Overview
Definition:
Duodenojejunal flexure mobilization refers to the surgical division of the peritoneal attachments, primarily the ligament of Treitz, to free the distal duodenum and proximal jejunum
The ligament of Treitz is a fibromuscular band extending from the diaphragm to the third and fourth parts of the duodenum, acting as a landmark defining the junction between the duodenum and jejunum.
Epidemiology:
The necessity for duodenojejunal flexure mobilization arises in specific surgical scenarios involving the upper gastrointestinal tract, such as severe duodenal obstruction, complex pancreaticoduodenal resections, or certain reconstructive procedures following gastric surgery
Its direct prevalence as a standalone procedure is rare, but it is an integral part of other complex operations.
Clinical Significance:
Accurate identification and mobilization of the duodenojejunal flexure are crucial for safe and effective surgery involving the distal duodenum and proximal jejunum
Failure to properly dissect this region can lead to injury to adjacent structures like the inferior mesenteric artery, splenic vein, or pancreas
Understanding this anatomy is vital for managing conditions like superior mesenteric artery (SMA) syndrome, duodenal diverticula, or implementing gastrojejunostomy reconstruction.
Indications
Absolute Indications:
Superior Mesenteric Artery (SMA) syndrome causing severe duodenal obstruction
Complete obstruction of the distal duodenum requiring bypass or resection
Conditions necessitating extensive mobilization of the proximal small bowel for reconstruction.
Relative Indications:
Certain complex pancreaticoduodenectomy (Whipple procedure) variants where distal duodenal mobilization is required for tumor clearance or reconstruction
Management of duodenal fistulas or perforations requiring extensive dissection
Resection of tumors involving the distal duodenum or proximal jejunum.
Contraindications:
Extensive intra-abdominal adhesions that make dissection unsafe
Patients with severe comorbidities precluding major surgery
Acute inflammation or infection at the operative site, which may need to be addressed before definitive mobilization.
Anatomy And Landmarks
Ligament Of Treitz:
A fibromuscular band originating from the left crus of the diaphragm and extending to insert on the posterior aspect of the duodenojejunal junction
It contains smooth muscle fibers that contract to aid in intestinal peristalsis and maintain the flexure.
Relations:
Posteriorly, it is related to the inferior mesenteric artery and vein, the left renal vein, and the uncinated process of the pancreas
Superiorly, it is continuous with the peritoneum of the duodenal diaphragm.
Vascular Supply:
The ligament is supplied by branches of the inferior mesenteric artery and the superior mesenteric artery
Awareness of these vessels is critical during dissection to avoid inadvertent bleeding.
Surgical Technique
Approach:
Typically performed via a midline laparotomy or a left subcostal incision, depending on the extent of the planned surgery
Laparoscopic approaches are also feasible for experienced surgeons.
Dissection Steps:
The surgeon identifies the ligament of Treitz and carefully dissects its peritoneal attachments from the posterior abdominal wall
Gentle traction on the duodenum and jejunum aids in defining the plane of dissection
The dissection proceeds medially, freeing the distal duodenum from the retroperitoneum, taking care to identify and ligate small vascular branches.
Important Considerations:
Maintain meticulous hemostasis
Avoid avulsing the ligament from the duodenal wall
Preserve adjacent vascular structures, particularly the inferior mesenteric artery
Consider the extent of mobilization required for the specific pathology and subsequent reconstruction.
Postoperative Care And Complications
Postoperative Management:
Intravenous fluids and electrolytes management
Nasogastric tube decompression if prolonged ileus is anticipated
Gradual reintroduction of oral feeding
Pain management
Monitoring for signs of infection or anastomotic leak.
Early Complications:
Hemorrhage from dissected vessels
Injury to adjacent organs (pancreas, aorta, vena cava, renal vessels)
Prolonged ileus
Wound infection.
Late Complications:
Internal herniation through the defect created by mobilization
Stricture formation at the dissected site
Recurrence of SMA syndrome if inadequate mobilization or underlying cause persists.
Prevention Strategies:
Meticulous surgical technique with careful dissection
Adequate hemostasis
Avoiding excessive tension on the bowel
Secure closure of any large peritoneal defects created during mobilization
Close postoperative monitoring.
Key Points
Exam Focus:
The anatomical location and importance of the ligament of Treitz as a landmark
Indications for its mobilization, especially SMA syndrome
Potential complications and their management
Understanding the surgical steps and potential pitfalls.
Clinical Pearls:
Always confirm the identity of the ligament of Treitz
Gentle dissection is paramount
Understand the embryological basis for its attachments
If performing a Whipple procedure, a thorough knowledge of its dissection is essential for a tension-free reconstruction.
Common Mistakes:
Mistaking other peritoneal folds for the ligament of Treitz
Aggressive dissection leading to avulsion of mesenteric vessels or injury to the pancreas
Inadequate mobilization leading to persistent obstruction
Failing to close mesenteric defects, risking internal herniation.