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286 Mesenteric component of right colectomy
15–30 seconds before activating the stapling mechanism,
to reduce residual edema (Figure 19.10a). Once red addi-
tional pedicular bleeding is managed by placing clips
obliquely across the staple line.
e staple line (on the mesocolic side) can be grasped
using a traumatic grasper and retracted upward away from
the retroperitoneum. is places the mesofascial interface
under tension and facilitates further mesofascial separa-
tion (Figure 19.10b). Separation is best done under high
magnication as fascial bers tend to ride up onto the
undersurface of the mesocolon. It is possible to dissect
directly through the fascia, although there is a danger of
entering the retroperitoneum. e latter is frequently asso-
ciated with bleeding, which, although minor, can obscure
ones view of the mesofascial interface. It is preferable to
gently sweep the fascia posteriorly, in as hemostatic a man-
ner as possible (Figure 19.10b).
Mesofascial separation (and hence mesenteric detach-
ment) continues laterally until the right peritoneal reection
is reached. Oen the right colon is encountered before the
right peritoneal reection. e colon is lied upward and the
fascia at the colofascial interface swept posteriorly (Figure
19.10c). e right peritoneal reection is reached in this man-
ner. It should not be divided just yet as it suspends the colon
from the abdominal wall, preventing it falling into the
operative fi ld and impeding progress (Figure 19.10c). Once
the peritoneal reection is reached, the patient’s position is
changed to permit direct access to and allow peritonotomy of
Medial to lateral approach—The ileocolic adipovascular pedicle
Ileocolic
adipovascular
pedicle
(a)
(b)
(c)
Ileocolic
pedicle
Toldt’s
fascia
Mesenteroto
my
Skeletonized
ileocolic
vessel
Figure 19.9 Laparoscopic view of ileocolic adipovascular pedicle before (a) and after (b) (see also QR 6/4) dissection through
the mesentery to enter the mesofascial plane. In (a) the mesentery is intact. The ileocolic pedicle is visible after the cecum has
been retracted toward the right. In (b) the mesentery on the near side of the pedicle has been divided through. The fascia is
visible draped onto the under surface of the mesentery. (c) Isolation of the ileocolic pedicle using a curved retraction device.
Minimally invasive right mesocolectomy 287
the peritoneal reection. e positional changes and actions
are identical to those conducted during the lateral-to-medial
approach and will be described next.
Lateral-to-medial mesenteric detachment
e patient is placed right shoulder and head up. e colic
component of the hepatic exure is retracted toward the
right iliac fossa, thereby exposing the hepatocolic perito-
neal reection (Figure 19.11a). is can then be directly
divided through (i.e., peritonotomy) to expose Toldt’s fas-
cia and the underlying retroperitoneum (Figure 19.11b).
e colic and mesenteric components of the hepatic ex-
ure can then be swept away from the underlying fascia and
retroperitoneum. As the mesentery is separated from the
posterior abdominal wall, the duodenum and pancreas
come into view. e process of separation is continued
medially until further mobilization is impeded by the
root region of the mesentery.
e patient is then placed head down and right shoulder
up. e lateral extremity of the colon is then retracted toward
the left iliac fossa, thereby exposing the right peritoneal refl c-
tion (Figure 19.12a). e peritonotomy is continued through
this structure. Th s exposes the colofascial and mesofascial
interface (Figure 19.12b). By sweeping the colon and there-
aer the mesocolon medially, the interface components are
separated and the mesocolon detached. At this point, the
intestine and mesentery are still attached at the small intesti-
nal mesentery and associated peritoneal refl ction.
