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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1441_Библиотеки_им_академика_М_И_Перельмана.pdf
xi
How to access three-dimensional models
usingQR codes
Each figu e legend in this book will direct the reader to a
QR code. e QR code to be accessed is specifi d in the fi st
number in the following annotation: “QR 2/3.” Th s directs
the reader to QR code 2 and annotation 3.
e QR codes are listed below. Using the example above,
the reader should identify QR 2 below and scan the QR code
with a QR reader (i.e., in a smart phone, lap-top, or tablet).
e reader then will be brought to a three-dimensional
model relating to the figu e legend and figu e in question,
with a series of numbers overlaying the model. By clicking
on the number 3, the reader will be brought to a particular
viewpoint of the model.
QR codes and models can also be accessed directly at the
website “www.mpgs.ie.”
QR 1 - Overview of mesentery
and intestine
QR 2 - Mesentery, peritoneum
and intestine
QR 3 -
QR 2d - Mesentery, peritoneum
and intestine
QR 4 - Sectioned view of right
and left mesocolon
viewed from below up
QR 6 - Sectioned right and left
mesocolon viewed
from below up
QR 8 - Medial view of base of small
intestinal mesentery
QR 7 - Colon and mesocolon
Sectioned view of right
and left mesocolon
as seen from above I
QR 5 - Sectioned view of the
mesosigmoid as seen
from above down
QR 3d -Sectioned view of right
and left mesocolon
as seen from above II
xii How to access three-dimensional models usingQR codes
QR 9 - Splenic flexure in isolation
QR 10 - Splenic region with
flexure removed
QR 12 - Hepatic region with
flexure removed
QR 11 - Hepatic flexure in isolation
QR 13 - Mesorec
tum and fascia
xiii
Acknowledgments
We the authors gratefully acknowledge the insight and advice offered by the following individuals:
Ann Brannigan
Consultant Colorectal Surgeon
Mater Misericordiae Hospital
University College Dublin
Dublin, Ireland
John P. Burke
Consultant Colorectal Surgeon
Beaumont Hospital
Dublin, Ireland
Manish Chand
Consultant Colorectal Surgeon
Department of Surgery and Interventional Sciences
University College London
London, United Kingdom
Eoghan Condon
Consultant Surgeon
Department of Surgery
University Hospital Limerick
University of Limerick
Limerick, Ireland
Peter Dockery
Department of Anatomy
School of Medicine
National University of Ireland
Galway, Ireland
Jonathon Efron
Ravitch Division of GI Surgery
Department of Surgery
The Mark M Ravitch Professor of Surgery and Urology
Johns Hopkins University
Baltimore, Maryland
Bill Heald
Pelican Cancer Foundation
Basingstoke Hospital
Basingstoke, United Kingdom
Awad M. Jarrar
Department of Cellular and Molecular Medicine
Lerner Research Institute
Cleveland Clinic
Cleveland, Ohio
Mathew Kalady
Department of Colorectal Surgery
Digestive Diseases Institute
Cleveland Clinic
Cleveland, Ohio
Miranda Kiernan
Department of Surgery
Graduate Entry Medical School
University of Limerick
Limerick, Ireland
Ravi Kiran
Department of Surgery
Columbia University Medical Center
Mailman School of Public Health
Center for Innovation and Outcomes Research
Division of Colorectal Surgery
New York Presbyterian Hospital-Columbia
New York, New York
Joep Knol
Consultant General and Colorectal Surgeon
Jessa Hospital
Hasselt, Belgium
Ian Lavery
Department of Colorectal Surgery
Digestive Diseases Institute
Cleveland Clinic
Cleveland, Ohio
xiv Acknowledgments
Jeremy Lipman
Associate Professor of Surgery
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Staff Colorectal Surgeon
Cleveland Clinic Foundation
Cleveland, Ohio
Deirdre McGrath
4i Centre for Interventions in Inammation, Infection and
Immunity
Graduate Entry Medical School
University of Limerick
Limerick, Ireland
Manus Moloney
Department of Gastroentrology
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Brendan J. Moran
Peritoneal Malignancy Institute
Basingstoke Hospital
Basingstoke, United Kingdom
James W. Ogilvie Jr.
