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306 Mesenteric considerations in resection ofthetransverse colon
Skeletonization of inferior mesenteric vein
Left
mesocolon
Left
mesocolon
Duodenum
under
retraction
Inferior
mesenteric
vein pedicle
(a)
(b
)
Peritonoto
my
margin of lef
t
mesocolon
Duodenum
under
retraction
Figure 21.11 (a) The free margin of the left mesocolon as observed from above (i.e., from the head) to below (to the feet).
The inferior mesenteric vein is apparent. (b) The inferior mesenteric vein after its isolation and skeletonization.
Open transverse mesocolic mobilization and division 307
Duodenum Mesenteric free margin
in left mesocolon
Left mesocolon
Free margin of the left mesocolon (alternate view)
Figure 21.12 (See also QR 2/10.) The free edge of the left mesocolon as viewed from below superiorly.
Transverse colon mobilized off the pancreas
Head of
pancreas
Root region
of mesente
ry
Second part
of duodenum
(a)
Figure 21.13 (a) The second part of the duodenum and head of pancreas are exposed once the transverse mesocolon has
been mobilized off via mesofascial separation. This process is impeded at the mesenteric root region where the superior
mesenteric artery comes through from behind the head of the pancreas. (Continued)
308 Mesenteric considerations in resection ofthetransverse colon
Isolating the middle colic adipovascular pedicle
Mesenteric
root region
(a)
(b)
Transverse
mesocolon
Middle colic
adipovascular
pedicle
Transverse
mesocolon
Middle colic
vessel
Figure 21.14 (See also QR 1/6-8.) (a) Intraoperative appearance of the avascular mesentery on either side of the middle colic
pedicle. (b)Thefully isolated and skeletonized middle colic pedicle before the point at which it bifurcates into its main branches.
Right colic
adipovascular
pedicle
Avascular
mesentery
Transverse
mesocolon
(b)
Figure 21.13 (Continued) (b) Right colic adipovascular pedicle.
References 309
colic itself as it can be quite short. If too short, then direct
skeletonization and division could lead the surgeon onto
the superior mesenteric trunk and into potential diculty
(Figure 21.14b).
FUTURE DIRECTIONS
e description provided above is a roadmap for anatomic
detachment and disconnection of the transverse meso-
colon. is is an essential component of total mesocolic
excision (also called subtotal colectomy), extended right
and left hemicolectomy. Future eff rts could utilize the
roadmap provided in the international standardization of
transverse mesocolic mobilization.
SUMMARY
When the transverse mesocolon is operatively approached
based on mesocolic and peritoneal contiguity, its mobili-
zation and division can be fully standardized and thereby
reproduced.
REFERENCES
1. Coffey, J.C., Surgical anatomy and anatomic
surgery—Clinical and scientic mutualism. Surgeon,
2013. 11(4): 177–182.
2. Sehgal, R. and J.C. Coffey, Historical development
ofmesenteric anatomy provides a universally applica-
ble anatomic paradigm for complete/total mesocolic
excision. Gastroenterol Rep, 2014. 2(4): 245–250.
3. Treves, F., Lectures on the anatomy of the intestinal
canal and peritoneum in man. Br Med J, 1885.
1(1264): 580–583.
4. Netter, F.H., Atlas of Human Anatomy.
ElsevierHealth Sciences, Philadelphia, PA, 2014,
pp.267–276.
5. Sinnatamby, C.S., Last’s Anatomy: Regional and
Applied. Elsevier Health Sciences, New York, 2011,
p.257.
6. Standring, S., Gray’s Anatomy: The Anatomical Basis
of Clinical Practice. Churchill Livingstone/Elsevier,
Edinburgh, Scotland, 2008, p. 1137.
7. Coffey, J.C. etal., Mesenteric-based surgery
exploitsgastrointestinal, peritoneal, mesenteric
andfascial continuity from duodenojejunal exure
to the anorectal junction—A review. Dig Surg, 2015.
32(4): 291–300.
8. Coffey, J.C. etal., Terminology and nomencla-
ture incolonic surgery: Universal application of
a rule-based approach derived from updates on
mesenteric anatomy. Tech Coloproctol, 2014. 18(9):
789–794.
9. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
10. Culligan, K. etal., The mesocolon: A histological
and electron microscopic characterization of the
mesenteric attachment of the colon prior to and
after surgical mobilization. Ann Surg, 2014. 260(6):
1048–1056.
11. Milsom, J.W. etal., Laparoscopic Colorectal Surgery.
Springer, New York, 2006, pp. 203–229.
12. Delaney, C.P., Netter’s Surgical Anatomy and
Approaches. Elsevier Health Sciences, New York,
2013, pp. 277–286.
13. Delaney, C.P. etal., Operative Techniques
inLaparoscopic Colorectal Surgery.
WoltersKluwerHealth, Philadelphia, PA, 2013,
pp.55– 64, 109–122.
311
22
Mesenteric considerations in small bowel
resection
J. CALVIN COFFEY, EOGHAN CONDON, AND DAVID W. WALDRON
The fewer the facts, the stronger the opinion.
Arnold H. Glasow
AIM
To demonstrate the mesenteric and peritoneal factors
involved in conducting a small bowel resection.
INTRODUCTION
e small bowel mesentery fans out considerably at the
intestinal margin [1–4]. Where it becomes attached to the
posterior abdominal wall, it is considerably shorter in diag-
onal extent (i.e., from the duodenojejunal exure to the ileo-
cecal junction) (Figure 22.1). Mesenteric elongation at the
intestinal margin confers a signicant mobility and means
that most small bowel resections can be conducted without
encroaching on the zone of attachment of the mesentery.
at being the case, the primary technical concern in
small bowel resection becomes hemostatic mesenterectomy,
for which there are numerous approaches. By far, the most
dicult mesentery is that seen in active Crohn’s disease
(Figure 22.2). As surgical management of the Crohn’s mes-
entery has been extensively dealt with in previous chapters,
the current chapter will focus on division of the normal
appearing mesentery.
Before commencing a mesenterectomy, it is important
to identify the superior mesenteric artery root region. is
is located medial to the duodenojejunal exure at the base
of the transverse mesocolon (Figure 22.3). e middle colic
adipovascular pedicle arises from it. Any dissection of the
small intestinal mesentery must avoid this region unless
absolutely required, as vascular compromise here could
have catastrophic implications (Figure 22.3).
Backlighting the mesentery (Figure 22.4) almost always
provides a vascular road map divisible into adipovascular
and avascular regions (Figure 22.4). Interpedicular areas
can be disrupted using a variety of techniques but many
usethe tip of an artery clip to create an opening on either
side of an adipovascular pedicle. e pedicle itself can be tied
(with 0-0 Vicryl
©
sutures) or suture ligated. A mesenterot-
omy is developed by repeating this process. e mesenter-
otomy is continued from the proximal to distal intestinal
resection margin. ere are several methods of intestinal
division. Ifan end-to-end anastomosis is planned, then sim-
ple transection with a straight Mayo scissors is sucient.
If a side/side anastomosis is required, then staple-division
with a stapling division and oversewing of the staple line is
hemostatic. As occurs with colorectal resections, the time
spent in intestinal staple-division and anastomosis is oen
less than that involved in mesenterectomy itself.
Currently used tissue sealant devices such as the harmonic
scalpel may reduce the time required to complete mesenter-
otomy, when used appropriately. ey are not entirely suited
to the bulky mesentery. Many would agree that while they cut
the mesentery eff ctively, their hemostatic eff ct is limited in
this context.
Ideally any mesenteric defect should be closed by
approximating the mesenterotomy edges. While some
suggest that it is unnecessary to close a mesenteric defect
greater than 5 cm in diameter, most recommend closure
if possible. Mesenteric herniation (see Chapters 7 and 16)
is associated with considerable morbidity and a not insig-
nicant mortality [5]. If mesenteric stumps have been
suture ligated, these may be used as suture anchor points
Aim 311
Introduction 311
Special considerations 313
Special considerations: Reoperative surgery 314
Summary 314
References 314
312 Mesenteric considerations in small bowel resection
for interrupted 2-0 Vicryl
©
sutures. Sutures should not be
placed deep in the mesentery and need only capture the
outer mesothelial layer. e aim is to achieve mesothelial
approximation, which creates a tissue bridge. Deep suture
placement can lead to mesenteric bleeding and hematoma
formation. While the latter is generally self-limiting due
to tamponade, the resultant hematoma can cause vascu-
lar compromise and threaten an adjacent anastomosis.
e simplest means of managing a mesenteric hematoma
is to exert focal digital pressure between the index nger
and thumb on the hematoma. If this fails, then the mes-
entery can be straddled between two 10 × 10 cm swabs.
is achieves a greater pressure over a broader region.