e patient is placed further head down and the ileoce-
cal junction visualized from below. is exposes the ileocecal
component of the peritoneal reection (Figure 19.13a), which,
following division, exposes the underlying mesofascial plane
(Figure 19.13b). Sweeping the mesentery away from the fascia
Staple
division
of pedicle
(a)
(b)
(c)
Medial to lateral approach—The ileocolic adipovascular pedicle
Undersurface
of right
mesocolon
Toldt’s
fascia
Fascia overlying
retroperitoneu
m
Undersurface
of right
mesocolon
Toldt’s fascia
overlying
retroperitoneum
Figure 19.10 (See also QR 6/4.) Laparoscopic view of division of the ileocolic pedicle using stapling device (a). Once the
pedicle has been divided, the right mesofascial plane becomes evident (b). The plane is the interface between the right
mesocolon (above) and the fascia (beneath). (c) Mesofascial separation involves sweeping the mesocolon away from the
underlying fascia to mobilize the mesentery.
288 Mesenteric component of right colectomy
Hepatocolic peritoneal reflection
Hepatocolic
peritoneal
reflection
Toldt’s fascia
overlying
retroperitoneu
m
Peritonotomy
of hepatocolic
reflection
Colic
component
of hepatic
flexure
(a)
(b)
C
olon
Figure 19.11 (See also QR 6/7 and 8.) Laparoscopic view of the hepatocolic peritoneal reection before (a) and after (b)
peritonotomy through it. To generate this view of and access to the hepatocolic reection, the patient is placed head up
and the colic component of the exure retracted inferiorly. In obese patients, the reection may be obscured from view by
the omentum.
Minimally invasive right mesocolectomy 289
Right peritoneal reflection
Right
peritoneal
reflection
(a)
(b)
Peritonoto
my
Right
mesocolon
Mesofacial
interface
Toldt’s fascia
on right
Figure 19.12 (See QR 6/3.) (a) Laparoscopic view of the right peritoneal reection during peritonotomy. (b) Mesofascial
plane as seen during laparoscopic right mesocolectomy, following division of the right peritoneal reection. The mesofas-
cial plane is formed by the right mesocolon and underlying right mesocolic (i.e., Toldt’s) fascia.
290 Mesenteric component of right colectomy
mobilizes the mesentery in this region. e nal stage of
mobilization involves extending the peritonotomy toward
the duodenojejunal exure (Figure 19.14). Further separa-
tion of the mesentery from underlying fascia is eventually
impeded by the root region of the mesentery.
At this point, the complex of intestine and mesentery
and intestine have been fully mobilized. e remaining
attachment is the middle colic adipovascular pedicle and
the root region where the superior mesenteric artery comes
through the pancreas.
A short incision of approximately 4 cm is made trans-
versely in the right ank that allows exteriorization of even
the bulkiest mesenteries. e terminal ileum can be divided
between Kocher clamps as can the colon. Most place a suture
on the divided end in case it retracts intraperitoneally.
SPECIAL CONSIDERATIONS
e mesentery in Crohn’s disease is always thickened and
hypervascular, and many recommend that it is not divided
intraperitoneally. In line with this, most recommend that
Small bowel
mesentery
Left mesocolon
Peritoneal reflection at base
of small bowel mesentery
Figure 19.14 (See QR 3d/3 and QR 8/1.) Laparoscopic view
of the peritoneal reection at the base of the small bowel
mesentery, where this adheres to the posterior abdominal
wall. The small bowel must be retracted to the right upper
quadrant to generate this view of the reection.
Peritoneal reflection at ileocecal junction
Pe
ritonotomy
edge
Ileocecal
peritoneal
reflection
(a
)
(b)
Toldt’s
fascia
Ileocecal
peritonea
l
reflection
Figure 19.13 (See QR 2/1.) Laparoscopic view of the ileocecal peritoneal reection before (a) and after (b) peritonotomy
through it. The mesofascial plane is apparent after peritonotomy and is formed by the mesentery and underlying fascia
(Toldt’s fascia). To obtain this view, the patient is placed head down and the cecum is retracted toward the head.
References 291
the mesentery and specimen be fully exteriorized to the
abdominal surface, at which point the mesentery can be
divided as previously described. e advantage of this
approach lies in the fact that loss of vascular control of the
adipovascular pedicle is more readily dealt with when it has
been exteriorized in the rst instance.
