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266 Mesenteric component of rectal resection
into view. ecomponents of this plane are separated to
detach the distal left mesocolon from the retroperitoneum
(Figure 18.14).
Given mesenteric continuity, detachment, or mobili-
zation in one region facilitates mobilization in adjacent
regions. Distal mobilization of the left mesocolon brings
the surgeon onto the correct plane of mobilization under
the mesosigmoid. At this point, further mobilization will
be hampered by the peritoneal reection at the left lateral
aspect of the mesosigmoid (Figure 18.15). e reection
is not always readily apparent and frequently obscured
by congenital adhesions that must be divided through
(Figure18.15). ey can be minimal or extensive, in which
case they form a sheetlike structure resembling the perito-
neal reection at the base of the mesosigmoid. Even experi-
enced surgeons can be surprised to nd when, aer dividing
Mobilization of junction between descending and sigmoid colon
Left peritoneal
reflection
(a)
(b)
Mesosigmoid
Sigmoid
Left
mesocolon
Mesosigmoid
Mesosigmoidal
(Toldt’s) fascia
l
Figure 18.14 (See also QR 2d/1-2.) Mobilization of junction between descending and sigmoid colon. (a) Lateral peritoneal
reection prior to peritonotomy and identication of mesofascial plane. A forceps has been used to directly grasp the
reection. The diathermy is then used to divide it without encroaching on underlying structures. (b) Exposure of mesofas-
cial plane following peritonotomy of lateral peritoneal reection.
Open total or partial mesorectal excision 267
Mesosigmoidal mobilization (left/lateral aspect)
Left-sided
congenital
adhesions
Left lateral
mesosigmoidal
reflection
Descending
colon
Mesosigmoidal
fascia
Mesosigmoid
(a)
(b)
(c)
Figure 18.15 (See also QR 2d/1-2.) Mesosigmoidal mobilization (left/lateral aspect). (a) Intraoperative view of the mesosigmoid
and mesosigmoidal mesofascial plane. (b) The left peritoneal reection has been grasped with a forceps and retracted away
from the mesosigmoid which has been retracted to the right. This places the reection under stretch and facilitates its division.
(c) The reection and underlying mesosigmoidal fascia have been retracted to the left and the mesosigmoid to the right.
This exposes the mesofascial plane and its components can be separated.
268 Mesenteric component of rectal resection
through what was thought to be the peritoneal reection,
the true peritoneal reection comes into view. Once con-
genital adhesions are divided, the lateral aspect of the meso-
sigmoid is always observed, as is the peritoneal reection
at the base of this. Division of the reection (coupled with
the above mesofascial mobilization) means the mesofascial
plane formed by mesosigmoid, and underlying fascia can be
further mobilized (Figure 18.15).
As was the case for the left colon and mesocolon, iden-
tication of the interface enables detachment of the meso-
sigmoid from the retroperitoneum and retention of the
fascia overlying the retroperitoneum. Many complete this
activity digitally by gently sweeping the fascia posteriorly
and the mesosigmoid anteriorly, and in this manner sepa-
rate the mesosigmoid as far medially as possible. Complete
mobilization is impeded by the right peritoneal reection at
the right side of the base of the mesosigmoid (Figure18.16).
is is identifi d by liing the sigmoid and mesosigmoid
anteriorly, off the retroperitoneum, thereby exaggerat-
ing the right-sided mesosigmoidal peritoneal reection.
Peritonotomy here joins the lateral to medial and medial to
lateral planes of mobilization (Figure18.16).
At this point, the distal mesosigmoid is now mobile and
it remains to detach the rest of the mesosigmoid. e le
hand is placed underneath the mesosigmoid, to lift the adi-
povascular pedicle forward, and the pedicle is further mobi-
lized until impeded by the origin of the IMA (Figure18.17).
Anavascular interpedicular region occurs proximal to the
IMA pedicle and can be dissected through. is activity
eff ctively isolates the pedicle for skeletonization, clamping,
Mesosigmoid
Right
mesosigmoidal
peritoneal
reflection
(a)
(b)
Peritonotomy
of peritoneal
reflection
Pe
ritonotomy
of peritoneal
reflection
Mesosigmoidal
(Toldt’s ) fascia
Mesosigmoidal mobilization (right/medial aspect)
Figure 18.16 Mesosigmoidal mobilization (right/medial aspect). Right-sided peritoneal reection at the base of the meso-
sigmoid pre (a) and post (b) peritonotomy. (a) To demonstrate the peritoneal reection at the medial (right) side of the
mesosigmoid the sigmoid and mesosigmoid have been retracted anteriorly and to the left, that is, away from the retro-
peritoneum. (b) When the peritoneal reection has been divided through, the mesofascial interface is identied.
