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206 Instruments used during mesenteric-based colorectal surgery
Hemostasis can be obtained using sealant devices by
focally grasping a bleeding point and activating without
cutting (if the sealant device has dual cutting and coagula-
tion functions). Th s is useful in skeletonizing tissue around
major vessels and in dividing across avascular mesenteric
regions between adipovascular pedicles.
ese devices should be used cautiously as their active
blades can reach considerable temperatures. e eect
of temperature on tissue is demonstrated as follows.
At<70°C, tissue changes are minimal, even within mes-
entery. Between 70°C and 150°C, there is minor shrink-
age and blanching caused by denaturation of collagen.
At temperatures >150°C, cells rupture as the cytoplasm
reaches boiling point and rapidly expands. For tempera-
tures between 200°C and 300°C, tissue carbonizes and
begins to vaporize [24,25].
Mesosigmoidal
fascia
(a)
(b)
Peritoneal
reflection
Diathermy tip
Inferior
mesenteric
adipovascular
pedicle
Diather
my
Bovie/diathermy
Figure 15.8 (a) (See also QR 13/6.) Use of Bovie or monopolar diathermy device to separate the mesentery and associated
fascia. (b) Use of Bovie to skeletonize the inferior mesenteric arterial pedicle.
Vapor evacuation during laparoscopic and robotic surgery 207
e type of hemostatic device used is determined by
the anatomic nature of the tissue. Normal mesentery can
be divided through easily using most sealant devices.
Many sealant devices can obtain a hemostatic seal-
ant eff ct in vessels up to 7mm in diameter. ese have
also been used, albeit with extreme care, in challenging
mesenteries [16,17]. In severe Crohn’s disease, the mes-
entery is greatly thickened and wraps around the intes-
tinal surface (i.e., creeping fat or fat wrapping) (Figure
15.9 and Chapter 7) [26]. is is due to an exaggerated
but as yet unexplained mesenchymal reaction within the
mesentery [27]. A similar mesenchymal phenomenon
sometimes occurs in complicated diverticular and neu-
roendocrine disease, and in mesenteric desmoid tumors.
In each of these scenarios, the approach to mesenterot-
omy and mesenterectomy must be appropriately tailored.
Although sealant devices are useful in separating the
mesentery and intestine at their intersection, they should
not be used along the body of the mesentery in Crohn’s
or diverticular disease. A reliable approach to hemostatic
mesenterotomy in Crohn’s disease is detailed in Chapter
16 on general techniques.
Newer modalities in obtaining hemostasis
Emerging mechanisms of hemostasis involve newer hemo-
static agents. e formats used include gels, foams, or
hemostatic pads (Figure 15.10). In the laparoscopic and
robotic setting, hemostatic pads can be introduced through
a 12mm port and then placed on the site of bleeding. It is
oen successful in circumstances where more conventional
approaches have not worked. Several newer agents that are
liquid or powder based are emerging for use in open, laparo-
scopic, and robotic surgery. ese have had success deep in
the pelvis where bleeding can be troublesome, remote, and
dicult to identify.
VAPOR EVACUATION DURING
LAPAROSCOPIC AND ROBOTIC SURGERY
Vapor arises due to the eff cts of thermal sealants on mes-
enteric tissue and should always be evacuated as quickly as
possible. is is particularly important where ne dissec-
tion of planar components is required, or when the fat of
major adipovascular pedicles is being dissected through.
In the laparoscopic and robotic context, clear views are
essential to diffe entiate adipose from vascular tissue and
avoid inadvertently pinching the side of the vessel in ques-
tion. Increases in vapor obscure views of anatomic planes
and surgeons need oen withdraw the scope until an over-
view of the regional anatomy is regained. Not surpris-
ingly, this activity disrupts progress, is time-consuming,
and alters the operative view considerably. A number of
strategies have recently been developed to deal with this
issue. Some use smoke evacuators including the “chim-
ney,” which is an inexpensive channel connected to a port
(Figure 15.11). Although these are inexpensive they may
compromise pneumoperitoneum if left fully open on a con-
tinuous basis. e Airseal
®
device (SurgiQuest, Inc., CT,
Figure 15.10 Hemostatic pad.
Small intestinal
mesentery
Ileum
Fat wrapping
Mesenteric fat wrapping
Figure 15.9 Fat wrapping around the serosal surface of
the terminal ileum.
Adapter connects
to laparoscopic port
Vapor extraction device
Exit port
Figure 15.11 “Chimney” vapor extraction device for lapa-
roscopic surgery.
