Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1441_Библиотеки_им_академика_М_И_Перельмана.pdf
346 Future directions
EDUCATION
In order to explain the mesenteric basis of intestinal surgery,
a number of atlases required development. ese included
cadaveric, digital, radiologic, operative (open and laparo-
scopic) atlases and also an atlas based on appearances in the
visual human project. Together with this book, these form
the basis of a curriculum. e educational utility of this
curriculum could be formally determined in undergraduate
and postgraduate contexts. Target audiences would include
all undergraduate medical students as well as postgraduate
trainees across surgical, radiologic, pathology-based, gas-
troenterologic, and oncologic training programs.
SUMMARY
Clarication of mesenteric, peritoneal, and fascial structure
has provided an array of opportunities across scientic and
clinical disciplines. Collectively, these represent an oppor-
tunity to refresh academic investigation in numerous fi lds
and across many disease processes. e mesentery may now
be systematically studied.
347
Appendix A: Operative templates
J. CALVIN COFFEY, D. PETER O LEARY, AND LEON G. WALSH
Everyone must row with the oars he has.
English proverb.
e following series is a list of descriptive templates for open,
laparoscopic, and robotic colorectal surgery. e descrip-
tions are based on the anatomy described in Chapter2 and
the nomenclature in Chapter 9. e reader should also use
Chapters 13 (laparoscopic/robotic atlas) and 14 (open atlas)
for reference.
e operative templates provide a method of rigorously
standardizing the resection process, the recording of this,
and the manner in which it is taught to future generations.
e templates focus solely on the mesenteric component of
the operation. Standard descriptions such as laparotomy,
port placement, and obtaining pneumoperitoneum are not
addressed.
TEMPLATE I: LAPAROSCOPIC/ROBOTIC
RIGHT MESOCOLECTOMY
Procedure: e patient was placed in a slight head down
position with the right shoulder up, and the small bowel and
associated mesentery were reected off the right mesocolon
to provide unimpeded mesocolic access.
An appendices epiploicae was grasped using a toothed
grasper placed through the right iliac fossa port. is was
used to retract the cecum toward the anterior abdominal
wall. e ileocolic adipovascular pedicle was brought under
tension and thus exaggerated.
A peritonotomy was conducted through the mesothe-
lium overlying the interpedicular region on the ileal side
of the ileocolic adipovascular pedicle. e plane between
the overlying mesocolon and the underlying fascia (i.e.,
mesofascial plane) was entered and developed from medial
to lateral. Mesofascial separation was continued by deect-
ing the mesocolon anteriorly and Toldt’s fascia posteriorly.
e 30° lens was angled downward, and interpedicular
mesentery on the colonic side of the vascular pedicle was iden-
tifi d. A peritonotomy was started and the mesofascial plane
entered again and developed. e plane of dissection on the
ileal and the colonic side of the vascular pedicle were joined.
e adipovascular pedicle was skeletonized using the harmonic
scalpel until the vessels contained within it were identifi d.
A stapling device was inserted through the 10/12mm
port in the left upper quadrant. e blade jaw was placed
posterior to the ileocolic vessel and the instrument red.
einstrument was opened and withdrawn, thereby pro-
viding unimpeded access to the mesofascial plane.
Mesofascial separation was continued as far laterally under
the right mesocolon and thereaer under the right colon until
the right peritoneal reection was encountered. Mesofascial
separation was repeated toward the hepatic exure, thereby
liing the mesenteric component of the exure off the retro-
peritoneum. Continuing this process, the colic component of
the exure was mobilized. is was continued until the hepa-
tocolic reection of the hepatic exure was encountered.
e patient was then placed in a slight head up position,
and the hepatocolic peritoneal reection was identifi d. e
reection was placed under traction. is was achieved by
grasping an appendices epiploicae at the hepatic exure and
retracting the colic component of the hepatic exure toward
the left iliac fossa. e hepatocolic peritoneal reection was
then directly divided (i.e., peritonotomy) using a tissue seal-
ant device and the peritonotomy was extended laterally to
the right peritoneal reection.
e right peritoneal reection was divided as far inferi-
orly as was possible. e patient was positioned in a head
down position, and the ileocecal peritoneal reection over-
lying the ileocecal mesenteric confl ence and mesoappendix
was identifi d. A peritonotomy here was continued laterally
toward the divided margin of the right peritoneal reec-
tion. e peritonotomy was next continued medially along
the base of the small intestinal mesentery. e mesofascial
plane was exposed in this manner, and separation of its
components fully freed the small intestine and right meso-
colon, as far proximally as the mesenteric root region.
A short transverse incision (approximately 4 cm) was
made in the right ank, and the wound edges kept apart
using a wound retractor. e specimen was exteriorized,
and the terminal ileum divided between Kocher clamps as
was the transverse colon in the region of the hepatic exure.
Aer division of the intestinal tract, the proximal and distal
mesenterotomies were completed and the mesenterectomy
348 Appendix A: Operative templates
and colon resection formally completed. e specimen was
then delivered and inspected.
To perform a hand-sewn anastomosis, the ileal mesen-
tery was dissected free off the mesenteric border for approx-
imately 1 cm. is was repeated on the colonic side, thus
permitting visualization of all intestinal layers for an ana-
tomic hand-sewn anastomosis.
