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256 Mesenteric component of rectal resection
Left mesocolon mobilization
Inferior
mesenteric
adipovascular
pedicle
Perivascular
connective
tissue
Undersur
face
of mesocolon
Left
mesocolic
(Toldt’s ) fascia
(b)
(a)
Figure 18.4 (See also QR 3d/1-2 and QR 2/11.) Left mesocolic mobilization. (a) Laparoscopic view of the inferior mesenteric
artery (IMA) after mobilization and skeletonization. (b) Laparoscopic view of the left mesocolon and adherent underlying
mesocolic (i.e., Toldt’s) fascia. This view becomes readily apparent after division of the inferior mesenteric vessels. The left
ureter is visible deep to the fascia.
Inferior
mesenteric
adipovascular
pedicle
Mesosigmoidal
(Toldt’s ) fascia
Inferior
mesenteric
adipovascular
pedicle
Mesosigmoidal
(Toldt’s ) fascia
(c) (d)
Mesosigmoid Mesosigmoid
Figure 18.3 (Continued ) Mesosigmoidal mobilization. (c) Laparoscopic view of mesofascial separation overlying mesosig-
moid and underlying fascia. (d)Corresponding digital image demonstrating peritoneal, mesenteric, and fascial regional
anatomy at this point in dissection.
Technique: Laparoscopic/Robotic 257
the left side (see earlier) and the right joined (Figure 18.8).
isopens the posterior midline fully and the contour of the
posterior surface of the mesorectum is seen (Figure 18.8).
At this point, the surgeon can dissect distally in the
posterior midline for a considerable distance (sometimes
reaching the pelvic oor). e principle of the dissection is
always the same; identication of the mesofascial interface,
and separation of components of this (Figures 18.6 through
18.8). is ensures that the mesorectum is gradually detached
but not disrupted. Dissection is directed through the fascia,
sweeping it anteriorly toward the rectum, to maintain an
intact mesorectal package. is is more easily achieved in the
posterior midline compared with laterally where the fascia is
signicantly attenuated and may even be absent.
Good traction and countertraction are essential along
the lateral and anterolateral aspects of the mesorectum
(Figures 18.6 through 18.8). e fat of the pelvic side wall in
the anterolateral extremes of dissection encroaches on that
of the mesorectum at the zone of adherence (i.e., T zone)
(Figure 18.9). If traction is placed anteriorly and counter-
traction posteriorly, a subtle interface is oen evident here
and provides an anatomic landmark to dissect through. In
an obese individual, a planar anatomic dissection can be
quite dicult here. If one develops the mesofascial plane
anteriorly and posteriorly, then one isolates the zone of
adherence and can dissect through it more readily. is
remains a region of technical diculty and focus for future
studies (Figure 18.9).
Division of the pararectal peritoneal reflections
(a)
Upper
rectum
Peritonotomy
through
right pararectal
re˜ec tion
(b)
Upper
rectum
Pe
ritonotomy
through left
pararectal
re˜ec tion
Figure 18.5 Division of the pararectal peritoneal reections. (a) (See also QR 2d/5.) Laparoscopic view of division of the right
pararectal peritoneal reection. (b) (See also QR 2d/6.) Robotic view of division of the left pararectal peritoneal reection.
258 Mesenteric component of rectal resection
e next step is the anterior rectum. e peritoneum of
the anterior midline (in the pouch of Douglas) is deected
anteriorly. e surgeon grasps the anterior surface of the dis-
tal rectum with an atraumatic grasper and lis the rectum
upward, o the pelvic oor, and posteriorly toward the sacrum
(Figure 18.10). is places the anterior peritoneal reection
under tension and exaggerates the groove at the reection.
In the female, the anterior peritonotomy is made along the
line of the groove, thereby gaining access to the rectovaginal
septum (Figure 18.10). In the male (Figure 18.11), the anterior
peritonotomy is started 5mm anterior to the groove. In this
manner, the seminal vesicles come into view.
In the male, the seminal vesicles become apparent ante-
riorly and once identifi d can be deected anteriorly. One
will note that with adequate anterior retraction and rectal
countertraction (upward and posteriorly) a plane of dissec-
tion develops at this location and can be followed posterior
to the seminal vesicles, posterior to the prostate and dis-
tally onto the distal rectum (Figure 18.11). is dissection
is done under high magnication, with vapor extraction,
and proceeds in a gradual manner ensuring hemostasis
throughout. e orientation of the prostate is an impor-
tant consideration when the patient is in the supine or head
down position. e prostate is positioned forward and infe-
rior to the seminal vesicles, as is the membranous urethra.
