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126 Operative nomenclature
Transverse
colon
Colic component
of splenic flexure
Mesenteric
component of
splenic flexure
Peritoneal
component of
splenic flexure
Descending colon(b)
Splenic flexure
Transverse
mesocolon
Left
mesocolon
Transverse
colon
Flexure removed
Descending colon
(a)
Legend
Mesentery
Fascia
Colon
Peritoneum
Figure 9.12 (See also QR 9 and 10.) (a) Digitized view of the splenic exure with the exure itself removed. The remaining
anatomic structures and their relations are apparent. (b) Digital view of the splenic exure removed from related anatomic
structures. The relations between the colon, mesentery, fascia, and peritoneum are apparent.
Peritoneal reection 127
Lateral mesosigmoidal
peritoneal reflection
Mobile mesosigmoid
Mobile region
of mesosigmoid
Proximal
sigmoidal flexure
Lateral aspect of
mobile region
of mesosigmoid
Lateral peritoneal
reflection after
division of
congenital
adhesions
Congenital
adhesions
Distal sigmoidal flexure
(a) (b)(c)
Proximal
sigmoidal
flexure
Figure 9.13 (See also QR 7/4-6.) (a) Schematic 2.5D image demonstrating the mesosigmoid as one might encounter it
intraoperatively in the undisturbed format. The divided line is the line of the left mesosigmoidal peritoneal reection that
is obscured from view at rst. (b) The mesosigmoid has been partially mobilized by dividing congenital adhesions and the
line of the left mesosigmoidal peritoneal reection is exposed distally. (c) When congenital adhesions are fully divided, then
the mobile component of the mesosigmoid is free and, when medialized, exposes the full extent of the left mesosigmoidal
peritoneal reection. This represents the true starting point of mesosigmoidal mobilization in colorectal surgery. (Courtesy
of CCF. Copyright 2010.)
Mesosigmoid
Left mesocolon
(a)
Mobile mesosigmoid
Attached
mesosigmoid
(b)
Sigmoid
proximal to
rectosigmoid
junction
(d)
Distal
sigmoid
Mobile
mesosigmoid(c)
Attached
mesosigmoid
Figure 9.14 (See also QR 5/1.) Schematic illustrations of the axial sections through the mesosigmoid at successively more
distal levels. The mesosigmoid comprises attached and mobile regions. The attached component is the distal continuation
of the left mesocolon. Both the attached and mobile regions’ margins converge at the rectosigmoid junction where the
mesosigmoid continues distally as the mesorectum.
128 Operative nomenclature
Right mesosigmoidal peritoneal reection: Surface meso-
thelium of the left mesocolon near the midline. It is contigu-
ous above with the mesothelium on the undersurface of the
transverse mesocolon. Below, it is continuous with the right
mesosigmoidal peritoneal reection. Medially, the meso-
thelium separates from the mesocolon to continue onto the
posterior abdominal wall.
Le mesosigmoidal reection: Distal continuation of the
le peritoneal reection along the left lateral aspect of the
mesosigmoid (Figure 9.22).
Right mesosigmoidal reection: Peritoneal reection at
the medial aspect of the mesosigmoid.
Pararectal reections: Peritoneal reections at either side
of the rectum and mesorectum. e left pararectal reec-
tion is a continuation of the left mesosigmoidal reection.
e right pararectal reection is a continuation of right
mesosigmoidal reection (Figure 9.23).
Anterior reection: Peritoneal refl ction formed by merg-
ing of the right and left pararectal refl ctions in the rectovesi-
cal pouch of Douglas, in the anterior midline (Figure9.23).
FASCIA
Waldeyer’s fascia: A condensation of Toldt’s fascia in the
distal pelvis interposed between the distal apex of the
mesorectum and the sacrum posteriorly. e fascia lls
thespace created between the termination of the mesorec-
tum and the surrounding pelvis.
Toldt’s fa scia: Fascia interposed between the mesentery
and the retroperitoneum wherever mesentery is attached
to the latter (i.e., right and left mesocolon, attached compo-
nent of mesosigmoid and mesorectum). Zones of the fascia
are termed according to the region of mesentery associated.
e fascia around the mesorectum is termed the mesorec-
tal fascia. e fascia interposed between attached meso-
sigmoid and retroperitoneum is termed the mesosigmoidal
fascia. Gerota’s fascia corresponds to the region of Toldt’s
fascia that surrounds perirenal fat. Waldeyer’s fascia is a ret-
rorectal condensation of the mesorectal fascia in the distal
pelvis.