Rarely, the pathology encountered impedes the develop-
ment of either the colofascial or mesofascial interface. An
example occurs in a T4 colonic adenocarcinoma that has
invaded locally through the mesentery to involve underlying
fascia. e fascia is noticeably thickened in this context and
its division can lead to fracturing of tumor and intraperito-
neal spillage. In these circumstances, one approach is to rst
mobilize circumferentially in the correct anatomic plane but
not to tackle the region in question at rst. Once circumfer-
ential mobilization has been achieved, the surgeon is in a bet-
ter position to assess the true level of local invasion. is is
important as it rst enables one to limit the anatomic extent of
the resection required. Second, it facilitates a more anatomic
and surgical approach to obtaining oncologic clearance.
FUTURE DIRECTIONS
e above description is a universally applicable template
for detachment and disconnection of the mesentery during
ileocolic resection. Such a template is essential in standard-
ization of techniques by which right-sided intestinal lesions
are removed.
SUMMARY
e surgical activities required in open, laparoscopic, and
robotic right mesocolectomy are based on mesenteric, peri-
toneal, fascial, and intestinal continuity as well as contigu-
ity between these. In keeping with this, all mesenteric stages
(i.e., detachment and disconnection) can be described in
terms of peritonotomy, mesofascial separation, mesenter-
otomy, and mesenterectomy.
REFERENCES
1. Coffey, J.C., Surgical anatomy and anatomic
surgery—Clinical and scientic mutualism. Surgeon,
2013. 11(4): 177–182.
2. Coffey, J.C. etal., Terminology and nomenclature in
colonic surgery: Universal application of a rule-based
approach derived from updates on mesenteric
anatomy. Tech Coloproctol, 2014. 18(9): 789–794.
3. Culligan, K. etal., Review of nomenclature in colonic
surgery—Proposal of a standardised nomenclature
based on mesocolic anatomy. Surgeon, 2013. 11(1):
1–5.
4. Coffey, J.C. etal., Mesenteric-based surgery exploits
gastrointestinal, peritoneal, mesenteric and fas-
cial continuity from duodenojejunal exure to the
anorectal junction—A review. Dig Surg, 2015. 32(4):
291–300.
5. Coffey, J.C. and P. Dockery, Colorectal cancer:
Surgery for colorectal cancer—Standardization
required. Nat Rev Gastroenterol Hepatol, 2016.
13(5): 256–257.
6. Sehgal, R. and J.C. Coffey, Historical develop-
ment of mesenteric anatomy provides a universally
applicable anatomic paradigm for complete/total
mesocolic excision. Gastroenterol Rep, 2014. 2(4):
245–250.
7. Sehgal, R. and J.C. Coffey, The development of
consensus for complete mesocolic excision (CME)
should commence with standardisation of anatomy
and related terminology. Int J Colorectal Dis, 2014.
29(6): 763–76 4.
8. Sehgal, R. and J.C. Coffey, Standardization of the
nomenclature based on contemporary mesocolic
anatomy is paramount prior to performing a com-
plete mesocolic excision. Int J Colorectal Dis, 2014.
29(4): 543–544.
9. Adamina, M. etal., Laparoscopic complete meso-
colic excision for right colon cancer. Surg Endosc,
2012. 26(10): 2976–2980.
10. Bertelsen, C.A. etal., Can the quality of colonic
surgery be improved by standardization of surgi-
cal technique with complete mesocolic excision?
Colorectal Dis, 2011. 13(10): 1123–1129.
11. Bertelsen, C.A. etal., Disease-free survival after com-
plete mesocolic excision compared with conventional
colon cancer surgery: A retrospective, population-
based study. Lancet Oncol, 2015. 16(2): 161–168.
12. Galizia, G. etal., Is complete mesocolic excision
with central vascular ligation safe and effective in
the surgical treatment of right-sided colon cancers?
