the anatomy of the mesentery, associated fascia, and
peritoneal reections have recently been claried, it is not
surprising that past surgeons may have digressed into retroperitoneal planes during their dissection [14–18]. us,
one should anticipate encountering planes that may not be
familiar territory for the intestinal surgeon (in particular
if one was not involved in the original operation) (Figures
25.10 and 25.11) [12–15]. Perhaps the commonest example
of this arises when, during the original operation, the surgeon veered retrofascial in the dissection. In these cases, the
muscle bers of the iliopsoas will be apparent at reoperation. is in turn should alarm the surgeon to the possibility
of marked anatomic displacement of retroperitoneal structures (i.e., the ureters).
Dissection in
wrong plane
correct
plane
(a)
Correct
plane
Dissection in
correct plane
Figure 25.10 Showing dissection in (a) incorrect and (b) correct plane surgery.
References 341
Co
(b)
Incorrect plane surgery II
t plane under
rrect
plane
(a)
Incorrect
plane
Neoperitoneum
over rectum
Correc
neo-mesothelium
Figure 25.11 Showing dissection in (a) incorrect and (b) correct plane surgery.
SUMMARY
Reoperative abdominal surgery mostly requires complete
separation of the entire intestine and mesentery distal to the
duodenojejunal exure. is in turn requires a crystallized
understanding of mesenteric, peritoneal, and fascial anatomy, and how these are altered in the reoperative context.
REFERENCES
1. Senagore, A.J., Can reoperative surgery be protable? Maximizing reimbursement. Clin Colon Rectal
Surg, 2006. 19(4): 251–253.
2. Morris, A.M. etal., Reoperation as a quality indicator
in colorectal surgery: A population-based analysis.
Ann Surg, 2007. 245(1): 73–79.
342 Mesenteric considerations in reoperative abdominal surgery
3. Archampong, D. et al. Workload and surgeon’s
specialty for outcome after colorectal cancer
surgery. Cochrane Database Syst Rev, 2012. Issue 3.
Art. No.: CD005391.
4. Aquina, C.T. et al., High volume improves outcomes:
The argument for centralization of rectal cancer
surgery. Surgery, 2016. 159(3): 736–748.
5. Yeo, H.L. et al., Surgeon annual and cumulative
volumes predict early postoperative outcomes after
rectal cancer resection. Ann Surg, 2016. [Epub ahead
of print].
6. diZerega, G., Peritoneal Surgery. Springer, New York,
1999, pp. 117–131, 217–227.
7. Diamond, M.P. and M.L. Freeman, Clinical
implications of postsurgical adhesions. Hum Reprod
Update, 2001. 7(6): 567–576.
8. Davies, S.W. et al., A comparative analysis between
laparoscopic and open adhesiolysis at a tertiary care
center. Am Surg, 2014. 80(3): 261–269.
9. Joris, J.L. et al. Prevalence, characteristics and
riskfactors of chronic postsurgical pain after
laparoscopic colorectal surgery: Retrospective
analysis. EurJ Anaesthesiol, 2015. 32(10): 712–717.
10. Mallick, I.H. etal., Management and outcome of
pouch-vaginal stulas after IPAA surgery. Dis Colon
Rectum, 2014. 57(4): 490–496.
11. Fiscon, V. etal., Laparoscopic reversal of Hartmann’s
procedure. Updates Surg, 2014. 66(4): 277–281.
12. Genser, L. etal., Postoperative and long-term
outcomes after redo surgery for failed colorectal
or coloanal anastomosis: Retrospective analysis of
50 patients and review of the literature. Dis Colon
Rectum, 2013. 56(6): 747–755.
13. Fazio, V.W. etal., Ileal pouch anal anastomosis:
Analysis of outcome and quality of life in 3707
patients. Ann Surg, 2013. 257(4): 679–685.
14. West, N.P. etal., Pathology grading of colon cancer
surgical resection and its association with survival:
A retrospective observational study. Lancet Oncol,
2008. 9(9): 857–865.
15. Coffey, J.C., Surgical anatomy and anatomic
surgery—Clinical and scientic mutualism. Surgeon,
2013. 11(4): 177–182.
