Retroperitoneal Right-Sided Visceral Mobilisation: The Cattel–Braasch Manoeuvre

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Executive Summary

The Cattel–Braasch manoeuvre is a specialized surgical technique designed for comprehensive retroperitoneal right-sided visceral mobilisation. Grounded in the anatomical observation of the small mesentery’s attachment to the posterior abdominal wall, the procedure facilitates the mobilisation of the entire duodenum, pancreas head, small bowel, and right colon.

Key advantages of this manoeuvre include:

  • Speed and Safety: It is recognized as one of the fastest mobilisation techniques with minimal blood loss due to the utilization of avascular planes.

  • Extensive Exposure: When completed, it provides unparalleled access to the entire retroperitoneum, including major vessels like the abdominal aorta and inferior vena cava (IVC), as well as renal and mesenteric structures.

  • Clinical Utility: It allows for the complete displacement of the small and large bowel outside the abdominal cavity to facilitate complex retroperitoneal interventions.

Anatomical Foundation

The manoeuvre is predicated on the "line of fusion" known as the white line of Toldt. This structure consists of the peritoneal reflection at the lateral wall of the cecum and ascending colon. The surgical field for this manoeuvre is defined by two primary landmarks:

  1. Origin: The common bile duct.

  2. Termination: The ligament of Treitz.

The procedure relies on the small mesentery’s attachment to the posterior abdominal wall along a short oblique line, allowing surgeons to exploit avascular planes for rapid mobilisation.

Component: The Extended Kocher Manoeuvre

The Extended Kocher manoeuvre is a critical subset of the Cattel–Braasch procedure. It specifically addresses the mobilisation of the total duodenum and the head of the pancreas.

Objectives of the Extended Kocher Manoeuvre:

  • Total mobilisation of the duodenopancreatic complex.

  • Full exposition of the right kidney and its hilum.

  • Exposure of the right renal veins, IVC, abdominal aorta, celiac plexus, and the superior mesenteric artery (SMA).

Surgical Methodology

The procedure is executed through a series of progressive mobilisations of the right colon, the duodenopancreatic complex, and the small bowel.

Phase I: Right Colon Mobilisation

  1. Positioning: The ascending colon is lifted and pulled gently toward the left side of the abdomen.

  2. Incision: Electrocautery is used to cut the lateral parietal peritoneum, extending from the right iliac external artery up to the hepatoduodenal ligament.

  3. Structure Separation: If required, the right ureter and gonadal vessels are localized and separated from the mesocolic plane.

Phase II: Duodenopancreatic Mobilisation (Extended Kocher)

  1. Peritoneal Incision: The peritoneum on the right side of the duodenum is cut.

  2. Foramen Omentale: The inferior avascular border of the foramen omentale (Winslow) is incised.

  3. Posterior Access: The avascular surface between the IVC and the posterior side of the pancreas head/duodenum is cut. These structures are then mobilised up to the SMA and the abdominal aorta.

Phase III: Small Bowel Mobilisation

  1. Resetting: The previously mobilised right colon and duodenopancreatic complex are temporarily returned to their physiological positions on the right.

  2. Small Bowel Shift: The small bowel is moved to the right side of the abdomen to visualize the parietal peritoneum between the Treitz ligament and the right iliac external artery.

  3. Final Release: The peritoneum is cut from the ligament of Treitz to the distal part of the right iliac external artery. The small bowel is then completely freed from the retroperitoneum from the right iliac vessels up to the SMA.

Anatomical Exposure Post-Manoeuvre

Upon completion of the Cattel–Braasch manoeuvre, the colon and small bowel can be placed on the upper abdomen and thorax, secured with wet gauze and retractors. This provides surgical access to the following organs and structures:

Category

Exposed Structures

Major Vessels

Abdominal aorta (below SMA), Inferior Vena Cava (IVC), Infrarenal aorta, Iliac vessels (bilateral)

Mesenteric Vessels

Superior Mesenteric Artery (SMA), Inferior Mesenteric Artery (IMA), Inferior Mesenteric Vein (IMV)

Viscera

Posterior side of the duodenum, Pancreas head, Both kidneys

Urological/Other

Both ureters, Celiac trunk and plexus, Left adrenal gland, Left adrenal vein

Clinical Precautions

The procedure requires strict adherence to safety protocols to prevent vascular compromise of the mobilised organs:

  • Torsion Prevention: Surgeons must avoid torsion of the colon and small bowel mesentery, as this can lead to acute ischemia.

  • Perfusion Monitoring: Constant vigilance regarding the blood perfusion of the small bowel and colon is mandatory throughout the procedure.

  • Mechanical Fixation: Following mobilisation, the bowels should be covered with wet gauze and secured using abdominal retractor blades or manual assistance to maintain stable exposure.