Overview
Definition:
The Kocher maneuver involves mobilizing the duodenum and pancreas to expose the underlying retroperitoneal structures
The Cattell-Braasch maneuver, a more extensive version, mobilizes the entire right colon and small intestine from the retroperitoneum, providing access to the entire right side of the abdomen and pelvis.
Indications:
These maneuvers are crucial for achieving adequate surgical exposure in complex abdominal surgeries
They facilitate access to retroperitoneal structures such as the aorta, vena cava, kidneys, ureters, and pancreaticoduodenal region
Indications include oncologic resections, major vascular repairs, pancreaticoduodenectomy (Whipple procedure), and management of trauma or complex infections in the retroperitoneum.
Clinical Significance:
Adequate exposure is paramount for safe and efficient surgery
These maneuvers allow surgeons to identify, manipulate, and resect or repair structures within the retroperitoneum with reduced risk of injury to adjacent organs
They are particularly important for improving visualization during challenging oncologic resections and complex reconstructive procedures.
Kochermaneuver
Description:
The Kocher maneuver specifically focuses on dissecting the retroperitoneal attachments of the duodenum and the anterior surface of the head of the pancreas.
Steps:
1
Incise the peritoneum along the lateral border of the descending duodenum
2
Bluntly and sharply dissect the avascular plane between the duodenum and the uncinated process of the pancreas
3
Retract the mobilized duodenum and head of the pancreas medially to expose the inferior vena cava, aorta, and right renal vein.
Structures Exposed:
Inferior vena cava, aorta, right renal vein, common bile duct, gastroduodenal artery.
Cattellbraaschmobilization
Description:
This is a more extensive mobilization that begins with the Kocher maneuver and extends to mobilize the entire ascending colon, cecum, and terminal ileum.
Steps:
1
Perform Kocher maneuver to mobilize the duodenum and head of the pancreas
2
Incise the peritoneum along the lateral border of the ascending colon
3
Dissect the avascular plane between the ascending colon and the retroperitoneum
4
Mobilize the cecum and terminal ileum
5
Retract the entire right hemicolon and mobilized duodenum medially to expose the entire right side of the retroperitoneum and the right iliac fossa.
Structures Exposed:
Includes structures from Kocher maneuver plus right ureter, right ovarian/testicular vessels, common iliac vessels, appendix (if mobilized with cecum).
Preoperative Considerations
Patient Assessment:
Thorough evaluation of patient comorbidities, including cardiovascular, pulmonary, and renal function
Assessment of nutritional status and coagulation parameters.
Imaging Studies:
Review of cross-sectional imaging (CT, MRI) to delineate the anatomy of the retroperitoneum, identify any masses, and assess vascular relationships
Angiography may be indicated for suspected vascular pathology.
Anesthetic Management:
Careful anesthetic planning, considering the duration of the surgery and potential for significant blood loss
Adequate venous access and potential for invasive monitoring are essential.
Surgical Technique And Tips
Dissection Plane:
Maintaining the correct avascular plane is crucial to avoid injury to major vessels and nerves
The plane is typically between the peritoneum and the posterior fascia of the retroperitoneum.
Hemostasis:
Meticulous hemostasis is vital due to the rich vascular supply in the retroperitoneum
Careful ligation and electrocautery are essential.
Retraction:
Gentle but adequate retraction is needed to provide visualization without causing ischemic injury to the mobilized organs
Self-retaining retractors are often used.
Identification Of Structures:
Systematic identification and preservation of vital structures such as the inferior vena cava, aorta, renal vessels, and ureters are paramount
Anatomical variations should be anticipated.
Complications
Early Complications:
Hemorrhage from major vessels (vena cava, aorta, renal vessels)
Injury to ureters, duodenum, or pancreas
Postoperative ileus
Fluid and electrolyte disturbances
Infection.
Late Complications:
Adhesions and subsequent bowel obstruction
Incisional hernia
Recurrent retroperitoneal bleeding
Chronic pain
Lymphocele formation.
Prevention Strategies:
Careful dissection, meticulous hemostasis, identification and protection of vital structures, judicious use of retractors, and prompt management of any intraoperative injuries
Postoperative care focusing on early mobilization and fluid management helps prevent ileus and electrolyte imbalances.
Key Points
Exam Focus:
Understand the indications, contraindications, and detailed steps of both Kocher and Cattell-Braasch maneuvers
Recognize the vital structures at risk during each step
Recall common complications and their management.
Clinical Pearls:
Always identify the duodenum first during Kocher maneuver
The avascular plane is key
Be prepared for significant bleeding and have adequate suction and coagulators ready
For Cattell-Braasch, remember to mobilize the cecum and terminal ileum as a unit with the right colon for complete exposure.
Common Mistakes:
Inadequate mobilization leading to poor exposure
Injury to the superior mesenteric artery or vein
Transection of the ureter
Failure to control retroperitoneal bleeding
Over-retraction causing ischemic injury.