- Surgical Approach
- Key factors
- Proximity to ampulla
- Injury characteristics - Simple vs complex
- Circumference of involved duodenum
- Associated injuries - Biliary tree, pancreas, vascular
- Can’t really dissect D2 away from pancreas - closely apposed and inter-reliant on blood supply
- D3 exposure via left medial visceral rotation - Cattell Brasch and SB mesentery mobilisation
- D4 exposure by mobilising ligament of Treitz
- Intramural haematoma
- Leave alone if possible
- Can cause duodenal obstruction but should settle with time
- If doesn’t - warrants exploration
- Operative Possibilities
- Simple suture repair
- Duodenal diversion
- Suction drainage peri-duodenal
- Damage control preceded Whipple’s
- Options
- Laceration and perofation
- Simple suture repair
- Closure of longitudinal duodenotomy transversely if length <50% is of circumference
- Omental or serosal patch
- Complete transection
- Primary anastomosis often possible if mobility permits (D1,D3,D4)
- May need reconstruction
- Proximal to ampulla - antrectomy and Bilroth II
- Distal to ampulla - R&Y duodenojejunal anastamosis and closure of distal duodenum
- D2 - R&Y end-to-side duodenojejunal anastamosis
- Pyloric exclusion with gastrojejunostomy
- Consider this in high risk repairs to divert gastric content and improve chance of healing + make a leak easier to manage
- Other options
- Duodenal Diverticulation - this is dated
- This is Bilroth II gastrectomy + closure of duodenal injury + placemnet of a decompressive catheter into the duodenum (also described is performing a truncal vagotomy and biliary drainage at the same time to decrease the fluid in the repair)
- Triple tube decompression
- Damage control surgery followed by Whipple
- Consider cholangiogram if close to ampulla/bile duct
Difficult duodenum