Anatomic Landmarks for Laparoscopic Colon Resection John Marks MD Chief: Section of Colorectal Surgery Main Line Health System Professor: Lankenau Institute of Medical Research Director: Fellowship in Minimally Invasive Colorectal Surgery and Rectal Cancer Management

Critical Anatomy Blood Vessels Nerves Attachments Relationships to Other Organs

Normal Development of Intestine

Normal Development of Intestine- Normal Anatomy Line of Toldtz SMA diagonal axis

Right Colon - 1 Superior mesenteric artery Ileocolic pedicle Bare spot of duodenum Relationship to the Pancreas Embryologic fusion plane R colon mesentery Right ureter

Right colic - either branch of ICA, MCA A Garcia-Ruiz, JW Milsom, KA Ludwig, P Marchesa. Right Colonic Arterial Anatom. Dis Colon Rectum 1996;39(8):906-911 56 cadavers Ascending colon ileocolic artery - 66% middle colic artery - 23.3% right colic artery - 10.7% Right colic - either branch of ICA, MCA Middle colic artery - 98.2% - independent 3.6% double arteries Anomalies - branch of hepatic artery, splenic artery

Image Position Lap Right Colon

Right Colon - 1

Right Colon - 2 Gastrocolic ligament Hepatorenocolic Ligament Line of Toldt Attachment of ileum to pelvis

Right Colon - 2

Middle Colic Right Colic Ileocolic 32.8 45.2 67.4 3 - 70 20 - 70 A Garcia-Ruiz, JW Milsom, KA Ludwig, P Marchesa. Right Colonic Arterial Anatom. Dis Colon Rectum 1996;39(8):906-911 Length Before Branching Mean (mm) Range (mm) Middle Colic Right Colic Ileocolic 32.8 45.2 67.4 3 - 70 20 - 70 20 -120

Middle Colic Artery SKIP

Left Colon - 1 View of perforating vein of gastrocolic ligament Entry into lesser sac Posterior wall of stomach Inferior pancreas

Gastrocolic Ligament

Left Colon - 1

Left Colon - 2 Upper attachment Line of Toldt Splenorenal colic ligament Embryologic fusion plane between mesentery Gerota’s fascia Transverse mesocolon

Left Colon - 2

Left Colon

Left Colon - 3 IMV medially Gruber’s ligament IMA medially Right ureter Embryologic fusion plane of descending colon

Left Colon - 3

Left Colon - 4 Hypogastric nerves Left ureter Left gonadal vessel IMA & left colic branch White line of Toldt

Left Colon - 4

Rectum - 1 R & L pararectal sulcus R hypogastric nerves at pelvic brim Areolar plane anterior to hypogastric nerves Proper plane along TME Seminal vesicles & Nervi Erigentes

Rectum - 1

Rectum - 2 R & L lateral stalk Levator ani Anal canal

Rectum - 2

Pelvic Floor