In the case of a stapled anastomosis, two sutures were
placed one on either side of the mesentery at the mesenteric
border of the cut end of the ileum. e anvil of a circular
stapling device was then secured using a 2-0 Prolene purse
string in the ileum, and the circular stapling device was itself
introduced into the colon having grasped the divided end of
the colon with four Babcocks. e sharp, pointed end of the
docking device of the stapler itself was brought through a tae-
nia coli in the transverse colon. e sharp end was removed
and the anvil then inserted into the shaft of the docking
device. e gun was then red aer which a linear stapler
was used to staple closed the divided end of the colon. e
linear staple line was oversewn using 2-0 Vicryl running or
interrupted sutures. Two sutures were placed on either side of
the mesentery on the ileum and used to buttress the anasto-
mosis between ileum and colon in the region of the mesen-
tery. Further 3-0 Vicryl sutures were placed in an interrupted
manner circumferentially along the circular staple line.
e mesenterotomy margin was inspected for bleeding,
and any found was controlled via judicious suture ligation.
e mesenteric window was closed by approximating the
mesenteric margins. e specimen was returned intraperi-
toneally. Final checks for hemostasis were systematically
conducted along the peritonotomy margin, the surface of
the right mesocolic fascia, and at the mesenteric stumps of
any major vessel ligated.
TEMPLATE II: OPEN RIGHT
MESOCOLECTOMY
Procedure: A midline laparotomy was performed to ensure
adequate right mesocolic access. e edges of the laparotomy
wound were placed under gentle retraction using a self-
retainer. e small bowel and mesentery were deected o
the right mesocolon and held in position using a moist swab.
e cecum was lied anteriorly. is placed the ileocecal
peritoneal reection under stretch, causing the groove at
the reection to be exaggerated and providing a landmark
for the commencement of the dissection. Aperitonotomy
of the reection here exposed the colofascial interface.
Colofascial separation was achieved using the handheld dia-
thermy. is exposed the mesofascial interface which was
separated in a similar manner. e right colon was then
grasped, lied anteriorly, and tension transmitted to the
right peritoneal reection. e original peritonotomy was
continued through this, thus exposing the colofascial inter-
face, and the components of this were separated. is pro-
cess was continued medially until the mesofascial interface
whereupon mesofascial separation was conducted.
e colic component of the hepatic exure was grasped
and retracted toward the left iliac fossa. In so doing, the hepa-
tocolic reection was exposed and the original peritonotomy
further extended here. is provided access to the colofas-
cial and mesofascial interface at the exure. Interface com-
ponents were separated as far medially as the root region of
the mesentery. Mesofascial separation proceeded cautiously
at the duodenum and head of pancreas to prevent damage to
either or tearing of mesenteric vessels in this region.
Once mobilization and medialisation were completed,
the terminal ileum and the colon were divided between
Kocher clamps, and a hand-sewn ileocolic anastomosis was
fashioned in the usual manner. In the event of a stapled
anastomosis, this was conducted as described earlier.
e mesenterotomy margin was inspected for bleed-
ing, and any found was controlled via suture ligation. e
mesenteric window was then closed by approximating the
mesenteric margins. e specimen was returned intraperi-
toneally. Final checks for hemostasis were systematically
conducted along the peritonotomy margin, the surface of
the right mesocolic fascia, and at the mesenteric stumps of
any major vessel ligated.
TEMPLATE III: LAPAROSCOPIC/ROBOTIC
MESOSIGMOIDAL MOBILIZATION
Procedure: e patient was placed in a slight head down
position with the shoulders neutral. As a result, the small
bowel and mesentery gravitated away from the pelvis to
expose the right side of the base of the mesosigmoid. Aer
unimpeded mesocolic access was obtained, the dissection
began.
An appendices epiploicae was grasped and retracted
anteriorly. e peritoneal groove at the base of the meso-
sigmoid became prominent. e fold formed by the inferior
mesenteric adipovascular pedicle was exaggerated.
e mesothelium of the peritoneal reection was grasped
and a peritonotomy commenced using a tissue sealant
device. e mesofascial interface was identifi d and com-
ponents carefully separated liing the mesosigmoid anteri-
orly and sweeping the fascia posteriorly. e 30° lens was
reoriented to visualize the undersurface of the mesosigmoid
and facilitate further mesofascial separation. e ureter and
gonadal vessels were evident deep to the fascia.
e peritonotomy was extended proximally over the adi-
povascular pedicle which was again further freed via meso-
fascial separation. e camera orientation was changed to
view the le mesocolon. e left shoulder was elevated caus-
ing the small bowel to gravitate away from the left mesocolon
and expose the latter up to the level of the duodenojejunal
exure. ese maneuvers provided unimpeded access to the
le mesocolon. e 30° lens was again reoriented to iden-
tify the mesocolon proximal to the adipovascular pedicle.
A peritonotomy here enabled dissection through the mesen-
tery into the mesofascial plane where separation of interface
components was conducted. e net eff ct was to further
Appendix A: Operative templates 349
isolate the adipovascular pedicle. Mesocolic fat on the far
side of the pedicle was gently freed using the curved and
blunt blade of the Endo-mini retract.
e IMA was divided using a linear stapling device (or
clips) placed through a left iliac fossa 10/12mm port. e
jaws of the stapling device were closed for 1 minute aer
which it was red, opened, and removed. Residual staple line
bleeding was controlled by clipping diagonally across the
staple line. Once the adipovascular pedicle was fully divided
the undersurface of the left mesocolon and the le mesofas-
cial interface were identifi d. Similarly, access to the mesofas-
cial interface beneath the mesosigmoid was also developed.