208 Instruments used during mesenteric-based colorectal surgery
United States) has recently been developed, which main-
tains pneumoperitoneum while also ltering vapor. is is
increasingly used to prevent rectal billowing in transanal
total mesorectal excision and transanal minimally inva-
sive surgery. Smoke evacuation devices have been shown
to provide a good fi ld of view and reduce risk of expo-
sure to harmful carcinogens [28]. Devices that maintain
pneumoperitoneum and simultaneously extract vapor are
extremely useful in robotic colorectal surgery.
FUTURE DIRECTIONS
Current instruments are not without limitations. ese pro-
vide a basis for future instrument development. For example,
it is not uncommon to experience diculty in retracting the
small bowel and mesentery off the left mesocolon to achieve
unimpeded left mesocolic access. is is because of (1) the
extent to which the small bowel and associated mesentery
elongate and (2) the relatively short zone at which the mes-
entery attaches to the posterior abdominal wall. at being
the case, future eff rts should aim to address these issues
and develop appropriate retraction mechanisms.
SUMMARY
For optimal mesenteric-based colorectal surgery, the
surgeon must have mechanisms that ensure unimpeded
mesenteric access, reliable hemostatic mobilization, and
mesenterectomy. Instruments that are currently avail-
able enable the surgeon achieve the these goals, but there
is considerable room for improvement at multiple levels.
Improved mesenteric access, more ecient peritonotomy,
mesofascial access, and separation are clinical needs that
should be addressed in future biodesign.
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211
16
General techniques in mesenteric-based
colorectal surgery
J. CALVIN COFFEY AND JEREMY LIPMAN
It is sometimes necessary to step backward in
order to go forward.
French saying
AIM
e aim is to demonstrate techniques in peritonotomy,
mesenterotomy, mesofascial separation, mesenterectomy,
and vascular skeletonization and division, in open, laparo-
scopic, and robotic contexts.
IMPORTANCE OF MESENTERIC
PRINCIPLES
In the past , intestinal surgery focused ma inly on the intestinal
component of surgery, almost to the exclusion of the mesen-
teric component [1–6]. When considered in totality, one sees
that the most time in colorectal and intestinal procedures
is spent manipulating, dividing, and mobilizing mesentery.
Bowel division and anastomosis can now be safely completed
in a matter of minutes, with current suturing approaches or
stapling devices. In contrast, a signicantly greater propor-
tion of time is spent in gently separating components of the
mesofascial interface, in as bloodless and anatomic a man-
ner as is possible. A comprehensive review of online videos
demonstrating robotic and laparoscopic colorectal surgery
enables subdivision of the duration of the video into mesen-
teric and intestinal components. On average, the mesenteric
component is 2.5 times longer than the intestinal component.
ere is no doubt that a considerable proportion of intesti-
nal surgery is spent dividing peritoneal reections, mobiliz-
ing and div iding mesentery, or skeletonizing the components
of an adipovascular pedicle (Figure 16.1). Surgeons are
increasingly aware of these individual and separate compo-
nents, a point that can be attributed to an improved under-
standing of mesenteric, fascial, and peritoneal reection
anatomy in general [7–12]. is was greatly assisted through
the development of the anatomic principles of total mesorec-
tal excision followed shortly aer by total mesocolic excision
(and complete mesocolic excision) [1,13–30]. e central
principles of these approaches are extensive (i.e., complete)
and intact mesenterectomy to improve oncologic outcomes.
It is likely that emphasis on the mesenteric basis of surgery
will increase further given new perspectives and further
improvements in our understanding.
Increasing evidence points toward a role for the
mesentery in driving homeostatic systems. Derangements
in these have long been associated with atherosclerosis,
diabetes mellitus, and metabolic syndrome. Recent iden-
tication of mesenteric involvement has shed new light
on the function of the mesenteric organ in general and is
likely to inuence the technical approach to mesenterec-
tomy in the future [31–44].
Aim 211
Importance of mesenteric principles 211
Preoperative preparation and patient setup 212
Instruments used in robotic, laparoscopic, and open
colorectal surgery 214
Patient position and mesenteric access 214
Displacing mesentery 216
Preparation of the operative eld 216
Division of mesentery (mesenterotomy) 220
Clearing mesentery from theintestinal margin 222
Greater omentum 225
Colo- and mesofascial interface 226
Gravity 226
Specimen extraction 226
Closing the mesenteric defect 229
Summary 230
References 230
212 General techniques in mesenteric-based colorectal surgery
PREOPERATIVE PREPARATION
ANDPATIENT SETUP
As part of the formal multidisciplinary workup of patients
with colon and rectal cancer, it is important to stage the dis-
ease in the context of involvement of the mesorectum or the
mesocolon. is is more readily achieved at the level of the
rectum because of the availability of clear-cut radiologic cor-
relates for the mesorectum. It is more dicult for the colon
as our understanding of the radiographic appearance of the
associated mesentery is less well developed. Moreover, no
studies to date have evaluated the radiologic appearance of the
mesentery in disease states, and in the context of recent devel-
opments in our understanding of its anatomy (Figure 16.2).