Aprospective study. Int J Colorectal Dis, 2014.
29(1):89–97.
13. Hohenberger, W. etal., Standardized surgery for
colonic cancer: Complete mesocolic excision and
central ligation—Technical notes and outcome.
Colorectal Dis, 2009. 11(4): 354–364; discussion
364–365.
14. Kang, J. etal., Laparoscopic right hemicolectomy
with complete mesocolic excision. Surg Endosc,
2014. 28(9): 2747–2751.
15. Killeen, S. etal., Complete mesocolic resection and
extended lymphadenectomy for colon cancer: A sys-
tematic review. Colorectal Dis, 2014. 16(8): 577–594.
16. Siani, L.M. and C. Pulica, Stage I-IIIC right colonic
cancer treated with complete mesocolic excision and
central vascular ligation: Quality of surgical speci-
men and long term oncologic outcome according
to the plane of surgery. Minerva Chir, 2014. 69(4):
199–208.
17. Sondenaa, K. etal., The rationale behind complete
mesocolic excision (CME) and a central vascular
ligation for colon cancer in open and laparoscopic
surgery: Proceedings of a consensus conference. Int
J Colorectal Dis, 2014. 29(4): 419– 428.
292 Mesenteric component of right colectomy
18. Storli, K.E. etal., Short term results of complete (D3)
vs. standard (D2) mesenteric excision in colon cancer
shows improved outcome of complete mesenteric
excision in patients with TNM stages I-II. Tech
Coloproctol, 2014. 18(6): 557–564.
19. West, N.P. etal., Complete mesocolic excision with
central vascular ligation produces an oncologically
superior specimen compared with standard surgery
for carcinoma of the colon. J Clin Oncol, 2010. 28(2):
272–278.
20. West, N.P. etal., Understanding optimal colonic cancer
surgery: Comparison of Japanese D3 resection and
European complete mesocolic excision with central
vascular ligation. J Clin Oncol, 2012. 30(15): 1763 –1769.
21. Willaert, W. and W. Ceelen, Extent of surgery
in cancer of the colon: Is more better? World J
Gastroenterol, 2015. 21(1): 132–138.
22. Yao, H.W. and Y.H. Liu, Re-examination of the stan-
dardization of colon cancer surgery. Gastroenterol
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23. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
24. Culligan, K. etal., The mesocolon: A histological
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293
20
Mesenteric component of exure mobilization
J. CALVIN COFFEY AND NEIL J. SMART
The characteristic of scientic progress is our
knowing that we did not know.
Gaston Bachelard
AIM
To demonstrate the mesenteric, peritoneal, and fascial
components of exural mobilization.
INTRODUCTION
Mobilization (or detachment) of the exures has tra-
ditionally been viewed as a dicult fi ld in colorectal
surgery, even for the experienced surgeon. is is not sur-
prising given that descriptions of mobilization have had
to rely on the concept of mesenteric discontinuity (see
Chapter2) [1–7]. In keeping with this, surgical texts have
faced a considerable challenge in precisely describing ex-
ure mobilization. ree factors have contributed to the
challenge. First, all previous appraisals (with the excep-
tion of the most recent edition of Gray’s anatomy) were
based on the principle of mesenteric discontinuity [8–11].
Although “discontinuity” implies the existence of start
and end points, neither has been described. Second, the
small intestinal, transverse, and sigmoid mesenteries were
depicted as “inserting” along a linear “attachment” [1,5].
In keeping with this, the linear attachment of the trans-
verse mesocolon extends from the hepatic to the splenic
exures. Finally, the shape of the mobilized mesentery has
little resemblance to that which it adopted in the undis-
turbed state. is means that it is not possible to infer
structure from the excised organ.
e reader is advised to recapitulate the principle points
outlined in Chapter 2 prior to proceeding. However, a
brief summary of the more important anatomic points will
be provided here. First and foremost, the mesentery and
mesocolon are continuous entities from duodenojejunal
flexu e to the mesorectum. Th s means that a mesenteric
conuence occurs at the flexu es [3–5,7]. For example,
at the hepatic flexu e, a conuence occurs between right
and transverse mesocolon. At the splenic flexu e, a con-
uence occurs between transverse and left mesocolon.