Importantly, one should never place sutures in a blind
manner in the mesentery. e net result of that is a worsen-
ing of the bleeding and extension of the hematoma.
In open surgery, the entire intestinal and mesenteric
complex from duodenojejunal (DJ) exure to ileocecal level
is relatively easily demonstrated. In contrast, the plicated
and elongated nature of the intestinal margin makes visu-
alization more challenging in the robotic and laparoscopic
setting. ere are several contexts in which it is necessary
to visualize the small bowel and as such the surgeon must
Non-intestinal
zone
Ascending
colon
Transverse colon
Small bowe
l
mesentery
Right
mesocolon
Zone of continuity
between right mesocolon
and small bowel mesentery
Intestinal
margin
of mesente
ry
(a)
(b)
Figure 22.1 Small bowel mesentery.
Fat wrapping in Crohn’s disease
Fat wrapping
at stricture
Normal
bowel and mesentery
Figure 22.2 Mesenteric changes seen in Crohn’s disease.
In this setting the mesentery is thickened and difcult to
divide through in a hemostatic manner. The mesentery
also extends over the circumference of the intestine as
“fat wrapping” or “creeping fat.”
Special considerations 313
have a strategy to deal with the mesentery and intestinal
tract safely. One approach is the small bowel walk in which
the intestine is grasped (using an atraumatic grasper) and
then grasped further proximally with a second grasper.
e graspers are spread apart in an action that splays open
the intervening gastromesenteric region for examina-
tion. To progress proximally, the distal grasper is placed
just distal to the proximal grasper, which is then replaced
more proximally. e intervening intestine and mesentery
between is again exposed by spreading the graspers.
is technique is particularly important in the setting
of a normal appendix where one is obliged to out rule the
presence of a Meckel’s diverticulum. It is also important in
laparoscopic ileal pouch anal anastomosis where it is critical
to generate sucient intestinal and mesenteric reach to per-
mit a tension free ileoanal anastomosis. In the latter case,
the small intestinal mesentery should be fully mobilized
up to the superior mesenteric artery (SMA) root region.
To achieve this, surgeon and assistant are positioned at
the patient’s left iliac fossa and the monitor at the patient’s
right shoulder. Optimum patient position is head and right
shoulder down, the eff ct of which is for the small intestine
to gravitate into the right upper quadrant and away from
the mesenteric base.
SPECIAL CONSIDERATIONS
Not infrequently the colorectal surgeon is requested to har-
vest a mesenteric lymph node for biopsy purposes. Although
the laparoscopic approach is feasible, it is hazardous and
many would recommend an open approach. Alimited mid-
line laparotomy is usually sucient as intestinal and mes-
enteric mobility allow delivery of the mesentery into the
wound. Careful preoperative assessment is crucial to deter-
mine the position of the target node relative to the mesen-
teric base and the root region of the mesentery. Excision
commences by supercial division of the surrounding
Peritoneal reflection at base of small bowel mesentery
DJ junction
Peritoneal
reflection
Small bowel
mesentery
Posterior
abdominal wall(a)
Small bowel
mesentery
Mesenterotomy
Mesenterotomy
margin
Kocher clamps on
mesenteric stumps
for hemostasis(b)
Figure 22.3 (a) The small bowel peritoneal reection
at the base of the small bowel mesentery, in a cadaver.
(b)Division of a thickened mesentery in Crohn’s disease.
Backlighting small bowel mesentery
Mesenteric vessels
observed on backlighting
Mesenterotomy
margin
Figure 22.4 Backlighting the mesentery during a proce-
dure. This allows differentiation of adipovascular from
nonvascular interpedicular regions.