16. 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.
17. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
18. 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.
Future directions
J. CALVIN COFFEY
26
Introduction 343
History 343
Anatomy 343
Embryology 343
Histology 344
Toldt’s fascia 344
Physiology 344
Pathology 344
If the facts don’t t the theory, change the facts.
Albert Einstein
INTRODUCTION
At this point in time the structure of the mesentery has
been claried which means that it may now be approached
in a rigorously systematic manner. is realization presents
considerable opportunities in an array of basic and applied
sciences. Perhaps the most exciting opportunity lies in
the prospect of refreshing our approach to normality and
disease in general. Already, the systematic evaluation of
the mesentery has led to novel diagnostic and therapeutic
modalities. is chapter will demonstrate the opportunities
that lie ahead.
HISTORY
It is intriguing to note the discrepancy that occurred
between surgical and anatomic approaches to the mesentery. While good-quality surgery relied on the principles of
peritoneal, mesenteric, and fascial contiguity, anatomists
argued in favor of mesenteric fragmentation and complexity. Even today, case reports continue to emerge describing
the presence of a right and le mesocolon as anomalous. It
is feasible this arose due to the eects of earlier preservation
methodologies. It was also contributed to by the fact that
the shape of the mesentery, once detached and disconnected
Radiology 345
Nomenclature 345
Surgical instrumentation 345
Total mesorectal excision 345
Gastroenterology 345
Education 346
Summary 346
from the abdominal wall, bears no resemblance to the
shape it had in the undisturbed format. Notwithstanding
past events the scientic and clinical community are now
optimally positioned to re-explore the role of the mesenteric
organ in general.
ANATOMY
Numerous questions can now be directly tackled based
on clarications in mesenteric anatomy. For example, the
distribution of the postganglionic enteric nervous system
may be better characterized in the context of mesenteric
contiguity. Up to the present, descriptions of the enteric
nervous system are clear in relation to preganglionic
neurons and the location of the three ganglia. However,
descriptions of postganglionic neurons have always been
lacking and for the most part, there are few informative
descriptions detailing their anatomic course aer leaving
the three major ganglia.
EMBRYOLOGY
e concept of peritoneal, mesenteric, and fascial contiguity is radically dierent to that of a complex and fragmented
structure. e embryologic development of the mesentery
and associated structures has to date been based on the concept of mesenteric discontinuity. Perhaps not surprisingly,
the theories developed to explain the conceptual absence of
a right and le mesocolon (i.e., the sliding and regression
343
344 Future directions
theories) were not generally taken up. Itnow remains to
review mesenteric development based on their continuity
in adulthood. is should rst focus on the mesentery itself,
and thereaer the development of the fascial and peritoneal
reection draped around it.
HISTOLOGY
Several intriguing questions arise here. Perhaps the most
pressing is a histologic characterization of the zone of intersection between the intestinal tract and the mesentery.
Atthis zone, a connective tissue contiguity links both components of the intestine and mesentery. Cellular and molecular activities in this zone are likely to be highly signicant
in normality and disease. In eect, this is the “hilum” of the
intestine, where blood vessels, nerves, and lymphatic channels enter or leave the intestine. It is at least several meters
in length.
A further key question lies in the concept of tissue spe-
cialization. is refers to the adoption of specic and unique
features by a tissue, in order to fulll a function. In the
heart cardiomyocytes are specialized to permit contraction.
In the nervous system, neurons are specialized to permit
transmission of electrochemical signals along considerable
distances. e question arises as to whether a cellular and
tissue-type specialization also occurs within the mesentery.
e occurrence of such a specialization would strengthen
the argument in favor of designating the mesentery as an
organ in itself.
Recent studies have demonstrated mesenteric mesothe-
lial plasticity. When mesenteric mesothelium is expanded
exvivo, it can transform into a variety of mesenchymal cell
types. is process may contribute invivo to adhesion formation. It may also contribute mesenchymal cells to the
mesentery and intestinal tract in Crohn’s disease. ese are
intriguing possibilities that should be further investigated.
e mesentery has dierent functions at dierent time
points, all of which are largely under-investigated. In the
embryo, during development, it provides a cellular platform
within which cellular specialization can occur in specic
zones. Specialization in the ventral region of the mesentery leads to development of the liver. Specialization in
mesentery adjacent the duodenum generates the pancreas.