Although the terms right and left mesocolic fascia are
new, they are intuitive and keeping with the aforementioned
systematized approach to nomenclature.
CONGENITAL ADHESIONS
Mesosigmoidal congenital adhesions: Congenital adhesions
that occur between the lateral aspect of the mesosigmoid
and the parietal peritoneum of the left liac fossa.
Duodenal congenital adhesions: Adhesions that occur
between the fourth part of the duodenum and the le
mesocolon.
Right congenital adhesions: Congenital adhesions
between the right peritoneal reection and the parietal peri-
toneum of the right paracolic gutter.
Flexure extracted
Rectosigmoid junction removed
Figure 9.15 Schematic illustration of the region where
the mesosigmoid continues distally as the mesorectum.
This gastromesenteric junction has been conceptu-
ally removed from the image to illustrate the meso-
sigmoid and mesorectum both proximally and distally,
respectively. (Courtesy of CCF. Copyright 2010.)
Peritoneal reflection
at the base
of the intestine
Small
intestinal
mesentery
Jejunum
Small intestinal peritoneal reflection
Figure 9.16 (See also QR 8/1.) View of the medial aspect
of the peritoneal reection at the base of the small intesti-
nal mesentery, in a cadaver.
Congenital adhesions 129
Ileocecal
peritoneal
reflection
(a)
(b)
Terminal
ileum
Ileocecal peritoneal reflection
Ileocecal
peritoneal
reflection
Terminal
ileum
Appendix
Legend
Mesentery
Fascia
Colon
Peritoneum
Figure 9.17 (a) Ileocecal peritoneal reection at the inferolateral aspect of the ileocecal junction, as seen in a cadaver.
(b) (See also QR 2/2.) 2.5D snapshot of 3D digital model demonstrating the inferolateral peritoneal reection. An ana-
tomic demarcation is not apparent between this region of the peritoneal reection, and continuous zones (i.e., the right
peritoneal reection and the small bowel mesenteric reection).
130 Operative nomenclature
Right peritonea
l
reflec
tion being
divided
Right mesocolon
(a)
Small bowel mesentery
Right mesocolon
Peritoneal
reflection
Toldt’s fascia(b)
Mesentery
Fascia
Colon
Peritoneum
Legend
Peritonotomy
edge
Figure 9.18 (a) (See also QR 3/3.) View (from below up) of the divided right peritoneal reection at the lateral aspect of the
right colon in a cadaver. (b) (See also QR 3/3.) 2.5D snapshot of 3D digital model of the right mesocolon and colon. The
model has been sectioned through to demonstrate the anatomic relationships of its components. The viewpoint is from
above (i.e., from the hepatic exure) distally, and the right peritoneal reection can be visualized.
Technical nomenclature 131
SURGICAL ADAPTATION OF ANATOMIC
TERMINOLOGY
As mentioned earlier, an eff ctive nomenclature is one com-
prising elements that, when combined, convey a meaning that
would not be apparent when used in isolation. e examples
given included nomenclature used in mathematics and chem-
istry. In both cases, the elements of each nomenclature can be
combined to convey meaning, rules, and functions.
Terminology used in resectional colorectal surgery has
changed little over the past half century. Terms such as ileo-
colic resection, anterior resection, and proctosigmoidec-
tomy primarily reect the intestinal component of resection
and ignore the mesenteric component. Examination of time
spent in mesenteric mobilization, division, and resection
reveals this comprises a greater component of gastrointes-
tinal resection than heretofore acknowledged. It is reason-
able therefore to place a greater emphasis on the mesenteric
component. e anatomic terminology described earlier
consists of individual elements that, when combined, con-
vey the activities required for complete mesenterectomy
[1–4,33]. ey provide the basis of a systemized approach to
surgical nomenclature in general.
RESECTIONAL NOMENCLATURE IN
COLORECTAL SURGERY
In resectional surgery, terminology can be broadly divided
into two categories: the rst category (operative nomen-
clature) is a code of operative titles (i.e., total mesorectal
excision); the second category (technical nomenclature) is
a code of individual activities that, collectively, combine to
make up an operation. e former has recently undergone a
welcome transformation with the emergence of terms such
as total mesorectal excision and complete mesocolic exci-
sion [2]. A further similar term is total mesocolic excision.
In contrast, terminology related to specic activities (i.e.,
peritonotomy, mesenterectomy) is entirely lacking. Both
operative and technical nomenclature can be improved on
in a systemized manner by utilizing the anatomic terminol-
ogy listed earlier.
