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136 Operative nomenclature
25. Sehgal, R. and J.C. Coffey, Historical development of
mesenteric anatomy provides a universally applica-
ble anatomic paradigm for complete/total mesocolic
excision. Gastroenterol Rep, 2014. 2(4): 245 –250.
26. Sehgal, R. and J.C. Coffey, The development of
consensus for complete mesocolic excision (CME)
should commence with standardisation of anatomy
and related terminology. Int J Colorectal Dis, 2014.
29(6): 763–76 4.
27. Charnsangavej, C. etal., CT of the mesocolon.
Part1. Anatomic considerations. Radiographics,
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28. Charnsangavej, C. etal., CT of the mesocolon.
Part2. Pathologic considerations. Radiographics,
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29. Ramachandran, I. etal., Multidetector computed
tomography of the mesocolon: Review of anatomy
and pathology. Curr Probl Diagn Radiol, 2009. 38(2):
84–90.
30. Coffey, J.C. etal., An appraisal of the computed
axial tomographic appearance of the human mes-
entery based on mesenteric contiguity from the
duodenojejunal exure to the mesorectal level. Eur
Radiol, 2016. 26(3): 714 –721.
31. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
32. 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.
33. Coffey, J.C. etal., Mesenteric-based surgery exploits
gastrointestinal, peritoneal, mesenteric and fascial
continuity from duodenojejunal exure to the anorec-
tal junction—A review. Dig Surg, 2015. 32(4): 291–300.
34. Standring, S., Gray’s Anatomy: The Anatomical Basis
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137
10
Teaching mesenteric principles
J. CALVIN COFFEY, DEIRDRE McGRATH, AND COLIN PEIRCE
An investment in knowledge pays the best interest.
Benjamin Franklin
AIM
e second half of this book focuses on the application of
the scientic principles described in the preceding chap-
ters, to mesenteric-based surgery. Before commencing, it is
appropriate to describe the educational modalities that will
be used to convey the principles involved.
INTRODUCTION
e following chapters detail the mesenteric basis for intesti-
nal surgery distal to the duodenojejunal exure. e concepts
involved are largely 3D and cannot be conveyed adequately
using conventional educational modalities. To overcome this
challenge, several novel educational instruments were developed
including digital, operative (open, laparoscopic, and robotic),
cadaveric, and radiologic atlases of the mesenteric organ.
Collectively, these generate a curriculum that facilitates an
understanding of mesenteric-based surgery [1–11]. e follow-
ing chapters describe these educational modalities as well as the
opportunities that now are present in the educational context.
DIGITAL ATLAS AND DEMONSTRATION
OF MESENTERIC PRINCIPLES
Novel approach to depicting living anatomy
e principles of anatomic continuity form the cornerstone
of modern-day colorectal surgery [8]. Peritoneal, colonic, and
mesenteric continuit y and contiguity mea ns that peritonotomy,
mesofascial separation, and mesenterectomy are key activities
required for excision, at any level distal to the duodenojejunal
exure. However, continuity presents an educational challenge
in that there are no boundaries delimiting continuous regions
of the peritoneum, the colon, and the associated mesentery.
Moreover, when the gastromesenteric complex is resected
intraoperatively, the shape it adopts bares little if any resem-
blance to the shape it had in the abdomen [2,8]. Digital sculpt-
ing provides an opportunity to overcome these issues. Using
digital methodologies such as ZBrush (Pixologic, Los Angeles,
Unites States), Cinema 4D (Maxon Computer Ltd., Bedford,
United Kingdom), Maya (Maya Digital Studios, Mumbai,
India), and RenderMan (Pixar, California, United States), it is
possible to generate high-delity mesenteric models that can be
regionally colored, deformed, and sectioned (Figure 10.1)[12].
In keeping with this, a digital atlas of the mesentery, colon,
and peritoneum was generated (Chapter2). e educational
value of these models is illustrated in the chapter on exures
(Chapter20), where the exures were conceptually excised to
demonstrate the relationships between anatomic components
(i.e.,peritoneal reection, colon, and mesentery).
New dimensions in surgical education
As technology became integral to the twenty-rst cen-
tury educational environment, several opportunities in
undergraduate and postgraduate surgical education arose.