Increasingly, however, radiologists acknowledge that
the previously referred to “anterior pararenal space” cor-
responds to the mesocolon and that “anterior renal fascia”
corresponds to Toldt’s fascia (Figure 16.3) [45–48]. at
being the case, the main body of the mesentery and its pos-
terior boundary are readily identifi d [48].
A problem remains in identifying the anterior bound-
ary. As the small intestinal mesentery continues laterally
to become the right mesocolon, then it follows they are
similar in radiologic appearance. Given this, and given also
that the small intestinal mesentery overlies the right and le
mesocolon, it is dicult to identify the anterior boundary
of the mesocolon. is problem will only be overcome when
Middle colic adipovascular pedicle
Middle colic vessel
Mesenteric
root region
Figure 16 .1 Laparoscopic demonstration of the middle
colic adipovascular pedicle, looking superiorly.
Right mesocolon and Toldt’s fascia
Mass in
cecum
Right
mesocolon
Mass in right
mesocolon
Toldt’s fascia
right mesocolic fascia
Figure 16.2 Computerized axial tomographic image of a mass in the right colon, with an associated mass in the right
mesocolon. Intraoperatively the patient had a nodal mass in the right mesocolon that was tethered to but had not pen-
etrated Toldt’s fascia.
Preoperative preparation andpatient setup 213
we can reliably and reproducibly diffe entiate small intes-
tinal from mesocolic mesentery. For the present, however,
wehave to infer the anterior interface [7,48].
ese points are directly relevant to the radiologist and
surgeon as they aid in interpreting radiographic imaging
and thus in planning an intestinal resection. Withincreas-
ing recognition of radiographic regions corresponding to
the right and left mesocolon and with increased recog-
nition of the concept of mesocolic continuity, surgeons
and radiologists can better interpret the computer tomo-
graphic (CT) appearance of the mesocolon preoperatively
[48]. is aids in determining the extent or stage of disease,
and in preempting intraoperative technical challenges in
achieving a total mesocolic excision. An example of this is
shown in Figure 16.2 where neoplastic extension into the
right mesocolon and thereaer into the underlying fas-
cia was identifi d prior to operation. Using this approach,
the surgeon could gauge the level of technical diculty
likely to be encountered and make appropriately tailored
preparations.
e radiographic appearance of the mesentery can help in
anticipating intraoperative diculties. e bulky mesentery
presents several challenges not least of which is a soft consis-
tency and a tendency to bleed (Figures 16.3 and 16.4). In these
circumstances, minimal traction leads to tearing and trouble-
some bleeding that can be dicult to control. On the other
hand, the thin mesentery is also challenging. Lack of fat means
that it is dicult to dierentiate mesentery from underlying
fascia and retroperitoneum (Figure16.5). When the fascia is
extremely thin, it is easy to transgress into the retroperitoneum
(Figure 16.6). e ideal case is one where visceral adiposity is
moderate, can be readily dierentiated from underlying fas-
cia, and does not bleed on gentle retraction.
Preoperative radiologic assessment helps develop a tech-
nical impression of other diculties likely to be encountered.
Radiotherapy aects the mesentery inamannerthat leads to
Transverse mesocolon
Splenic flexure
mesentery
Anterior renal (Toldt’s) fascia
Descending
colon
Anterior renal
(Toldt’
s) fascia
Left
mesocolon
Figure 16.3 Computerized axial tomographic image demonstrating the anterior renal fascia. It is now known that this cor-
responds to Toldt’s fascia. Fat in the retroperitoneum is separated from the left mesocolon by Toldt’s fascia.
Mesenteric obesity
Intact mesentery
Obese
transverse
mesocolon
Surface of mesentery
disrupted
Figure 16.4 Intraoperative demonstration of mesentery in
an obese patient. The mesenteric surface was inadvertently
disrupted in the region demonstrated. This was followed
by localized bleeding from mesenteric vessels.