Mesosigmoidal mobilization was continued by deecting the
mesosigmoid anteriorly and the fascia posteriorly. is was
extended laterally until the peritoneal reection on the le
side of the mesosigmoid was reached. e 30° lens was again
reoriented to directly visualize the left peritoneal reection.
A peritonotomy was created and extended cephalad as far as
the descending colon and caudally as far as the le pararectal
fold. is completed mesosigmoidal mobilization.
TEMPLATE IV: OPEN MESOSIGMOIDAL
MOBILIZATION
Procedure: e surgeon, positioned on the patient’s le,
grasped the sigmoid colon, and lied it anteriorly. is
exposed congenital adhesions between the lateral aspect of
the mesosigmoid and the parietal peritoneum of the left iliac
fossa. Once these were divided through, the peritoneal reec-
tion at the lateral aspect of the mesosigmoid became appar-
ent. e junction between the sigmoid and the descending
colon was identifi d and lied anteriorly. is placed the
lateral peritoneal reection under traction, thereby exagger-
ating the reection groove. A peritonotomy was commenced
here and extended cephalad and then caudally. e perito-
notomy exposed the colofascial interface between left colon
and underlying fascia. Interface components were separated
until the mesofascial interface was encountered and simi-
larly separated.
e sigmoid was retracted anteriorly, thereby transmit-
ting traction to the interface between the mesosigmoid
and underlying fascia. e interface was then divided with
monopolar diathermy, thereby separating the mesosigmoid
and allowing its mobilization anteriorly off the fascia over-
lying the retroperitoneum. Further progress in this man-
ner was facilitated by completing the lateral peritonotomy
as far distally as the left pararectal fold. Mesothelial release
here facilitated further mesofascial separation of the meso-
sigmoid and underlying fascia. is was completed as far
medially as possible, until completion was impeded by the
peritoneal reection at the right side of the mesosigmoid. A
peritonotomy on the right side was then extended cephalad
and caudally.
At this point, the inferior mesenteric adipovascular ped-
icle was retracted anteriorly. e left mesocolon cephalad
to the pedicle was dissected through thereby fully isolating
the pedicle. is was skeletonized and the vessels contained
divided between clamps then suture ligated. is completed
open mesosigmoidal mobilization.
TEMPLATE V: LAPAROSCOPIC/ROBOTIC
MOBILIZATION OF THE SPLENIC FLEXURE
Procedure: e left peritoneal reection was divided as
far cephalad as possible. A prominent band of adhesions
occurred just distal to the colic component of the splenic
exure and was divided. e proximal descending colon
was grasped with an atraumatic grasper and retracted to the
right iliac fossa. Peritonotomy of the left peritoneal reection
was continued cephalad. is exposed the left colofascial
interface. e components of the latter were separated by
displacing the fascia posteriorly and the colon anteriorly.
is was continued until the mesofascial interface was
encountered. As part of le mesocolic mobilization, the le
mesocolon had been fully mobilized off the underlying fas-
cia as far proximally as was feasible. ese steps fully mobi-
lized the le mesocolon.
e patient was placed in a slight head up position.
e greater omentum was grasped just outside the gastro-
epiploic arcade, using the atraumatic grasper. It was also
grasped adjacent this, in a similar manner, and the inter-
vening omentum was divided through. e lesser sac was
entered, and the division of the greater omentum was con-
tinued laterally. e upper surface of the transverse meso-
colon became apparent. Toward the exure, the omentum
and splenocolic peritoneal reection coalesced. e patient
was placed left shoulder up, and the omentum where they
coalesced was divided through. is action exposed the
underlying mesentery and the peritoneal reection. e
reection was divided around to the free edge of the le
peritoneal reection.
Following division of the peritoneal reection, the meso-
fascial interface at the exure was apparent. e interface
components were separated by sweeping the mesenteric
conuence medially and the fascia posteriorly. is process
was continued medially until limited by the adipovascular
pedicle of the middle colic vessels. is completed laparo-
scopic/robotic mobilization of the splenic exure.
TEMPLATE VI: OPEN MOBILIZATION
OFTHE SPLENIC FLEXURE
Procedure: e patient was placed head up. e surgeon was
positioned between the legs and the assistant (positioned
above the left upper quadrant) retracted the left upper quad-
rant. A further assistant (positioned on the right) retracted
the small bowel and mesentery to the right. is exposed
the entirety of the le mesocolon. e left colon and mesoco-
lon had been mobilized as an earlier part of the procedure.
A peritonotomy of the left peritoneal reflection was
extended cephalad and caudally, thereby exposing the
colofascial interface. The interface components were
350 Appendix A: Operative templates
separated sweeping the fascia posteriorly. This continued
until the mesofascial interface on the left was reached.
Further colo- and mesofascial separation were permitted
by lengthening the peritonotomy toward the colic com-
ponent of the splenic f lexure. Just distal to the latter, a
prominent band of congenital adhesions were divided
through in a hemostatic manner.
Attention then turned to the transverse colon. e
greater omentum was lied cephalad and the colon cau-
dally, exposing the peritoneal reection between the two.