Importantly, it should be noted that all nomenclature
will have some limitations. Notwithstanding this, eff rts
should continue to develop this aspect of colorectal surgi-
cal science. As our understanding of anatomy and surgery
continues to evolve, it is likely that the associated nomen-
clature will also synchronously develop [34]. To facilitate
this development, we propose the following operative
terminologies (Table 9.1):
●
Small bowel resection could be altered to small intestinal
mesenterectomy and the prefix total or partial may be
added to indicate the extent of the mesenterectomy.
“Small intestinal” could be omitted from the terminology
as it is implicit in resection of the associated mesentery.
Th s is because it is not possible to retain a segment of
small bowel once the associated mesentery has been
removed.
●
Right colic excision is better termed right mesocolectomy
and again the prex total or partial can be introduced to
indicate the extent of the mesenterectomy.
TECHNICAL NOMENCLATURE
is refers to the individual surgical activities that collec-
tively describe the operation in question. e following will
focus on the activities required for mobilization, division,
and resection of the mesentery. e activities required for
intestinal division and anastomosis are beyond the scope of
this chapter.
Mesenteric-based activities are largely targeted toward
the peritoneal reection, the mesentery itself, and the
underlying fascia. As a result, and based on the anatomic
terminology listed earlier, there is now an opportunity to
generate an appropriate technical nomenclature in a sys-
temized manner [1,4]. An example of this principle relates
to peritoneal reections. Peritonotomy is essential to access
the colo- or mesofascial plane. Table 9.2 lists the terms that
describe the individual surgical activities required for mes-
enteric mobilization, division, and resection.
Hepatocolic
peritoneal reflection
Transverse colon
Hepatocolic peritoneal reflection
Right colon
T
ransverse mesocolon
Figure 9.19 (See also QR 2/4.) 2.5D snapshot of 3D
digital model demonstrating the hepatocolic peritoneal
reection. The view is from above downward. The hepato-
colic peritoneal reection is continuous laterally with the
right peritoneal reection.
132 Operative nomenclature
Peritoneal reflection
(a)
Transverse
colon
Greater
omentum
Omentocolic peritoneal reflection
Peritonotom
y
margin
Peritonotomy of reflection(b)
Transverse colon
Greater
omentum
Figure 9.20 (a) Omentocolic reection connecting the greater omentum and underlying transverse colon, as seen in a
cadaver. (b) View of the omentocolic reection in a cadaver following peritonotomy of the reection.
Partial or total right mesocolectomy 133
PARTIAL OR TOTAL RIGHT
MESOCOLECTOMY
A description of “total” or “partial right mesocolec-
tomy” follows [4]. e description is based on the earlier
nomenclature and aims to illustrate the utility of this
nomenclature.
A peritonotomy of the ileocecal reection is made and
continued laterally to the right peritoneal reection. If the
colon/mesentery complex is lied away from the posterior
abdominal wall, the colofascial and mesofascial planes and
respective components are apparent. Colofascial followed
by mesofascial separation is then conducted. Peritonotomy
of the ileocecal reection is continued medially toward the
duodenojejunal exure along the small bowel mesenteric
reection (i.e., at the base of the small intestinal mesentery).
is exposes the mesofascial interface formed by the right
mesocolon and Toldt’s fascia. Mesofascial separation frees
the right mesocolon from the retroperitoneum without
entering the retroperitoneum proper.
e dissection is then turned to the lateral aspect of the
right/ascending colon where peritonotomy of the right peri-
toneal reection exposes the colofascial or mesofascial inter-
face here. Components of the latter a re then separated. When
this process is continued medially, the small intestinal mes-
entery, right mesocolon, right colon, ileocecal junction, and
Left peritoneal reflection
Toldt’s fascia
Left (descending) colon
Left peritoneal reflection
Figure 9.21 Image from cadaver where the viewpoint
is from inferior to superior, along the left peritoneal
reection. The peritoneal reection has been divided
distally to expose the colofascial interface beneath it.
Left mesosigmoidal
peritoneal reflection
Sigmoid colon
Left
(descending) colon
Left mesosigmoidal peritoneal reflection
Left peritoneal
reflection
Figure 9.22 (See also QR 2d/1-2.) 2.5D snapshot of 3D
digital model demonstrating the left mesosigmoidal
peritoneal reection from lateral to medial.
Left
pararectal
peritoneal
reflection
Right
pararectal
peritoneal
reflection
Right mesosigmoidal
peritoneal reflection
Pararectal peritoneal reflection
Figure 9.23 (See also QR 2d/5-7.) Right and left para-
rectal peritoneal reections demonstrated using a 2.5D
snapshot from a 3D digital sculpture. The reections
coalesce in the anterior midline as the anterior reection
in the pouch of Douglas.
