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196 Appearance of the mesentery during opencolorectal surgery
Ileocolic adipovascular pedicle
Right colic
adipovascular
pedicle
Mesenterotomy
through avascula
r
region
Ileocolic
adipovascular
pedicle
(a)
(b)
Figure 14.19 Ileocolic adipovascular pedicle before (a) (see also QR 1/5) and during (b) isolation for division.
Appearance of adipovascular pedicles during open mesenteric-based colorectal surgery 197
Middle colic adipovascular pedicle
Middle colic adipovascular
pedicle
Transverse
mesocolon
Figure 14.20 Middle colic adipovascular pedicle.
Mesosigmoidal adipovascular pedicle
Mesosigmoid
Skeletonized IMARetroperitoneum
Figure 14.21 Inferior mesenteric adipovascular (IMA) pedicle.
198 Appearance of the mesentery during opencolorectal surgery
SUMMARY
An atlas of the appearance of t he mesentery, associated perito-
neum, and fascia as observed during open mesenteric-based
surgery, was developed. e images contained are a reference
atlas and aid in conducting mesenteric based surgery in the
open context.
Inferior mesenteric vein adipovascular pedicle
Duodenum
Left
mesocolon
Inferior mesenteric
vein
(a)
(b)
Mesenterotomy
through avascular
region of left
mesocolon
Figure 14.22 Inferior mesenteric vein adipovascular pedicle. (a) Intraoperative view of the inferior mesenteric vascular
pedicle as viewed from above during an open low anterior resection. (b) Intraoperative view of the inferior mesenteric vein
after skeletonization using diathermy.
199
15
Instruments used during mesenteric-based
colorectal surgery
J. CALVIN COFFEY AND JOHN P. BURKE
The best place to nd helping hands is at the
end of your own arms
Confuscius
AIMS
e aims of this chapter are to summarize the main activi-
ties required during mesenteric-based surgery and to
describe instruments currently available to permit these.
e following descriptions are not meant to indicate the
authors’ personal preference.
INTRODUCTION
e following is not meant as a comparison of ecacy of
outcomes associated with instrumentation, but rather a
description of how currently available instruments enable
one achieve the goals of mesenteric-based surgery. ese
include (1) the development of unimpeded mesenteric
access and (2) hemostatic dissection.
INSTRUMENTS USED TO OBTAIN
UNIMPEDED MESENTERIC ACCESS
Mesenteric-based surgery requires adequate access to
permit identication of planes and development of their
component structures [1–13]. is is dealt with in detail
elsewhere but will be touched on briey here. e surgeon
must have sucient access as to permit (1) identication of
the mesentery/mesocolon, (2) separation of the components
of the mesofascial interface, and (3) uncompromised access
to adipovascular pedicles (Figure 15.1). Without these
mesenteric-based colorectal surgery becomes a frustrating
and potentially hazardous undertaking and oentimes is
not possible.
e techniques and instruments used differ greatly
between open, laparoscopic, and robotic contexts. e
introduction of robotic platforms will introduce additional
factors [14].
Open surgery: Unimpeded mesenteric
access
For open colorectal surgery, it is crucial to ensure that the
edges of the abdominal wall are well retracted and that
the primary surgeon has an unimpeded view and access
to the mesentery. As this is an imperative for any abdomi-
nal surgery, reliable self-retaining retractors such as the
Gosset, Balfour, or rib spreader should be available from
the outset (Figure 15.2). Other excellent retraction mech-
anisms include the Omni-Tract (Omni-Tract Surgical)
and Bookwalter reactor (Cod man). ese are somewhat
Aims 199
Introduction 199
Instruments used to obtain unimpeded mesenteric access 199
Open surgery: Unimpeded mesenteric access 199
Laparoscopic/robotic surgery: Unimpeded mesenteric
access 201
Regaining pneumoperitoneum following
atransabdominal incision during
laparoscopic/roboticsurgery 202
Hemostasis 202
Sources of bleeding 202
Devices to enable hemostatic dissection during
mesenteric-based surgery 205
Suction/irrigation 205
Bovie or diathermy 205
Hemostatic sealant devices 205
Newer modalities in obtaining hemostasis 207
Vapor evacuation during laparoscopic and
roboticsurgery 207
Future directions 208
Summary 208
References 208
200 Instruments used during mesenteric-based colorectal surgery
expensive and time-consuming in setup, but they signi-
cantly increase the range of retraction possible.
