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226 General techniques in mesenteric-based colorectal surgery
division of omento-mesocolic adhesions eventually disrupts
the adherence between the greater omentum and mesocolon
suffici tly to permit entry into the lesser sac proper. Liing
the stomach superiorly and following the transverse meso-
colon toward the pancreas will demonstrate short adhesions
between the mesocolon and either the pancreas or stomach.
Although these should also be divided one must bear in mind
that dissection here brings one down onto the true root of the
mesentery (i.e., the origin of the superior mesenteric artery).
e principles of robotic and laparoscopic separation
of the mesocolon and greater omentum are the same,
although the approach is diffe ent. It is however possible
to adopt a similar approach in laparoscopic separation, by
grasping the transverse colon and liing the greater omen-
tum in the opposite direction. is will identify the reec-
tion between the two and permit its division. An alternative
approach is to grasp the greater omentum just distal to
the greater curvature of the stomach, with traction in one
direction and with counter-traction exerted by the assis-
tant in the opposite direction. e intervening omentum
is then divided until the lesser sac is entered (Figure 16.21).
Omental division is continued to where the right and le
contributions to the gastroepiploic arcade occur, when the
direction of dissection changes angle toward the splenic
exure. While this process separates the greater omen-
tum off the transverse mesocolon, a bulk of omentum will
remain attached to the colon. is is useful, however, and
can in turn be exploited during retraction. Retraction of
the colon toward the right iliac fossa places the fascial
attachment of the mesocolon under stretch. Alternatively,
the patient can be placed in the steep right shoulder down
position, and the resultant eff ct of gravity on omentum
and colon means that the colo- and mesofascial interfaces
at the splenic exure are easily identifi d, accessed, and
separated (see Chapter 20).
COLO- AND MESOFASCIAL INTERFACE
One of the key techniques in colorectal and intestinal
surgery is identication of the interface formed between
mesocolon (or colon) and Toldt’s fascia (Figure 16.22).
Inmost reference texts, authors highlight the white line of
Toldt as the landmark at which to commence mobilization.
Peritonotomy in this region is very useful, but only when
one keeps the concept of colo- and mesofascial planes in
mind. If not, the retrofascial plane is frequently entered
(Figure 16.23) and the retroperitoneum dissected. To avoid
this, some surgeons emphasize peritonotomy one centime-
ter medial to the white line of Toldt. e problem here is
that in the case of the right and left colon, “one centimeter
medial” brings one directly onto the colonic surface.
e key point to keep in mind is that peritonotomy
provides access to the colo- or mesofascial plane. In keep-
ing with this, peritonotomy medial to the white line of
Toldtshould be done with a view to identifying this plane.
Aer peritonotomy, the colon is placed under traction away
from the posterior abdominal wall. Traction is transmitted
to the plane and the interface between colon or mesocolon,
and fascia, is apparent. is principle is universally appli-
cable (Figure 16.24). As such, this concept will be reiterated
throughout this book (Figure 16.25).
GR AVITY
e eects of gravity on tissue form a useful adjunct
in laparoscopic and open surgery. In fact, in laparo-
scopic surgery, it is crucial to exploit gravity in keeping
the greateromentum and small bowel/mesentery off the
mesocolic operative fi ld.
Countering the eff cts of gravity is also centrally impor-
tant. It must be overcome in liing mesentery off the ret-
roperitoneum to place the meso- or colofascial interface
under stretch. It is only by placing this plane under stretch
that one identifi s the interface. Examples of this occur on
the right and left sides where the mesocolon is lied off the
retroperitoneum.
SPECIMEN EXTRACTION
is is a technical activity that generally receives little
attention. Injudicious extraction leads to tissue trauma,
mesenteric devascularization and can signicantly compro-
mise an operation. It is particularly relevant in laparoscopic
and robotic surgery where a port site is elongated to permit
exteriorization. Provided mesenteric mobilization is com-
plete, the length of an extraction site can remain minimal.
emain reason for this lies in the fact that mesentery is
malleable and will conform in shape to that of the extraction
site. us, an ordinarily bulky greater omentum or mesen-
tery or colon can be removed through a small extraction site.
Stomach
Lesser sac
Lesser sac
Transverse
mesocolon
Greater omentum
Figure 16.21 Intraoperative view of the lesser sac after
dividing the greater omentum to gain access.
Specimen extraction 227
(c)
Mesosigmoid
mesocolic fascia
Mesosigmoid
mesocolon
Right
mesocolon
Toldt’s
fascia
(b)
Mesofacial plane
Mesocolon
Toldt’s fascia
Retr
operitoneum
(a)
Figure 16.22 (a) Schematic illustration of the mesofascial plane. (b) Intraoperative (laparoscopic surgery) demonstration of
the mesofascial plane. (c) Intraoperative (open surgery) view of the mesofascial plane.
