Overview
Definition:
The Mattox maneuver, also known as the left medial visceral rotation or CME (Congenital Mesenteric-to-Embryonic) rotation, is a surgical technique used primarily in laparoscopic abdominal surgery
It involves mobilizing the left colon and its associated mesentery to provide wider exposure of the retroperitoneum, particularly the aorta and its branches
This maneuver facilitates access to deeper structures and allows for easier dissection and management of pathology in the left upper quadrant and retroperitoneal spaces.
Epidemiology:
The application of the Mattox maneuver is not tied to specific epidemiological data of a disease but rather to the surgical approach for various abdominal pathologies
It is commonly employed in procedures such as complex nephrectomies, adrenalectomies, aortic aneurysm repair, distal pancreatectomy, and oncologic resections involving left-sided retroperitoneal structures
Its frequency of use is therefore dependent on the incidence of these surgical conditions and the prevalence of laparoscopic approaches for them.
Clinical Significance:
The Mattox maneuver is crucial for achieving adequate exposure in the retroperitoneum and left upper quadrant during laparoscopic surgery
It allows for safe and efficient dissection of major vascular structures, nerves, and lymphatic tissues
By rotating the left colon medially, surgeons gain unimpeded access to the left renal vein, aorta, celiac axis, superior mesenteric artery, and surrounding lymph nodes
This enhanced visualization and access are critical for complex oncologic resections, management of vascular pathology, and minimizing injury to vital structures, ultimately improving patient outcomes and reducing operative time.
Indications
Primary Indications:
Left-sided adrenalectomy
Radical nephrectomy for large renal masses or infiltrative tumors
Left radical nephroureterectomy
Aortic aneurysm repair (infrarenal, juxtarenal, pararenal)
Management of retroperitoneal tumors
Distal pancreatectomy
Splenectomy when extensive retroperitoneal dissection is required
Resection of large or invasive retroperitoneal lymph nodes.
Relative Indications:
Complex pancreaticoduodenectomy (Whipple procedure) for improved visualization of the superior mesenteric artery
Certain cases of gastric surgery requiring extensive retroperitoneal dissection
Management of left-sided vascular anomalies.
Contraindications:
Extensive adhesions from previous surgery or inflammation in the left upper quadrant or along the left colon
Significant bowel obstruction
Unstable patients requiring immediate, rapid intervention
Surgeons unfamiliar with the technique and its potential complications.
Preoperative Preparation
Patient Assessment:
Thorough patient evaluation including cardiopulmonary status, renal function, and coagulation profile
Review of imaging studies (CT, MRI) to assess tumor extent, vascular anatomy, and presence of adhesions
Nutritional assessment and optimization.
Bowel Preparation:
Standard mechanical bowel preparation with clear liquids for 24-48 hours prior to surgery
Prophylactic antibiotics to cover common enteric flora, typically a second-generation cephalosporin or a broader-spectrum agent if indicated.
Anesthesia Considerations:
General anesthesia with endotracheal intubation
Invasive arterial monitoring for hemodynamic stability, especially in aortic procedures
Central venous access
Nasogastric tube insertion for gastric decompression
Positioning of the patient to optimize intra-abdominal access and operative ergonomics.
Equipment Setup:
Standard laparoscopic tower with high-definition monitor, insufflator, and light source
A variety of laparoscopic instruments including dissectors, graspers, scissors, suction-irrigation devices, and an energy device (e.g., bipolar cautery, ultrasonic dissector)
Specialized retractors may be beneficial for maintaining visceral rotation
Endoscopic staplers and energy sealing devices.
Procedure Steps
Trocar Placement:
Typically, a standard four-port or five-port setup is used
Port placement is guided by the operative goal, with primary working ports in the left upper quadrant and suprapubic region
Additional ports for retraction and camera manipulation are placed strategically.
