Duodenal trauma
Executive Summary
The management of duodenal trauma requires a profound understanding of retroperitoneal anatomy, vascular supply, and specific surgical maneuvers. The duodenum is a largely fixed, retroperitoneal structure whose blood supply is intimately shared with the head of the pancreas, making its repair surgically demanding. Key takeaways for clinical management include:
Mandatory Exploration: All periduodenal hematomas identified during laparotomy, whether from blunt or penetrating trauma, must be explored to rule out underlying perforation.
Vascular Preservation: The duodenum and pancreas share the pancreaticoduodenal arcades; attempting to separate these organs frequently results in duodenal ischemia.
Exposure Maneuvers: The Kocher and Cattell-Braasch maneuvers are the primary techniques for mobilizing the duodenum and exposing retroperitoneal structures.
Repair Priorities: Most lacerations can be managed with debridement and primary transverse duodenorrhaphy. Complex injuries may require segmental resection, pyloric exclusion, or, in rare destructive cases, a pancreaticoduodenectomy (Whipple procedure).
Supportive Care: Wide drainage and distal feeding access (jejunostomy) are essential components of managing complex duodenal injuries.
Surgical Anatomy and Clinical Context
The duodenum is approximately 25 cm in length and is the most fixed portion of the small intestine. It lacks a mesentery and lies anterior to the right kidney, renal vessels, right psoas muscle, inferior vena cava (IVC), and aorta.
Anatomical Divisions
Vascular and Duct Considerations
The vascular supply is derived from anterior and posterior pancreaticoduodenal arcades on the surface of the pancreas. The common bile duct and main pancreatic duct drain into the ampulla of Vater in the second portion. An accessory pancreatic duct typically drains approximately 2 cm proximal to the ampulla.
General Surgical Principles
Hematoma Management: Periduodenal hematomas must be opened and explored. A seromuscular incision should be made over the hematoma, which is then evacuated to allow for a full-thickness inspection of the duodenal wall.
Debridement and Repair: Most lacerations are managed with debridement and transverse closure (duodenorrhaphy). Transverse closure is preferred to prevent luminal narrowing.
Drainage: Wide local drainage using closed suction drains is mandatory for all repairs. Drains should be placed near but not directly overlying the repair site.
Feeding Access: For complex injuries, distal feeding access via a jejunostomy tube should be routinely considered.
Operative Techniques: Exposure
Effective exposure is critical for identifying injuries and protecting surrounding structures like the Superior Mesenteric Vein (SMV).
Kocher Maneuver
This involves incising the lateral peritoneal attachments of the first, second, and third portions of the duodenum.
The C-loop and pancreatic head are retracted medially.
This exposes the posterior surfaces of the duodenum and provides access to Gerota’s fascia, the right kidney, and the IVC.
Cattell-Braasch Maneuver (Right Medial Visceral Rotation)
Used to increase exposure to the third and fourth portions of the duodenum and retroperitoneal vessels.
The lateral peritoneal attachments of the right colon are incised from the hepatic flexure to the cecum.
The incision is extended onto the visceral peritoneum, posterior to the small bowel mesentery, toward the ligament of Treitz.
The right colon and small bowel are retracted cephalad and to the left, exposing the superior mesenteric vessels.
Surgical Repair Strategies
Primary Repair and Resection
Duodenorrhaphy: Performed in two layers using a full-thickness continuous 3-0 absorbable suture for the inner layer and 3-0 seromuscular Lembert sutures for the outer layer.
Longitudinal Repair: If transverse closure is impossible due to inadequate mobilization, a longitudinal repair may be used, provided it does not cause significant luminal narrowing.
Segmental Resection: Required for transections or injuries involving >50% of the circumference of the first, third, or fourth portions. Reconstruction involves an end-to-end duodenoduodenostomy or duodenojejunostomy.
Roux-en-Y: Utilized if a tension-free primary anastomosis cannot be achieved.
Pyloric Exclusion
This technique is reserved for severe injuries requiring complex repair or repairs with tenuous blood supply, particularly in the second portion of the duodenum.
An anterior gastrotomy is created near the pylorus.
The pylorus is grasped and closed from the inside using a purse-string suture or a stapling device (e.g., TA 55).
A gastrojejunostomy is then created at the site of the gastrotomy.
Management of Destructive Injuries
Destructive injuries to the pancreatic head and duodenum may require a pancreaticoduodenectomy (Whipple procedure). These patients are often hemodynamically unstable; in such cases, damage control techniques (resection without anastomosis, wide drainage, and exteriorization) are utilized, with reconstruction delayed for a staged second operation.
Critical Tips and Pitfalls
Ischemia Risk: Never attempt to separate the second portion of the duodenum from the head of the pancreas, as this destroys the shared blood supply.
Vascular Injury: The superior mesenteric vein and its branches are highly susceptible to injury during excessive traction during mobilization maneuvers.
Ampulla of Vater: Repairs involving the medial aspect of the second portion must be performed with extreme care to identify and preserve the ampulla of Vater. If necessary, these injuries can be explored from within the lumen via a lateral duodenotomy.
Mobilization: Avoid dissection that leads to devascularization and subsequent duodenal necrosis.
Ligament of Treitz: When dividing the ligament of Treitz to expose the distal duodenum, proceed carefully to avoid injuring the superior mesenteric artery, which lies to the left of the junction.
