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146 Teaching mesenteric principles
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147
11
Gastroenterology
J. CALVIN COFFEY AND MANUS MOLONEY
Sometimes one has to go a very long distance
out of his/her way, to come back a short dis-
tance correctly.
Edward Albee
AIM
e rst aim is to discuss the association been mesenteric
related events and discomfort experienced by patients dur-
ing lower intestinal endoscopy. e second aim is to discuss
the emerging concept of endoscopic mesenteric mapping
(EMM) and the clinical opportunities presented.
INTRODUCTION
Pain during endoscopy
Colonoscopy is one of the most commonly performed endo-
scopic procedures worldwide with over 500,000 performed
annually in the United States alone [1–4]. Colonoscopy
training programs are required to assess competency of
trainees performing colonoscopies [5–11]. A cecal intuba-
tion rate of 90% is one of the competency criteria set down
by the joint advisory group (JAG) on intestinal endoscopy.
JAG requires 200 procedures be performed prior to assessing
for competency [12–16]. Colonoscopy training programs
currently rely on the Halstedian apprenticeship model [17].
Competency in colonoscopy is assessed on a range of factors
including adenoma detection rate, polyp retrieval and cecal
intubation rates, and, crucially, patient comfort levels. e
competent colonoscopist is one who can reach the cecum
with minimal patient discomfort. is ability becomes
more important, when multiple intubations are required in
order to resect and retrieve right-sided lesions.
It is feasible (though unproven) that mesenteric factors
contribute to abdominal discomfort patients experience
during colonoscopy. Pain during endoscopy is multifacto-
rial, but classic arguments suggest it mainly relates to colonic
stretch [18]. Although there is a subgroup of patients in
whom simple insertion of the scope into the rectum triggers
signicant pain, these are in the minority. It is suggested that
this pain is contributed to by preexisting psychologic factors
[19–22]. e dimensions of the colon are such that consider-
able insuation would be required to cause colonic stretch.
It is widely recognized that patients can perceive pain with
minimal insuation, as the endoscopist rounds a exure.
In the absence of colonic stretch, it is likely that mesenteric
stretch (or tension within the mesentery) leads to discom-
fort and pain. As there are six exures in total (including the
rectosigmoid), the opportunities for placing the mesentery
under stretch are frequent. us, it is not unreasonable to
argue that pain during endoscopy is contributed to by mes-
enteric factors such as stretch and tension [18,23].
Tension can be placed in the mesentery in a number of
dierent locations. Generally speaking, these correspond to
where the intestinal tract changes from being mobile to being
attached to the abdominal wall, or vice versa (i.e., the fle -
ures). Examples include the flexu e between the rectum and
sig moidand between sigmoid and descending colon. e lat-
ter can be associated with a particularly acute angulation. Th s
becomes even more angulated aer insuation of the sigmoid.
Further examples of acute angulation include the splenic,
hepatic, and ileocecal exure. ere are numerous approaches
to negotiating these in as ecient a manner as possible; these
include suctioning as one advances, maintaining the endo-
scope as straight as possible, having the patient adopt posi-
tion in which gravity alters the conformation of the exure,
and direct manual abdominal pressure (altering the confor-
mation of the colon) [24,25].
Aim 147
Introduction 147
Pain during endoscopy 147
Endoscopic mesenteric mapping 148
Summary 148
References 148
148 Gastroenterology
When a loop is created, patients experience discomfort
on advancement of the scope. is discomfort is mainly
attributed to colonic stretch, but it is likely it is also con-
tributed to by mesenteric stretch. If the colon stretches then
the attached mesentery must also stretch. Histologic studies
demonstrate numerous nerve endings at the region of inter-
section between the bowel wall and associated mesentery
[26–28]. Looping is predisposed to by intestinal and mesen-
teric factors. While the length of both is important, the dif-
ferential in length between the intestinal and the attached
mesentery is probably more important. is diffe ential is
greatest in the sigmoid region, followed by the ileocecal and
transverse colonic regions.
Endoscopic mesenteric mapping
More recently, endoscopic identication of the mesen-
teric pole is gaining attention as a means of negotiating
the colon and minimizing mesenteric tension or looping.
e approach used is referred to as endoscopic mesenteric
mapping (EMM) [29]. It is based on the suggestion that
if the trajectory of the endoscope follows the mesenteric
border of the intestinal tract, this must correspond to the
trajectory of the mesentery, and is thus less likely to create
a loop or stretch. EMM has other potential uses in map-
ping polyp location [29]. e mucosal or luminal aspect of
the colon is generally homogenous in appearance, and at
present, it is not possible to precisely establish circumfer-
ential position. It is reasonable to suggest that if one could
identify the mesenteric pole (i.e., via EMM) this would
provide a reference landmark. ese data, when collated
with distance from the anal verge, could help pinpoint
polyp location.