134 Operative nomenclature
mesenteric conuence are fully mobilized. e mesentery is
intact, as is the fascia overlying the retroperitoneum.
A peritonotomy of the hepatocolic refl ction is performed.
Th colic component of the hepatic exure is exposed and
components of the colofascial interface separated. emes-
enteric component of the hepatic flexu e must then be sepa-
rated, via mesofascial separation, from the underlying fascia.
Medially, in the region of the second part of the duodenum
and head of pancreas, the mesentery thins out to comprise
mainly a mesothelium only (i.e., the base of the transverse
mesocolon).
e greater omentum (which is attached to the upper
surface of the transverse mesocolon) is separated from the
transverse mesocolon, to achieve complete mobilization
of the transverse mesocolon. is is done by rst dividing
(i.e., peritonotomy) the omentocolic reection attaching the
under surface of the greater omentum to the transverse
colon. Next, focal adhesions attaching the under surface of
the greater omentum and upper surface of mesocolon are
divided. is fully exposes the lesser sac. By adopting the
earlier approach, the entire right colon and mesocolon can
be mobilized without disruption of the mesocolic package.
e resultant mobility means that the associated mesenteric
organ can be lied out of the peritoneal cavity for easy iden-
tication of contained vessels [4].
e ileocolic adipovascular pedicle is apparent within
the right mesocolon/small bowel mesenteric conuence.
Other vascular pedicles include the right and middle colic
adipovascular pedicles. In these, peritonotomy followed
by adipose clearance skeletonizes the contained ves-
sels and permits their division. Mesenterotomy of inter-
pedicular mesentery separates the region for resection.
Anterograde mesenterotomy up to the intestinal margin
completes the mesenterectomy. Gastrointestinal resection
is completed by division and anastomosis. ese steps,
and the nomenclature associated, are beyond the remit of
the current text.
APPLICATION OF TERMINOLOGY TO
RADIOLOGICAL NOMENCLATURE
Digital imagery provided by the visual human project
enables identication of the mesentery, associated fas-
cial and peritoneal attachments, in full color, and as one
might in a cadaveric dissection [30,33,35–38]. e avail-
ability of matching CT and MRI images has meant that
shapes identifi d on radiologic imaging can be correlated
to corresponding structures in the cadaver [39]. Using this
approach, the structure previously referred to as the “ante-
rior renal fascia” is seen to correspond to Toldt’s fascia, and
the “anterior pararenal space,” to the left mesocolon [30].
us, the anatomic nomenclature detailed in the rst com-
ponent of this chapter can also be applied to describe struc-
tures identifi d in radiologic appraisals of the abdomen.
Table 9.1 Summary of current terminology, proposed terminology, and abbreviations associated
withproposed surgical terminology
Current terminology Proposed terminology Abbreviation
Right hemicolectomy Right colectomy and mesocolectomy Right mesocolectomy (RMC)
Left hemicolectomy Left colectomy and mesocolectomy Left mesocolectomy (LMC)
Sigmoidectomy Sigmoidectomy and mesosigmoidectomy Mesosigmoidectomy (MSE)
Anterior resection Mesosigmoidectomy and mesorectal excision MSE + TME
Total colectomy Total mesocolectomy TMC
Table 9.2 Summary of various descriptors for conduction mesenteric surgery
Terms Denition
Peritonotomy Division of the peritoneum
Mesenterectomy Resection of part or all of a mesenteric region
Mesenterotomy Line of division of the mesentery
Colofascial plane Interface between colon and the underlying Toldt’s fascia
Mesofascial plane Interface between mesocolon and the underlying fascia
Colofascial separation Separation of components of the colofascial plane
Mesofascial separation Separation of components of the mesofascial interface
Retrofascial interface Interface formed between the retroperitoneum and overlying Toldt’s fascia
Retrofascial separation Surgical separation of the components of the retrofascial interface
References 135
FUTURE DIRECTIONS
e utility of the nomenclatures developed should be
formally tested in a trial setting.
SUMMARY
A functional nomenclature comprises elements that can
be combined in numerous formats to convey meaning that
would not otherwise be apparent. An anatomic nomenclature
was developed based on recent advancements in our under-
standing of mesenteric and peritoneal anatomy. From this, an
operative nomenclature was developed, which was applied to
colorectal surgery. e nomenclature is universally applicable
(even in non [mal] rotation and situs inversus) and enables the
application of a scientic rigor that heretofore has been lacking.
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