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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1441_Библиотеки_им_академика_М_И_Перельмана.pdf
186 Appearance of the mesentery during opencolorectal surgery
Medial aspect
of mesosigmoid
(a
)
(b)
Sigmoid colon
Legend
Mesentery
Fascia
Colon
Peritoneum
Right medial
mesosigmoidal reflection
Inferior mesenteric
adipovascular pedicle
(c)
(d)
Mesosigmoidal peritoneal reflections
Figure 14.9 Peritoneal reections at either side of the base of the mesosigmoid. (a) (See also QR 2d/3,4.) Reection
at right (medial) side of the mesosigmoid. (b) (See also QR 2d/3,4.) Magnied view of the reection as seen in (a). (c)
Intraoperative view of this region of the reection. Thesigmoid and mesosigmoid are retracted to the left. This lifts the
mesosigmoid away from the retroperitoneum and brings the right mesosigmoidal reection into view. (d) (See also QR
2d/8,9.) Digital view of the lateral aspect of the mesosigmoid. A peritonotomy through the left mesosigmoidal reec-
tion has been included to demonstrate the mesosigmoid as it curves onto and becomes attached to the posterior
abdominalwall.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 187
Pararectal peritoneal reflections
C
B
Rectum
Anterior
peritoneal reflection
Right
pararectal
reflection
Left
pararectal
reflec
tionz
(a)
(b)
(c)
Sigmoid colon
Divided left
pararectal
peritoneal
reflection
Mesorectum
Divided edge of
right pararectal
reflection
Mesorectum
Figure 14.10 Pararectal peritoneal reections. (a) (See also QR 2d/5.) Digital view from above. (b) Open surgical view of
the left pararectal reection undergoing division (thumbnail demonstrates the point of view). (c) (See also QR 2d/6,7.)
Open surgical view of the right pararectal reection undergoing division (thumbnail demonstrates the point of view).
188 Appearance of the mesentery during opencolorectal surgery
Mesofascial plane beneath small bowel mesentery
B and C
Small intestinal
mesentery
Small intestinal
peritoneal reflection
(a)
(b)
Small bowel
mesentery
Small bowel mesenteric
peritoneal reflection
Small bowel
mesentery
Mesofascial
interface
(c)
Toldt’s
fascia
Legend
Mesentery
Fascia
Colon
Peritoneum
Figure 14.11 Mesofascial plane generated by the small intestinal mesentery and Toldt’s fascia. (a) (See also QR 3/5.)
Digital overview of the peritoneal reection at the base of the mesentery. (b) Open surgical view demonstrating how the
reection is grasped for division. (c) Open surgical view of the mesofascial plane exposed after division of the reection.
The mesofascial plane is the interface between the fascia and the mesentery.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 189
Right mesofascial plane
Appendix
Undersurface
of mesentery
Right mesofacial
plane (Toldt’s fascia
)
Peritonotomy
Legend
Mesentery
Fascia
Colon
Peritoneum
(a)
Divided ileocecal
peritoneal reflection
(b)
Mesofascial
interface/plane
Right
mesocolon
Toldt's fascia
Figure 14.12 Mesofascial plane generated at the ileocecal junction between the mesentery and Toldt’s fascia. (a) Digital
image demonstrating peritonotomy of the reection and exposure of the underlying mesofascial plane. (b) Open surgical
view of the mesofascial plane formed by the fascia and mesentery (the thumbnail demonstrates the point of view).
190 Appearance of the mesentery during opencolorectal surgery
Right mesofascial plane
Legend
Mesentery
Fascia
Colon
Peritoneum
Appendix
Undersurface
of mesentery
Right mesofacial
plane (Toldt’s fascia)
Peritonotomy
(a)
Right colon
Right
mesocolon
Toldt’s fascia
(b)
Undersurface of
right mesocolon
Right mesocolic
fascia still attached
to right mesocolon
Right mesocolic
fascia mobilised o˜
right mesocolon
(c)
Figure 14.13 Mesofascial plane generated by the right mesocolon and Toldt’s fascia. (a) Digital view. (b) Open view.
(c)Intraoperative view of the mobilized right mesocolon, Toldt’s fascia and the retroperitoneum. The fascia is still attached
to the right mesocolon on the left of the eld of view. It has been separated from the mesocolon on the right.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 191
Transverse mesocolon and omentum
Greater
omentum
Transverse
colon
Transverse
mesocolon
Omento-mesocolic
interface
Figure 14 .14 Upper aspect of the transverse mesocolon after the greater omentum has been mobilized free.
192 Appearance of the mesentery during opencolorectal surgery
Left mesofascial plane/interface
Left mesofacial
plane/interface
Descending colon
Legend
Mesentery
Fascia
Colon
Peritoneum
Left mesocolic
(Toldt’s ) fascia
(a)
(b)
Left mesocolon
(deep surface)
Undersurface of
left mesocolon
Left
mesocolic
(Toldt’s
) fascia
Left
mesofascial
plane/interface
Left mesocolic fascia
(overlying retroperitoneum)
Figure 14.15 Mesofascial plane generated by the left mesocolon and Toldt’s fascia. (a) Digital view. (b) (See also QR 6/2.)
Open view. Themesofascial plane is formed at the interface of the left mesocolon (top of picture) and the fascia beneath.
To generate this view, the left mesocolon is lifted away from the retroperitoneum thus placing the mesofascial inter-
face under tension. The bres of the fascia then become apparent and can be separated from the undersurface of the
mesocolon.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 193
Peritoneal
reflection
Mesosigmoid
peritoneal reflection
(a)
(b)
(c)
Sigmoid colon
Mesosigmoidal mesofascial plane
Mesosigmoid
Mesofacial
interface
Toldt’s fascia
Divided edge
of peritoneal reflec
tion
Figure 14.16 (a) Digital model demonstrating the medial aspect of the mesosigmoid and the technical approach
adoptedin gaining access to the mesofascial plane in this region. (b) Right mesosigmoidal reection prior to division.
(c)Exposure ofmesofascial plane after peritonotomy of reection. The mesofascial plane occurs at the interface between
the mesosigmoid and the underlying mesosigmoidal (i.e., Toldt’s) fascia.
194 Appearance of the mesentery during opencolorectal surgery
Mesofacial plane between mesorectum and fascia
(b)
Mesorectum
reflected
anteriorly
Mesofacial
interface
Mesorectal
fascia
(a)
Pr
ostate/seminal
vesicle retracted
anteriorly
Rectum
deflected
posteriorly
Mesorectal
(Toldt’s ) fascia
Figure 14.17 Mesofascial plane generated by the mesorectum (in front) and the mesorectal (Toldt’s) fascia posteriorly.
In(a) (see also QR 13/3) the rectum is deected posteriorly, and anterior structures anteriorly. The intervening fascia
comes under stretch andcan be visualized. The reverse approach was applied in (b) (see also QR 13/4) deecting the rec-
tum anteriorly. This places the fascia under stretch. As a result the mesofascial interface can be identied and its compo-
nents separated.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 195
Mesofascial plane between mesorectum and fascia
(a)
(b)
Mesorectum
Divided edge
of peritoneal
reflection
Mesofascial
interface
on the left
Mesorectu
m
Mesofascial
interface
Mesorectal
fascia
Divided
peritoneum
Figure 14.18 Mesofascial plane exposed after division of the left (a) (see also 13/5 and QR 2d/5) and right (b) (see also
QR13/6 and QR 2d/6,7) pararectal peritoneal reections.