We recently conducted a study in which a standard
ultrasound probe was applied to the inner surface of intes-
tinal tract that had been opened longitudinally. e probe
was swept around the circumference with a view to deter-
mining whether mesentery could be positively identifi d.
Mesentery was identiable. In addition, a transition was
observed where the mesentery stopped. ese ndings
indicate that mesenteric and nonmesenteric regions of
the intestinal circumference could be diffe entiated sono-
graphically. On this basis, it is likely that the mesentery
will be identiable in endoscopic instruments in which an
ultrasound probe is incorporated.
Endoscopic ultrasound using dedicated linear array and
radial echoendoscopes is used for structural evaluation of
the luminal wall and adjacent tissues in the intestinal tract.
Ultrasound probes that go through the accessory channels
of standard endoscopes are commercially available. At pres-
ent, EUS is widely used in local staging of rectal cancer in
determining the type of surgery required and whether pre-
operative neoadjuvant chemoradiation is needed [30–33].
Endoanal ultrasound is a well-established technique in
imaging of the anal sphincter. EUS enables the investiga-
tor to map out sphincter defects [34–39]. Similarly, EUS can
be used in imaging perianal stulas [40–47]. Fujinon and
Olympus are market leaders in this technology. e cur-
rent indications for these technologies are for staging and
diagnostic procedures involving lung, upper intestinal,
and rectal malignancies. eir application in delineating
and mapping the anatomical mesocolon and its mesenteric
attachments has yet to be clinically developed but is could
have wide-ranging diagnostic implications in day-to-day
practice.
SUMMARY
Mesenteric stretch is likely a major contributor to discom-
fort during lower intestinal endoscopy. EMM could provide
a trajectory that would lead to less discomfort for patients
undergoing this procedure. Mapping based on a mesenteric
reference could aid in polyp localization.
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PART 2
12 Mesenteric-based colorectal surgery 153
13 Appearance of the mesentery during laparoscopic/robotic colorectal surgery 157
14 Appearance of the mesentery during opencolorectal surgery 177
15 Instruments used during mesenteric-based colorectal surgery 199
16 General techniques in mesenteric-based colorectal surgery 211
17 Mesenteric component of sigmoid colectomy 233
18 Mesenteric component of rectal resection 251
19 Mesenteric component of right colectomy 277
20 Mesenteric component of exure mobilization 293
21 Mesenteric considerations in resection ofthetransverse colon 301
22 Mesenteric considerations in small bowel resection 311
23 Mesenteric considerations in ileal pouch analanastomosis 317
24 Mesenteric considerations in ostomyformationand reversal 323
25 Mesenteric considerations in reoperative abdominal surgery 333
26 Future directions 343
153
12
Mesenteric-based colorectal surgery
J. CALVIN COFFEY AND IAN LAVERY
It is once again the vexing problem of iden-
tity within variety; without a solution to this
disturbing problem, there can be no system, no
classication.
Roman Jakobson
AIMS
e aim of this chapter is to defi e mesenteric-based sur-
gery, variants of this, and the outcomes associated. e
second aim is to demonstrate how future resources are
probably best directed at standardizing colorectal sur-
gery worldwide rather than continued attempts at proving
supremacy of one concept over another. A fi al aim is to
demonstrate the importance of generating a curriculum to
enable the standardization process.
MESENTERIC-BASED SURGERY DEFINED
Colorectal surgery is divisible into two categories, mesen-
teric and non-mesenteric based.
Mesenteric-based surgery is where the mesentery is
detached and disconnected along dened anatomic planes.
Non-mesenteric-based surgery is where mesenteric
detachment and disconnection are not guided by dened
anatomic planes.
Subtypes of mesenteric surgery include total mesorec-
tal excision (TME), complete mesocolic excision (CME),
and total mesocolic excision (TMCE), and variants of each.
ese have formed the cornerstone of good quality colorec-
tal surgery for over a century. Remarkably, they are not glob-
ally practiced (see following discussion).
In mesenteric-based surgery, the mesentery is mobilized
intact, allowing a targeted division of contained vessels
and of the mesentery itself [1–4]. e planes involved are
accessed by division through the peritoneal reection.