Department of Colorectal Surgery
Spectrum Health/Ferguson Clinic
Michigan State University
Grand Rapids, Michigan
D. Peter O’Leary
Department of Surgery
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
James O’Riordan
Department of General and Colorectal Surgery
Tallaght Hospital
Dublin, Ireland
Nicola O’Riordan
Department of Surgery
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Colin Peirce
Department of Surgery
University Hospitals Limerick
Limerick, Ireland
Feza Remzi
Professor of Surgery
Director, Inammatory Bowel Disease Center
NYU Langone Medical Center
New York, New York
Jonathon Roddy
Department of Surgery
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Shaheel M. Sahebally
Department of Surgery
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Martin Shelly
Department of Radiology
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Neil J. Smart
Department of Colorectal Surgery
University of Exeter Medical School
Royal Devon & Exeter Hospital
Exeter, United Kingdom
Mattias Soop
Department of Colorectal Surgery
University of Manchester
Manchester, United Kingdom
Salford Royal Hospital
Salford, United Kingdom
David W. Waldron
Department of Surgery
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Leon G. Walsh
University of Limerick Hospitals Group
University Hospital Limerick
Limerick, Ireland
Steven D. Wexner
Digestive Disease Center
Department of Colorectal Surgery
Cleveland Clinic Florida
Weston, Florida
Florida Atlantic University College of Medicine
Florida International University College of Medicine
Miami, Florida
PART 1
1 History 3
2 Mesenteric and peritoneal anatomy 11
3 Embryologic development of the mesentery, peritoneal reection, and Toldt’s fascia 41
4 Histology of the mesentery 47
5 Toldt’s fascia 57
6 Mesenteric physiology 69
7 Pathology of the mesentery 85
8 Radiographic appearance of the mesenteryandperitoneum 109
9 Operative nomenclature 119
10 Teaching mesenteric principles 137
11 Gastroenterology 147
3
1
History
J. CALVIN COFFEY AND NICOLA O’RIORDAN
Two roads diverged in a wood, and I—
I took the one less travelled by,
And that has made all the difference.
Robert Frost
INTRODUCTION
For centuries, the mesentery and associated peritoneal
lining have been regarded as structurally complex. In 1885,
Sir Frederick Treves provided the fi st comprehensive
description of both, emphasizing that while some mesenteric
regions persisted in adulthood, others regressed and were
lost [1]. For example, the small intestinal mesentery, trans-
verse, and sigmoid mesocolon were consistently identiable
in adults, while the right and left mesocolon were identi-
able in a minority only. Treves’ descriptions were welcome
at the time, given the apparent complexity of the topic, and
were subsequently indoctrinated in virtually all anatomic,
embryologic, clinical, and related literature [1–3]. To the
present, the fi st chapter of most reference texts on intestinal
surgery focuses on anatomy and physiology and is based on
Treves’ descriptions. A review of later chapters dealing with
techniques in intestinal removal identifies a remarkable dis-
parity. e right and left mesocolon are invariably present
in the adult and must be resected like any other mesenteric
region. Put simply, intestinal surgery has always relied on
the persistence of all regions of the mesentery.
Numerous factors contributed to the divergence of
anatomic and surgical approaches to the mesentery and
peritoneum. Since the time of Treves’ anatomic-based
research, surgeons focused increasingly on cellular aspects
of disease. With increasing awareness of the molecular basis
of surgical disease, the emphasis of research shied away
from the anatomic-based craft component. More recently,
laparoscopic and robotic surgery have increased focus on
the “cra” component of surgery. In keeping with this,
the fi ld of surgical anatomy has increased in relative sig-
nicance and led to the demonstration of continuity of the
mesenteric organ from the small intestinal mesentery to the
mesorectum [4,5]. e following chapter will demonstrate
these shiing trends and clarify the manner in which recent
demonstrations allow a reconciliation of anatomic and sur-
gical approachesto this important organ. is chapter n-
ishes by demonstrating the opportunities that now occur
across a broad array of clinical and non-clinical sciences.
CARL TOLDT (1840–1920)
Carl Florian Toldt was born on May 3, 1840, in Bruneck,
Austria. Aer spending much of his childhood repair-
ing clocks, he received his doctorate in 1864 at St. Joseph’s
University in Vienna and was appointed Professor of
Anatomy at the University of Vienna in 1875 (Figure 1.1). He
became Professor of Anatomy at the German university in
Prague. He subsequently returned to Vienna in 1884 to work
with his colleague, Langer, and together they established
the Anatomy Institute of Vienna. Carl Toldt’s best-known
anatomic work was Anatomischer Atlas für Studierende
und Aerzte (An Atlas of Human Anatomy for Students and
Physicians) (Figure1.2), which was translated into English.
Despite the superb quality of this work, and its anatomic
accuracy, it has been little referenced overall. Toldt died
from pneumonia in Vienna in November 1920 [6–9].