While the anatomy of the colic component of the flexu es
is self-evident, that of the peritoneal refl ctions is not and
should also be described. In the case of the hepatic flexu e,
a peritoneal refl ction is draped over the right colon as
it approaches the hepatic flexu e, that is, the “right peri-
toneal refl ction.” Th s continues around the hepatocolic
conuence as the hepatocolic peritoneal refl ction. Asim-
ilar arrangement occurs at the splenic flexu e insofar as
the splenocolic peritoneal refl ction forms the cephalad
aspect of the flexu e and continues around the colic com-
ponent as the “left peritoneal refl ction.” Th s peritoneal
refl ction is draped over the descending colon where it
is attached to the posterior abdominal wall across Toldt’s
fascia [3–5].
Each exure can be universally described in terms of
four components. These are the (1) peritoneal, (2) colic,
(3)mesenteric, and (4) fascial.
Aim 293
Introduction 293
Role of digital sculpting 294
Mobilization of the splenic exure 294
Peritoneal component 294
Colic component 294
Mesenteric component 296
Hepatic exure 296
Peritoneal component 296
Colic component 296
Mesenteric component of the hepatic exure 296
Ileocolic mesenteric exure 296
Peritoneal component 296
Colic and mesenteric components 298
Duodenal and sigmoidal exures 298
Future directions 298
Summary 298
References 299
294 Mesenteric component of exure mobilization
A exure arises whenever the intestinal tract changes
from being attached (to the retroperitoneum) to nonat-
tached (and hence mobile) [3,4,7]. In keeping with this, a
exure occurs at the duodenojejunal junction, at the ileo-
cecal junction, at the junction between the descending and
sigmoid colon, and at the rectosigmoid junction. In total,
there are six exures and all can be conceptualized in the
same anatomical manner. Each comprises of exural colon
centered on a mesenteric conuence around which a perito-
neal reection helps maintain adherence to the retroperito-
neum [3,6,7].
Importantly, the mesenteric component of each exure
should be considered in terms of radial and longitudinal
axes. In the case of the splenic and hepatic exure, the radial
axis extends from a zone of attachment at the middle colic
adipovascular pedicle to a zone of mobility at the intesti-
nal margin. At the hepatic exure, the longitudinal axis
extends from the attached right mesocolon to the mobile
transverse mesocolon. At the splenic exure, the longitudi-
nal axis extends from the mobile transverse mesocolon to
the attached le mesocolon.
As transverse mesocolon anatomy continues to cause
confusion, it is also worthwhile at this point to recapitulate
its composition. At the transverse mesocolon, the mesen-
teric component of the hepatic and splenic exure coalesce
with the middle colic adipovascular pedicle. At the pedicle,
the mesocolon is attached, whereas at the intestinal margin
it is unattached and mobile.
ROLE OF DIGITAL SCULPTING
e lack of boundaries in the regional anatomy of con-
tinuous structures (i.e., mesentery, colon, peritoneum, and
fascia) has greatly hampered the depiction of exural mobi-
lization in general. Recent application of digital sculpting
in surgical education may overcome these challenges. It is
possible to generate high-delity 3D models, which, because
they are digital, can be sectioned, rotated, deformed, and
animated. Digital modeling and associated sowares
vastly expand our ability to explain the mesenteric basis of
colorectal surgery [7,12,13].
In keeping with the above, digital models will be used in
the following to demonstrate anatomic relationships between
mesenteric, peritoneal, colic, and fascial components of the
flexu es during dierent stages of mobilization. Each flexu e
will be presented in the form of a panel of images. Each panel
will comprise images demonstrating (1)the intact mesen-
tery as seen from diering angles and (2)sections depicting
the relationship of flexur l components.
