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348 Appendix A: Operative templates
and colon resection formally completed. e specimen was
then delivered and inspected.
To perform a hand-sewn anastomosis, the ileal mesen-
tery was dissected free o the mesenteric border for approximately 1cm. is was repeated on the colonic side, thus
permitting visualization of all intestinal layers for an anatomic hand-sewn anastomosis.
In the case of a stapled anastomosis, two sutures were
placed one on either side of the mesentery at the mesenteric
border of the cut end of the ileum. e anvil of a circular
stapling device was then secured using a 2-0 Prolene purse
string in the ileum, and the circular stapling device was itself
introduced into the colon having grasped the divided end of
the colon with four Babcocks. e sharp, pointed end of the
docking device of the stapler itself was brought through a taenia coli in the transverse colon. e sharp end was removed
and the anvil then inserted into the sha of the docking
device. e gun was then red aer which a linear stapler
was used to staple closed the divided end of the colon. e
linear staple line was oversewn using 2-0 Vicryl running or
interrupted sutures. Two sutures were placed on either side of
the mesentery on the ileum and used to buttress the anastomosis between ileum and colon in the region of the mesentery. Further 3-0 Vicryl sutures were placed in an interrupted
manner circumferentially along the circular staple line.
e mesenterotomy margin was inspected for bleeding,
and any found was controlled via judicious suture ligation.
e mesenteric window was closed by approximating the
mesenteric margins. e specimen was returned intraperitoneally. Final checks for hemostasis were systematically
conducted along the peritonotomy margin, the surface of
the right mesocolic fascia, and at the mesenteric stumps of
any major vessel ligated.
TEMPLATE II: OPEN RIGHT
MESOCOLECTOMY
Procedure: A midline laparotomy was performed to ensure
adequate right mesocolic access. e edges of the laparotomy
wound were placed under gentle retraction using a selfretainer. e small bowel and mesentery were deected o
the right mesocolon and held in position using a moist swab.
e cecum was lied anteriorly. is placed the ileocecal
peritoneal reection under stretch, causing the groove at
the reection to be exaggerated and providing a landmark
for the commencement of the dissection. Aperitonotomy
of the reection here exposed the colofascial interface.
Colofascial separation was achieved using the handheld dia-
thermy. is exposed the mesofascial interface which was
separated in a similar manner. e right colon was then
grasped, lied anteriorly, and tension transmitted to the
right peritoneal reection. e original peritonotomy was
continued through this, thus exposing the colofascial inter-
face, and the components of this were separated. is pro-
cess was continued medially until the mesofascial interface
whereupon mesofascial separation was conducted.
e colic component of the hepatic exure was grasped
and retracted toward the le iliac fossa. In so doing, the hepa-
tocolic reection was exposed and the original peritonotomy
further extended here. is provided access to the colofas-
cial and mesofascial interface at the exure. Interface com-
ponents were separated as far medially as the root region of
the mesentery. Mesofascial separation proceeded cautiously
at the duodenum and head of pancreas to prevent damage to
either or tearing of mesenteric vessels in this region.
Once mobilization and medialisation were completed,
the terminal ileum and the colon were divided between
Kocher clamps, and a hand-sewn ileocolic anastomosis was
fashioned in the usual manner. In the event of a stapled
anastomosis, this was conducted as described earlier.
e mesenterotomy margin was inspected for bleeding, and any found was controlled via suture ligation. e
mesenteric window was then closed by approximating the
mesenteric margins. e specimen was returned intraperitoneally. Final checks for hemostasis were systematically
conducted along the peritonotomy margin, the surface of
the right mesocolic fascia, and at the mesenteric stumps of
any major vessel ligated.
TEMPLATE III: LAPAROSCOPIC/ROBOTIC
MESOSIGMOIDAL MOBILIZATION
Procedure: e patient was placed in a slight head down
position with the shoulders neutral. As a result, the small
bowel and mesentery gravitated away from the pelvis to
expose the right side of the base of the mesosigmoid. Aer
unimpeded mesocolic access was obtained, the dissection
began.
An appendices epiploicae was grasped and retracted
anteriorly. e peritoneal groove at the base of the mesosigmoid became prominent. e fold formed by the inferior
mesenteric adipovascular pedicle was exaggerated.
e mesothelium of the peritoneal reection was grasped
and a peritonotomy commenced using a tissue sealant
device. e mesofascial interface was identied and com-
ponents carefully separated liing the mesosigmoid anteri-
orly and sweeping the fascia posteriorly. e 30° lens was
reoriented to visualize the undersurface of the mesosigmoid
and facilitate further mesofascial separation. e ureter and
gonadal vessels were evident deep to the fascia.
e peritonotomy was extended proximally over the adi-
povascular pedicle which was again further freed via mesofascial separation. e camera orientation was changed to
view the le mesocolon. e le shoulder was elevated causing the small bowel to gravitate away from the le mesocolon
and expose the latter up to the level of the duodenojejunal
exure. ese maneuvers provided unimpeded access to the
le mesocolon. e 30° lens was again reoriented to iden-
tify the mesocolon proximal to the adipovascular pedicle.
