Overview
Definition:
The right medial visceral rotation, also known as the Cattell-Braasch maneuver, is a surgical technique used to mobilize the ascending colon, cecum, and proximal small intestine from the retroperitoneal space to facilitate access to the posterior abdominal structures, particularly the hepatoduodenal ligament and the retroperitoneal vasculature
It involves incising the white line of Toldt and reflecting these structures medially.
Epidemiology:
Not applicable to a surgical technique
its application depends on the operative indication in abdominal surgery.
Clinical Significance:
Crucial for surgeons to gain wide exposure to the structures in the right upper quadrant and suprahepatic space
Essential for operations involving the liver, gallbladder, duodenum, and retroperitoneal lymph nodes, including oncologic resections and complex reconstructive procedures
Understanding this maneuver is vital for DNB and NEET SS surgery examinations, testing knowledge of abdominal anatomy and surgical approaches.
Indications
Primary Indications:
Exposure of the hepatoduodenal ligament for liver transplant explantation or implantation
Mobilization of the duodenum for pancreaticoduodenectomy (Whipple procedure)
Access to retroperitoneal lymph nodes for staging and resection in malignancies like right colon cancer or renal cell carcinoma
Exposure of the inferior vena cava and right renal vein for vascular control or tumor resection
Management of complex right-sided abdominal masses
Certain biliary reconstructive procedures.
Contraindications:
Extensive retroperitoneal fibrosis precluding adequate mobilization
Severe adhesions that would make mobilization unsafe
Uncontrolled coagulopathy that increases bleeding risk
Presence of a large, fixed right-sided colonic or hepatic mass extensively invading surrounding structures, making mobilization technically impossible or too risky
Patients with significant cardiopulmonary compromise who may not tolerate prolonged operative time associated with extensive dissection.
Relative Contraindications:
Previous extensive abdominal surgery with significant adhesions
Acute inflammatory conditions in the region that might increase friability of tissues
Presence of major vascular anomalies that could be inadvertently injured during dissection.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination focusing on prior surgeries, abdominal pain, bowel habits, and any symptoms suggestive of malignancy or inflammation
Assessment of nutritional status and comorbidities
Comprehensive review of relevant imaging studies including CT scans and MRIs to delineate anatomy, identify vascular structures, and assess tumor extent.
Imaging Review:
Detailed interpretation of abdominal CT scans, particularly with contrast, to map the vascular anatomy (e.g., SMA, SMV, IVC, renal vessels) and assess the extent of any pathology
Ultrasound may be used to evaluate gallbladder and liver
Angiography might be considered for complex vascular cases.
Informed Consent:
Detailed discussion with the patient about the procedure, including the rationale for the Cattell-Braasch maneuver, potential benefits, risks such as bleeding, injury to vital organs (bowel, vessels, bile ducts), infection, and the possibility of conversion to a different approach or procedure
Risks of intraoperative blood transfusion should also be discussed.
Bowel Preparation:
Routine bowel preparation with clear liquids and laxatives may be employed, although its efficacy for elective abdominal surgery is debated
Prophylactic antibiotics are administered intravenously prior to incision, typically covering gram-negative and anaerobic organisms, based on institutional protocols.
Procedure Steps
Incision And Exposure:
A generous midline laparotomy or a right subcostal incision (Kocher incision), or a combination thereof, is typically employed to provide adequate exposure of the right upper quadrant and right flank
The abdomen is explored for any unexpected findings, and the general condition of the abdominal organs is assessed.
Dissection Of Colon:
The ascending colon and hepatic flexure are identified
The peritoneum along the lateral border of the ascending colon, lateral to the white line of Toldt, is incised
This incision extends from the cecum superiorly to the hepatic flexure
Care is taken to stay close to the colon to avoid injury to the retroperitoneal structures.
Mobilization Of Bowel:
Using blunt and sharp dissection, the ascending colon, cecum, and a variable length of the distal small intestine are lifted medially off the retroperitoneum
This dissection plane is developed between the visceral peritoneum of the colon and the parietal peritoneum covering the retroperitoneum
The mesentery of the ascending colon is also partially mobilized.