Initial Mobilization:
The sigmoid colon and descending colon are usually mobilized first to gain access to the left retroperitoneum
The taeniae coli are divided along the lateral border of the descending colon, and the colon is dissected away from the retroperitoneal fat
The mesentery of the descending and sigmoid colon is incised along its avascular planes.
Medial Rotation Of Colon:
The key step involves elevating the left colon and its attached mesentery and rotating it medially, towards the midline of the abdomen
This effectively exposes the retroperitoneal structures, including the aorta, left renal vein, gonadal vein, ureter, and the left ureteropelvic junction
The spleen may also be retracted anteriorly and superiorly to further enhance exposure.
Retroperitoneal Dissection:
Once the retroperitoneum is exposed, dissection proceeds along anatomical planes
Careful identification and preservation of the left renal vein, aorta, and their branches are paramount
Lymph node dissection, if indicated, is performed at this stage
The dissected specimen is typically placed in an endoscopic retrieval bag.
Completion Of Procedure:
After the primary surgical task (e.g., nephrectomy, aortic repair) is completed, the colon is returned to its anatomical position
Hemostasis is meticulously checked
The specimen is removed through a larger port or an extended incision if necessary
The pneumoperitoneum is released, and the port sites are closed.
Postoperative Care
Pain Management:
Multimodal pain management including intravenous analgesics (opioids, NSAIDs), patient-controlled analgesia (PCA), and possibly regional blocks
Early ambulation to prevent venous thromboembolism and improve bowel function.
Fluid Management:
Intravenous fluid resuscitation to maintain adequate hydration and electrolyte balance
Monitoring of urine output is critical, especially after renal surgery
Gradual transition to oral intake as bowel function returns.
Dietary Advancement:
Initiation of clear liquids once bowel sounds are present and there is no evidence of ileus
Gradual advancement to a regular diet as tolerated, with attention to fiber intake for bowel regularity.
Monitoring And Discharge:
Close monitoring for signs of infection, bleeding, bowel ileus, or other complications
Drain management if placed
Discharge typically occurs when the patient is pain-controlled, tolerating oral intake, ambulating, and voiding adequately
Follow-up instructions for wound care, activity restrictions, and clinic appointments.
Complications
Early Complications:
Bleeding from major vessels (aorta, renal vein) or mesentery
Injury to the left ureter or surrounding structures
Bowel injury (colon, small bowel)
Injury to the spleen or pancreas
Conversion to open surgery due to technical difficulty or bleeding
Postoperative ileus
Wound infection or dehiscence.
Late Complications:
Bowel obstruction due to adhesions
Incisional hernia at port sites
Chronic pain
Recurrence of disease if used for oncologic resection
Stricture formation at the site of dissection or repair.
Prevention Strategies:
Meticulous anatomical identification and dissection
Careful use of energy devices to avoid collateral thermal injury
Adequate retraction to provide visualization
Thorough hemostasis
Use of endoscopic retrieval bags for specimens
Prompt conversion to open surgery when indicated
Careful bowel handling
Appropriate bowel preparation and antibiotic prophylaxis.
Key Points
Exam Focus:
Understanding the anatomical structures exposed by the Mattox maneuver (aorta, IVC, left renal vein, SMA)
Recognizing the indications and contraindications
Knowing the key steps of medial rotation of the colon and mesentery
Awareness of potential complications like vascular injury and ureteral damage.
Clinical Pearls:
Maintain adequate pneumoperitoneum throughout
Identify the avascular plane of Toldt's fascia for safe mobilization
Always identify and protect the left renal vein before further dissection
Be mindful of the gonadal vein and ureter during mobilization
Consider a left-sided approach for many retroperitoneal pathologies to avoid crossing the midline unnecessarily.
Common Mistakes:
Insufficient mobilization of the colon leading to poor exposure
Inadvertent injury to the left renal vein or aorta during dissection
Inadequate hemostasis, leading to postoperative bleeding
Excessive traction on the mesentery causing tears or bleeding
Failure to identify and protect the left ureter.