Open total or partial mesorectal excision 269
division, and ligation (Figure 18.17). A connective tissue
collar or cuff occurs surrounding the vessel formed by
coalescence of Toldt’s fascia and mesenteric connective tis-
sue. is property means the mesentery can be separated
from the vessel (thereby fully skeletonizing it) without dam-
age to the vessel.
There are minor vessels within the connective tis-
sue at the pedicle, and although bleeding from these is
inevitable, it is invariably minor. A more adventurous
dissection through the pedicle can lead to disruption
of the IMA that will bleed extensively unless hemosta-
sis is obtained there and then. The simplest means of
doing this involves placing the index finger of the left
hand around the pedicle, hooking up the pedicle, and
then pinching it between thumb and index finger (Figure
18.17). This stops bleeding, which allows the surgeon
IMA skeletonization and division
(a)
(b)
(c) (d)
Mesosigmoidostomy
Clamping of vessel Division prior to suture ligation
Isolation of infe
rior mesenteric vessel
Figure 18.17 Isolation (a, b), clamping (c), and (d) division of inferior mesenteric vascular pedicle.
270 Mesenteric component of rectal resection
time to obtain Kelly clamps and 0-0 Vicryl
®
sutures to
obtain hemostasis (Figure 18.17).
Some surgeons would now divide the proximal sigmoid
and hemostatically divide across the mesosigmoid toward
the cut edge of the IMA pedicle. is has been referred to
as the “division of convenience” and enables the surgeon
reect the sigmoid/mesosigmoidal complex forward, to
expose the posterior mesorectal plane (Figure 18.18).
Mobilization of the left mesocolon, colon, and splenic
exure as well as greater omentum has been described in
detail in the chapter of mesosigmoidectomy (Chapter 17),
and the reader is referred to that chapter for these steps.
At this point, the surgeon packs the divided colon into the
left ank using a large moist swab. Next, the sigmoid and
mesosigmoid are reected anteriorly to expose the meso-
rectal plane. is has aptly been called the “holy plane”
and is in fact a continuation of the mesofascial plane
(Figure 18.18) [20].
A number of points should be emphasized at this stage.
If the “holy plane” of mesorectal dissection is not apparent,
then it is likely that one has divided through the mesofas-
cial plane. is observation should alert the surgeon to the
possibility that he/she may be retrofascial in dissection and
the ureter compromised. e latter should be identifi d
and inspected to ensure that it is not in danger of division.
Ifdissection has been conducted as described earlier, then
one will see that peritoneal margins on the left and right
converge at the pelvic brim. From there, they separate as the
right and left pararectal peritoneal reection. e point at
which the peritoneal margins are closest corresponds to the
rectosigmoid junction, the end of the mesosigmoid, and the
start of the mesorectum.
e upper mesorectum is reected forward, placing the
bers of the mesorectal plane under tension (Figure 18.19).
Mesofascial separation here frees the posterior aspect of the
mesorectum from the mesorectal (Toldt’s) fascia. Based on
Posterior mesorectal mesofascial plane
Posterior
mesorectum
Posterior
mesorectum
Interf
ace/plane
Interface/plane
Mesorectal
(Toldt’s )
fascia
Mesorectal
(Toldt’s )
fascia
(a)
(b)
}
Figure 18.18 (See also QR 13.) (a, b) Intraoperative (open) demonstration of posterior aspect of mesorectum and posterior
mesorectal fascia. (a) The rectum and mesorectum are retracted anteriorly. Tension is transmitted to the mesofascial inter-
face and the components here (i.e. mesentery and fascia) can be differentiated. (b) The fascia can then be divided through
to mobilize the mesorectum as an intact mesenteric package.
Open total or partial mesorectal excision 271
surgeon’s preference, the right or left pararectal reection
is then divided through, thereby exposing the underlying
mesofascial plane.
e mesorectum remains attached laterally, anterolater-
ally, and anteriorly. e lateral and anterolateral aspects of
the mesorectum must then be separated from their pelvic
attachments. Th s is aided by the fact that a mesorectal plane
occurs circumferentially around the mesorectum. e plane
is partially interrupted at the zone of adherence.
