Name:
16 Duodenum Med
Description:
16 Duodenum Med
Thumbnail URL:
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Duration:
T00H08M47S
Embed URL:
https://stream.cadmore.media/player/9e7c714d-1c7c-4255-b828-1e5ee0d0501a
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/9e7c714d-1c7c-4255-b828-1e5ee0d0501a/1620Duodenum20Med.mov?sv=2019-02-02&sr=c&sig=I0Qrvz1f%2BeBUdIeOJvpsoRcuh1KjEr9%2FhmI%2BHAmw7QE%3D&st=2024-12-30T16%3A52%3A00Z&se=2024-12-30T18%3A57%3A00Z&sp=r
Upload Date:
2022-03-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
In this video, we will discuss the proper technique to expose the duodenum.
Segment:1 Objectives .
We will begin by reviewing the anatomy, followed by the necessary instruments and proper positioning, the techniques to expose the duodenum, and finally the tips and pitfalls of this exposure. The duodenum is approximately 25cm in length,
Segment:2 Anatomy.
and the most fixed part of the small intestine. It is divided into four parts.
The superior, or first portion, starts distal to the pylorus and is intraperitoneal along the anterior half of its circumference. It is attached superiorly to the hepatoduodenal ligament. Posterior to the first portion, lies the gastroduodenal artery, the common bile duct and the portal vein. The descending, or second portion, lies posterior to the hepatic flexure of the colon. With the hepatic flexure mobilized, the second portion of the duodenum is visible.
Laterally, the second portion of the duodenum has peritoneal attachments. The common bile duct courses within the hepatoduodenal ligament, and travels posterior, to insert into the duodenum in the second portion. Medially, it is intimately associated with the head of the pancreas, and shares a blood supply with it, from the anterior and posterior arcades. These anatomic points, make injuries to the second portion particularly challenging.
The transverse or third portion, is located in the retroperitoneum, posterior to the small bowel mesentery. A right visceral medial rotation, or Cattell-Braasch maneuver, is necessary for this exposure. The superior mesenteric vessels, as they cross the duodenum, are the surgical landmark, identifying the junction between the third and fourth portion of the duodenum. The ascending or fourth portion, is mostly retroperitoneal, starting at the crossing of the mesenteric vessels.
It briefly comes intraperitoneal, at its junction with the jejunum at the Ligament of Treitz. Posterior to the duodenum and pancreatic head, lies the inferior vena cava, and the renal veins on the right. The aorta and the superior mesenteric artery lie posterior to the duodenum, on the left side. The patient should be positioned supine,
Segment:3 Instrumentation and Positioning .
and the preparation should include the abdomen, from the nipples to the knees.
Instruments required, include a standard laparotomy tray, abdominal retractor, such as a Bookwalter, surgical staplers and a tube, for possible jejunal feeding access. A mid-line laparotomy is made in the skin, from the xiphoid process to the pubis symphysis, using a scalpel. Upon entry to the peritoneal cavity, a fixed self-retaining retractor, such as the Bookwalter is helpful. With the retractor in place, the anterior surface of the stomach, of the pylorus, the first portion of the duodenum and the hepatoduodenal ligament are easily visible.
In order to expose the distal part of the first portion and the second portion of the duodenum, the hepatic flexure of the colon must be mobilized. The colon is retracted immediately, and the peritoneal attachments are divided. Care should be taken to avoid injury to the underlining duodenum. Once the hepatic flexure has been mobilized, the underlying first and second portion of the duodenum are visible. A Kocher maneuver is performed, incising the lateral attachments of the duodenum, from just distal to the hepatoduodenal ligament, and around the second portion of the duodenum.
Mobilization of the duodenum is continued medially, and the duodenal and pancreatic head are retracted medially, exposing the underlying, inferior vena cava and right renal vein, taking care not to injure them. The distal most extent of the Kocher maneuver, is identified by the left renal vein, which approximates the location of the superior mesenteric vessels, as they cross over the junction of the third and fourth portions of the duodenum.
Further distal exposure of the duodenum, requires mobilization of the superior mesenteric vessels, where they cross over the duodenum. This is achieved with the right, visceral, medial rotation, or Cattell-Braasch maneuver. The right colon is retracted medially, and the white line of Toldt is sharply incised. Mobilization of the colon is continued around the cecum, until the terminal ileum. Once the right colon is mobilized, the small bowel is retracted to the right, exposing the base of the mesentery, from the ileocecal junction to the Ligament of Treitz.
The base of the mesentery is then divided along this line. The right colon and small bowel, are now able to be retracted towards the patient left chest, providing wide exposure of the retroperitoneal structures, and the posterior aspect of the duodenum. Care must be taken when retracting the bowel, once medial rotation has been completed, as the bowel is attached, only by the mesenteric vessels. The Cattell-Braasch maneuver also provides excellent exposure to the inferior vena cava and bilateral renal veins.
Note the location of the superior mesenteric artery after mobilization, and that it no longer crosses over the left renal vein. The final step to exposing the entirety of the duodenum, is to mobilize the Ligament of Treitz. The transverse colon is retracted superiorly, and the small bowel, inferiorly, placing tension on the ligament. The Ligament of Treitz, is then carefully incised. The location of the superior mesenteric artery at the base of the mesentery, should be identified by palpation, prior to incising the ligament, in order to avoid an inadvertent injury.
Once the Ligament of Treitz has been incised, the duodenum is now freely mobile through the defect in the mesentery. The extent of this mobilization, is demonstrated here, beginning at the stomach, into the first portion of the duodenum, around the C-loop and the second portion of the duodenum. And finally, the third and the fourth portions of the duodenum. While pyloric exclusions is not necessary in most duodenal injuries, particularly destructive ones may warrant it.
A gastrotomy is made with the electric cautery. The pylorus is then grasped, using a Babcock and delivered via the gastrotomy. A heavy silk suture is then used to close the pylorus. The gastrotomy is then used to create a gastrojejunostomy. An alternative method using a TA stapler may also be utilized across the pylorus, and is particularly useful, if a gastrojejunostomy is not to be performed, and a decompressive naso-gastric tube is left instead.
Segment:4 Tips and Pitfalls.
Avoid excessive traction during the Kocher and Cattell-Braasch maneuvers, as the superior mesenteric vein can easily be injured. Identify the superior mesenteric vessels, when mobilizing the Ligament of Treitz, to avoid inadvertent injury. During repairs of the second portion of the duodenum, be sure to identify and preserve the Ampulla of Vater. Separation of the pancreas and the second portion of the duodenum, will result in ischemia and necrosis of the duodenum.
The majority of injuries are amenable to primary repair or resection and anastomosis, with adequate exposure and mobilization. Pyloric exclusion should be used selectively. Always consider distal feeding access, and closed suction drains should always be placed. Thank you.
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