As a result, once one has developed the plane posterior to
the seminal vesicles, then there is a limited distance only
between this and the distal reaches of the rectum.
Left mesofascial separation
Mesorectum
Pe
ritonotomy of
left pararectal
reflection
Mesorectal
(Toldt’s ) fascia
(a)
(b)
Toldt’s
fascia
Mesorectum
Mesorectal
fascia
Left
mesorectum
Mesosigmoid
Figure 18.6 (a) (See also QR 2d/6.) Laparoscopic view of mobilization of the left mesofascial plane. As this proceeds, the
mesorectal fascia and left lateral aspect of the mesorectum are separated. (b) (See also QR 13/2.) Digital image demon-
strating regional anatomy during mesofascial separation in this anatomic location.
Technique: Laparoscopic/Robotic 259
Sometimes in the particularly obese individual, a distinct
plane cannot be readily identifi d in the anterior midline.
Rather than dissecting directly through here, the anterolat-
eral aspect of the mesorectal package is further mobilized on
either side. e rectum is then retracted upward and poste-
riorly, and the anterior midline deected further anteriorly.
ese activities mimic those in open surgery where the lipped
pelvic retractor (in the anterior midline) is inserted deep into
the pelvis and countertraction exerted upward and posteriorly
on the rectum. e eff cts of this combination of traction and
countertraction are to expose the correct plane of dissection in
the anterior midline (even in the massively obese male).
By now, the level of the dissection is deep in the pel-
vis. e principles of dissection are the same; traction and
countertraction demonstrate the mesofascial plane aer
which separation of whose components leads to further
mobilization. Mesenteric continuity means that dissecting in
a zone-based manner (i.e., posterior, followed by lateral and
then anterior zones) facilitates exposure of the correct plane
in adjoining zones. In other words, the plane of dissection in
one zone becomes apparent following anatomic mobilization
in an adjacent zone. Very occasionally, in the particularly
obese, it may be necessary to dissect directly through fat.
is should be minimized, and every eff rt should be made
to remain in an anatomic plane.
At the pelvic oor, Waldeyer’s fascia is identifi d in the
posterior midline (Figure 18.12). is is a condensation
of mesorectal/Toldt’s fascia and is not a separate entity as
Toldt’s
fascia
(b)
Mesosigmoid
Right
mesorectum
Mesorec
tum
Left mesofascial separation
Mesorectal
(Toldt’s) fascia
(a)
Peritonotomy of
right pararectal
reflection
Figure 18.7 (a) (See also QR 2d/5.) Robotic view of mobilization of the right mesofascial plane. As this proceeds, the
mesorectal fascia and right lateral aspect of the mesorectum are separated. (b) (See also QR 13/1.) Digital image demon-
strating regional anatomy during mesofascial separation at this point.
260 Mesenteric component of rectal resection
Posterior mesofascial separation
(b)
Mesorectal
(T
oldt’s) fascial
Mesorectum
Mesosig
moid
Mesorectum
Mesorectal
(Toldt’s) fascial
(a)
Figure 18.8 (a) Robotic view of mobilization of the posterior mesofascial plane. As this proceeds, the mesorectal fascia
and posterior aspect of the mesorectum are separated. (b) (See also QR 13/7.) Digital image demonstrating regional
anatomy during mesofascial separation.
Right zone of adhesion
Mesorectal
(T
oldt’s) fascia
Mesorectum
Right zone
of adhesion
Figure 18.9 Robotic view of the zone of adhesion on the right side.
Technique: Laparoscopic/Robotic 261
sometimes depicted. Similarities with Toldt’s fascia else-
where are demonstrated in Figure 18.12. A middle sacral
artery can sometimes occur here and division may cause
troublesome hemorrhage. e vessel is identiable when
dissecting through the fascia under high magnication.
epelvic oor becomes apparent directly in front of view.
With the patient in the lithotomy position, it has a verti-
cal orientation, and slopes diagonally inward as it radially
encroaches on the anal canal. As the mesorectum cones
inward at the distal rectum, the latter can sometimes come
into view suddenly, so careful high-magnication dissection
is again necessary. Dissection in the posterior midline
generally facilitates posterolateral dissection, which in turn
facilitates lateral and thereaer anterolateral dissection.
In completing this sequentially on the left and right, the
entire mesorectum/rectal complex is detached or mobilized
en bloc without disruption. e dissection is only complete
when the red/brown colored bers of the pelvic oor are
seen marking a distal boundary to further dissection.
