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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1441_Библиотеки_им_академика_М_И_Перельмана.pdf
177
14
Appearance of the mesentery during
opencolorectal surgery
J. CALVIN COFFEY AND JAMES O’RIORDAN
Science is the systematic classication of
experience.
George Henry Lewes
AIM
e aim is to demonstrate the appearance of the mesentery,
peritoneum, and fascia as seen during open mesenteric-
based surgery.
INTRODUCTION
e appearance of the abdomen at open surgery diers
dramatically from that during laparoscopic and robotic sur-
gery. Perhaps the single greatest dierence, apart from the
eects of overhead or natural light on tissues, is loss of the
20-fold magnifi ation and high-defin tion view aorded by
the laparoscope. e latter is substituted by unaided human
eyesight in the open setting. Th s means that individual mes-
enteric and intestinal structures appear more remote, and the
subtle planes used in colorectal surgery are more dicult to
identify. Given (1) dierences between laparoscopic/robotic
and open surgery, (2) most abdominal surgery continues
to be performed open, and (3)the open surgical approach
remains the fallback if laparoscopic (orrobotic) fails or is not
feasible, then it is essential to provide an atlas of the appear-
ance of colorectal surgical anatomy as observed during
mesenteric-based surgery in the open context.
METHODOLOGY
e images presented in the following were taken at open
surgery using a laparoscope mounted on a snake arm
(i.e.,the UL Exoscope) (Figure 14.1). is approach meant
the 20-fold magnication and high-resolution imagery
associated with laparoscopic surgery could be replicated
in the open surgical context. In order to orientate the
viewer, corresponding views were generated using a 3D
digital sculpture of the mesentery, gastrointestinal tract,
associated peritoneal reection, and fascia. Cadaveric
images are occasionally used to emphasize a particu-
lar anatomic point. e following will demonstrate the
appearance of the peritoneal reection, the colon and
mesofascial planes, and adipovascular pedicles, as seen
during open colorectal surgery.
APPEARANCE OF THE PERITONEAL
REFLECTION DURING OPEN
MESENTERIC-BASED COLORECTAL
SURGERY
1. Peritoneal reection at the base of the small intesti-
nal mesentery where it curves onto retroperitoneum
(Figure 14.2).
2. Ileocecal peritoneal reection (Figure 14.3).
3. Right peritoneal reection (Figure 14.4).
4. Hepatocolic peritoneal reection (Figure 14.5).
Aim 177
Introduction 177
Methodology 177
Appearance of the peritoneal reection during open
mesenteric-based colorectal surgery 177
Appearance of the colo- and mesofascial plane
during open mesenteric-based colorectal surgery 178
Appearance of adipovascular pedicles during open
mesenteric-based colorectal surgery 178
Summary 198
178 Appearance of the mesentery during opencolorectal surgery
5. Peritoneal reection between greater omentumandupper
surface of the transverse colon (Figure14.6).
6. Splenocolic peritoneal reection (Figure 14.7). Due
to adhesion of the greater omentum to the peritoneal
reection in this location, it can be dicult to demon-
strate this intraoperatively.
7. Left eritoneal reection (Figure 14.8).
8. Right and left esosigmoidal peritoneal reection
at the base ofthemobile component of the meso-
sigmoid (i.e.,where thelatter curves down and
becomes attachedto the posterior abdominal wall)
(Figure14.9).
9. Pararectal peritoneal reection on either side of the
rectum (Figure 14.10).
APPEARANCE OF THE COLO- AND
MESOFASCIAL PLANE DURING OPEN
MESENTERIC-BASED COLORECTAL
SURGERY
1. Small bowel mesentery and underlying fascia
(Figure14.11).
2. Ileocecal mesenteric conuence and underlying fascia
(Figure 14.12).
3. Right mesocolon and underlying fascia (Figure 14.13).
4. Transverse mesocolon aer mobilization of the greater
omentum (Figure 14.14).
5. Left esocolon and underlying fascia (Figure 14.15).
6. Mesosigmoid and fascia beneath mesosigmoidal
peritoneal reection (Figure 14.16). (a) Mesosigmoidal
peritoneal reection prior to peritonotomy. (b)
Exposure of mesosigmoidal fascia aer peritonotomy.
7. Mesorectum and fascia at posterior aspect of mesorec-
tum (Figure 14.17).
8. Mesorectum and mesorectal fascia aer division of
(a)left nd (b) right, pararectal peritoneal reection
(Figure14.18).