A peritonotomy of this was started near the midline and
lengthened toward the splenic exure. is exposed adhe-
sions between the greater omentum and the underlying
mesocolon. Division of these fully mobilized the transverse
mesocolon. ese processes (i.e., peritonotomy and mobi-
lization of the mesocolon) were continued laterally toward
the splenic exure. At the exure, the greater omentum
coalesced with the splenocolic peritoneal reection. is
complex was divided through laterally until the free edge of
the peritoneum of the left peritoneal reection was reached.
To aid in completing these activities, the transverse
colon and left colon on either side of the colic component
of the exure were grasped in the left hand of the surgeon
and retracted gently to the right iliac fossa. Once the perito-
neal and omental components of the exure had been fully
divided, the mesofascial interface was identiable. e fascia
was swept posteriorly thereby fully freeing the mesenteric
component of the exure. is was continued medially until
further progress was impeded by the adipovascular pedicle
of the middle colic vessels. is completed mobilization of
the splenic exure.
TEMPLATE VII: LAPAROSCOPIC/ROBOTIC
MOBILIZATION OF THE TRANSVERSE
MESOCOLON
Intraoperative ndings: For the purpose of this descrip-
tion, it is assumed that the transverse mesocolon is being
divided in the context of a laparoscopic total mesocolic exci-
sion. In this context, it is assumed that the mesosigmoid,
left mesocolon, and splenic exure have been mobilized (see
earlier). As mobilization of the mesosigmoid involved divi-
sion of inferior mesenteric adipovascular pedicles, a distal
mesenteric free margin is apparent. In addition, the greater
omentum has been freed from the underlying transverse
mesocolon from the midline to the splenic exure.
Procedure: e rst step is to fully separate the greater
omentum from the transverse mesocolon. If this is not com-
pleted, then it is not possible to fully separate the middle
colic adipovascular pedicle (as the omentum will be adher-
ent cephalad).
e patient was placed head up and the greater omen-
tum grasped via a grasper placed through the right upper
quadrant 5mm port. e omentum was raised toward the
anterior abdominal wall and grasped by the surgeon via
an atraumatic grasper placed through the right iliac fossa
port. is exposed the divided edge ofthe greater omentum
(i.e.,created as part of mobilization of the splenic exure).
is was divided across from the midline toward the hepatic
exure. At the exure, it coalesced with the hepatocolic
peritoneal reection and this complex was divided through.
As a result, the greater omentum was fully separated from
the cephalad aspect of the transverse mesocolon.
e second step was isolation of the middle colic adi-
povascular pedicle. e assistant repositioned the grasper
on the transverse mesocolon and raised this anteriorly. e
second assistant grasped the mesenteric component of the
splenic exure and lied this anteriorly. e eff ct was to
open out the transverse mesocolon in the region of middle
colic pedicle and simultaneously expose the free mesenteric
margin. is region of the mesentery is avascular and was
divided through using the sealant device. e mesenterot-
omy was continued to the lateral aspect of the middle colic
vessel. e avascular mesentery on the opposite side of the
pedicle was dissected through into the lesser sac. Mesenteric
fat was freed gently from the middle colic vessels. e mes-
enterotomy was continued onto the right lateral aspect of the
middle colic vessel. Using this approach, the middle colic
vessel was fully isolated and skeletonized and thus prepared
for division. is was completed using clips.
e middle colic vein and artery were surgically treated
in an identical manner. e mesenteric component of the
hepatic exure was lied anteriorly, and the mesenterotomy
created as described earlier was extended laterally through
this avascular region. is completed mobilization of the
transverse mesocolon.
351
Index
A
Abdominal wall hernia, 54
Acute angulation, 147
Adenitis, 98–99
Adhesion formation, 101
Adipocytes, 51–52
Adipovascular pedicles
anatomical terminology, 120–121
laparoscopy/robotic surgery
ileocolic adipovascular pedicle,
162, 173
inferior mesenteric adipovascular
pedicle, 162, 174
middle colic adipovascular
pedicle, 162, 173
open mesenteric-based colorectal
surgery
ileocolic adipovascular pedicle,
178, 196
inferior mesenteric adipovascular
pedicle, 178, 197
inferior mesenteric vein
adipovascular pedicle, 178, 198