Mobilization of the posterior and posterolateral mesorec-
tum means that the mesorectum can be retracted laterally
or anteriorly. Countertraction can be exerted on the lateral
aspect of the pelvis. is is achieved by placing the lipped pel-
vic retractor in an anterolateral location and tilting inward.
e combination of traction (on mesorectum) and counter-
traction (on pelvic side wall) is essential as it stretches the
mesorectal plane and provides a road map for further dis-
section. Dissection at this point follows the principles of
mesofascial separation, as elsewhere along the mesentery.
e fascia is swept toward the mesorectum to maintain an
intact package.
e mesorectal plane can be dicult to identify in obese
patients. In these, the normally areolar fascia is attenuated
due to pressure eff cts, with the result that traction and
countertraction may not lead to identication of the meso-
rectal plane.
At the zone of adherence, parasympathetic nerves,
lymphatics, and minute vessels approach the mesorectum
Mesorectum
(a)
(b
)
Mesorectal
(Toldt’s )
fascia
Interface/plane
Mesorectum
Left
pararectal
peritoneal
reflection
Interface/plane
Pararectal peritoneal reflection
Mesorectal
(Toldt’s )
fascia
Peritonotomy
of right
pararectal
reflection
Left
side
Right
Side
Figure 18.19 Intraoperative (open) demonstration of right (a) (see also QR 2d/5) and left (b) (see also QR 2d/6) pararec-
tal reection undergoing division with exposure of underlying mesofascial interface between mesorectum and adjacent
fascia. To generate these views the mesorectum is retracted away from the pelvis. This places the reection under stretch
and enables its division. The mesofascial plane is apparent after division.
272 Mesenteric component of rectal resection
tangentially. Here, the mesorectal plane is traversed by
these structures. ey represent an attachment that should
not yet be divided at this point.
Once the anterolateral mesorectum has been mobilized
as much as possible, the anterior mesorectum is mobilized.
e rectum is deected posteriorly by pressing back and
up on a moist 4 × 4cm swab on the anterior surface of the
rectum. e lipped pelvic retractor is placed in the anterior
midline and then angled backward so the peritoneal reec-
tion is placed under traction (via the rectum) and counter-
traction (via the peritoneal reection) (Figure18.20). is
in turn exaggerates the peritoneal reection. In the male, a
peritonotomy is made approximately 5mm anterior to the
reection, and in the female, peritonotomy is conducted
directly through it.
As earlier, the technical goal is the same, that is, mesofas-
cial identifi ation, component separation and detachment of
the mesorectum. Traction and countertraction will demon-
strate the mesofascial interface between the mesorectum and
fascia. In the female, the mesofascial interface is repeatedly
demonstrated by retracting the vagina anteriorly and the
rectum posteriorly. ere is a tendency to underestimate the
transverse extent of the vagina, which may be pulled postero-
laterally. To prevent digression into the vagina, the surgeon
repeatedly changes position of the lipped pelvic retractor and
his/her position on the anterior surface of the rectum.
Right
pararec
tal
reflection
Mesorectum
(a)
(b)
Anterior peritoneal reflection
Anterior
reflection
Rectum
Left
pararec
tal
reflection
Right
pararectal
reflection
Figure 18.20 Anterior peritoneal reection. (a) Intraoperative view of the anterior reection as the right-sided pararectal
peritoneal reection is divided onto the anterior component of the reection. To generate this view the rectum and mesorec-
tum are deected to the left. This places the mesofascial interface under tension. In turn, the components of the plane may
be differentiated and separated. (b) (See also QR 2d/7.) Appearance of anterior peritoneal reection after division of right
and left pararectal reection. The midline component of the reection is still intact and is next for division.
Special considerations: Mesorectal obesity in a narrow male pelvis 273
In the male, anterior peritonotomy coupled with trac-
tion and countertraction exposes the mesofascial interface
formed by the mesorectum and fascia. Anteriorly, the semi-
nal vesicles quickly come into view. Posteriorly, the fascia
overlying the anterior mesorectum is frequently referred
to as Denonvilliers’ fascia. e mesofascial plane between
this and the prostate anteriorly is demonstrated with con-
stant traction (posteriorly on the rectum) and countertrac-
tion (anteriorly on the prostate) (Figures 18.21 and 18.22).
Dissection here and in this plane will bring the surgeon to
the distal mesorectum where it cones inward.
At this point, the anterior, posterior, and posterolateral
attachments of the mesorectum have been separated. It
remains to detach the mesorectum from the anterolateral
zone of adherence. e zone can be discretely dissected
through using a tissue sealant device such as the harmonic
scalpel. By now, the mesorectum has been detached circum-
ferentially as far as the pelvic oor.
In the distal pelvis and just proximal to the pelvic oor,
Waldeyer’s (or retrorectal fascia) can sometimes cause
confusion. Division through the fascia leads the surgeon
to a potential space that can be somewhat edematous in
appearance.