APPEARANCE OF ADIPOVASCULAR
PEDICLES DURING OPEN MESENTERIC-
BASED COLORECTAL SURGERY
1. Ileocolic adipovascular pedicle (Figure 14.19)
2. Middle colic adipovascular pedicle (Figure 14.20)
3. Inferior mesenteric adipovascular pedicle
(Figure14.21)
4. Inferior mesenteric vein adipovascular pedicle
(Figure14.22)
Standard
camera stack
UL exoscope
Sterile cove
r
Snake arm
Snake arm
support
Standard
laparoscopic camera
Figure 14.1 Laparoscope mounted on a snake arm. This system captures images that closely approximate to the surgeon’s
point of view. Advantages include the fact that high-magnication and high-resolution images normally obtained during
laparoscopic or robotic surgery can be obtained during open surgery. Similar views cannot be obtained using standard
wall, head, tripod, or theater-light-mounted camera systems. As images are transmitted to a television stack, all theater
personnel can observe the procedure.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 179
Small
intestional
peritoneal
re˜e ction
Left
mesocolon
Mesosigmoid
(a)
(b)(c)
Small bowel
mesentery
Left
mesocolon
Small intestinal
mesentery
Peritoneal
reflection
Small intestinal
peritoneal reflection
Peritoneal reflection at the base of the small intestinal mesentery
Legend
Mesentery
Fascia
Colon
Peritoneum
Small intestinal
mesentery
Figure 14.2 (See also QR 3/5.) Peritoneal reection at the base of the small intestinal mesentery. (a) Digital model. The
point of view is demonstrated in the thumbnail image. (b) Intraoperative photograph demonstrating the peritoneal
reection at the base of the small intestinal mesentery. (c) Intraoperative image demonstrating increased adiposity in the
peritoneal reection at the base of the small intestinal mesentery (in an obese patient).
180 Appearance of the mesentery during opencolorectal surgery
Peritoneal reflection at the ileocecal junction
Terminal ileum
Terminal
ileum
Appendix
(a)
(b)
(c)
ileocecal
peritoneal reflection
ileocecal
peritoneal reflection
ileocecal
peritoneal reflection
Legend
Mesentery
Fascia
Colon
Peritoneum
Figure 14.3 Peritoneal reection at the ileocecal junction. (a) (See also QR 2/2.) Intraoperative view during open surgery.
The reection has been grasped with a pick-ups and divided with diathermy. (b) Digital view. (c) Ileocecal peritoneal
reection as observed in a cadaver.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 181
Right peritoneal reflection
Right
(ascending) colon
Right
peritoneal reflection
Divided edge
of peritonotomy
(b)
(a)
Legend
Mesentery
Fascia
Colon
Peritoneum
Right peritoneal
reflection
Figure 14.4 Right peritoneal reection. (a) (See also QR 6/3.) Digital view. (b) Intraoperative view of the right peritoneal
reection during division. It is being divided using diathermy. The colon is retracted to the right which transmits tension to
the right peritoneal reection.
182 Appearance of the mesentery during opencolorectal surgery
Colic component
of hepatic flexure
Transverse
colon
Hepatocolic peritoneal reflection
Legend
Mesentery
Fascia
Colon
Peritoneum
Hepatocolic
peritoneal reflection
(a)
(b)
(c)
Hepatocolic
peritoneal reflection
Liver under retraction
Liver edge
Divided edge of
reflection
Colic component
of hepatic flexure
Liver under retraction
Liver edge
Divided edge of
reflection
Colic component
of hepatic flexure
Hepatocolic
peritoneal
reflection
Figure 14.5 Hepatocolic peritoneal reection. (a) (See also QR 2/4.) Digital view. (b) and (c) The hepatocolic peritoneal
reection as seen during open surgery, In (c) a nger has been placed beneath the reection which is being divided using
diathermy.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 183
Omento-colic peritoneal reflection
Omento-colic
peritoneal reflection
Greater omentum
Transverse colon
(a)
Transverse
colon
Peritoneal
reflection
Omentum
(b)
Figure 14.6 Peritoneal reection connecting the greater omentum and transverse colon. (a) View from above down.
(b)View from upper left quadrant medially. By placing traction on the colon and counter-traction on the omentum
thereection becomes apparent under stretch. This enables its safe division using diathermy.
184 Appearance of the mesentery during opencolorectal surgery
Splenocolic peritoneal reflection
Transverse
colon at flexure
Splenocolic peritoneal reflection
(a)
(b)
Peritonotomy
of splenocolic
peritoneal
reflection
Splenocolic
peritoneal
reflection
Figure 14.7 Splenocolic peritoneal reection, (a) medial to lateral view and (b) (See also QR 2/5.) lateral to medial view.
The reection was divided through using a Ligasure. The greater omentum fuses with the splenocolic peritoneal reection
and so it is difcult to demonstrate the reection in isolation.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 185
Sigmoid
colon
Descending colon
Left peritoneal
reflection
(b)
Left peritoneal reflection
Sigmoid
colon
Transverse
colon
Descending
colon
Left
peritoneal
reflection
(a)
Legend
Mesentery
Fascia
Colon
Peritoneum
Figure 14.8 Left peritoneal reection. (a) (See also QR 2d/1,2.) Digital view. (b) Intraoperative view of the left peritoneal
reection. The reection has been grasped using a pick-ups. The colon is retracted medially, thereby bringing the reec-
tion under tension and enabling its division. The view is from the left upper quadrant downward.