Where the entire rectum is not bei ng removed (i.e., part ial
mesorectal excision), the mesorectum must be divided
across to expose the serosal surface of the rectum. It is
The anterior peritoneal reflection
Intact
anterior
re˜ec tion
(a)
(b)
Divided
anterior
reflection
Mesorectal
(T
oldt’s) fascia
Anterior
mesorectum/
Denonvillier’s
fascia
Peritonoto
my
margin
Mesorectum
on right
Figure 18.10 The anterior peritoneal reection I (nonobese female). (a) Laparoscopic view of operative eld seen as
the right pararectal peritonotomy is continued distally onto the anterior peritoneal reection. (b) (See also QR 2d/5-7.)
Regional anatomy after division through the anterior peritoneal reection.
262 Mesenteric component of rectal resection
important to take time to do this carefully and thoroughly.
Once the mesorectum has been divided, it retracts distally
and becomes dicult to grasp directly. Its fatty composition
means that it will bleed and tear if directly grasped. In order
to achieve adequate mesorectal division, the mesothelium
overlying the mesorectum is grasped with an atraumatic
grasper. Mesorectal fat can then dissected through using a
tissue sealant device such as the harmonic scalpel. is must
be done under high magnication (with a smoke extractor
or vapor extractor) and in a gradual manner. esuperior
Anterior peritoneal reflection II
Intact
anterior
reflection
(a)
(b)
Rectum
Pe
ritonotomy
of anterior
reflection
Anterior
mesorectum
Mesorectal
fascia
Proximal edge
of anterior
reflection
Divided right
pararectal
reflection
Divided left
pararectal
reflection
Figure 18.11 (See also QR 2d/5-7.) The anterior peritoneal reection II (obese male). (a) Intraoperative view demonstrat-
ing the intact anterior peritoneal reection prior to peritonotomy here. Both the left and right pararectal reections have
been divided to the level of the anterior peritoneal reection. (b) Regional anatomy evident after division of the anterior
peritoneal reection. Theanterior aspect of the mesorectum is apparent as is the fascia interposed between this and the
seminal vesicles/prostate.
Technique: Laparoscopic/Robotic 263
rectal artery and vein should be anticipated and can be
divided using vessel sealant device, clips, or a stapling
device. In general, these vessels are attenuated in the mid to
distal mesorectum and thus more suited to division using
vessel sealant devices such as the Ligasure™, vessel sealer or
harmonic scalpel. e rectum must be repeatedly deected
left and right to demonstrate residual mesorectal tissue on
both sides and in the posterior midline. It is only when
the rectum is fully skeletonized circumferentially that one
should consider dividing it.
Waldeyer’s (i.e., Toldt’s) fascia
Posterior
mesorectum
Rectum
Waldeyer’s
(i.e., Toldt’s )
fascia
Waldeyer’s
(i.e., Toldt’s )
fascia
Waldeyer’s
(i.e., Toldt’s
)
fascia
Rectum and
mesorectum
(a)
(b
)
(c)
Figure 18.12 Waldeyer’s fascia. The fascia is a condensation of Toldt’s fascia in the distal pelvis where it lls the space
created by tapering of the mesorectum away from the surrounding pelvis. Robotic demonstration of Waldeyer’s fascia
posterior to mesorectum (a), lateral to the mesorectum on the left (b), and lateral to the mesorectum on the right (c).
264 Mesenteric component of rectal resection
OPEN TOTAL OR PARTIAL MESORECTAL
EXCISION
Preoperative setup and intraoperative access-related con-
siderations are identical to those for total or partial meso-
sigmoidectomy so they will be mentioned here in brief
only. It is essential to generate unimpeded access to the
left mesocolon, the mesosigmoid, and the mesorectum. In
all cases, the IMA should be identifi d clearly and ligated
proximal to the origin of the left colic artery. Although
this is not a requirement in benign disease, it is anatomic,
is mesenteric based, and provides an excellent teaching
opportunity for trainees. Accordingly, many surgeons
routinely mobilize the inferior mesenteric adipovascular
pedicle to skeletonize and expose the vessel for safe liga-
tion and division. Inorder to achieve this safely and repro-
ducibly, one requires unimpeded access to the entire le
mesocolon. us, it may sometimes be necessary to divide
congenital adhesions that can occur between the DJ exure
and the le mesocolon.
Trendelenburg positioning is particularly useful in the
context of rectal dissection deep in the pelvis. is posi-
tioning ensures that the greater omentum, small bowel, and
associated mesentery slide out and away from from the pel-
vis, off the right surface of the mesosigmoid and anterior
surface of left mesocolon. Appropriate instrumentation is
essential in providing adequate access and exposure deep
in the pelvis, and, in this regard, few instruments are better
than the lipped pelvic retractor. e shaft of this retractor
has a long stem and is lipped at one extremity, while the arm
of the extractor is at a right angle at the proximal extremity.