middle colic adipovascular
pedicle, 178, 197
Adson tissue forceps, 330
Airseal
®
device, 207
Alexis self-retaining devices, 200
Alexis wound retractor, 200–202
Anatomischer Atlas Fur Studierende und
Aertze (Toldt, Carl), 3–4
Anterior resection, 131
Anterograde mesenterotomy, 134
Antibiotic-induced dysbiosis, 73
Aphthous ulceration, 89
Appendectomy, 340
Appendicitis, 90, 93, 95, 98
B
Babcocks clamp, 238
Bleeding
residual, 221–222, 236, 238
sources of, 202–204
Blunt-tipped curved retractor, 237
Bookwalter
®
retractor, 199–200, 239
Bovie/monopolar diathermy device,
205–206
C
Cancer
appendiceal, 76
bowel, 76
colon, 7, 64, 76, 99, 153, 212
colorectal, 64, 78, 344
gastric , 76
ova rian, 76
rectal, 6–7, 148, 153, 212
T4 intestinal, 334
Carcinomatosis, 76
Castleman’s disease, 101
CD34, 53
CD-35, 50
CD45, 53
“Chimney” vapor extraction
device,207
Cinema 4D, 112, 137
Colonoscopy, 94, 147, 345
Colorectal surgery
clearing mesentery from intestine
margin
adequate blood supply, 222, 224
adipovascular pedicles, 224
endoscopic stapling device, 225
far side of fat, 224
transinterstinal division and
stapling, 223–224
gravity eects, 226
and greater omentum, 223–224
instrument sets in laparoscopic and
open surgery
displacing mesentery, 216
lists, 214–215
patient positioning, 214–216
international standardization,
154–155
mesenteric anastomosis, 229–230
mesenteric-based surgery, 153
mesenterotomy
(division of mesentery)
anterograde approach, 220
in Crohn’s disease, 221–223
harmonic scalpel, 220–221
during open surgery, 220
tissue sealant devices, 220–221
2-0 Vicryl
®
suture, 221
0-0 suture, 222
mesofascial plane
laparoscopic view, 226–227, 229
open surgery, 226–227
schematic illustration, 226–227
non-mesenteric-based surgery,
153–154
online videos demonstrating
laparoscopic, 211
operative eld preparation, 216–220
patient setup, 212–214
peritonotomy
laparoscopic view, 226, 229
open surgical view, 226, 230
preoperative preparation, 212–214
resectional nomenclature in,
131, 134
retrofascial plane, 226–227
specimen extraction, 226, 229
Complete mesocolic excision
(CME),277
vs. non-CME , 154
principles, 153
Computerized axial tomography (CT), 6,
99, 109–110, 144–145, 254
anterior renal fascia, 213
fascial thickening, 65
lymphatic mass, 99
mesorectum, 115
right colon
lesion in, 65
mass in, 212
root of mesentery, 110–111
small intestinal mesentery and right
mesocolon, 114
Toldt’s fascia and peritoneal
reection, 112–113
352 Index
Congenital adhesions, 101–103, 128
Connective tissue layer, 51–53
Craft omponent of surgery, 3, 7–8
C-reactive protein (CRP), 70
Crohn’s disease, 90, 92, 103
and appendicitis, 90
backlighting , 311, 313
circulating brocyte levels, 90–91
CRP production, 90
cytokine production, 70, 72
extraintestinal disease
manifestations, 87
fat wrapping, 86–87, 311–312
brocytes, biomarker, 87, 90–91
gene expression in, 87
mesenchymal abnormalities, 87
mesenteric cytokine production,
70, 72
mesenteric thickening, 86
mesenterotomy in, 221–223
mucosal ulceration in, 87, 89
substance P production, 90
surgical recurrence, 86
Crohn’s disease activity index
(CDA I), 87
Custom lookup table (CLUT), 112
Cysts, 97
Cytokeratin 18, 53
D
D2-40 (podoplanin), 50
Deaver retractor, 242
Denonvillier’s fascia, 28, 57, 59,
253–254, 273
Desmoid tumor, 95–96
Diabetes, 103
Distal sigmoid exure, 123, 127
Diverticulitis, 233
Dual lumen devices, 205
Duodenal and sigmoidal exures, 298
Duodenal congenital adhesions, 128
Duodenojejunal (DJ) flexu e, 11, 34, 38,
44, 47, 101, 110, 117, 120, 137,
218, 290, 293, 312, 345, 348
E
Education, mesenteric principles, 346
anatomic contiguity, 137
digital atlas in surgical education
Cinema 4D, 137
Maya, 137
RenderMan, 137
3D digital models, 139–141
2D snapshots, 137–139
ZBrush, 137
digital models and intraoperative
images, 139, 143
future directions, 145
laparoscopy in open surgery, 139, 142
radiology, 14 5
surgical simulation, 139
visible human project, 145
Electrocautery instrument, 205
Embryologic development of
mesentery,41
future directions, 45
reverse engineering, 44–45
between duodenojejunal and
splenic exure, 44
left m socolon, 44
mesorectum, 44
mesosigmoid, 44
peritoneal reection regresses,
43–44
Embryology, 343–344
EMM, see Endoscopic mesenteric mapping
Endo Clinch
©
, 217
EndoGIA
™
stapling device, 349
Endo Mini-Retract
™
, 224
Endopelvic fascia, 252
Endoscopic mesenteric mapping (EMM),
147–14 8
Endoscopic ultrasound (EUS), 148
Enteric nervous system (ENS), 97
Enterotomy, 320, 325–326, 329
Epiploic appendagitis, 95–96
F
Fibroinfl mmatory process, 334
Flexural anatomy, 34
