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156 Mesenteric-based colorectal surgery
18. 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.
19. Rickles, A.S. etal., High rate of positive circumferen-
tial resection margins following rectal cancer surgery:
A call to action. Ann Surg, 2015. 262(6): 891–898.
20. Probst, C.P. etal., Extended intervals after neoadju-
vant therapy in locally advanced rectal cancer: The
key to improved tumor response and potential organ
preservation. J Am Coll Surg, 2015. 221(2): 430–440.
21. Monson, J.R. etal., Failure of evidence-based cancer
care in the United States: The association between
rectal cancer treatment, cancer center volume, and
geography. Ann Surg, 2014. 260(4): 625–631; discus-
sion 631–632.
22. Dietz, D.W., Multidisciplinary management of rectal
cancer: The OSTRICH. J Gastrointest Surg, 2013.
17(10): 1863–1868.
23. Galandiuk, S., Standardization or centralization: Can
one have one without the other? Circumferential
resection margins and rectal cancer. Ann Surg, 2015.
262(6): 899–900.
157
13
Appearance of the mesentery during
laparoscopic/robotic colorectal surgery
J. CALVIN COFFEY AND MANISH CHAND
Always remember that you are absolutely unique.
Just like everybody else.
Margaret Mead
AIM
e aim of this chapter is to demonstrate the appearance
of the structures utilized in mesenteric-based surgery from
duodenojejunal flexu e to mesorectal level, as seen during
laparoscopic and robotic surgery.
INTRODUCTION
e development of laparoscopic and robotic colorectal
surgery meant an instrument was interposed between sur-
geon and patient, and the surgeon could no longer directly
grasp tissue. In open surgery, tissue can be directly grasped
by the surgeon, and if one encountered unexpected bleed-
ing or contamination, it could be directly dealt with.
Asthis is clearly not the case for laparoscopic or robotic
surgery, it was imperative that surgeons minimized the
possibility of unexpected events. is led to an increased
interest in surgical anatomy and individuals such as Jeffe y
Milsom, Bartholomäus Böhm, and Kiyokazu Nakajima
must be congratulated in their development of an ana-
tomic and safe basis for laparoscopic colorectal surgery
[1]. From the outset, these authors emphasized the impor-
tance of a clear understanding of anatomy. e clinical
community is indebted to Prof. Bill Heald and Brendan
Moran, who demonstrated the importance of the surgical
anatomy in the open context in total mesorectal excision
[2–7]. ey also set a standard of video presentation that
greatly advanced the surgical educational process. e dis-
coveries of these clinical investigators laid the foundation
for recent investigations into mesenteric and fascial as well
as peritoneal reection structure.
e identication of mesenteric continuous showed that
mesenteric structure is far simpler than previously suggested.
Once this became apparent, then the structure of the contig-
uous peritoneal reection, greater omental attachments, and
congenital adhesions intuitively fell into place [8–18].
e following chapter will demonstrate the appearance of
the mesentery, associated peritoneal refl ctions, and under-
lying fascia as seen during laparoscopic and robotic surgery.
Images are presented with 3D models adjacent [8,13]. e3D
models depict regional anatomy in a schematic format and aid
in interpretation of the corresponding laparoscopic/robotic
image. e following presents the appearance of the peritoneal
refl ction, the mesentery and the fascia, as they are encountered
during laparoscopic and robotic mesenteric-based surgery.
LAPAROSCOPIC/ROBOTIC APPEARANCE
OF THE PERITONEAL REFLECTION
1. Peritoneal reection at the base of the small intesti-
nal mesentery where it curves onto retroperitoneum
(Figure 13.1).
2. Ileocecal peritoneal reection (Figure 13.2).
3. Right peritoneal reection (Figure 13.3).
4. Hepatocolic peritoneal reection (Figure 13.4).
Aim 157
Introduction 157
Laparoscopic/robotic appearance of the peritoneal
reection 157
Laparoscopic/robotic appearance of the colo- and
mesofascial plane 162
Laparoscopic/robotic appearance of adipovascular
pedicles 162
Summary 175
References 175
158 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Legend
Mesentery
Fascia
Colon
Peritoneum
Peritoneal re˜ec tion at base of small bowel mesentery
Small
intestinal
mesentery
Small
intestinal
mesentery
Small
intestinal
peritoneal
re˜ec tion
Small
intestinal
peritoneal
re˜ec tion
Jejunum
Small
intestinal
mesentery
Peritoneal
re˜ec tion
at the base of
the intestine
(a)
(b)
(c)
Figure 13.1 Peritoneal reection at the base of the small intestinal mesentery. (a) Laparoscopic view. (b) (See also QR 3/5.)
Digital view. (c)Peritoneal reection at the base of the small intestinal mesentery in a cadaver. Division of the reection
exposes the underlying colo- and mesofascial plane (Figure 13.10).
Laparoscopic/robotic appearance of the peritoneal reection 159
Ileocecal peritoneal re˜ec tion
Gas
inÿltration
beneath
peritoneal
mesothelium
Ileocecal
peritoneal
reflection
Needle insufflator placed
beneath surface mesothelium(a)
Appendix
Cecum
(c)
Terminal
ileum
Ileocecal
peritoneal
re°ec tion
Terminal
ileum
Ileocecal
peritoneal
re°ec tion
Legend
Mesentery
Fascia
Colon
Peritoneum
(b)
Figure 13.2 Peritoneal reection at the ileocecal region. (a) Laparoscopic/robotic view. (b) (See also QR 3/6.) Digital view.