CME, TME, and TMCE (and variants of each) are mes-
enteric based. Non-mesenteric-based surgery does not
exploit these planes nor the associated peritoneal reec-
tion in gaining access to them. Non-mesenteric-based
surgery does not emphasize careful separation of individ-
ual anatomic components of particular planes; it does not
emphasize preservation of the integrity of the mesenteric
lymphatic package. In it, the mesentery is detached from
the posterior abdominal wall in a nonanatomic fashion.
As a result, the retroperitoneum (and contained structures
including the ureters, duodenum, and gonadal vessels) are
threatened. e mesentery is divided across wherever is
rst convenient and this may even include at the junction
between it and the bowel wall [1–4].
Although the principles of TME and CME have formed
the cornerstone of excellent quality colorectal surgery for
over a century, description of the anatomic basis (and hence
surgical basis) was recent [2,4,5]. e anatomic basis for
TME was detailed by Professor Bill Heald in 1982 [6–8]. He
correlated reduced rates of local recurrence in rectal cancer
with dissection in a particular anatomic plane. In setting
down the anatomic basis for TME, Heald set off a renais-
sance in interest in the anatomic basis of mesenteric-based
surgery. In 2009, a similar phenomenon occurred in a sec-
ond paper demonstrating a correlation between anatomic
and hence mesenteric-based resection of right-sided colon
cancer. Hohenberger’s paper has rekindled the renaissance
that is mesenteric-based surgery [9]. Many have correctly
argued t hat there is nothing new in the technical approaches
described [10]. Whilethis may be strictly correct to say the
Aims 153
Mesenteric-based surgery dened 153
Future directions in colorectal surgery:
Internationalization of the mesenteric standard 154
Summary 155
References 155
154 Mesenteric-based colorectal surgery
fundamental achievements of Heald, Hohenberger, and
their coworkers, must be credited with rearming the rela-
tionship between anatomic-based surgery, and improved
outcomes aer cancer surgery.
It may seem remarkable that non-mesenteric-based
surgery continues to be practiced at all. Evidence that it is,
and in fact is widespread, comes from the studies of West
et al. [11–13]. ey developed three terms to address the
plane of surgery utilized and examine the rates at which
each plane was employed. In “mesocolic plane surgery,” the
mesocolon is excised intact, that is, the plane of dissection
is outside the mesentery. In “intramesocolic plane surgery,”
the mesocolon is disrupted and so the plane of dissection is
within the mesentery. In “muscularis propria plane surgery,”
the mesentery is divided at the intestinal margin practically
ush with the colon itself. West etal. examined pathology
specimens and noted the plane of surgery was mesocolic in
32%, intramesocolic in 44%, and muscularis propria based
in 24% [13]. e mean cross-sectional tissue area was sig-
nicantly higher in mesocolic plane surgery compared with
other types. e distance from the muscularis propria to
the mesocolic resection margin was greater in mesocolic
plane surgery, compared with both other subtypes. Quirke
etal. reported similar variability in the plane of dissection,
in analyzing mesorectal specimens in 1156 patients, in the
CR07 trial. Surgery was conducted in the mesorectal plane
in 52%, in the intramesorectal plane in 34%, and in the
muscularis propria plane in 13% [14].
e possibility of diffe ential outcomes associated with
mesenteric and non-mesenteric surgery was rst demon-
strated by Heald and more recently supported by the nd-
ings of West, Quirke, Hohenberger, and others. West etal.
found that mesocolic plane surgery was associated with a
15% improved survival on univariate analysis (although
this did not hold on multivariate analysis) [13]. Quirke
etal. found that circumferential resection margin positive
or negative status, as well as 3-year local recurrence rates,
correlated with the plane of surgery utilized [14].
FUTURE DIRECTIONS IN COLORECTAL
SURGERY: INTERNATIONALIZATION
OFTHE MESENTERIC STANDARD
As is oen the case with surgical approaches, dicul-
ties arise when it comes to applying scientic techniques.
Oentimes, it is found that surgery cannot be characterized
using the same scientic techniques as are readily applied
in other sciences. For example, there has never been, nor
will there ever be, a randomized control trial comparing
laparoscopic versus open cholecystectomy. Many cite the
example of the parachute in explaining this phenomenon.
Not many individuals would willingly sign up to the control
arm of a study examining the ecacy of parachute versus
no parachute in jumping from an airborne plane. Similar
issues arise in respect of mesenteric-based surgery and the
subtypes involved.