Traditional surgical texts present operations as a series of 2D
snapshots (oen in grayscale or black and white). e reader
is required to interpolate the changes in shape that occur in
the peritoneum, mesentery, and intestinal tract. With digital
Aim 137
Introduction 137
Digital atlas and demonstration of mesenteric principles 137
Novel approach to depicting living anatomy 137
New dimensions in surgical education 137
Surgical simulation 139
Intraoperative atlas in open, laparoscopic, and
robotic colorectal surgery 139
Radiologic atlas 145
Visible human project 145
Future directions 145
Summary 145
References 145
138 Teaching mesenteric principles
(a)
SRA
Fully mobilized
Fully mobilized
IMA
Mesorectum
Adipovascular
pedicle fold
Mesocolon, mesosigmoid, and mesorectum digital model
Medial view
Attached (i.e. apposed)
mesosigmoid
deep surface
Partially mobilized
Le
ft mesocolon
deep surface
(b) (c) Inferolateral viewInferomedial view
Figure 10.1 (a–c) Views of the mesentery from the left mesocolon to mesorectum (including the mesosigmoid) during
successive phases of mesosigmoidal detachment from the retroperitoneum. These are snapshots from a digital sculp-
ture of the mesentery in which the mesenteric regions have been color-coded for recognition. (a) Medial to lateral view
of the medial aspect of the mesentery after the inferior mesenteric adipovascular pedicle has been detached. (b) Medial
to lateral view of the mesentery after complete detachment of the mesosigmoid. (c) Lateral to medial view of stage as
demonstrated in (b). Abbreviations: IMA, inferior mesenteric artery; SRA, superior rectal artery.
Intraoperative atlas in open, laparoscopic, and robotic colorectal surgery 139
sculpting, the mobilization process can be captured at any
angle and at any point in time (Figure 10.2). In addition, the
component structures of digital models change in tandem.
us, the surgeon can visualize how an anatomic compo-
nent changed. Finally, digital models can be subdivided or
sectioned to provide any sectional view required [8,12].
e representation of 3D models in a text book format is
still limited due to the fact that the images are presented in
a attened or 2D plane. is problem can be overcome by
linking digital models to a net-based platform. For example,
a digital model can be archived at a web address and then
accessed from a text-embedded illustration using a simple
QR code. e QR code permits the reader to go from an
image on a page to a versatile digital model on either their
smartphone or laptop (Figure 10.3). Soware are such that
once the model is accessed (either by smartphone, tablet,
desktop, or laptop), the reader can zoom in or out, rotate the
model, or subtract or add diffe ent components. is facility
means the student, trainee, and surgeon can appreciate all
aspects of the 3D nature of the structures involved in mesen-
teric-based surgery.
In addition, 3D digital models can be imported into aug-
mented reality programs and then viewed as 3D objects as
if in object form in front of the reader. ree-dimensional
environments (theater, the abdomen) can be generated to
provide a virtual reality environment in which the reader
can conceptually enter (Figure 10.4).
Surgical simulation
e digital models generated for the purpose of illustrat-
ing the mesenteric basis of intestinal surgery also serve as
high-delity platforms for postgraduate surgical simula-
tion. It is likely that their application will increase in this
context, given the increasing requirement for simulation
in surgical education in general [13–17]. Future research
in this fi ld should therefore focus on developing means
of manually reproducing the activities of peritonotomy,
mesofascial separation, vascular skeletonization, and mes-
enterectomy, in the simulator context.
INTRAOPERATIVE ATLAS IN OPEN,
LAPAROSCOPIC, AND ROBOTIC
COLORECTAL SURGERY
Communication of the anatomic basis of total mesorec-
tal excision (TME) was greatly aided by persistence on the
part of Bill Heald and Brendan Moran in the generation of
high-resolution videos [18–20]. e excellent quality of their
recordings demonstrated, for the rst time, the mesofascial
plane and its components in the pelvis. is required a consid-
erable eff rt on the part of both these surgeons with insistence
on generating high-quality educational videos and images.
e widespread adoption and development of laparo-
scopic and robotic colorectal surgery has meant that sur-
geons can now more readily achieve the same quality images
as those obtained by Heald and Moran [21,22]. Laparoscopic
and robotic imaging provides a 20-fold magnication over
the human eye, and together with high-resolution images,
enable the surgeon record and later demonstrate the planes
utilized in mesenteric-based surgery. In addition, the use of
the laparoscope in open surgery has more recently provided
the same benets in this context (Figure 10.5). e 30° lapa-
roscopic lens, coupled with high magnication and resolu-
tion optics, enable the surgeon to demonstrate the planes
exploited in mesenteric surgery in the open context [23].
While the images generated are highly informative, their
combination with digital imagery orientates the reader in
relation to regional anatomy and greatly enhances the edu-
cational process (Figure 10.6).
