The Mesentery in Complete Mesocolic Excision

Abstract

The following article summarizes technical aspects of how to operate in the mesentery during complete mesocolic excision (CME). Increasingly, CME is being adopted and as such it is important to establish the anatomical basis of the techniques involved. This review thus serves to provide that foundation and explains the surgical techniques built on it.

Keywords: complete mesocolic excision; mesentery; surgery.

Fig. 1

Schematic diagram of Henle's trunk and constituent vessels.

Fig. 2

Schematic illustration of the “Open book model” (see text for description) of the structures involved in complete mesocolic excision of the right colon.

Fig. 3

( A ) Photograph of intraoperative view during early stage of CME. The illustration shows partial Kocherization of duodenum. The parietal peritoneum is about to be incised to access the anterior surface of the duodenum and pancreas. ( B ) Photograph of intraoperative view during stage of CME. The surface of the duodenum and uncinate process have been exposed. CME, complete mesocolic excision.

Fig. 4

Photograph demonstrating exposure of SMV and with ileocolic vein, during CME. CME, complete mesocolic excision; SMV, superior mesenteric vein.

Fig. 5

Photograph of intraoperative appearance of the SMV following resection in CME. A schematic has been overlain to illustrate the anatomy (color code: blue [SMV], red [duodenum]). ASPDV, anterior superior pancreaticoduodenal vein; CME, complete mesocolic excision; SMV, superior mesenteric vein.

Fig. 6

Flowchart demonstrating a pipeline whereby a 3D replica of the vasculature of the mesentery (as this relates to CME) can be generated. 3D, three-dimensional; CME, complete mesocolic excision.

Fig. 7

Top image: intraoperative view from the robotic console with 3D virtual reconstruction of mesenteric vessels displayed next to operative view with TilePro. 3D, three-dimensional.

Fig. 8

( A ) Photograph demonstrating the intraoperative view when ICG has been administered to evaluate perfusion during intracorporeal ileo-transverse anastomosis. ( B ) Photograph demonstrating the intraoperative view during injection of ICG into the colonic wall near a primary tumor. ( C ) Photograph demonstrating the intraoperative view of a mesenteric lymphatic vessel and associated lymph node, after administration of ICG. ( D ) Photograph demonstrating the intraoperative view of the ureter after retrograde injection of ICG. ICG, indocyanine green.