Unfortunately, it is not possible to prove supremacy of
mesenteric over non-mesenteric-based surgery. Proof would
involve a randomized trial in which surgeons credentialed
as being capable of mesenteric-based surgery are required
to conduct a non-mesenteric-based procedure on random-
ized patients. In order to obtain ethical approval, one needs
to demonstrate that the patient is protected at all points.
Extracting the colon and mesentery from the abdomen,
without attention to anatomic planes, is equivalent to sim-
ply wrenching it out and hoping for the best. As a result, it
would be unethical to conduct a trial comparing mesenteric
and non-mesenteric-based surgery.
A second and perhaps greater issue arises in that CME and
TME, and TCME are dicult (if not impossible) to precisely
dene. Similarly their corollary, non-CME, non-TME, and
non-TCME-based surgeries (collectively referred to as “con-
ventional” surgery) are equally dicult to dene, if not more
so. e reasons for this are anatomic. Mesenteric, peritoneal,
intestinal, and fascial continuity mean there are no anatomic
boundaries delimiting separate regions of each. For example,
there are no boundaries separating the right mesocolon from
the small intestinal mesentery or transverse mesocolon (they
are separate regions of the same entity). Similarly, it is not pos-
sible to anatomically dene the commencement of the rectum
and the end of the sigmoid colon. By extension of this argu-
ment, it is not possible to conduct a randomized trial compar-
ing CME with non-CME or TME with non-TME.
In the absence of randomized clinical trials, one is
required to rely on lower levels of evidence to support a
hypothesi s. e literature now abounds wit h studies compar-
ing CME and historic non-CME groups [15–17]. esame
holds for TME and non-TME historic groups [6]. In sur-
gery, historic comparisons suffer because one can never be
assured that a procedure falls into one category of surgery
or another. Overlaps will occur meaning that homogenous
groups ideally suited to statistical comparison are not avail-
able. Notwithstanding this, historic comparisons that fol-
lowed the introduction of TME-based surgical principles in
several countries demonstrate vast improvements in surgi-
cal, pathological, and outcome-related parameters [6]. ey
are compelling argument for the feasibility of international
standardization in colorectal surgery, when this emphasizes
a mesenteric based approach.
Emerging evidence indicates that eff rts at standard-
ization must be increased [18]. e recent results of the
OSTRiCh group demonstrate wide variability in circum-
ferential resection margin positivity rates. ey concluded
that rates of margin positivity remain high in the United
States. is is mirrored by the ndings of recent com-
parisons between laparoscopic and open surgery in which
circumferential resection positivity rates were 11.1% and
7.7% for laparoscopic and open resection of the rectum,
respectively [19–22].
It has been proposed that the answer to the issues
highlighted lie in either increased centralization or bet-
ter standardization. In a recent editorial, Susan Galandiuk
References 155
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own lives, they prefer to do so close to their family and com-
munity supports [23]. In other words, many patients who
will require colorectal surgery will not wish to (orindeed
cannot) travel to centers of excellence. In this context, the
need for a standardization, rather than centralization,
increases further.
Given the aforementioned, it may be proposed that
the surgical community move away from trying to prove
the impossible (i.e., the supremacy of CME or TME or
mesenteric-based surgery over non-CME, non-TME,
and non-mesenteric-based surgery) and focus instead on
establishing a universally reproducible standard by which
colorectal surgery can be safely conducted [1,2,5]. Such a
standard should be entirely anatomic based, universally
reproducible, and easily conveyed from one individual to
another. To achieve this, a formal curriculum should be
established, agreed, and then disseminated internationally.
SUMMARY
e terms CME and TME cannot be precisely dened.
Similarly, non-CME and non-TME or conventional sur-
gery cannot be precisely dened and rigorous compari-
sons between both types are not possible. In contrast, the
terms mesenteric and non-mesenteric based can be dened.
Notwithstanding this, clinical trials proving ecacy of one
standard over another are not ethical and thus will not be
conducted. In this context, future resources may be best
directed toward further consolidating the standardization
(rather than proving the supremacy of) mesenteric-based
surgery. Numerous international programs have already
achieved this in relation to TME.
e non-mesenteric standard of colorectal surgery
cannot be universally reproduced because it is not anatomic
based. e mesenteric-based standard can be universally
reproduced because it is founded on universally appli-
cable principles (anatomic, histologic, physiologic), which
are described in the rst half of this book. e second half
describes how surgeons adopt these principles to reproduc-
ibly achieve the standard of mesenteric-based colorectal
surgery. e second half thus serves as a surgical foundation
by which the principles of mesenteric-based surgery can be
universally taught and thus achieved.
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