314 Mesenteric considerations in small bowel resection
mesothelium, which sometimes has the eff ct of render-
ing the node more prominent. e dissection is then car-
ried directly down on to the surface of the node, which is
shelled from its mesenteric basin. Appropriate sized clips
are placed on associated vessels. Importantly, blind dissec-
tion of the mesentery in the hope that an impalpable node
will be encountered should be avoided. If the target node is
not palpable, then it is unlikely that mesenteric excavation
will proceed in an uncomplicated manner.
A similar situation sometimes arises in small intestinal
carcinoid with associated metastatic disease (Figure 22.5)
and in the case of mesenteric desmoid disease. e same
principles apply in so far as the root region must be avoided.
In general, preoperative CT evaluation establishes proxim-
ity of the mesenteric mass to the superior mesenteric artery
and vein.
SPECIAL CONSIDERATIONS:
REOPERATIVE SURGERY
Anatomic and mesenteric considerations of reoperative
abdominal surgery will be dealt with in detail in Chapter25.
Given the relevance of particular points to the current chapter,
a brief discussion of the small bowel mesenteric-based prin-
ciples of reoperative surgery will be included here. Reoperative
surgery requires a clear understanding of mesenteric anatomy
for several reasons. Given that the retroperitoneum and fascial
interface may have been excavated during initial surgery, these
are oen pulled up onto the lateral surface of the small intes-
tine to which they can adhere. In keeping with this, retroperi-
toneal structures such as the gonadal vessels and ureters are
threatened. Examples of settings in which this occurs include
reoperative surgery for Crohn’s disease or ileal pouch exci-
sion surgery [6–9]. Oentimes, the small intestinal mesentery
must be separated from the associated mesocolon, retroperi-
toneum, and anterior abdominal wall. It is only when one has
a crystallized view of normal mesenteric anatomy that one
can proceed in a manner that enables dierentiation of mes-
enteric, mesocolic, omental, and retroperitoneal fat. e latter
is crucial as it ensures that one does not violate or transgress
anatomic planes and cause trauma.
SUMMARY
e anatomic properties of the small intestinal mesentery
are such that it is suciently mobile at the intestinal margin,
to permit most resections. e root region, that is, where it
emerges to fan out and span the intestinal tract distal to the
duodenojejunal exure, should be avoided.
REFERENCES
1. Coffey, J.C., Surgical anatomy and anatomic
surgery—Clinical and scientic mutualism. Surgeon,
2013. 11(4): 17 7–182 .
2. Culligan, K. etal., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
3. Culligan, K. etal., The mesocolon: A histological and
electron microscopic characterization of the mesen-
teric attachment of the colon prior to and after surgi-
cal mobilization. Ann Surg, 2014. 260(6): 1048 –1056.
Carcinoid and mesenteric metastasis
Small
bowel
Carcinoid
(a) (b)
Isolated
lymphatic
metastasis
in mesentery
Figure 22.5 (a) Small intestinal carcinoid. (b) Metastatic lesion in the small bowel mesentery. The lesion arose from the
carcinoid in (a).
References 315
4. Coffey, J.C. etal., Mesenteric-based surgery exploits
gastrointestinal, peritoneal, mesenteric and fascial
continuity from duodenojejunal exure to the anorectal
junction—A review. Dig Surg, 2015. 32(4): 291–300.
5. Steele, S.R. etal., Complexities in Colorectal Surgery:
Decision-Making and Management. Springer,
NewYork, 2014, p. 504.
6. de Buck van Overstraeten, A., A. Wolthuis, and
A.D’Hoore, Surgery for Crohn’s disease in the era
of biologicals: A reduced need or delayed verdict?
World J Gastroenterol, 2012. 18(29): 3828–3832.
7. Garrett, K.A. etal., Outcome of salvage surgery
for ileal pouches referred with a diagnosis of
Crohn’s disease. Dis Colon Rectum, 2009. 52(12):
1967–1974.
8. Mallick, I.H. etal., Management and outcome of
pouch-vaginal stulas after IPAA surgery. Dis Colon
Rectum, 2014. 57(4): 490–496.
9. O’Riordan, J.M. etal., Long-term outcome of colec-
tomy and ileorectal anastomosis for Crohn’s colitis.
Dis Colon Rectum, 2011. 54(11): 1347–1354.