More recently, wound edge retractors have been
developed, which, when folded back on themselves, pro-
vide an automatic retraction mechanism for small- to
medium-sized laparotomy wounds. Examples include
the Alexis
™
wound edge protector (Applied Medical, CA,
United States) (Figure15.2). ey are used increasingly
in the laparoscopic and robotic setting in exteriorization
of the intestine and mesentery. Although they provide
excellent retraction of the fully relaxed abdominal wall,
intraperitoneal access is poor. Hence, all gastromesen-
teric mobilization must be conducted prior to their inser-
tion. Emerging evidence suggests that the Alexis
®
wound
Duodenojejunal flexure
Inferior mesenteric vein
Mesocolic access
Left mesocolon
Figure 15.1 Intraoperative (laparoscopic) demonstration of unimpeded access to the left mesocolon.
(d)(c)
(a)
(b)
Self-retaining retractor devices
Figure 15.2 (a) Omni-Tract, (b) Bookwalter, (c) Gosset, and (d) Alexis self-retaining devices used in open colorectal
surgery.
Instruments used to obtain unimpeded mesenteric access 201
retractor is associated with reduced wound-related infec-
tive complications [15].
Laparoscopic/robotic surgery:
Unimpededmesenteric access
In the laparoscopic setting, it is essential to position the
camera and other ports in a manner that gives immediate
and unimpeded access to all regions of the mesentery. One
is advised not to be prescriptive and to vary port number
and placement as required in order to achieve adequate
mesenteric access.
Most surgeons position the laparoscopic/robotic camera
either immediately above or below the umbilicus. A 30° lens
is optimal but not a requirement (it will certainly make one’s
life easier). Adequate CO
2
pneumoperitoneum is required
for mesocolic and mesenteric dissection and can generally
be achieved with intraperitoneal pressures of 15 mmHg.
Trocars should be placed using bladeless instruments
under direct vision. Prior to placement the abdominal wall
should be illuminated to prevent damage to subcutaneous
blood vessels. is is important as the trickling of blood
down the shaft of a port into the operative fi ld can limit
operative views.
Ports are placed on the side opposite where the surgical
intervention is to occur and at a distance of approximately
6cm (i.e., a hand’s breadth from each other) (Figure 15.3a).
is distribution prevents swording, that is, where instru-
ments impede each other by crossing (Figure 15.3b). It is
important that all ports are stabilized at the outset as dis-
lodgement and replacement slow progress and could lead
to a dangerous loss of pneumoperitoneum. A simple suture
placed in the skin and around the gas insuation port can
prevent the dislodgment of the port during surgery.
Swording
“No swording
”
(a)
(b)
“Swording”
Correct
port and
instrument
placement
Incorrect
port and
instrument
placement
Instruments go
across abdomen
at hand’s breadth
from each other
Figure 15.3 (a) Correct distancing of laparoscopic or robotic ports to avoid crossing or swording of instruments.
(b)Incorrect placement leads to instruments crossing and impeding further movement.
202 Instruments used during mesenteric-based colorectal surgery
Regaining pneumoperitoneum following
a transabdominal incision during
laparoscopic/robotic surgery
It is important to have a fail-safe mechanism of regain-
ing pneumoperitoneum aer an abdominal incision has
been created. e following is appropriate when the lap-
arotomy is limited in length (i.e., in the region of 5cm).
One approach is to use an Alexis wound edge protector.
e latter is rotated to closure and a penrose drain placed
around the point of closure. A clip is placed at this level
to secure the drain, and the skin edges are approximated
using towel clips. e complex is then pulled up ush with
the anterior abdominal wall, thus creating an airtight seal
for insuation.
HEMOSTASIS
e maintenance of hemostasis is a key requirement in
mesenteric-based surgery.
Sources of bleeding
In general, bleeding during mesenteric-based surgery arises
from one or more of four sources including the (1) mesen-
tery, (2) intestine, (3) fascia, and (4) adhesions. It is useful
to classify bleeding in this manner as it permits a system-
atic approach to obtaining hemostasis during and aer a
procedure. If bleeding is anticipated then it can be better
controlled. Systematic examination of the peritoneal cavity,
aer procedure completion, is more reassuring than a hap-
hazard search for residual bleeding points.
Mesenteric bleeding occurs when the mesentery has been
dissected through. In addition to the major mesenteric ves-
sels, minute vessels also occur just beneath the mesenteric
mesothelium, in the underlying connective tissue (Figure 15.4)
[16,17]. Bleeding from these is inevitable, as it is not possible
to avoid peritonotomy in conducting a mesenterectomy.
is bleeding is always quickly self-limiting. Heavy bleed-
ing from the mesentery occurs due to disruption of vessels
such as the inferior mesenteric artery or vein, colic vessels,
or substantive sigmoidal branches. is bleeding will not
stop spontaneously and requires particular measures to
regain hemostasis.