colosigmoid and rectosigmoid
exures, 38
duodenojejunal and ileocecal
exures, 34
hepatic exure, 33–34, 38
splenic exure, 34, 38
Flexural mesentery, 120–121
Flexure mobilization component
challenges, 293
digital sculpting role, 294
duodenal and sigmoidal exures, 298
hepatic exure mobilization,
296–297
ileocolic mesenteric exure
colic and mesenteric
components, 298
peritoneal, 296, 298
international standardization, 298
mesenteric confl ence, 293
occurrence, 294
radial and longitudinal axes, 294
splenic exure mobilization
colic, 294–296
mesenteric, 295–296
peritoneal, 294–295
transverse mesocolon anatomy, 294
Free fatty acids, 103
G
Gastroenterology, 345
endoscopic mesenteric mapping, 148
pa in duri ng endoscopy, 147–148
Gastrointestinal tract (GIT), 69
Gerota’s fascia, 120, 128
Gosset (self-retaining reactor), 199–200
Gut tropism, 73
H
Hand-sewn anastomosis, 348
Harmonic scalpel, 221, 225, 234, 239,
262–263, 273, 285, 304, 311,
347, 348
HBME-1, 53
Heald, Bill, 7, 139, 153
Hemicolectomy, 233
Hemostasis
devices
bovie/diathermy, 205–206
newer hemostatic agents, 207
sealant devices, 205–207
suction/irrigation, 205
source of bleeding, 202–204
Hemostatic pad, 207, 338
Hepatic exure
anatomic nomenclature, 123, 125
mobilization, 296–297
Hepatocolic reection, 28
Hindgut, 44
Hi stology, 3 44
characterization of, 54
connective tissue contiguity, 54
digital sculpture, 47–48
electron micrograph, 47–48
mesenteric mesothelium
immunohistochemical analysis,
50–53
and Told’s fascia, 47–49
mesothelial cell plasticity, 53–54
nomenclature, visceral and parietal
peritoneum, 49–50
photomicrograph, 47–48
Hohenberger, Werner, 6–7
I
IBS, see Irritable bowel syndrome
IgG4-related sclerosing mesenteritis, 97
Index 353
Ileal pouch anal anastomosis (IPAA)
bowstringing, 317
enterotomy creation, 319–320
positioning, 318 –319
stapled-divided anorectal junction,
317–318
suture reinforcement, 319, 321
terminal ileum, intraoperative
appe arance, 318–319
three-stage procedure, 317
two-stage procedure, 317
Ileocecal exure, 34, 120–121, 125,
147,298
Ileocecal mesenteric region, 121
Ileocecal peritoneal reection, 157, 159,
177, 180, 278, 281–282, 287,
347–348
Ileocolic adipovascular pedicle, 134, 162,
173, 178, 196, 285–287, 347
Ileocolic mesenteric exure
colic and mesenteric
components, 298
peritoneal, 296, 298
Ileocolic resection, 119, 123, 131, 277
Iliac vessels, 254
IMA, see Inferior mesenteric artery
IM V, see Inferior mesenteric vein
Indeterminate mesenteropathy, 101
adhesion formation, 101
atherosclerosis, 86, 103
diabetes, 103
irritable bowel syndrome, 103
metabolic syndrome, 103
Inferior mesenteric adipovascular
pedicle, 22–23, 25
Inferior mesenteric arteries anchor, 42
Inferior mesenteric artery (IMA),
22, 44, 97, 120–121, 138,
174, 202, 205, 219, 234, 237,
255–256, 303
Inferior mesenteric vein (IMV), 178, 198,
219, 239, 305–306
Ingenuity
®
, 87
Inguinal herniae, 74
Instrumentations
future development, 208
hemostasis, 202–204
hemostatic dissection
bovie/diathermy, 205–206
newer hemostatic agents, 207
sealant devices, 205–207
suction/irrigation, 205
unimpeded mesenteric access, 199
intraoperative (laparoscopic)
demonstration, 199–200
laparoscopic surgery, 201
for open surgery, 199–201
regaining pneumoperitoneum
during laparoscopic
surgery, 202
vapor evacuation during
laparoscopic and robotic
surgery, 207–208
Internal herniation, 95
Interpedicular (avascular) mesentery,
121–122
Intestinal mesentery, 120–121
Irritable bowel syndrome (IBS), 103
Ischemia, 95, 99
J
Jelonet, 330
Joint advisory group (JAG), 147
K
Kelly clamps, 221, 270
Kocher clamps, 221–222, 290, 324–326,
331, 333, 347–348
L
Laparoscopic partial/total
mesosigmoidectomy, sigmoid
colectomy
avascular interpedicular region,
236–237
Babcocks clamp placement, 238
blunt-tipped curved retractor
insertion, 237
colofascial separation, 239
fully skeletonized IMA, 236–237
linear staplers insertion, 237–238
medial to lateral mesosigmoid
mobilization, 234, 236
mesofacial separation, 238
mesosigmoid peritoneal reection,
234–235
peritonotomy, 234–235
Laparoscopic/robotic mobilization
greater omentum, 301–302
mesosigmoidal, 348–349
splenic exure, 302, 349
transverse mesocolon, 350
Laparoscopic/robotic surgery,
7–8,175
adipovascular pedicles
ileocolic adipovascular pedicle,
162, 173
inferior mesenteric adipovascular
pedicle, 162, 174
middle colic adipovascular
pedicle, 162, 173
colo-and mesofascial plane
ileocecal region between the
mesentery, 162, 168
left m socolon, 162, 171
mesorectal plane/interface,
162, 172
mesosigmoidal fascial plane/
interface, 162, 172
