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MESENTERIC PRINCIPLES OF
GASTROINTESTINAL
SURGERY
BASIC AND
APPLIED SCIENCE
MESENTERIC PRINCIPLES OF
GASTROINTESTINAL
SURGERY
BASIC AND
APPLIED SCIENCE
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
© 2017 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed on acid-free paper
Version Date: 20160812
International Standard Book Number-13: 978-1-4987-1122-7 (Pack - Book and Ebook)
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable
data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made.
The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them
and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical,
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There is nothing new under the sun.
Ecclesiastes 1:4-11
I could be bounded in a nutshell, and count myself
a king of innite space.
Hamlet, Act II, Scene 2
To Dee
and
Victor Warren Fazio
Master without peer
vii
Contents
Preface ix
How to access three-dimensional models usingQR codes xi
Acknowledgments xiii
PAR T 1 1
1 History 3
J. Calvin Coffey and Nicola O’Riordan
2 Mesenteric and peritoneal anatomy 11
J. Calvin Coffey, Peter Dockery, Brendan J. Moran, and Bill Heald
3 Embryologic development of the mesentery, peritoneal reection, and Toldt’s fascia 41
J. Calvin Coffey, Rishabh Sehgal, and Joep Knol
4 Histology of the mesentery 47
J. Calvin Coffey, Miranda Kiernan, and Leon G. Walsh
5 Toldt’s fascia 57
J. Calvin Coffey and Ravi Kiran
6 Mesenteric physiology 69
J. Calvin Coffey, Rishabh Sehgal, Awad M. Jarrar, and Mattias Soop
7 Pathology of the mesentery 85
J. Calvin Coffey, Jonathon Roddy, Miranda Kiernan, and Shaheel M. Sahebally
8 Radiographic appearance of the mesenteryandperitoneum 109
J. Calvin Coffey and Martin Shelly
9 Operative nomenclature 119
J. Calvin Coffey, Bill Heald, and Brendan J. Moran
10 Teaching mesenteric principles 137
J. Calvin Coffey, Deirdre McGrath, and Colin Peirce
11 Gastro enterolo gy 147
J. Calvin Coffey and Manus Moloney
PAR T 2 151
12 Mesenteric-based colorectal surgery 153
J. Calvin Coffey and Ian Lavery
13 Appearance of the mesentery during laparoscopic/robotic colorectal surgery 157
J. Calvin Coffey and Manish Chand
14 Appearance of the mesentery during opencolorectal surgery 177
J. Calvin Coffey and James O’Riordan
15 Instruments used during mesenteric-based colorectal surgery 199
J. Calvin Coffey and John P. Burke
16 General techniques in mesenteric-based colorectal surgery 211
J. Calvin Coffey and Jeremy Lipman
viii Contents
17 Mesenteric component of sigmoid colectomy 233
J. Calvin Coffey and Mathew Kalady
18 Mesenteric component of rectal resection 251
J. Calvin Coffey and Jonathon Efron
19 Mesenteric component of right colectomy 277
J. Calvin Coffey and Steven D. Wexner
20 Mesenteric component of exure mobilization 293
J. Calvin Coffey and Neil J. Smart
21 Mesenteric considerations in resection ofthetransverse colon 301
J. Calvin Coffey and Ian Lavery
22 Mesenteric considerations in small bowel resection 311
J. Calvin Coffey, Eoghan Condon, and David W. Waldron
23 Mesenteric considerations in ileal pouch analanastomosis 317
J. Calvin Coffey and James W. Ogilvie Jr.
24 Mesenteric considerations in ostomyformationand reversal 323
J. Calvin Coffey, Colin Peirce, and Ann Brannigan
25 Mesenteric considerations in reoperative abdominal surgery 333
J. Calvin Coffey and Feza Remzi
26 Future directions 343
J. Calvin Coffey
Appendix A: Operative templates 347
Index 351
ix
Preface
This work is intended to furnish the Student
and Practitioner with an accurate view of the
Anatomy of the Human Body, and more espe-
cially the application of this science to Practical
Surgery.
Henry Gray (1858)
MESENTERIC-BASED SURGERY DEFINED
Mesenteric-based surgery is where the surgeon exploits
mesenteric and associated structures in guiding an intesti-
nal resection. e associated structures are the peritoneal
refl ction and Toldt’s fascia. Rather than indiscriminately
dissecting through tissue, structures, and planes, the surgeon
selects certain structures and conducts a particular activity
related to that structure. For example, during sigmoid mobi-
lization for colectomy, the surgeon divides the peritoneal
refl ction at the right side of the base of the mesosigmoid
(via a peritonotomy), which exposes the underlying meso-
fascial plane. Th s plane is formed at the interface between
the mesosigmoid and the underlying Toldt’s fascia. e sur-
geon then separates the components of this plane to mobilize
the mesosigmoid.
Nonmesenteric-based surgery is one where the surgeon
does not adhere to a particular anatomic roadmap. e
mesentery is divided directly across and dissociated from
the posterior abdominal wall. During dissociation, the ret-
roperitoneum and contained structures are oen not recog-
nized before being damaged.
Examples of mesenteric-based surgery now abound
and include complete mesocolic excision, total mesorectal
excision, and total mesocolic excision. Variations are also
emerging, including transanal total mesorectal excision
and modifi d complete mesocolic excision. As part of these
procedures, the surgeon accesses the mesofascial plane in a
targeted manner (through division of the peritoneal reec-
tion), then mobilizes an intact mesentery without its disrup-
tion. Similarly, the retroperitoneum and covering fascia are
preserved. When the mesentery is suciently mobilized,
the vessels contained within are selected, skeletonized, and
divided, and the mesentery is similarly divided up to the
level of the intestine.
Several terms have been used in reference to nonmesen-
teric-based surgery. ese include “conventional” surgery,
“non-CME surgery, and “non-TME surgery.” Unfortunately,
the terms “CME” and “TME” have not been scientically
dened in the rst instance, and so the related terms also
lack defi ition.
Mesenteric-based surgery has been practiced internation-
ally for over a century and thus is far from new. However, it
is certainly not universally practiced, and considerable varia-
tion has been demonstrated. e variation is explained by
the disparity that has persisted between anatomic and sur-
gical approaches to the intestine for the past century. While
mesenteric-based surgery is far from new, it is remarkable that
its anatomic basis has only recently been formally described.
is means that the principles can now be reproducibly
taught and conducted in an entirely standardized manner.
is book is composed of two parts. In the rst part, the
mesentery, peritoneum, and associated fascia are charac-
terized. In the second part, the data explained in the rst
are applied to all aspects of resectional colorectal surgery.
Surgical anatomy, activities, and operations are carefully
dened to enable all surgeons to reproducibly conduct
mesenteric-based surgery.
J. Calvin Coff y