Specialization at the periphery of the mesentery results in
formation of the intestine. is function of the mesentery
should be further investigated with a few to determining the
regional switches required for the formation of each.
In the adult, the mesentery functions as a major fat
depot. e body draws on this reserve for energy substrates
required to maintain homeostasis. e capacity of this depot
increases dramatically in the viscerally obese. In the adult,
the mesentery maintains the intestine at a distance from
the anatomic mainframe of the body, while simultaneously
keeping it connected at the intestinal hilum. At the hilum, a
constant exchange occurs between the intestine and mesentery. Recognition of the mesentery as a substantive structure
in its own right will lead to increased investigation of both
these functions, i.e., caloric depot and signal exchange.
TOLDT’S FASCIA
Several questions arise in relation to the fascia. It occurs
wherever the mesentery is attached to the posterior
abdominal wall. e mechanism by which it develops is not
known. Striking macroscopic similarities with adhesions
may shed light on the cellular and molecular mechanisms
that underpin both. e aim of this chapter is to be highly
speculative. In keeping with this, it has been suggested that
mesenteric apposition and adherence attachment across
Toldt’s fascia were important in the development of vertical, upright ambulation in Homo sapiens. Attachment
means the colon and small intestine are maintained out of
the pelvis when one adopts an upright position. Without
mesenteric attachment both would fall into pelvis and
function would be impaired, on standing upright.
PHYSIOLOGY
Increasing data points to a central physiologic role for the
mesentery. It is uniquely positioned between the intestinal
tract and the body proper. Here, it samples environmental
cues and thereaer regulates local mucosal inammatory
responses. In addition, it regulates systemic events including brinolytic, coagulation, and inammatory cascades.
PATHOLOGY
It is clear that numerous pathologic processes aect the
mesentery and that it has the same vulnerability to vascular, inammatory, mesenchymal, and malignant processes as other organs and systems. It is unclear as to
whether some pathologies could be considered primary
or secondary mesenteropathies. For example, increasing evidence points to early development of mesenteric
inammation in Crohn’s disease and its subsequent progression to involve the adjacent intestinal tract. In unraveling the chronology of disease, it is feasible the interface
between the intestinal tract and the mesentery could hold
important clues and that cellular and molecular events
at this anatomic junction could be important. It is also
likely that the identication of a mesenchymal continuity
between the mesentery and adjacent intestinal tract (i.e.,
the gastrointestinal-mesenteric axis) provides an important platform in the development of continuous disease
processes. Moreover, the connective tissue platform also
surrounds the adventitia of veins that drain the mesentery.
Hence, there is a systemic connective tissue contiguity that
may explain the extraintestinal manifestations of intestinal diseases or the intestinal manifestations of extraintestinal diseases.
Gastroenterology 345
RADIOLOGY
As clarication of mesenteric, fascial, and peritoneal structures was a recent development, reappraisal of the radiologic appearance of these was similarly recent. In keeping
with this, it remains to recharacterize the radiologic appearance of all forms of intra-abdominal pathology distal to the
duodenojejunal exure. is would aid in the preoperative
staging of malignancy, planning of operative approaches
(i.e., anticipation of multivisceral resections), as well as in
the spatial interpretation of disease spread in conditions
such as pancreatitis and diverticular disease. For example,
in pancreatitis, uid collections oen track beneath the le
mesocolon, from the lesser sac, and dissect the mesocolon
o the underlying mesentery. In Crohn’s and diverticular
disease, extramesenteric disease spread may point to an
underlying stula. In colorectal cancer, lymphadenopathy
within the mesocolon might prompt the introduction of
chemotherapy in the neoadjuvant context.
A further opportunity arises due to the anatomic central-
ity of the mesentery. e intestine, distal to the duodenojejunal exure, is eectively centered on the mesentery. As a
result, by commencing radiologic appraisals of the intestine
with the mesentery, a composite picture of abdominal and
pathological anatomy can be generated by the radiologist.
is style of approach, the mesentery-rst, remains to be
rigorously investigated.