(c)Peritoneal reection at inferolateral aspect of ileocecal junction, in a cadaver. The peritoneal reection is divided to
provide access to the mesofascial plane in this location (see Figure 13.11).
160 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Right peritoneal reflection
(a)
(b)
(c)
Ascending colon
Right peritoneal
reflection
Right
peritoneal reflection
Needle for
insufflating beneath
peritoneal reflection
Legend
Mesentery
Fascia
Colon
Peritoneum
Right
peritoneal reflection
(partially divided)
Figure 13.3 Right peritoneal reection. (a) Laparoscopic view. (b) (See also QR 2/3.) Digital view. (c) Right peritoneal
reection in a cadaver. The peritoneal reection must be divided to provide access to the colo- and mesofascial plane of
dissection (Figure 13.12).
Laparoscopic/robotic appearance of the peritoneal reection 161
Hepatocolic peritoneal reflection
Colic component
of hepatic flexure
Colic component
of hepatic flexure
Transverse
colon
Hepatocolic
peritoneal reflec
tion
Divided hepatocolic
peritoneal reflection
Hepatocolic
peritoneal
reflection
(a)
(b)
Legend
Mesentery
Fascia
Colon
Peritoneum
Figure 13.4 Hepatocolic peritoneal reection. (a) Laparoscopic/robotic view. This view is achieved by placing the patient
head up and retracting the colic component of the hepatic exure toward the left iliac fossa. (b) (See also QR 2/4.)
Digitalview.
162 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
5. Peritoneal reection between greater omentum and
upper surface of the transverse colon (Figure 13.5).
6. Splenocolic peritoneal reection (Figure 13.6). Dueto
adhesion of the greater omentum to the peritoneal
reection in this location, it can be dicult to demon-
strate in isolation intraoperatively.
7. Left eritoneal reection (Figure 13.7).
8. Left eritoneal reection at the base of the mobile
component of the mesosigmoid (i.e., where the latter
curves down and becomes attached to the posterior
abdominal wall) (Figure 13.8).
9. Pararectal peritoneal reection on either side of the
rectum (Figure 13.9).
LAPAROSCOPIC/ROBOTIC APPEARANCE
OF THE COLO- AND MESOFASCIAL PLANE
1. Small bowel mesentery and underlying fascia
(Figure13.10)
2. Ileocecal mesenteric conuence and underlying fascia
(Figure 13.11)
3. Right mesocolon and underlying fascia (Figure 13.12)
4. Transverse mesocolon aer mobilization of the greater
omentum (Figure 13.13)
5. Left esocolon and underlying fascia (Figure 13.14)
6. Mesosigmoid and underlying fascia (Figure 13.15)
7. Mesorectum and associated fascia (Figure 13.16)
LAPAROSCOPIC/ROBOTIC
APPEARANCEOF ADIPOVASCULAR
PEDICLES
1. Ileocolic adipovascular pedicle (Figure 13.17)
2. Middle colic adipovascular pedicle (Figure 13.18)
3. Inferior mesenteric adipovascular pedicle (Figure 13.19)
Omento-colic peritoneal reflection
Omento-c
olic
reflection
Greater
omentum
T
ransverse
colon
Figure 13.5 Laparoscopic/robotic view of the peritoneal reection connecting the greater omentum and transverse colon.
Laparoscopic/robotic appearanceof adipovascular pedicles 163
Splenocolic peritoneal re˜ec tion
Spleen
Transverse colon
Splenocolic
peritoneal
re˜ec tion
Colic componen
t
of splenic ˜exure
Descending colon
Divided edge
of splenocoli
c
peritoneal
re˜ec tion
(a)
(b)
Legend
Mesentery
Fascia
Colon
Peritoneum
Figure 13.6 Splenocolic peritoneal reection. (a) Laparoscopic/robotic view. (b) (See also QR 2/5.) Digital view.
Demonstration of the reection in isolation of the greater omentum is difcult given the variable degree to which the
omentum fuses with the reection.
164 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Left peritoneal re˜ec tion
Descending
colon
Divided left
peritoneal
re˜ec tion
Edge of
peritoneotomy
Left
peritoneal
re˜ec tion
Edge of
peritoneotom
y
Legend
Mesentery
Fascia
Colon
Peritoneum
Descending
colon
(a)
(b)
Figure 13.7 Left peritoneal reection. (a) Laparoscopic view. (b) (See also QR 2d/1-2.) Digital view. Division of the reec-
tion is required in order to access the colo- and mesofascial planes of dissection (Figure 13.14).
Laparoscopic/robotic appearanceof adipovascular pedicles 165
Left peritoneal reflection at base of mesosigmoid
Descending
colon
Mesosigmoi
d
Divided left
peritoneal
reflection
(b)
(a)
Figure 13.8 Left peritoneal reection at the base of the mesosigmoid. (a) Laparoscopic/robotic view. (b) (See also
QR2d/1-2.) Digital view.