right mesocolon, 162, 169
small bowel mesentery, 162, 167
transverse mesocolon aer
mobilization of greater
omentum, 162, 170
development, 157
peritoneal reection
at base of small bowel mesentery,
157–158
greater omentum and transverse
colon, 162
hepatocolic peritoneal reection,
15 7, 161
at ileocecal region, 157, 159
left eritoneal reection, 162,
164 –165
pararectal peritoneal reection,
162, 166
right peritoneal reection,
15 7, 16 0
splenocolic peritoneal reection,
162, 163
rectum
anterior peritoneal reection, 258,
261–262
left m socolon mobilization,
255–256
left m sofascial separation,
255–256, 258–259
mesosigmoidal mobilization,
255–256
pararectal peritoneal reection
division, 255, 257
posterior mesofascial separation,
257, 2 6 0
right zone of adhesion, 257, 260
Waldeyer’s fascia identication,
259, 261, 263
vapor evacuation during, 207–208
Le mesocolon
anatomic nomenclature, 123
laparoscopic/robotic surgery, 162, 171
reverse engineering, 44
Left eritoneal reection, 33–34
LigaSure
™
device, 184, 225, 239, 263
Linear stapling devices, 236–237, 239,
348–349
Lymph nodes, 54
Lymphoma, 99
354 Index
M
Magnetic resonance imaging (MRI), 6,
109–110, 112–113, 145, 254
Maryland dissector, 224
Maya, 137
Mesenterectomy, 90, 131, 134, 137, 139,
202, 207, 211, 222, 230, 233,
239, 249, 251, 255, 277, 284, 311,
345, 348
Mesenteric-derived mesenchymal cells
(MMCs), 90
Mesenteric lymph node cavitation
syndrome, 101
Mesenteric neurologic pathology, 97
Mesenteropathies, see Indeterminate
mesenteropathy; Primary
mesenteropathy; Secondary
mesenteropathy
Mesenterotomy, 134, 350
anterograde, 134
colorectal surgery
anterograde approach, 220
in Crohn’s disease, 221–222
harmonic scalpel, 220–221
during open surgery, 220
tissue sealant devices, 220–221
2-0 Vicryl
®
suture, 221
0-0 suture, 222
interpedicular mesentery, 134
margin, 348
through avascular region, 196, 198
Mesentery
anatomic nomenclature, 121–128
cellular and extracellular
composition, 54
hi story, 343
Mesentery anatomy, 8, 343
adipovascular and avascular
mesenteric regions, 16, 18
attachments of, 11–12
class teaching
anchorage and elongation, 42
gastromesenteric complex
attachment, 43
peritoneal reection, 42–43
rotation, 41–42
Toldt’s fascia, 43
zones of attachment, 42
digital sculpture, 13–14
future directions, 38
greater omentum vs. transverse
mesocolon, 20
hepatic exure, 20–21, 23
inferior mesenteric adipovascular
pedicle, 22–23, 25
left m socolon, 22, 24
limitations, 38
mesosigmoid
congenital adhesions, 26
mesorectum, 28–29
mesosigmoidal angles, 25–26, 28
transverse axis, 25, 27
middle colic adipovascular pedicle,
20, 23
peritoneal reection, 28–29, 33–34
right iliac fossa, 14, 16
right mesocolon, 16, 18–19
root region, 14
small intestinal mesentery, 14, 16–17
splenic exure, 21–23
transverse mesocolon, 20, 22–23
Treves’ descriptions, 11–12
white line of Toldt, 23, 25–26
Mesoappendix, 121, 123–124
Mesorectal fascia, 128
Mesorectum, 28–29
anatomic nomenclature, 123, 128
computerized axial tomography, 115
reverse engineering, 44
Mesosigmoid
anatomic nomenclature, 123, 127
reverse engineering, 44
Mesosigmoidal congenital adhesions, 128
Mesosigmoidectomy; see also Laparoscopic
partial/total mesosigmoidectomy,
sigmoid colectomy
rectum
anterior peritoneal reection, 272
fascia overlying anterior
mesorectum, 273
IMA skeletonization and division,
268–270
mesosigmoidal mobilization,
266–268
mobilization of junction between
descending and sigmoid colon,
264, 266
pararectal peritoneal reection,
270–272
posterior mesorectal mesofascial
plane, 270
total, 233
Mesothelial cell plasticity, 53–54
Mesothelial-to-mesenchymal
transformation, 54
Metabolic syndrome, 103
Middle colic adipovascular
pedicle,20,23
Midgut, 44
Minimally invasive surgery, 7
Mobile mesosigmoid, 123, 127
Moran, Brendan, 139
Muscularis propria plane surgery, 154
Mycobacterium tuberculosis, 101
Myd88 deciency, 73
N
Neuroendocrine tumors, 100–101
Nomenclature, 135, 345
anatomic
congenital adhesions, 128
fascia, 128
mesentery, 121–128
pedicles, 120–121
peritoneal reection, 125, 128–132
surgical adaptation, 131
in chemistry and mathematics, 119, 131
exures, 120–121
partial or total right mesocolectomy,
133–134
radiological, 120, 134
resectional
operative, 131, 134
technical, 131, 134
rule-based, 120
utility of, 135
visceral and parietal peritoneum, 49–50
Nonexural mesentery, 120
Non-mesenteric-based surgery, 153–155
O
Omni-Tract
®
reactor, 199–200, 239
Open mesenteric-based colorectal
su rgery, 198
of abdomen, 177
adipovascular pedicles
ileocolic adipovascular pedicle,
178, 196