A peritonotomy here enabled dissection through the mesentery into the mesofascial plane where separation of interface
components was conducted. e net eect was to further
Appendix A: Operative templates 349
isolate the adipovascular pedicle. Mesocolic fat on the far
side of the pedicle was gently freed using the curved and
blunt blade of the Endo-mini retract.
e IMA was divided using a linear stapling device (or
clips) placed through a le iliac fossa 10/12mm port. e
jaws of the stapling device were closed for 1 minute aer
which it was red, opened, and removed. Residual staple line
bleeding was controlled by clipping diagonally across the
staple line. Once the adipovascular pedicle was fully divided
the undersurface of the le mesocolon and the le mesofas-
cial interface were identied. Similarly, access to the mesofas-
cial interface beneath the mesosigmoid was also developed.
Mesosigmoidal mobilization was continued by deecting the
mesosigmoid anteriorly and the fascia posteriorly. is was
extended laterally until the peritoneal reection on the le
side of the mesosigmoid was reached. e 30° lens was again
reoriented to directly visualize the le peritoneal reection.
A peritonotomy was created and extended cephalad as far as
the descending colon and caudally as far as the le pararectal
fold. is completed mesosigmoidal mobilization.
TEMPLATE IV: OPEN MESOSIGMOIDAL
MOBILIZATION
Procedure: e surgeon, positioned on the patient’s le,
grasped the sigmoid colon, and lied it anteriorly. is
exposed congenital adhesions between the lateral aspect of
the mesosigmoid and the parietal peritoneum of the le iliac
fossa. Once these were divided through, the peritoneal reec-
tion at the lateral aspect of the mesosigmoid became apparent. e junction between the sigmoid and the descending
colon was identied and lied anteriorly. is placed the
lateral peritoneal reection under traction, thereby exaggerating the reection groove. A peritonotomy was commenced
here and extended cephalad and then caudally. e perito-
notomy exposed the colofascial interface between le colon
and underlying fascia. Interface components were separated
until the mesofascial interface was encountered and similarly separated.
e sigmoid was retracted anteriorly, thereby transmitting traction to the interface between the mesosigmoid
and underlying fascia. e interface was then divided with
monopolar diathermy, thereby separating the mesosigmoid
and allowing its mobilization anteriorly o the fascia overlying the retroperitoneum. Further progress in this manner was facilitated by completing the lateral peritonotomy
as far distally as the le pararectal fold. Mesothelial release
here facilitated further mesofascial separation of the mesosigmoid and underlying fascia. is was completed as far
medially as possible, until completion was impeded by the
peritoneal reection at the right side of the mesosigmoid. A
peritonotomy on the right side was then extended cephalad
and caudally.
At this point, the inferior mesenteric adipovascular ped-
icle was retracted anteriorly. e le mesocolon cephalad
to the pedicle was dissected through thereby fully isolating
the pedicle. is was skeletonized and the vessels contained
divided between clamps then suture ligated. is completed
open mesosigmoidal mobilization.
TEMPLATE V: LAPAROSCOPIC/ROBOTIC
MOBILIZATION OF THE SPLENIC FLEXURE
Procedure: e le peritoneal reection was divided as
far cephalad as possible. A prominent band of adhesions
occurred just distal to the colic component of the splenic
exure and was divided. e proximal descending colon
was grasped with an atraumatic grasper and retracted to the
right iliac fossa. Peritonotomy of the le peritoneal reection
was continued cephalad. is exposed the le colofascial
interface. e components of the latter were separated by
displacing the fascia posteriorly and the colon anteriorly.
is was continued until the mesofascial interface was
encountered. As part of le mesocolic mobilization, the le
mesocolon had been fully mobilized o the underlying fascia as far proximally as was feasible. ese steps fully mobilized the le mesocolon.
e patient was placed in a slight head up position.
e greater omentum was grasped just outside the gastro-
epiploic arcade, using the atraumatic grasper. It was also
grasped adjacent this, in a similar manner, and the intervening omentum was divided through. e lesser sac was
entered, and the division of the greater omentum was continued laterally. e upper surface of the transverse meso-
colon became apparent. Toward the exure, the omentum
and splenocolic peritoneal reection coalesced. e patient
was placed le shoulder up, and the omentum where they
coalesced was divided through. is action exposed the
underlying mesentery and the peritoneal reection. e
reection was divided around to the free edge of the le
peritoneal reection.
