Duodenal Trauma

Osama Algohary
Consultant General Surgeon
Surgical Anatomy
The duodenum lies in front of the right kidney and renal vessels, the IVC, and the aorta.
Exposure after medial rotation of the duodenum and head of the pancreas.
The head of the pancreas and the 2nd portion of the duodenum derive their blood supply from
the anterior and posterior pancreaticoduodenal arcades.
Attempts to separate the 2 organs at this location usually result in ischemia of the duodenum.
Duodenal anatomy.
Drawing (a) & coronal CT image (b) show the anatomic relationships of the duodenum: Stomach (black *). 1st segment of
the duodenum (green arrow; green area in a). 2nd segment of the duodenum (pink arrow; pink area in a). 3rd segment of
the duodenum (yellow arrow; yellow area in a). 4th segment of the duodenum (orange arrow; orange area in a). GB (brown
* and brown area in a). Pancreas (brown arrow), aorta (white * and red area in a). Inferior vena cava (IVC) (blue * and blue
area in a).
Anatomic relationships of the duodenum at CT. (a) Axial CT image shows the 1st segment of the duodenum
(dashed outline in a–d) and the gallbladder (white arrow) and IVC (green arrow). (b) Coronal CT image
shows the 2nd segment of the duodenum and the liver (*), common bile duct (orange arrow), portal vein
(red arrow), and pancreatic duct (purple arrow). (c) Axial CT image shows the 3rd segment of the
duodenum and the SMA (blue arrow) and aorta (yellow arrow).
Anatomic relationships of the duodenum at CT.
(d) Axial CT image shows the 4th segment of the duodenum and the D-J junction (green arrow) and aorta
(yellow arrow). Figure 26.1 The duodenum lies in front of the
right kidney and renal vessels, the inferior vena
cava, and the aorta. Exposure after medial rotation
of the duodenum and head of the pancreas.
Duodenal trauma. (a) Duodenal contusion in a 63-year-old man following a motor vehicle collision. Axial
CT angiogram shows diffuse wall thickening of the duodenum with hyperattenuation, likely a duodenal hematoma
(white arrow) with adjacent hemoperitoneum (*). Note the devascularization of the left kidney owing to injury to the
left renal artery (black arrow). (b, c) Duodenal hematoma in a 65-year-old man following blunt trauma to the abdomen.
Axial (b) and coronal (c) CT angiograms of the abdomen show a high-attenuation collection centered in the
2nd and 3rd segments of the duodenum, consistent with hematoma (*).
Duodenal trauma in two patients. (a, b) Duodenal perforation in a 58-year-old man following a deceleration
injury. Axial (a) and coronal (b) oral and intravenous abdominal ce-CT images show foci of extraluminal
gas (arrow), with wall thickening of the second segment of the duodenum (arrowhead). (c) Duodenal
transection in a 66-year-old man following a motor vehicle injury. Coronal ce-CT image of the abdomen
shows discontinuity of the duodenal wall (arrow) with extensive periduodenal hemorrhage (*). Note the
liver laceration (arrowhead).
Duodenal Injury Severity (AAST Organ Injury Scaling Committee)
Advance one grade for multiple injuries up to grade III. D1, first portion of duodenum; D2, second portion
of duodenum; D3, third portion of duodenum; D4, fourth portion of duodenum
AAST: The American Association for the Surgery of Trauma
Duodenal Injury: Algorithm for Management
Triple Tube Ostomy
1) The retrograde duodenostomy: with 14 Fr Foley catheter at the antimesenteric border about 15 cm distal
to the ligament of Treitz.
2) Gastrostomy with 14 Fr Foley catheter was performed
3) A 10 Fr feeding tube was placed at the antimesenteric border about 10 cm distal to the retrograde
duodenostomy as feeding jejunostomy (FJ)
Hematoma of the 2nd part of the duodenum due to blunt trauma.
All duodenal hematomas secondary to blunt or penetrating trauma found during laparotomy
should be explored to rule out underlying perforation.
The anterior portion of the 1st part of the duodenum is intraperitoneal and easily
visible.
After mobilization of the right colon hepatic flexure, the anterior surface of the 2nd &
3rd of the duodenum and the head of the pancreas come into view.
In performing a Kocher maneuver, the duodenum is mobilized medially
until the IVC and left renal vein are exposed.
In performing a Cattell-Braasch maneuver, the right colon is mobilized and the bowel is retracted to the
right.
An incision is made along the retroperitoneum below the small bowel mesentery in an oblique fashion from
the ileocecal junction toward the ligament of Treitz.
This will allow full superior retraction of the viscera exposing the 4th portion of the duodenum.
Complete exposure of the entire duodenum with the viscera retracted
superiorly and to the left.
Exposure of the distal portion of the 4th part of the duodenum can also be achieved by
releasing the ligament of Treitz as it attaches to the base of the transverse mesocolon.
The transverse mesocolon is retracted superiorly (a) and the division of the ligament of Treitz
exposes and mobilizes the D-J junction (b).
Complete exposure of all parts of the duodenum after the Cattell-Braasch maneuver.
The viscera is retracted superiorly and to the left.
The SMVs are no longer crossing the duodenum.
Pyloric exclusion:
a. A gastrotomy (circle) is created along the greater curvature of the stomach which will also be used to create a
gastrojejunostomy.
b. The pylorus is then grasped with a Babcock clamp and delivered through the gastrotomy.
c. An 0 absorbable suture is utilized to close the pylorus (circle) and a gastrojejunostomy is created.
Stapled pyloric exclusion: A window on the posterior surface of the pylorus
is dissected to allow passage of a TA stapler across the pylorus.
Pyloric Exclusion
(A) CT showing air in retroperitoneum; (B) grade IV duodenal injury in third portion;
(C) duodenal repair; (D) pylorus closed; (E) gastrojejunostomy; (F) feeding
jejunostomy.
 Duodenal Trauma

References:
• RadioGraphics 2020; 40:1441–1457.
• Atlas of surgical techniques in trauma, 2nd ed, 2020.
• Surgical decision making, 6th ed, 2020.
• Sao Paulo Med J. 2008; 126(6):337-41.
• Indian J Surg, 2018, 80(1):9–13.