inferior mesenteric adipovascular
pedicle, 178, 197
inferior mesenteric vein
adipovascular pedicle, 178, 198
middle colic adipovascular
pedicle, 178, 197
colo-and mesofascial plane
beneath small bowel mesentery,
178, 188
ileocecal region between mesentery
and Toldt’s fascia, 178, 189
left m sofascial plane/interface,
178, 192
between mesorectum and fascia,
178, 194–195
mesosigmoidal mesofascial plane,
178, 193
right mesocolon, 178, 190
transverse mesocolon and
omentum, 178, 191
Index 355
peritoneal reection
greater omentum and transverse
colon, 178, 183
hepatocolic peritoneal reection,
177, 182
ileocecal peritoneal reection,
177,180
le peritoneal reection, 178, 185
mesosigmoidal peritoneal
reections, 178, 186
pararectal peritoneal reections,
178, 187
right peritoneal reection, 177,181
at small intestinal mesentery, 177, 179
splenocolic peritoneal reection,
178, 184
UL Exoscope, 177–178
Open mesosigmoidal mobilization, 349
Open mesosigmoidectomy, 239–249
Open mobilization of the splenic exure,
349–350
Openl right mesocolectomy, 348
Open right mesocolectomy, right
colectomy
colofascial separation, 278
congenital adhesions and right
peritoneal reection, 278–279
cutting/stapling techniques, 279, 284
hepatocolic peritoneal refl ction,
279,283
inferolateral peritoneal reection
division, 278–279, 281
mesofacial separation, 278–279
omento-colic peritoneal reection,
279, 284
Operative nomenclature, 131, 134
Osiri X, 110, 112
P
Pain during endoscopy, 147–148
Parietal peritoneum, 26, 48–50, 57, 101–102,
128, 243, 264, 334, 336, 349
Partial mesorectal excision (PTME),254
Partial/total right mesocolectomy, 133–134
Pathology, 342; see also Indeterminate
mesenteropathy; Primary
mesenteropathy; Secondary
mesenteropathy
Patient positioning, 286–287
access, 214–215
rectal dissection deep in pelvis, 264
reverse Trendlenberg position, 239
in steep Trendelenburg, 234
T-ba rs, 216
Peritoneal carcinomatosis, 76, 99–100
Peritoneal reection, 28–29, 33–34
anatomic nomenclature
anterior reection, 128, 133
hepatocolic peritoneal reection,
125, 131
inferolateral peritoneal reection,
125, 129
left m sosigmoidal reection,
128,133
le peritoneal reection, 125, 133
omentocolic reection, 125, 132
pararectal reections, 128, 133
right medial peritoneal
reection,128
right mesosigmoidal reection, 128
right peritoneal reection,
125, 130
small bowel peritoneal reection,
125, 128
laparoscopic/robotic appearance
at base of small bowel mesentery,
157–158
greater omentum and transverse
colon, 162
hepatocolic peritoneal reection,
15 7, 161
at ileocecal region, 157, 159
left eritoneal reection, 162,
164 –165
pararectal peritoneal reection,
162, 166
right peritoneal reection, 157, 160
splenocolic peritoneal reection,
162, 163
open mesenteric-based colorectal surgery
greater omentum and transverse
colon, 178, 183
hepatocolic peritoneal reection,
177, 182
ileocecal peritoneal reection,
177,180
le peritoneal reection, 178, 185
mesosigmoidal peritoneal
reections, 178, 186
pararectal peritoneal reections,
178, 187
right peritoneal reection, 178, 181
at small intestinal mesentery,
177,179
splenocolic peritoneal reection,
178, 184
Peritonotomy, 7, 25, 28, 32, 131, 133–134,
137, 172, 174, 193, 202, 205, 216,
226, 229–230, 234–235, 239,
244–245, 247, 255, 257–262,
268, 296, 298, 347–350
Phlegmon, 98, 233–234, 249, 338
Physiology, mesentery
C-reactive protein, 70
cytokine production, 70–72
future studies, 79
mesenteric mesothelium activities,
74–75
mesothelial
lymphatics, 76–78
plast icity, 74–76
secretion and absorption of
peritoneal fl id, 75–76
migration during embryologic
development, 70–71
as regulatory hub, 71, 73–74
visceral adiposity, 69–71
Pneumoperitoneum, 201–202,
207–208, 345
Point cloud–based approach, 112
Port placement, 234, 255, 347
Postoperative leak, 338
Primary mesenteropathy
Crohn’s disease (see Crohn’s disease)
cysts, 97
epiploic appendagitis, 95–96
internal herniation, 95
ischemia, 95
non (mal) rotation
anatomy, 92–94
clinical implications, 93–94
molecular basis, 93
schwannoma, 97
sclerosing mesenteritis, 97
volvulus, 93–95
Proctosigmoidectomy, 119, 131, 277
Proximal sigmoid exure, 123, 127
R
Radiology, 6, 117, 345
atlas reference, 112, 116
future studies, 117
history of mesenteric imaging, 109–110
implication on abdominal disease,
116–117
Osiri X, 110, 112
peritoneal reection, 110
Visual Human Project, 110, 112
Radiotherapy, 213
Randomized control trial, 154
Rectosigmoid, 123, 128, 147
Rectum, TME, 251
anatomy
digital model of, 251–252
in female, 254
lateral ligaments, 253–254
localization, 251
mesosigmoidal reection, 253