228 General techniques in mesenteric-based colorectal surgery
Iliopsoas muscle
(beneath fascia)
Mesosigmoidal
fascia
Mesocolon
Toldt’s fascia
Retroperitoneum
Toldt’s
fascia
Duodenum
Head of
pancreas
(a)
(b)
(c)
Retrofascial plane
Figure 16.23 (a) Schematic illustration of retrofascial plane of dissection. (b) Intraoperative (open) example of dissection in
the retrofascial plane. (c) Intraoperative (laparoscopic) view of dissection in the retrofascial plane.
Closing the mesenteric defect 229
Forexample,following a laparoscopic or robotic total meso-
colectomy, the entire gastro-mesocolic complex can be eased
through a stoma-sized defect in the abdominal wall.
at is not to say that extraction always proceeds eort-
lessly. Sometimes it can be quite dicult. A number of
approaches can be utilized to facilitate this. In the fi st
instance, a fi ger can be invaginated along the side of
the mesentery through the extraction site into an intra-
peritoneal location. In this manner, a component of the
mesentery can be digitally eased into an extra-peritoneal
position. Th s has the eect of releasing an adjoining mes-
enteric region, allowing more mesentery and associated
colon through. Oentimes, a spiral twisting of the speci-
men within the extraction site allows the intestinal tract
to disengage through the aperture, bringing the associated
mesentery with it. A fi al (somewhat traumatic) approach
is to introduce abdominal retractors to widen an extrac-
tion aperture allowing a greater amount of mesentery and
colon through. If these measures fail, then the incision
should be widened.
CLOSING THE MESENTERIC DEFECT
Although the term “anastomosis” is not generally applied
to the divided margins of the mesentery, it is a legitimate
application of the term. In general, surgeons do not “anasto-
mose” cut ends of mesentery except to prevent internal her-
nia formation. is is not always required if the mesenteric
fenestration created during a resection is wide enough to
permit small bowel to freely move in and out. It is required,
though, when the mesenteric defect (i.e., the hernia neck)
is narrow in which case there is an increased likelihood of
incarceration or strangulation [65]. Anastomosing mesen-
teric margins is generally conducted using a running or
interrupted 2-0 absorbable stitch.
A further consideration is the conformation of the
mesenteric anastomosis. Just as an intestinal anastomosis
has end–end or end–side conformation, so too does the
mesentery. By denition, and end-to-side intestinal anas-
tomosis will have an end–side mesenteric anastomosis.
econformation of the mesenteric anastomosis may have
Laparoscopic view of mesofacial plane
Peritonotomy
exposing
mesosigmoid
and fascia
(i.e., mesofascia
l
plane)
Peritonotomy
margin
Mesosigmoid
(a)
(b)
Mesosigmoidal
(Toldt’s ) fascia
Peritonotomy margin
Figure 16.24 Laparoscopic views of (a) peritonotomy and (b) view of mesofascial plane.
230 General techniques in mesenteric-based colorectal surgery
a clinic–pathologic correlate. Data indicate that recurrence
of Crohn’s disease tends to occur proximal to the intesti-
nal anastomosis, although the reason for this is unknown.
iscould be explained by the conformation of the mesen-
teric anastomosis. In an end–end anastomosis, two cut ends
of the mesentery are joined. As both have been divided, both
are sources of ongoing inammation. e proximal pole of
the mesenteric anastomosis is rst to encounter the eff cts
of environmental factors within the intestine. is, coupled
with the conformation of the mesenteric anastomosis, could
explain the distribution of recurrent Crohn’s disease, proxi-
mal to the intestinal anastomosis. It could also explain the
apparent reduction in the development of recurrent Crohn’s
disease following a side–side intestinal anastomosis. In this
setting, divided edges of the mesentery do not come into
direct contact.
SUMMARY
Most operative of time in resectional colorectal surgery is
spent in mobilizing and resecting the mesentery. As a result,
the surgeon must be familiar with approaches to perito-
notomy, mesenterotomy, mesofascial separation, mesen-
terectomy, and vascular skeletonization and division. e
colorectal surgeon must be able to achieve these goals in the
robotic, laparoscopic, and open surgical context.
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Open view of mesofacial plane
Peritonotomy
Peritonotomy
margin
Mesosigmoidal
(i.e., Toldt’s )
fascia
Mesosigmoidal
fascia
Mesosigmoid
Mesosigmoid
(a)
(b)
Figure 16.25 Open surgical views of (a) peritonotomy and (b) mesofascial plane.
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233
17
Mesenteric component of sigmoid colectomy
J. CALVIN COFFEY AND MATHEW KALADY
Once you have mastered a technique, you hardly
need look at the recipe again and can take off
on your own.
Julia Child
AIMS
To demonstrate the mesenteric and peritoneal basis of
sigmoidal resection.