Bleeding can also occur at the intestinal margin of
the mesentery, if the marginal vessel has been divided.
Bleeding here is an encouraging rather than problematic
sign (so long as it is appropriately controlled aer identi-
cation). Many deliberately divide this vessel and observe
for pulsatile bleeding. ey rst place an artery clip on
the distal aspect of the marginal vessel and then divide
the vessel proximal to this. If bleeding is brisk then a
further artery clip is placed proximally. e absence of
pulsatile mesenteric bleeding is a discouraging sign and
should prompt dissection back to a level where brisk
bleeding occurs.
At the completion of a procedure, and before closing
the abdomen, it is important to inspect the full length
of the mesenterotomy to ensure adequate hemostasis
[18–22].
Minute vessels also occur within Toldt’s fascia where they
are paired with lymphatic channels [16,17,23]. In separat-
ing the fascia from the overlying mesocolon (i.e., mesofas-
cial separation), they come under stretch and can bleed. In
general, this bleeding is self-limiting, but it can obscure the
operative fi ld and increase diculty in identifying opera-
tive planes (Figure 15.5a and b). It is important at the com-
pletion of a colorectal procedure to thoroughly examine the
fascia for residual bleeding points. Some suggest, probably
correctly, that ooze from these is worsened by antithrom-
botic prophylactic agents and contributes to generation of
postoperative collections.
Identication of fascial vessels can guide mesofascial
separation. If minute vessels remain on the undersurface
of the mesocolon, these are by denition intrafascial. e
identication of spiral fascial vessels indicates that residual
fascia remains draped to the undersurface of the mesentery
and should be peeled off to expose the vibrant yellow of the
mesentery/mesocolon (Figure 15.6).
Fascial bleeding also occurs when fascia and retroperi-
toneum are excavated to identify the ureter for safeguard-
ing. is is commonly conducted by many surgeons who
advocate placing a vessel loop around the ureter to further
Mesosigmoidal fascia
Peritonotomy margin
Peritonotomy margin
Hemostatic peritonotomy of peritoneal reflection
Figure 15.4 Intraoperative (open) view of hemostatic
peritonotomy along the right side of the base of the
mesosigmoid.
Hemostasis 203
protect it. Fascial breach and retroperitoneal excavation
can be obviated if the surgeon is mesofascial in plane dur-
ing dissection (see Chapter 16). While both are associated
with bleeding, neither is likely to cause hemodynamic com-
promise. However, this will predispose to postoperative
collection development that can, in turn, become second-
arily infected and lead to more signicant bleeding. In the
coagulopathic patient, or the reoperative context, fascial,
and retroperitoneal bleeding can be particularly trouble-
some and should be avoided as much as possible.
Mesosigmoid
fascia
Peritoneal reflection
Nonhemostatic
mesofascial
separation
Mesosigmoid
fascia
Mesosigmoid
under fascia
Mesosigmoid
(b)
Hemostatic
mesofascial
separation
Mesofascial separation
(a
)
Mesosigmoid
Figure 15.5 (a) Intraoperative (open) view of hemostatic separation of the mesosigmoid and mesosigmoidal fascia.
(b)Intraoperative (open) view of nonhemostatic separation of the mesosigmoid and mesosigmoidal fascia. The mesofascial
plane is clearly evident in (a) but not in (b) due to the presence of blood.
204 Instruments used during mesenteric-based colorectal surgery
Right mesocolon
(undersurface)
Right mesocolic
(Toldt’s ) fascia
Right mesocolic
(Toldt’s ) fascia
(b)
Retroperitoneum
Legend
Fascia
Colon
Peritoneum
Mesentery
Right mesofascial
interface/plane
Right
mesocolon
Cecum
Right mesofascial separation
Peritonotomy
margins
(a)
Right mesocolic (Toldt’s ) fascia
Figure 15.6 (a) 2.5D image derived from a 3D digital sculpture demonstrating the relationship between the right mesoco-
lon and fascia after division of the peritoneal reection. (b) Intraoperative image demonstrating the same relationship. The
undersurface of the right mesocolon, Toldt’s fascia, and the retroperitoneum are evident. The fascia has been separated
from the mesocolon on the right but not the left side of the image.