MOBILIZATION OF THE SPLENIC FLEXURE
Peritoneal component
In open surgery, the rst assistant retracts the upper le
abdominal wall to expose the left upper quadrant, while
a second retracts the small bowel, transverse colon, and
greater omentum to the right. is permits the surgeon
to grasp the left colon and retract it medially. Traction is
thus transmitted to the left peritoneal reection which is
divided (i.e., peritonotomy) and as far proximally as pos-
sible (Figure 20.1). A complex of transverse oriented adhe-
sions occurs just distal to the splenic exure. When this is
divided through, the lateral peritoneal reection is exposed
and divided. Peritonotomy exposes the colofascial and
mesofascial interface and their components (Figure 20.1).
e colofascial interface is formed by the left colon and
Toldt’s fascia. When the colon is retracted medially, the
interface is exaggerated and the fascia can be peeled off or
separated with diathermy. is results in colonic, but not
mesocolic, mobilization. For mesocolic detachment, the
left colon is lied away from the retroperitoneum. Traction
is then transmitted to the mesofascial interface and com-
ponents of this separated, either by peeling the fascia back
or by diathermy. Left mesocolic mobilization is continued
as far medially and cephalad as possible. When the conu-
ence between left and transverse mesocolon is freed from
the retroperitoneum, the lesser sac is entered and the pan-
creas reached.
At this stage, the exure is still attached by the sple-
nocolic peritoneal reection. In the past, this was sharply
divided (in a somewhat blind manner) aer which the le
upper quadrant was packed to tamponade inevitable bleed-
ing. While the reection itself is not well vascularized, the
overlying greater omentum is. At the exure, the omentum
fuses to varying degrees with the peritoneal reection. Asa
result, sharp division through this complex is invariably fol-
lowed by generous hemorrhage.
e complex of splenocolic peritoneal reection and
greater omentum can be divided in an anatomic and hemo-
static manner. e surgeon begins in the midline where the
greater omentum is retracted vertically and countertraction
placed on the transverse colon. e reection between both
stretches and can be hemostatically divided. is exposes
adhesions between greater omentum and transverse meso-
colon. ese are divided until the lesser sac is fully opened.
e surgeon can now place a hand into the lesser sac,
under the greater omentum, and divide through this toward
the splenic exure (Figure 20.1). At the exure, it is possible
to insinuate the index nger of the left hand under the sple-
nocolic peritoneal reection, between it and the mesenteric
conuence. In this way, the splenocolic reection is sepa-
rated enough to hemostatically divide it, without injuring
the underlying mesentery. Continuing this process laterally,
the surgeon reaches the divided margin of the left peritoneal
reection, thus completing division of the peritoneal com-
ponent of the exure.
Colic component
As the transverse colon is already mobile, only the
descending colon and colic component of the exure must
be mobilized or detached. On the le, division of the le
peritoneal reection exposes the colofascial interface.
Mobilization of the splenic exure 295
Splenic flexure
(e)
Mesenteric
component
of flexure
Peritoneal
component
Intact
(a)
(b)
(c) (d)
Fascial
component
of flexure
Peritoneal component
of flexure
Intestinal
component
of flexure
Colofascia
l
separation
Mesenteric
component
Peritoneal
component
Figure 20.1 (See also QR 9 and 10.) (a) 2.5D image derived from a 3D digital model of the splenic exure. (b) The exure
(including all components) has been slightly displaced from adjacent structures to demonstrate continuity of each and
contiguity between each. (c)Section through the exure demonstrating the splenocolic reection and its relationship
to underlying colic and mesenteric exural components. (d) Section through the descending colon where it has been
separated from the underlying fascia (i.e., colofascial separation). (e) Demonstration of mesenteric component of splenic
exure in terms of longitudinal and radial axes.