NOMENCLATURE
Colorectal nomenclature is lacking in accuracy. In
efforts to overcome this limitation, investigators have
gone to lengths to devise an improved nomenclature. It
is unlikely, given the complexity of colorectal surgery,
and the components involved, that any one terminology
can be all-encompassing. For example, proctosigmoid-
ectomy is accurate but ignores the mesenteric component of resection. TME is also accurate, but ignores the
intestinal component of resection. The term complete
mesocolic excision ignores the fact that the small intestinal mesentery is continuous with the right mesocolon
making a complete mesocolic excision technically challenging. Notwithstanding these points, the nomenclature recently developed (total mesocolic excision, total
mesorectal excision, and complete mesocolic excision)
represent advancements in the overall systematization of
colorectal surgery. Thisiscrucial if colorectal surgery is
to be fully standardized. As a result, consensus should
be sought in relation to the nomenclaturized to underpin
the craft component of this surgical subspecialty.
In resectional colorectal surgery, most operative time
is spent in accessing, then mobilizing and resecting the
associated mesentery. e length of time spent in conducting this prompts the development of novel instrumentation
and methodologies by which peritonotomy, mesofascial
separation, and mesenterectomy could be more eciently
achieved. Gas and hydrodissection are currently under
investigation, as are spacer devices such as those used in
laparoscopic hernia surgery. In gas dissection, the needle
ordinarily used to decompress a gallbladder is inserted just
beneath the peritoneal reection. e CO2 used to create a
pneumoperitoneum is then rerouted through the needle.
Subperitoneal planes are exaggerated and provide a useful road map for targeted peritonotomy. Achieving a more
rapid and ecacious mesofascial separation remains a challenge. It is feasible that radiologic cannulation of the mesofascial interface may provide radiologists with a mechanism
of mobilizing the mesentery, without surgeons having to
do so. If this approach was combined with magnetic-based
mobilization of the intestine, then many of the components
of mesenteric-based surgery (i.e., peritonotomy, mesofascial
and colofascial separation) may one day be achieved by a
radiological and hence less invasive means than that presently required.
TOTAL MESORECTAL EXCISION
Along most of its length, the mesorectum is well
demarcated from surrounding structures in the pelvis.
An exception occurs laterally and deep to the peritoneal
reection. is region has been aptly termed the zone of
adherence, or T zone, to denote the tangential apposition
of autonomic nerves and blood vessels. Previously, this
was referred to as the lateral ligament and it was long held
this provided an anatomic means by which the middle
rectal vessel could access the mesorectum. A review of the
visual human project full color dataset fails to identify
the zone of adherence and clearly demonstrates a circummesorectal plane separating the entirety of the mesorectum from adjacent structures. Given this discrepancy
eorts should focus on further delineating the anatomy
of this region.
GASTROENTEROLOGY
Technologies should be developed and incorporated in
endoscopes to permit identication of the mesenteric pole
of the colon. Endoscopic mesenteric mapping would provide a trajectory that, if followed, could result in less discomfort for patients undergoing colonoscopy. Endoscopic
mesenteric mapping would enable the localization of
lesions along the circumference of the colon, and if coupled with longitudinal data, could enable pinpoint localization of lesions in the colon. Mapping of the mesentery
would permit its transintestinal biopsy, similar to that
conducted for the prostate, is could have diagnostic
value in a variety of disease contexts.
346 Future directions
EDUCATION
In order to explain the mesenteric basis of intestinal surgery,
a number of atlases required development. ese included
cadaveric, digital, radiologic, operative (open and laparoscopic) atlases and also an atlas based on appearances in the
visual human project. Together with this book, these form
the basis of a curriculum. e educational utility of this
curriculum could be formally determined in undergraduate
and postgraduate contexts. Target audiences would include
all undergraduate medical students as well as postgraduate
trainees across surgical, radiologic, pathology-based, gastroenterologic, and oncologic training programs.
