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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1441_Библиотеки_им_академика_М_И_Перельмана.pdf
166 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Pararectal peritoneal re˜ec tion
Anterior
re˜ec tion
Left
pararec
tal
re˜ec tion
Rectum
Right
pararec
tal
re˜ec tion
Sigmoid
colon
(a)
Rectum
Left
pararectal
re˜ec tion
Right
pararectal
re˜ec tion
Anterior
peritoneal
re˜ec tion
Sigmoid
colon(b)
Figure 13.9 Pararectal peritoneal reections. (a) Laparoscopic/robotic view. (b) (See also QR 2d/5-7.) Digital view.
Laparoscopic/robotic appearanceof adipovascular pedicles 167
Mesofascial
plane/interfac
e
Toldt’s fascia
Small bowel
mesentery
Pe
ritonotomy
margin
Cecum
(a)
Region of
mesofascial
plane/interface
Toldt’s fascia
over
retroperitoneum
Small bowel
mesentery
Mesofascial plane/interface
(b)
Legend
Mesentery
Fascia
Colon
Peritoneum
Figure 13.10 Mesofascial plane generated by the small intestinal mesentery and Toldt’s fascia. (a) Laparoscopic/robotic view.
(b)Digital view. The mesofascial plane is evident after division of the peritoneal reection at the base of the small intestinal
mesentery (Figure 13.1).
168 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Peritonotomy
margin
Appendix
Terminal ileum
Ileocecal
mesenteric
con˜uence
Mesofascia
l
interface
Toldt’s
fascia
Terminal
ileum
Mesentery
Cecum
Toldt’s fascia
Peritonotomy
margin
Ileoceacal mesofascial plane
Legend
Mesentery
Fascia
Colon
Peritoneum
(a)
(b)
Figure 13.11 Mesofascial plane generated at the ileocecal junction between the mesentery and Toldt’s fascia.
(a)Laparoscopic/robotic view. (b) Digital view. The mesofascial plane is evident after division of the peritoneal reection in
this region (Figure 13.2).
Laparoscopic/robotic appearanceof adipovascular pedicles 169
Right mesofascial plane/interface
Ascending
colon
Right
mesocolon
under
paritoneum
Right
mesofascial
plane/interface
Right mesocolic (Toldt’s ) fascia
Cecum
Right
mesocolon
Right
mesofascial
interface/plane
Retr
operitoneum
Right mesocolic (Toldt’s ) fascia
Peritonotomy
margins
(a)
(b)
Legend
Peritonotomy
margins
Mesentery
Fascia
Colon
Peritoneum
Figure 13.12 Mesofascial plane generated by the right mesocolon and Toldt’s fascia. (a) Laparoscopic/robotic view.
(b)Digitalview. The colo- and mesofascial plane are evident after division of the peritoneal reection in this region
(Figure 13.3).
170 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Omento-mesocolic plane/interface
Greater omentum
Omento-mesocolic
interface
Transverse mesocolon
(cephalad aspect)
Spleen
Figure 13.13 (See also QR 2/9.) Laparoscopic/robotic view of upper aspect of the transverse mesocolon after the greater
omentum has been mobilized free.
Laparoscopic/robotic appearanceof adipovascular pedicles 171
Left mesofascial plane/interface
Deep surface
of left mesocolon
Left
mesocolon
(deep surface)
Left mesocolic
(Toldt’s ) fascia
Left mesocolic fascia
(overlying retroperitoneum)
Left
mesofascial
plane/interface
Left mesofascial
plane/interface
Descending colon
Legend
Mesentery
Fascia
Colon
Peritoneum
(a)
(b)
Figure 13.14 (See also QR 6/2.) Mesofascial plane generated by the left mesocolon and Toldt’s fascia. (a) Digital view.
(b)Laparoscopic/robotic view.
172 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Mesosigmoidal
(Toldt’s ) fascia
Mesosigmoidal fascial plane/interface
Mesosigmoid
(lateral aspect)
Mesosigmoidal
plane/interface
Figure 13.15 Laparoscopic/robotic appearance of the mesofascial plane formed by the mesosigmoid and Toldt’s fascia.
Theplane is evident after the peritoneal reection has been divided in this region.
Mesorectal plane/interface (TME plane)
(a) (b)
Legend
Mesentery
Fascia
Colon
Peritoneum
Right
Mesorectum
Toldt’s
Fascia
Rectum
Peritonotomy
margin
Pelvic
sidewall
Mesorectal
(Toldt’s) fascia
Mesorectal
plane/interface
Figure 13.16 Mesofascial plane generated by the mesorectum and Toldt’s fascia. (a) Laparoscopic/robotic view. This view
is obtained by retracting the rectum to the left and extending the peritonotomy at the medial aspect of the mesosigmoid.
(b) (See also QR 13/1-7.) Digital view.
Laparoscopic/robotic appearanceof adipovascular pedicles 173
Ileocolic
adipovascular pedicle
Ileocolic adipovascular pedicle
Figure 13.17 (See also QR 1/5.) Laparoscopic/robotic appearance of the ileocolic adipovascular pedicle.
Middle colic adipovascular pedicle
Transverse mesocolon
Middle colic
adipovascular
pedicle
Lesser
sac
Toward
mesenteric
root region
Transverse
mesocolon
Figure 13.18 (See also QR 1/7,8.) Laparoscopic/robotic appearance of the middle colic adipovascular pedicle.
174 Appearance of the mesentery during laparoscopic/robotic colorectal surgery
Inferior mesenteric adipovascular pedicle
(c) (d)
Inferior mesenteric
adipovascular pedicle
Mesosigmoid
peritoneal reflection(a) (b)
Inferior mesenteric
adipovascular pedicle
Peritoneal
reflection
Sigmoid colon
Figure 13.19 (See also QR 2/11 and QR 2d/3 and 4.) Laparoscopic/robotic appearance of the inferior mesenteric
adipovascular pedicle. (a) (See also QR 2d/3 and QR 2/11.) Digital model demonstrating the medial aspect of the
mesosigmoid (viewed from below up) after division of the peritoneum and mobilizing of the mesosigmoid from Toldt’s
fascia. (b)Intraoperative view of medial aspect of mesosigmoid as seen during laparoscopic mobilization of the inferior
mesenteric artery vascular pedicle. A peritonotomy has been commenced which exposes the underlying mesofascial
interface between mesosigmoid and underlying Toldt’s (i.e., mesosigmoidal) fascia. (c)Intraoperative view of the medial
aspect of the mesosigmoid and the contained vascular pedicle of the inferior mesenteric artery. The medial (apposed)
mesosigmoid has been mobilized via mesofascial separation from the underlying fascia (Toldt’s or the mesosigmoidal
fascia). (d)Intraoperative view of the fully mobilized and skeletonized inferior mesenteric artery as seen during
laparoscopic mobilization of the mesosigmoid.
References 175
SUMMARY
An atlas of the laparoscopic and robotic appearance of the
mesentery, associated peritoneum, and fascia, as seen dur-
ing mesenteric-based surgery, was developed. is atlas
provides a reference to aid in the performance of mesen-
teric-based colorectal surgery.
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