Toldt’s descriptions were based on dissection of fresh
cadavers that had not been exposed to corrosive preservative
Introduction 3
Carl Toldt 3
Sir Frederick Treves 4
Limited support for Toldt’s observations 6
Radiology 6
Renaissance in focus on the mesentery 7
Laparoscopic and robotic surgery: The craft of
colorectal surgery 7
Anatomic continuity: A simpler principle 8
Future directions 8
Summary 8
References 8
4 History
agents. He rst observed that intestinal mesenteries did not
simply comprise two thin layers of closely apposed cells (i.e.,
the mesothelia) but rather contained vessels, nerves, and fat.
He called the resultant complex of structures the “lamina
mesenteria propria” (Figure 1.3). While Treves described
disappearance of the right and left mesocolon as humans
matured into adults, Toldt maintained they persisted and
attached (i.e., attened against) to the abdominal wall.
Where they attached, Toldt identifi d a thin seam of con-
nective tissue (Toldt’s fascia) separating mesentery from
abdominal wall, just as two layers of rock might be sepa-
rated by a seam of rock (see Chapter 2). Toldt suggested that
wherever the mesentery attached to the abdominal wall, the
cellular layer lining both (i.e., the mesothelium) underwent
a “gradual disappearance” to “admit contact and fusion of
their connective tissue laminae.” Toldt also suggested that
the outer cellular layer of the intestine, the tunica serosa,
could undergo a similar process and merge with the cov-
ering mesothelium of adjacent mesentery. ere is a strik-
ing similarity between current descriptions, and those of
Toldt, and it is remarkable that his work should have been
so infrequently referenced over the past two centuries [6–9].
SIR FREDERICK TREVES
Frederick Treves was born in Dorset, England, in 1853
(Figure 1.4). He received his medical education at the
London School of Medicine and became assistant surgeon
at the London hospital in 1879. In 1883 he was appointed
as surgeon and head of the department of Anatomy. He
famously housed Joseph Merrick, “the Elephant Man,” in his
attic until Merrick died in 1890 [6,10]. Treves was awarded
the Jacksonian prize for dissertations on the pathology,
diagnosis, and treatment of obstruction of the intestine and
numerous Hunterian lectures on the anatomy of the intes-
tinal canal and the peritoneum. He served in the Boer war
in 1899. He was knighted by King Edward VII on whom he
performed an appendectomy in 1902. He was a noted travel
writer and took up nal residence in Geneva (Switzerland)
due to poor health. He died of peritonitis in 1923 [6,10,11].
Treves described the human mesentery as fragmented.
Accordingly, the right and left mesocolic components of
the mesentery are, according to Treves, mostly absent in
the adult human. He described the small intestinal, trans-
verse, and sigmoid mesentery as persisting into adulthood
and attaching directly to the abdominal wall (Figure 1.5).
At the time, his descriptions provided a welcome rational-
ization of what was, and still is, regarded as a complex ana-
tomic topic (i.e., mesenteric and peritoneal anatomy in the
adult human). Although some aspects of his descriptions of
the mesentery and peritoneum are now regarded as inaccu-
rate, he was correct in describing a “mesenteric root” at the
origin of the superior mesenteric artery. He was also cor-
rect in describing the mesentery of the appendix as arising
from the undersurface of the mesentery in the right iliac
fossa. Treves’ stunning descriptions were made at a time
when signicant advances were occurring in anatomic and
Figure 1.1 Carl Toldt (1840–1920).
Figure 1.2 Cover illustration of Anatomischer Atlas Fur
Studierende und Aertze.
Sir Frederick Treves 5
Einstrahlung des Bindegewebes der Lamina
mesenterii propria in die Darmwand
Lamina mesenterii
propria
Venenzweig
Fettgewebe
Epithelium
Tunica serosa mesenterii
Tela subserosa
Tunica
muscularis
Stratum longitudinale
Stratum circulare
Tunica serosa intestini
Tunica mucosa
Tela submucos
a
9
/
1
Durchtritt eines Arterienzweiges durch die
Tunica muscularis
Figure 1.3 The mesentery and adjacent intestine is demonstrated. Toldt drew submesothelial connective tissue as well
as a mesenteric connective tissue lattice. He demonstrated a contiguity between these and the connective tissue of the
outer layers of the intestine. (Taken from Carl Toldt’s Anatomischer Atlas Fur Studirende und Aertze.)
Figure 1.4 Sir Frederick Treves (1853–1923).
Left colic
attachmen
t
Right colonic
attachment
Figure 1.5 Mesenteric attachments and peritoneal anatomy
in the adult human as per Sir Frederick Treves. Themesen-
tery of the small intestine, transverse, and sigmoid colon are
depicted by Treves as having linear attachments to the pos-
terior abdominal wall. The attachment of the right and left
colon is indicated (arrows). These correspond to the regions
where a right or left mesocolon, if present, would be located.