INTRODUCTION
e term “sigmoidectomy” is similar to right hemicolec-
tomy and anterior resection insofar as it omits reference to
that component of the procedure that requires most time
(i.e., detachment and disconnection of the mesosigmoid)
[1,2]. It has been suggested that the term “sigmoidectomy” be
substituted by “total” or “partial mesosigmoidectomy” [1,2].
Total mesosigmoidectomy directly references the mesenter-
ectomy, and given that removal of the sigmoid is implicit
(it is not possible to retain the sigmoid in the absence of a
mesosigmoid), the word “sigmoidectomy” could be justi-
ably substituted by “mesosigmoidectomy.” is is analogous
to total mesorectal excision, complete mesocolic excision,
and total mesocolectomy.
PREOPERATIVE PREPARATION
Preoperative radiographic imaging provides numerous
opportunities for preparation prior to surger y. Assessmentof
visceral adiposity (i.e., mesenteric adiposity) provides the
surgeon with an indication of the level of technical di-
culty likely to be encountered. is is particularly impor-
tant in inammatory conditions such as diverticulitis where
the mesentery can be grossly inamed and edematous.
In these cases, the mesentery diffe s considerably (from
normal) in terms of consistency and vascularity. Some cor-
rectly argue that the diverticular mesentery resembles that
seen in Crohn’s disease [3,4]. Although mesenteric thicken-
ing occurs in both, fat wrapping (creeping fat) is unique to
Crohn’s disease [5–7]. Surgical management of the mesen-
tery in both settings can be quite challenging.
e identication of an abscess on preoperative imag-
ing is technically important. An abscess is a walled-o
collection of pus. In the case of an intraperitoneal abscess
derived from a sigmoidal process, the “walling o” eff ct, or
compartmentalization, generally involves multiple organs
including bladder, small bowel (and associated mesentery),
sigmoid, and mesosigmoid. In this setting, it is particularly
important to have clear understanding of mesenteric and
peritoneal reection anatomy as it is imperative to accu-
rately diffe entiate individual structures [8]. If dissection
proceeds indiscriminately then mesenteric injury is inevi-
table, bleeding extensive, and the surgeon may be compelled
to resect bowel that could otherwise have been retained.
Although the general rule is to avoid operating in the
setting of a phlegmon, this may not be possible in patients
who failed conservative management, or in emergencies.
Most prefer to separate phlegmon components under
direct vision and although this can be done via minimally
invasive means (by careful and anatomic separation), the
Aims 233
Introduction 233
Preoperative preparation 233
Preparation of the operative eld 234
Techniques: Laparoscopic/robotic partial/total
mesosigmoidectomy 234
Open mesosigmoidectomy 239
Special considerations: Unable to identify the
correctanatomic plane for mobilization 249
Future directions 249
Summary 249
References 249
234 Mesenteric component of sigmoid colectomy
commonest approach is via open laparotomy. Some adopt
a hybrid approach where splenic exure and left colon/
mesocolon are rst mobilized using minimally invasive
means (i.e., robotically or laparoscopically). Separation of
phlegmon components is then done via a short (lower mid-
line) incision. is approach has been used to good eff ct in
the setting of a diverticular colovesical stula [9–13].
Two additional points are important in diverticular sur-
gery. Oentimes, either the bladder or ureter can be involved.
Ideally, this should be preempted on review of preoperative
imaging and not encountered unexpectedly during an oper-
ation. Urologic support may be required and should be orga-
nized preoperatively, and consideration should be given, in
advance, to ureteric stent placement [14–16].
PREPARATION OF THE OPERATIVE FIELD
As with most colorectal surgery, it is imperative to set up
the operative fi ld correctly. e primary aim is to develop
unimpeded mesocolic access from the mesosigmoid to the
splenic exure. In laparoscopic and robotic settings, this
can beachieved placing a 10/12mm port in the right lower
quadrant and a 5 mm (or 8 mm in the case of robotic sur-
gery) port in the right upper quadrant as well as a 5 mm
(or8 mm) port in the left lower quadrant, to assist in retrac-
tion. Port placement may be adjusted based on overall body
habitus and intraperitoneal anatomy. e optimal scope
has a 30° lens. Patient positioning in Trendelenburg with
the right side down, allows the small bowel (and associ-
ated mesentery) and greater omentum to fall away from the
left mesocolon and mesosigmoid. When this is technically
dicult and it is not possible to remove the small bowel
and mesentery from the pelvis, it is likely due to adhesions
between the small bowel mesentery and mesosigmoid.
Adhesions frequently occur between greater omentum and
left mesocolon. ese should be divided to ensure unim-
peded mesocolic access as far medially as the duodenoje-
junal exure. Although it is feasible to conduct a total or
partial mesosigmoidectomy without full direct access to
the left mesocolon, this increases the possibility of intraop-
erative complications and should ideally be avoided.