Devices to enable hemostatic dissection during mesenteric-based surgery 205
DEVICES TO ENABLE HEMOSTATIC
DISSECTION DURING
MESENTERIC-BASED SURGERY
Suction/irrigation
Mesenteric-based surgery relies on maintaining the opera-
tive fi ld as bloodless as possible. Blood obscures mesofascial
and colofascial plane components and the interface between
these. Bleeding is inevitable, which means the surgeon must
fi st have means of clearing blood from theoperative fi ld to
expose the underlying anatomy.
e presence of even minor amounts of blood can
obscure subtle interfaces and lead to digression from ana-
tomic planes. On this basis, availability of an operational
suction and irrigation are essential from the outset of a
procedure. Irrigation can be achieved with a variety of solu-
tions including sterile water or normal saline. e interface
between fascia and mesocolon, and that between colon and
fascia, is subtle and thus easily missed. To avoid this, many
surgeons irrigate extensively as they proceed. In the open
context, frequent irrigation with normal saline or water
from a bladder syringe clears blood to reveal the underly-
ing anatomy. In the laparoscopic and robotic context, dual
lumen devices (Figure 15.7) can be used for gentle meso-
or colofascial separation, allowing concurrent irrigation
(orsuction) and dissection.
In select circumstances, a tonsil swab (15cm × 15cm ×
8 ply) is introduced intraperitoneally to absorb blood and
simultaneously exert a localized tamponade eect. esize
of the swab means that downward pressure is broadly
distributed and can aid in meso- and colofascial separa-
tion. In this manner, the surgeon achieves hemostasis and
simultaneously dissects. A few points should be mentioned
that facilitate its usage during laparoscopic surgery. Lack
of familiarity here can lead to frustration and time loss.
For intraperitoneal insertion, the cap of a 12mm port is
removed and the swab introduced directly down the port.
e swab will absorb blood and swell, which means that
it must be unfolded prior to its removal. Sometimes, it
may trap within a port. Should this occur the port should
be removed, the swab gently pushed out, and the port
reinserted.
Bovie or diathermy
e electrocautery instrument used most frequently in
open colorectal surgery is the monopolar diathermy (or
Bovie) (Figure 15.8). e system comprises an active elec-
trode as well as an inactive or dispersive electrode. is
creates a circuit through which the electrical current
(which converts to heat) can be dispersed to ground. In
mesenteric-based colorectal surgery, monopolar dia-
thermy is used in dividing peritoneal reections (perito-
notomy), separating fascia from overlying mesentery, or
in dividing through avascular mesenteric (i.e., interpedic-
ular) regions (Figure 15.8a). Ineach of these, the mesen-
tery is thin. It can also be used with care, in skeletonizing
adipovascular pedicles and exposing contained vessels
(Figure 15.8b).
Monopolar diathermy cannot stop bleeding from sig-
moidal, superior rectal, or inferior mesenteric diameter
arteries. Other sealant devices are more useful in this con-
text (see “Hemostatic sealant devices” section). Monopolar
diathermy is exceptionally useful for ne dissection in
clearing mesentery off the serosal surface of the intestinal
tract or in clearing an appendices epiploicae off the intesti-
nal surface. is activity is important in enabling the diffe -
entiation of mucosal, submucosal, and seromuscular layers
of the gastrointestinal tract during anastomosis formation
(seeChapter 16).
An additional use lies in division of congenital adhe-
sions before commencing mesenteric mobilization. Many
use the tip of the monopolar diathermy to divide con-
genital adhesions and thereaer the peritoneal reection.
is activity exposes the mesofascial interface. ecom-
ponents of this may then be separated using the same
approach.
As can be seen from earlier, the monopolar diathermy
has a wide variety of uses in mesenteric-based surgery.
Perhaps its single greatest advantage lies in the fact that it
permits a hemostatic dissection that has largely substituted
sharp scissors-based dissection. Where the Bovie cannot
achieve hemostatic dissection, newer sealant devices can be
used to excellent eff ct.
Hemostatic sealant devices
As mentioned earlier, the occurrence of vessels immediately
beneath mesothelial surfaces, coupled with their occur-
rence within the fascia and mesenteric connective tissue,
means that bleeding is inevitable. In the past, this bleed-
ing was extensive as surgeons relied on sharp dissection
using dissecting scissors. Nowadays, devices are available
that both seal and cut meaning that a hemostatic dissection
can readily be achieved. Th s has radically reduced volumes
of blood loss during colorectal surgery. When their use is
combined with anatomic dissection, the blood loss can be
imperceptibly low.
Irrigation button
Dual purpose suction and irrigation device
Suct
ion button
Figure 15.7 Dual lumen device that enables suction or
irrigation.