SUMMARY
Clarication of mesenteric, peritoneal, and fascial structure
has provided an array of opportunities across scientic and
clinical disciplines. Collectively, these represent an opportunity to refresh academic investigation in numerous elds
and across many disease processes. e mesentery may now
be systematically studied.
Appendix A: Operative templates
J. CALVIN COFFEY, D. PETER O LEARY, AND LEON G. WALSH
Everyone must row with the oars he has.
English proverb.
e following series is a list of descriptive templates for open,
laparoscopic, and robotic colorectal surgery. e descriptions are based on the anatomy described in Chapter2 and
the nomenclature in Chapter 9. e reader should also use
Chapters 13 (laparoscopic/robotic atlas) and 14 (open atlas)
for reference.
e operative templates provide a method of rigorously
standardizing the resection process, the recording of this,
and the manner in which it is taught to future generations.
e templates focus solely on the mesenteric component of
the operation. Standard descriptions such as laparotomy,
port placement, and obtaining pneumoperitoneum are not
addressed.
TEMPLATE I: LAPAROSCOPIC/ROBOTIC
RIGHT MESOCOLECTOMY
Procedure: e patient was placed in a slight head down
position with the right shoulder up, and the small bowel and
associated mesentery were reected o the right mesocolon
to provide unimpeded mesocolic access.
An appendices epiploicae was grasped using a toothed
grasper placed through the right iliac fossa port. is was
used to retract the cecum toward the anterior abdominal
wall. e ileocolic adipovascular pedicle was brought under
tension and thus exaggerated.
A peritonotomy was conducted through the mesothe-
lium overlying the interpedicular region on the ileal side
of the ileocolic adipovascular pedicle. e plane between
the overlying mesocolon and the underlying fascia (i.e.,
mesofascial plane) was entered and developed from medial
to lateral. Mesofascial separation was continued by deecting the mesocolon anteriorly and Toldt’s fascia posteriorly.
e 30° lens was angled downward, and interpedicular
mesentery on the colonic side of the vascular pedicle was iden-
tied. A peritonotomy was started and the mesofascial plane
entered again and developed. e plane of dissection on the
ileal and the colonic side of the vascular pedicle were joined.
e adipovascular pedicle was skeletonized using the harmonic
scalpel until the vessels contained within it were identied.
A stapling device was inserted through the 10/12mm
port in the le upper quadrant. e blade jaw was placed
posterior to the ileocolic vessel and the instrument red.
einstrument was opened and withdrawn, thereby providing unimpeded access to the mesofascial plane.
Mesofascial separation was continued as far laterally under
the right mesocolon and thereaer under the right colon until
the right peritoneal reection was encountered. Mesofascial
separation was repeated toward the hepatic exure, thereby
liing the mesenteric component of the exure o the retroperitoneum. Continuing this process, the colic component of
the exure was mobilized. is was continued until the hepa-
tocolic reection of the hepatic exure was encountered.
e patient was then placed in a slight head up position,
and the hepatocolic peritoneal reection was identied. e
reection was placed under traction. is was achieved by
grasping an appendices epiploicae at the hepatic exure and
retracting the colic component of the hepatic exure toward
the le iliac fossa. e hepatocolic peritoneal reection was
then directly divided (i.e., peritonotomy) using a tissue sealant device and the peritonotomy was extended laterally to
the right peritoneal reection.
e right peritoneal reection was divided as far inferi-
orly as was possible. e patient was positioned in a head
down position, and the ileocecal peritoneal reection overlying the ileocecal mesenteric conuence and mesoappendix
was identied. A peritonotomy here was continued laterally
toward the divided margin of the right peritoneal reection. e peritonotomy was next continued medially along
the base of the small intestinal mesentery. e mesofascial
plane was exposed in this manner, and separation of its
components fully freed the small intestine and right mesocolon, as far proximally as the mesenteric root region.
A short transverse incision (approximately 4 cm) was
made in the right ank, and the wound edges kept apart
using a wound retractor. e specimen was exteriorized,
and the terminal ileum divided between Kocher clamps as
was the transverse colon in the region of the hepatic exure.
Aer division of the intestinal tract, the proximal and distal
mesenterotomies were completed and the mesenterectomy
347