TECHNIQUES: LAPAROSCOPIC/ROBOTIC
PARTIAL/TOTAL MESOSIGMOIDECTOMY
e rst major component of “medial to lateral” meso-
sigmoidectomy is mobilization of the inferior mesenteric
adipovascular pedicle from the posterior abdominal wall
(Figure 17.1a). is commences with peritonotomy of the
right mesosigmoidal peritoneal reection. To facilitate this,
the mesosigmoid must be lied away from the retroperito-
neum, thereby exaggerating the groove created by the peri-
toneal reection. Peritonotomy in the correct location may
be followed by inltration of the mesofascial plane with CO
2
.
is “CO
2
dissection” can greatly aid in the identication of
the correct plane of dissection and in facilitating mesofas-
cial separation. In sequentially separating the mesosigmoid
from underlying fascia, the adipovascular pedicle is gradu-
ally mobilized. Given the importance of these steps they
will be described in further detail in the following.
e sigmoid colon is grasped at an appendices epi-
ploicae using a grasper (placed through a left iliac fossa
5mm port). It is then lied toward the anterior abdomi-
nal wall. is has the eff ct of liing the mesosigmoid o
the retroperitoneum. In so doing, the peritoneal reection
at the base of the mesosigmoid is exaggerated providing
an anatomic landmark for the commencement of dissec-
tion (Figure 17.1). e surgeon grasps the medial aspect of
the mesosigmoid with an atraumatic grasper and places
it under further tension. Using the tissue sealant device,
such as the Harmonic scalpel, the mesothelium is divided
(i.e., peritonotomy) along a number of centimeters. It
is important to limit the depth of the peritonotomy as
digression into the mesosigmoid at this location leads to
bleeding that obscures the mesofascial plane.
e mesosigmoidal fascia resembles the mesorectal
fascia and is areolar in appearance [17–19]. As a result,
it is not uncommon for the surgeon to experience some
diculty in immediately identifying the mesofascial
plane at this point in the operation. Cautious dissection
here is usually successful in this context as the mesofas-
cial interface is a plane of minimal resistance that emerges
with traction and dissection in the correct orientation. If
one is clearly in the mesosigmoid then dissection should
stop, and a separate peritonotomy created closer to the
posterior abdominal wall. Importantly, the surgeon
should never proceed with mobilization of the adipo-
vascular pedicle, until the mesofascial interface has been
identifi d and developed. ere are occasions (albeit rare)
when this is not possible despite all eff rts. In this setting,
one is best advised to develop the mesofascial interface
elsewhere rst. is approach is encapsulated in Victor
Fazio’s term “Circle the enemy.”
e 30° lens is exceptionally useful at this stage in the
procedure. Once a window has been made, and the begin-
nings of the mesofascial interface separated (Figure 17.2),
the lens face is reoriented to look “underneath” the meso-
sigmoid. is permits further mesofascial separation
from medial to lateral. Gradually, further medial to lateral
mesofascial separation becomes easier (compared with
the starting mobilization). e focus of dissection returns
to the medial aspect of the mesosigmoid where mesothe-
lium is divided proximally (thereby extending the initial
peritonotomy). As the overall aim is to free the inferior
mesenteric artery (IMA) adipovascular pedicle from the
retroperitoneum, extension of the peritonotomy should
proceed cephalad, back up along the origin of the IMA,
toward the le mesocolon.
Mesosigmoidal fat is divided under high magnication
(with a vapor extractor in use), thereby separating the
adipovascular reection off the retroperitoneum. In so
doing, the 30° lens is repeatedly reoriented to visualize
the under surface of the mesosigmoid and the mesofascial
interface (Figures 17.1 and 17.2).
Techniques: Laparoscopic/robotic partial/total mesosigmoidectomy 235
Extension of
peritonotomy
Mesosigmoidal
(Toldt’s ) fascia
Retroperitoneum
(d)
Inferior
mesenteric
artery
Extension of peritonotomy
PeritonotomyMesosigmoid
(b
) Toldt’
s fascia
Retroperitoneum(c)
Mesosigmoid
peritoneal
reflection
(a)
Mesosigmoidectomy
Sigmoid colon
Figure 17.1 Panel demonstrating the right (lateral) aspect of the base of the mesosigmoid and the peritoneal
reection in this location. (a) Image of digital model demonstrating the reection here. (b) Intraoperative appear-
ance of mesosigmoidal peritoneal reection as seen at the commencement of a laparoscopic mesosigmoidectomy.
A peritonotomy has been commenced. (c) The peritonotomy in (b) has been lengthened, exposing the underlying fascia
(Toldt’s or the mesosigmoidal fascia) and the overlying mesosigmoid. (d) When the peritonotomy is lengthened further
proximally, the inferior mesenteric artery comes into view.