Identification Of Structures:
As the bowel is reflected medially, the retroperitoneal structures become visible
Key structures include the right ureter, right gonadal vessels, inferior vena cava (IVC), superior mesenteric artery (SMA) and vein (SMV), and the right kidney
Careful identification and preservation of these structures are paramount.
Division Of Mesentery:
If necessary for further exposure, the mesentery of the colon can be divided
The superior mesenteric vein is a critical structure to identify and protect during this dissection
The mesentery is divided carefully, ligating or coagulating perforating vessels to control bleeding
The right colic and ileocolic vessels are identified and ligated.
Completion Of Maneuver:
The mobilized segment of bowel is retracted medially, allowing excellent visualization of the posterior abdominal wall, the duodenum, pancreas, liver, and suprahepatic space
The procedure is then continued based on the original surgical plan, utilizing this enhanced exposure
Once the primary surgical task is completed, the bowel is returned to its anatomical position, and the abdominal cavity is closed.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and fluid balance is essential
Patients are observed for signs of hemorrhage, infection, or intra-abdominal complications
Postoperative pain management is crucial.
Fluid And Electrolyte Balance:
Intravenous fluids are administered to maintain hydration and electrolyte balance
Nasogastric tube decompression may be required if significant bowel manipulation has occurred or if there is concern for ileus
Electrolyte levels are monitored and corrected as needed.
Ambulation And Diet:
Early ambulation is encouraged to prevent deep vein thrombosis and promote gastrointestinal motility
Diet is advanced as tolerated, starting with clear liquids and progressing to a regular diet as bowel function returns (presence of bowel sounds, flatus, and bowel movements).
Wound Care:
Wound care includes dressing changes as per protocol and monitoring for signs of surgical site infection
Early removal of drains, if placed, is generally favored to reduce infection risk.
Complication Surveillance:
Vigilant surveillance for complications such as ileus, anastomotic leak (if applicable), deep vein thrombosis, pulmonary embolism, wound infection, and delayed hemorrhage
Investigations such as abdominal X-ray, ultrasound, or CT scan may be performed if complications are suspected.
Complications
Early Complications:
Hemorrhage from major vessels (e.g., IVC, SMV, renal vessels) or collateral branches
Injury to the duodenum, pancreas, ureter, or bowel
Postoperative ileus
Wound infection
Deep vein thrombosis and pulmonary embolism
Acute kidney injury due to ureteral or renal vessel manipulation
Biliary leak or injury.
Late Complications:
Adhesions leading to small bowel obstruction
Incisional hernia
Chronic pain
Recurrent infection
Potential for malabsorption if extensive small bowel is involved in the mobilization and subsequent adhesions
Vascular compromise to the mobilized bowel segment if mesentery is overly disturbed.
Prevention Strategies:
Meticulous dissection with careful identification of all anatomical structures
Use of intraoperative imaging or navigation aids if available and indicated
Precise ligation of vessels
Gentle handling of tissues
Adequate but not excessive mobilization
Appropriate use of drains
Prophylaxis against DVT and infection
Careful postoperative management and early mobilization.
Key Points
Exam Focus:
The Cattell-Braasch maneuver is primarily about achieving maximal exposure of the retroperitoneum and structures on the right side of the abdomen
Key structures to identify and protect are the IVC, SMV, SMA, and right ureter
Its application in pancreaticoduodenectomy and liver surgery is frequently tested.
Clinical Pearls:
Start the peritoneal incision lateral to the ascending colon at the white line of Toldt
Dissect sharply but stay close to the colon to minimize risk to retroperitoneal structures
If significant bleeding occurs, identify the source meticulously rather than blind clamping
Adequate exposure is key to preventing iatrogenic injuries
The extent of mobilization can be tailored to the surgical need.
Common Mistakes:
Inadequate exposure leading to blind dissection
Injury to the IVC, SMV, or SMA
Transection or injury to the right ureter
Excessive mobilization that compromises vascular supply to the bowel segment
Failure to identify and manage bleeding promptly
Not adequately checking for bowel viability after reduction.