Mobilization of the mesosigmoid digital model
Mobile
mesosigmoid
Apposed
mesosigmoid
Left
mesocolon
Apposed
mesosigmoid
(a)
Left mesocolon
deep surface
Mobile
mesosigmoid
Apposed
mesosigmoid
deep surface
SRA
IMA
(b)
Figure 10.2 Views of the mesosigmoid and mesorectum.
These are snapshots from a digital sculpture of the mes-
entery in which mesenteric regions have been color-coded
for recognition. (a) Antero-posterior view (from the left)
of the mesentery prior to mobilization (i.e., detachment)
demonstrating the relationship between the apposed and
mobile regions of the mesosigmoid. (b) Similar viewpoint
demonstrating the relationship between the apposed and
mobile regions of the mesosigmoid after full detachment
from the retroperitoneum. Abbreviations: IMA, inferior
mesenteric artery; SRA, superior rectal artery.
140 Teaching mesenteric principles
Linking text embedded images to online digital models
Printed image with
scannable QR code
(a)
(b)
The human mesentery
Online, digital
rotatable model
Peritoneum, mesentery,
fascia, and intestine
Figure 10.3 (See also QR 2/1.) Flow-chart demonstrating how (a) an image within a text can be linked (through a QR
code) to an (b) online digitalmodel. The reader can then rotate, magnify, and section the model online depending on
the application they view itin. This QR-code capability greatly aids in teaching 3D concepts that are not readily conveyed
through standard text-embedded educational modalities.
Intraoperative atlas in open, laparoscopic, and robotic colorectal surgery 141
Linking text embedded images to online digital models
(a)
Printed image with
scanable QR code
Peritoneum, mesentery,
fascia and intestine
Virtual reality
walk through
(b)
(c)
Figure 10.4 (a–c) Panel demonstrating the manner in which a user can visualize an image in a standard textbook, then
link to anonline virtual reality (VR) model of the digital sculpture, through a QR code. If the application used to visualize
the sculpture is VR based, then the user can visualize it in any VR environment. This approach greatly aids in conveying
threedimensional concepts that are not readily apparent using standard educational modalities.
142 Teaching mesenteric principles
Use of laparscope in open surgery
Peritonotomy
of peritoneal reflection
Mesosigmoidal
(Toldt’s ) fascia
Peritonotomy
of peritoneal reflection
Peritonotomy of
medial aspect of mesosigmoid
(a
)
(b)
(d)(c)
Mesosigmoidal
(Toldt’s) fascia
Mesosigmoid
Inferior mesenteric
adipovascular pedicle
Figure 10.5 (a) 2.5D snapshot of the medial aspect of the mesosigmoid after mobilization. The image is derived from a
3D digital sculpture. (b) The UL Exoscope setup including a malleable snake arm, metal frame, and standard 30 degree
laparoscope. (c) (See also QR 5/3 and QR 2/11.) View of the medial aspect of the mesosigmoid during an open resection,
asseen with the UL Exoscope. Aperitonotomy has been commenced. The mesosigmoidal fascia is apparent. (d) (See also
QR 5/3 and QR 2/11.) View after extension of the peritonotomy seen in (c).
Intraoperative atlas in open, laparoscopic, and robotic colorectal surgery 143
Digital models and intraoperative images
Digital model
Left (descending) colon
Sigmoid colon
Left mesosigmoidal
peritoneal reflection
Intraoperative (open) view
Left iliac fossa
Descending colon
Distal
Intraoperative (open) view
Divided lef
t
peritoneal
reflection
Edge of
peritonotomy
Proximal
Junction between sigmoid
and descending colon
Left lateral
peritoneal reflection
Figure 10.6 (See also QR 2d/1,2.) The top image is a 2.5D snapshot from a 3D digital sculpture demonstrating the
peritoneal reection lateral to the mesosigmoid and left mesocolon. The bottom left imaged demonstrates the divided
peritoneal reection viewed from above down (at open surgery). The bottom right image is the divided peritoneal
reection looking from below up (laparoscopic view). This combination of images conveys three dimensional concepts
required to understand the operative anatomy involved in dividing the peritoneum and gaining access to surgical planes.
144 Teaching mesenteric principles
Application of visible human project
Toldt’s fascia
Toldt’s fascia
Toldt’s fascia
(a)
(c)
(b)
Retroperitoneum
Retroperitoneum
Retroperitoneum
Peritoneal
reflection
Left
mesocolon
Peritoneal
reflection
Peritoneal
reflection
Left mesocolon
Left mesocolon
Figure 10.7 (a) Appearance of Toldt’s fascia, the left mesocolon, and left peritoneal reection in the full-color data set
of the Visible Human Project. (b) Computerized axial tomographic image (axial plane) corresponding to the region in (a).