Using the principles outlined earlier, the mesorectum is
detached from its pelvic attachments to the level of the dis-
tal rectum where it tapers inward at the anorectal junction.
e surface of the rectum can be identifi d by longitudinal
muscular bers. Care is needed here as the bers can be
attenuated and the rectal wall quite thin. e rectum is now
ready for division, which can be done using a stapling device
or by simply dissecting across with a scissors if a hand sewn
coloanal or ileoanal anastomosis is envisaged.
SPECIAL CONSIDERATIONS: COLOANAL
ANASTOMOSIS
One of the challenges in conducting a distal anastomosis is
delivering the bowel into the anal canal without traumatiz-
ing it. In the case of a coloanal anastomosis, the colon and
mesentery are brought through the anal canal and ampu-
tated at a level that permits a tension-free anastomosis.
is is only possible if the entire left mesocolon and splenic
exure have been mobilized fully back to the middle colic
adipovascular pedicle. If there is insucient intestinal and
mesenteric reach, then further mobilization is required.
SPECIAL CONSIDERATIONS: MESORECTAL
OBESITY IN A NARROW MALE PELVIS
Visceral adiposity in the male pelvis presents considerable
technical challenges. is is particularly relevant anterolat-
erally and in the anterior midline where Toldt’s fascia may
be attenuated to the point of being absent. is may relate to
pressure eff cts, as the fascia is sandwiched between meso-
rectal and pelvic side wall adiposity. e resultant problem
is compounded by the length and narrow nature of the male
pelvis. For example, it may be dicult to get a size 6 hand
into the pelvis and exert traction, let alone countertrac-
tion. Finally, the zone of adherence can be particularly well
developed in the viscerally obese. is is not helped by the
fact that we, as the surgical community, continue to struggle
with the anatomic properties of this zone. Collectively, the
aforementioned diculties signicantly increase the chal-
lenge inherent in identifying the mesofascial plane in the
viscerally obese male.
To cater for this, one approach involves identifi ation of
the mesorectal fascial plane as far anterolaterally as is feasible
(which may not be very far) and to then commence the ante-
rior dissection in the midline as described earlier. Th s cre-
ates a bridge of fatty tissue between the anterior midline and
the anterolateral dissection. Traction on the rectum allows
the surgeon to introduce the jaws of a hemostatic sealant
device across the bridge and the latter can be divided. Th s
should be done as close to the mesorectum as possible. In
extreme cases, it may not be possible to t the left hand on
the rectum and a retractor in the pelvis for countertraction.
When this is the case, the surgeon should place his/her hand
on the rectum and then slide the jaws of the tissue sealant
device over the fi gers. Although this approach is guided
more by feel than by direct view, it will allow the surgeon to
successfully detach the mesorectum. Th s approach is a last
resort as it is nonanatomic and should be reserved for excep-
tional circumstances only.
Rectum/mesorectum
displaced posteriorly
Mesorectal fascia
Anterior mesorectal fascia
Figure 18.21 Intraoperative (open) demonstration of the
fascia overlying the anterior mesorectum. The seminal
vesicles and prostate have been retracted anteriorly.
Theanterior mesorectum is demonstrated posteriorly.
The intervening fascia is remarkably thin and very difcult
to demonstrate.
274 Mesenteric component of rectal resection
Mesorectum transection
Divided
mesorectum
Posterior
mesorectum
Division of
posterior mesorectum
Anterior
mesorectum
(a) (b)
(c) (d)
Figure 18.22 (a) Division of anterior mesorectum during partial mesorectal excision. (b) Anterior rectum following
clearance of distal mesorectum. (c, d) Posterior mesorectum prior to and after separation from distal rectum and prior to
division.
References 275
FUTURE DIRECTIONS
Detachment and disconnection of an intact mesorectum
are the cornerstone of safe resection of the rectum. e steps
involved are described above and could help in the interna-
tional standardization of this procedure. Unfortunately, a
clinical trial is unlikely to be conducted that will denitely
prove the benets of mesenteric versus non-mesenteric-
based resection of the rectum. at being the case, then
future eff rts should focus on an international standardiza-
tion of the steps involved in mesenteric-based resection of
the rectum.
SUMMARY
e surgical activities required in both open, laparoscopic
and robotic total (and partial) mesorectal excision are based
on mesenteric, peritoneal, fascial, a nd intestinal continuity as
well as contiguity between each of these. e primary goals
are intact detachment and disconnection of the mesorectum
and rectum. ese are achieved by peritonotomy, mesofas-
cial separation, mesenterotomy, and mesenterectomy.
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