214 General techniques in mesenteric-based colorectal surgery
signifi ant technical challenges. It sometimes causes mesen-
teric inammation resulting in fusion of planar components
(i.e., mesentery and fascia) [49–55]. A knowledge of mes-
enteric anatomy enables the surgeon to identify planes and
separate relevant components with minimal damage [7]. e
eects of radiotherapy are patient specific, in some instances
extensive, and in others minimal. Little is known regarding
the histologic and molecular eects of radiotherapy on mes-
entery, and as such this represents an important avenue for
future research. e radiographic appearance of radiation-
related mesenteric changes should forewarn the surgeon to
particular technical challenges.
INSTRUMENTS USED IN ROBOTIC,
LAPAROSCOPIC, AND OPEN
COLORECTAL SURGERY
Table 16.1 lists some of the instruments useful in achiev-
ing the goals involved in open, laparoscopic, and robotic
mesenteric-based surgery. ese will be referred to in the
descriptions that follow.
Patient position and mesenteric access
Laparoscopic mesenteric-based surgery requires the patient
to be placed in somewhat extreme positions. ese are neces-
sary to permit adequate mesenteric access (Figure 16.7). Th s,
coupled with the duration of laparoscopic procedures, means
that patients may be subjected to prolonged pressure at several
points of neurologic or musculoskeletal vulnerability (i.e., com-
mon peroneal nerve). ere are numerous reports of medico-
legal cases derived from complications related to positioning
[56–60]. As a result, it is a major concern in mesenteric-based
surgery. In contrast, it may be that extremes of position can be
avoided during robotic colorectal surgery. e versatility of the
wristed instruments may provide capabilities that obviate plac-
ing the patient in steep Trendlenberg position.
ere are very few regions of the small intestine and
associated mesentery that themselves are not directly acces-
sible. In contrast, mesocolic access must be developed. Patient
positioning helps enormously in this regard. is applies for
both open and laparoscopic surgery, but given that the mes-
entery cannot be manually displaced in the laparoscopic
and robotic context, positioning becomes relatively more
important in these. For laparoscopic, but not for robotic,
surgery, it must be possible to place the patient in steep (or
reverse) Trendlenberg position, if required. Prior to start-
ing one must ensure that the patient is adequately secured
to prevent their sliding on the operating table. A sudden
change in position, or the inability to safely generate a par-
ticular position, may force a conversion to an open opera-
tion, or greatly increase the technical diculty (Figure 16.7).
Toldt’s fascia
Toldt’s fascia
Right gonadal
vessel
Right ureter
Toldt’s fascia (open surgery)
Figure 16.6 Intraoperative (open) view of relationship
between mesentery, fascia, and underlying retroperito-
neum. The fascia is translucent and provides an extremely
thin barrier to the retroperitoneum.
Mesentery in thin patient
Sigmoid vessel
Mesosigmoid
Superior rectal
adipovascular pedicle
Inferior mesenteric
adipovascular pedicle
Figure 16.5 Intraoperative view of extremely thin mesen-
tery. Fat is minimal and contained vessels are thus readily
identiable. There is a relative lack of connective tissue
around these vessels, which means there is an increased
risk of bleeding on minimal retraction.
Instruments used in robotic, laparoscopic, and open colorectal surgery 215
Table 16.1 Key instrument utilized in open and laparoscopic mesenteric surgery
Open Robotic/Laparoscopic
Metzenbaum scissors Robotic/laparoscopic stack system
Monopolar diathermy 30° camera
Deaver retractor Gas tubing and cables
Hand-held abdominal retractor Ports: 12, 10, 8, 5 mm
Kelly retractor Energy sealant device/monopolar diathermy
Self-retaining abdominal retractor Bipolar fenestrated grasper
Artery clips Monoplar curve tip scissors
Babcock tissue forceps Vessel sealer
Debakey tissue forceps Pencil diathermy
Needle holder Wound protector
Energy sealant device Endoscopic stapling device
Surgical stapling device Endoscopic circular stapler
Suction and irrigation device Smoke extractor
Large-sized swabs/packs Endoscopic suction and irrigation device
(a)
(c)
(d)
(b)
Mesocolic access
Poor
mesocolic
access
Excellent
mesocolic
access
Left
mesocolon
Figure 16.7 Examples of adequate and inadequate mesenteric access in the context of the left mesocolon. Where mesen-
teric access is inadequate the small bowel (and associated mesentery) overlie the left mesocolon (a, b). The omentum can
also overlie it as a result of adhesions between the latter and the colon. Where access is adequate there is an unimpeded
access to the mesocolon (c, d).