Narrower versions are available and some adaptations have
a light source connected along the shaft to permit illumi-
nation of the distal pelvis. Many would rightly advocate a
headlamp to provide adequate illumination of the distal
pelvis. is simple measure facilitates careful dissection in
anatomic planes at all stages of the dissection. Additional
tips that help with mesorectal access include carefully
spreading the legs upward and outward or placing a large
10 × 10cm swab against the perineum, thereby forcing the
perineum upward and forward.
Video recording of open mesorectal
excision
e development of the concept of TME by Professor Bill
Heald and Mr Brendan Moran was greatly aided by their
insistence on using high magnication and resolution
recordings for demonstration purposes [17–19]. In the recent
past, we adapted the capabilities of the laparoscope and
combined this with an external snake arm in the form of
the UL exoscope (Figure 18.13). While the surgeon and the
assistant perform the procedure, it is our custom to request
a resident or medical student (also scrubbed) to control the
position of the tip of the exoscope as well as the orientation
of the 30° lens. Images are then transmitted in the usual
manner to a television monitor mounted on a stack. In this
manner, the open surgical procedure is readily conveyed
to all theater staff including nursing and anesthetic sta.
Although we do not have quantitative data to support the
following, we have noticed that this transforms the opera-
tive environment. Where previously the open dissection
could not be visualized by anybody other than the actual
operating surgeon, images transmitted via the laparoscope
to a laparoscopic stack demonstrate the entire operation to
all in the operating room. Once videos have been obtained,
they are edited in Final Cut Pro (Apple Inc., Cupertino, CA)
and an audio accompaniment established aer which they
are archived (Figure18.13). e University of Limerick (UL)
exoscope adaptation thus overcomes many of the limitations
of previous modalities of video recording and rendition by
transmitting the surgeon’s point of view in a high denition
and high magnication format, to all in the operating room
(Figure 18.13).
Most importantly from a technical perspective, this means
that the subtle fascial planes between mesorectum and the
associated fascia are readily visible, rendered, and depicted.
Techniques
e reader is referred to Chapter 17 and to the open section
of mesosigmoidectomy for details related to mesosigmoidal
and mesocolic mobilization. Certain points will be mentioned
here however. ere is a tendency to commence the mobiliza-
tion at the mesosigmoidal level. is is particularly the case for
junior surgeons. It is dicult to do, and so should be avoided,
because the fascia in this region is areolar and attenuated. As
a result of these properties, it is dicult to identify the inter-
face formed between fascia and overlying mesosigmoid. Even
experienced surgeons can transgress into nonanatomic planes
in this region, entering either the retroperitoneum posteriorly
or the mesosigmoid anteriorly. Both are associated with bleed-
ing that, although minor, is sucient to obscure the fascial
interface and the plane in which one aims to dissect.
e surgeon begins by liing the proximal sigmoid
upward (away from the retroperitoneum). is places the
mesosigmoid and junction between descending and sigmoid
colon under tension (Figure 18.14). e eff ct is to transmit
tension to the peritoneal reection and the groove formed at
this is exaggerated. e white line of Toldt will be apparent
at the left peritoneal reection. In general, it is absent at the
mesosigmoidal reection. Beneath the attached component
of the mesosigmoid the fascia is areolar, less dense, and as
such a prominent white line is not apparent where the fas-
cia coalesces with the parietal peritoneum. is is another
reason why the surgeon should not rely entirely on the iden-
tication of the white line of Toldt as a landmark for the
commencement of peritonotomy.
e distal left peritoneal reection is divided expos-
ing the underlying colofascial interface. e colon is
retracted anteriorly, placing the interface under stretch,
and exaggerating the bers of Toldt’s fascia (Figure 18.14).
Colofascial separation permits medial mobilization of the
descending colon and brings the mesofascial interface
Open total or partial mesorectal excision 265
UL exoscope used during Ileal pouch–anal anastomosis
(c) (d)
Mesorectum
Rectum staple
transected just above
anorectal junction
Ileal pouch–anal
stapled anastomosis
Rectum above
anorectal junction
Ileal pouh
Anal
anastomosis
Anterior
(a) (b)
Figure 18.13 (a) UL exoscope. The 30° laparoscope lens is mounted on a snake arm and bracket. The complex is referred
to as the UL exoscope. (b–d) Represent views that can be obtained using the UL-exoscope concept. (b) Intraoperative
view of the distal rectum following its mobilization. The rectum has been retracted posteriorly. (c) Distal rectum follow-
ing transection just proximal to the anorectal junction. (d) Intraoperative view of ileal-pouch anal anastomosis after the
anastomosis has been completed.