Structures corresponding to Toldt’s fascia, the mesocolon, and peritoneal reection are evident. Bottom image demon-
strates the corresponding region in 3D, after importing the CT data set into Osirix (c). Toldt’s fascia, the left mesocolon,
and the peritoneal reection can be visualised in 3D.
References 145
RADIOLOGIC ATLAS
Although it is crucial that the surgeon be able to interpret
the operative fi ld in terms of mesenteric and peritoneal
parameters, it is equally important that he/she be able to
plan an operation according to the same parameters. To
facilitate this, a radiologic atlas of mesenteric anatomy was
recently developed (Chapter 8) [9]. e atlas serves numer-
ous functions; in the fi st instance, it is a reference against
which the computerized axial tomographic appearance of
the normal mesentery can be compared in general. Second,
this provides a means for reappraising the appearance of
the mesentery in disease states. From the surgical perspec-
tive, the radiologic atlas provides an important tool that
helps in the preoperative preparation of patients and in
deciding on intraoperative strategies. By way of example,
radiologic evidence of disease progression outside of with
the normal mesenteric, peritoneal, and fascial planes is a
sign of advanced disease that is usually refl cted in a tech-
nically challenging operation.
VISIBLE HUMAN PROJECT
e generation of a radiologic atlas would not have been
possible without the data provided by the visual human
project (VHP) [9,24–26]. In the latter, human anatomy can
be observed in full color format and cross-checked against
corresponding computerized axial tomographic (CT) and
magnetic resonance imaging (MRI) (Figure 10.7). As a
result, exures can be identifi d insitu in the full color data-
set and corresponding regions identifi d in CT and MRI
images [9]. e resolution of images in the VHP is such that
fascial planes can be identifi d, extracted, and then recon-
structed. Similarly, undisturbed peritoneal reections can
be identifi d, traced, exported, and reconstructed [9,24–26].
Images taken from the VHP full color dataset were essen-
tial in providing proof of concept in relation to mesenteric,
peritoneal, and fascial continuity, as well as the technical
implications thereof. As an extension of this, images from
the VHP help demonstrate the planes that form the corner-
stone of mesenteric-based surgery.
FUTURE DIRECTIONS
Many of the educational modalities described above were
recent developments generated from the need to convey
complex three dimensional concepts. ese now require
formal validation in trial contexts.
SUMMARY
Mesenteric-based surgery is founded on the principles of
mesenteric, peritoneal, fascial, and intestinal continuity and
their contiguity. In order to convey these principles in the
robotic, laparoscopic, and open context, a number of educa-
tional instruments were developed. ese capture the three
dimensional and contiguous nature of these structures.
ey overcome the limitations arising from the lack of ana-
tomic demarcation between continuous mesenteric zones.
ey are used interchangeably in the following chapters.
REFERENCES
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a rule-based approach derived from updates on
mesenteric anatomy. Tech Coloproctol, 2014. 18(9):
789–794.
3. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
4. Culligan, K. etal., Review of nomenclature in colonic
surgery—Proposal of a standardised nomenclature
based on mesocolic anatomy. Surgeon, 2013. 11(1):
1–5.
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colic lymphangiology—An immunohistochemical
and stereological analysis. J Anat, 2014. 225(4):
463–472.
6. 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.
7. Sehgal, R. and J.C. Coffey, Historical develop-
ment of mesenteric anatomy provides a universally
applicable anatomic paradigm for complete/total
mesocolic excision. Gastroenterol Rep, 2014. 2(4):
245–250.
8. Coffey, J.C. etal., Mesenteric-based surgery exploits
gastrointestinal, peritoneal, mesenteric and fas-
cial continuity from duodenojejunal exure to the
anorectal junction—A review. Dig Surg, 2015. 32(4):
291–300.
9. Coffey, J.C. etal., An appraisal of the computed
axial tomographic appearance of the human mes-
entery based on mesenteric contiguity from the
duodenojejunal exure to the mesorectal level. Eur
Radiol, 2016. 26(3): 714–721.
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Surgery for colorectal cancer—Standardization
required. Nat Rev Gastroenterol Hepatol, 2016.
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friend or foe? Curr Opin Gastroenterol, 2016. 32(4):
267–273.
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