Following division of the peritoneal reection, the meso-
fascial interface at the exure was apparent. e interface
components were separated by sweeping the mesenteric
conuence medially and the fascia posteriorly. is process
was continued medially until limited by the adipovascular
pedicle of the middle colic vessels. is completed laparoscopic/robotic mobilization of the splenic exure.
TEMPLATE VI: OPEN MOBILIZATION
OFTHE SPLENIC FLEXURE
Procedure: e patient was placed head up. e surgeon was
positioned between the legs and the assistant (positioned
above the le upper quadrant) retracted the le upper quadrant. A further assistant (positioned on the right) retracted
the small bowel and mesentery to the right. is exposed
the entirety of the le mesocolon. e le colon and mesocolon had been mobilized as an earlier part of the procedure.
A peritonotomy of the left peritoneal reflection was
extended cephalad and caudally, thereby exposing the
colofascial interface. The interface components were
350 Appendix A: Operative templates
separated sweeping the fascia posteriorly. This continued
until the mesofascial interface on the left was reached.
Further colo- and mesofascial separation were permitted
by lengthening the peritonotomy toward the colic component of the splenic f lexure. Just distal to the latter, a
prominent band of congenital adhesions were divided
through in a hemostatic manner.
Attention then turned to the transverse colon. e
greater omentum was lied cephalad and the colon caudally, exposing the peritoneal reection between the two.
A peritonotomy of this was started near the midline and
lengthened toward the splenic exure. is exposed adhe-
sions between the greater omentum and the underlying
mesocolon. Division of these fully mobilized the transverse
mesocolon. ese processes (i.e., peritonotomy and mobi-
lization of the mesocolon) were continued laterally toward
the splenic exure. At the exure, the greater omentum
coalesced with the splenocolic peritoneal reection. is
complex was divided through laterally until the free edge of
the peritoneum of the le peritoneal reection was reached.
To aid in completing these activities, the transverse
colon and le colon on either side of the colic component
of the exure were grasped in the le hand of the surgeon
and retracted gently to the right iliac fossa. Once the perito-
neal and omental components of the exure had been fully
divided, the mesofascial interface was identiable. e fascia
was swept posteriorly thereby fully freeing the mesenteric
component of the exure. is was continued medially until
further progress was impeded by the adipovascular pedicle
of the middle colic vessels. is completed mobilization of
the splenic exure.
TEMPLATE VII: LAPAROSCOPIC/ROBOTIC
MOBILIZATION OF THE TRANSVERSE
MESOCOLON
Intraoperative ndings: For the purpose of this description, it is assumed that the transverse mesocolon is being
divided in the context of a laparoscopic total mesocolic excision. In this context, it is assumed that the mesosigmoid,
le mesocolon, and splenic exure have been mobilized (see
earlier). As mobilization of the mesosigmoid involved division of inferior mesenteric adipovascular pedicles, a distal
mesenteric free margin is apparent. In addition, the greater
omentum has been freed from the underlying transverse
mesocolon from the midline to the splenic exure.
Procedure: e rst step is to fully separate the greater
omentum from the transverse mesocolon. If this is not completed, then it is not possible to fully separate the middle
colic adipovascular pedicle (as the omentum will be adherent cephalad).
e patient was placed head up and the greater omentum grasped via a grasper placed through the right upper
quadrant 5mm port. e omentum was raised toward the
anterior abdominal wall and grasped by the surgeon via
an atraumatic grasper placed through the right iliac fossa
port. is exposed the divided edge ofthe greater omentum
(i.e.,created as part of mobilization of the splenic exure).
is was divided across from the midline toward the hepatic
exure. At the exure, it coalesced with the hepatocolic
peritoneal reection and this complex was divided through.
As a result, the greater omentum was fully separated from
the cephalad aspect of the transverse mesocolon.
e second step was isolation of the middle colic adipovascular pedicle. e assistant repositioned the grasper
on the transverse mesocolon and raised this anteriorly. e
second assistant grasped the mesenteric component of the
splenic exure and lied this anteriorly. e eect was to
open out the transverse mesocolon in the region of middle
colic pedicle and simultaneously expose the free mesenteric
margin. is region of the mesentery is avascular and was
divided through using the sealant device. e mesenterot-
omy was continued to the lateral aspect of the middle colic
vessel. e avascular mesentery on the opposite side of the
pedicle was dissected through into the lesser sac. Mesenteric
fat was freed gently from the middle colic vessels. e mes-
enterotomy was continued onto the right lateral aspect of the
middle colic vessel. Using this approach, the middle colic
vessel was fully isolated and skeletonized and thus prepared
for division. is was completed using clips.
e middle colic vein and artery were surgically treated
in an identical manner. e mesenteric component of the
hepatic exure was lied anteriorly, and the mesenterotomy
created as described earlier was extended laterally through
this avascular region. is completed mobilization of the
transverse mesocolon.