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Division of the mesentery of the bowel is usually an easy step in the operation that can be done without any issue. One of the conditions, which is an exception to the rule, is the mesentery of Crohn’s disease. The small bowel mesentery of Crohn’s disease will be foreshortened, very thickened, and may be firm/hard. It’s not uncommon to encounter bleeding if the usual techniques are used to control the mesentery. Although division of the mesentery can be done laparoscopically or robotically, it will be technically challenging due to risk of bleeding.
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There are few techniques to consider:
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Preferably, this part of the procedure is done using open technique after the bowel is exteriorized.
When exteriorizing the specimen, if the incision is small, have a lower threshold than usual to extend the incision. Pulling on the bowel to exteriorize the thick mesentery may cause tears in the mesentery that causes bleeding.
One way to get better exposure without extending the incision significantly is to exteriorize the colon, divide it, and place a 3-0 Vicryl suture in the antimesenteric corner and return it back to the abdominal cavity after you tag that suture with hemostat, and then exteriorize the thickened terminal ileum. Sometimes, the mesentery is very thickened and cannot be totally exteriorized via a laparoscopic extraction incision. In this scenario, it may be best to convert to an open operation.
Using an energy source to divide the mesentery is not recommended because it may not completely seal the mesenteric vessels and will cause bleeding. This is due to the significant thickness and scarring of the mesentery, especially close to the bowel wall. If one uses an energy source then it is best to take the mesentery in layers and further away from the bowel wall where the mesentery may not be as thick as it is close to the bowel wall.
Score the mesentery superficially.
Start dividing the mesentery using Kelly clamps and suture ligation to control the mesentery.
When the mesentery is divided between the Kelly clamps, make sure of the following:
Not to divide the mesentery beyond the end of the tip of the Kelly clamp.
Divide the mesentery close to the clamp that is on the specimen side, leaving a cuff of tissue on the staying side. Otherwise, the vessel might retract and the tie may slip.
Multiple small bites of mesentery should be taken when clamping. If one takes large bites then the suture might not control the vessel, because of the thickness of the mesentery (Figure 20-1).
Use 0 or 2-0 Vicryl to control the mesentery by doing a suture ligature. After you place the first knot, release the Kelly clamp and then re-grab quickly, and complete a total of four knots. After that suture is cut, place a free suture and tie it around the Kelly clamp using a sliding knot and make sure it’s completely down, but be careful not to tear ...