Kocher manoeuvre

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The Kocher manoeuvre is a surgical procedure to expose structures in the retroperitoneum behind the duodenum and pancreas. In vascular surgery, it is described as a method to expose the abdominal aorta. It usually has been in contrast to midline laparotomy and right retroperitoneal space dissection. These two procedures have been used for diverse cases, but have approximately equivalent outcomes. [1]

Contents

The Kocher manoeuvre may also refer to a procedure used to reduce anterior shoulder dislocations by externally rotating the shoulder, before adducting and internally rotating it.[ citation needed ]

Uses

Technique

The Kocher manoeuvre involves the following steps:

  1. Patient Positioning: The liver is retracted upwards, and the right colic flexure is retracted downwards. The surgeon typically stands on the left side of the patient for better access. [2]
  2. Duodenal Mobilization: The surgeon rolls the second part of the duodenum, making an incision about 3 cm from the duodenal rim. The duodenum, along with the head of the pancreas, is mobilized, detached from the inferior vena cava and aorta, with the superior mesenteric vessels limiting further mobilization. [2]
  3. Fascial Layers: Underlying the duodenum and head of the pancreas is an avascular plane known as the fusion fascia of Treitz. This fascia, along with the pancreatic capsule, is crucial for the bloodless detachment and mobilization of these structures. [2]
  4. Mesoduodenum Restoration: The Kocher manoeuvre restores the mesoduodenum, rendering the duodenum movable. The posterior surfaces of the duodenum and pancreas become visible, allowing for the examination of the hidden peripheral parts of the common bile duct. [2]
  5. Portal Exposure: The manoeuvre exposes the porta hepatis, allows dissection of the hepatoduodenal ligament, and provides access to the lesser sac by opening the foramen of Winslow. [2]
  6. Limitations: The Kocher manoeuvre has limitations, as only the first and proximal second parts of the duodenum and the head of the pancreas can be mobilized. For complete mobilization, the Cattell manoeuvre is required, involving the mobilization and reflection of the cecum, ascending colon, and right colic flexure [2]

History

In 1895, Jourdain first talked about moving the duodenum in the body. Theodor Kocher, who the Kocher maneuver is named after, wrote a detailed explanation of this in 1903. He explained that during early development, the duodenum is freely hanging in the belly. [3] In children, it's even more flexible, but as they grow, it sticks to the back of the belly and is covered in a layer of peritoneum. Kocher figured out that by loosening it, the duodenum could be moved like it was in the early stages of development. [3]

Kocher also knew that the duodenum and pancreas are initially hanging freely in the belly, connected by a mesentery. The Kocher maneuver brings these organs back to their original position in the belly. [3] Since Kocher's time, we've learned more about how the duodenum and pancreas develop and settle into their final position in the body. This study will briefly explain these processes, outline the surgical anatomy of the area, and discuss some clinical issues related to embryology and anatomy. [3]

Related Research Articles

<span class="mw-page-title-main">Duodenum</span> First section of the small intestine

The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In mammals it may be the principal site for iron absorption. The duodenum precedes the jejunum and ileum and is the shortest part of the small intestine.

<span class="mw-page-title-main">Gallbladder</span> Organ in humans and other vertebrates

In vertebrates, the gallbladder, also known as the cholecyst, is a small hollow organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath the liver, although the structure and position of the gallbladder can vary significantly among animal species. It receives and stores bile, produced by the liver, via the common hepatic duct, and releases it via the common bile duct into the duodenum, where the bile helps in the digestion of fats.

<span class="mw-page-title-main">Bile duct</span> Type of organ

A bile duct is any of a number of long tube-like structures that carry bile, and is present in most vertebrates. The bile duct is separated into three main parts: the fundus (superior), the body (middle), and the neck (inferior).

<span class="mw-page-title-main">Common bile duct</span> Gastrointestinal duct

The bile duct is a part of the biliary tract. It is formed by the union of the common hepatic duct and cystic duct. It ends by uniting with the pancreatic duct to form the hepatopancreatic ampulla. It possesses its own sphincter to enable regulation of bile flow.

<span class="mw-page-title-main">Pancreaticoduodenectomy</span> Major surgical procedure involving the pancreas, duodenum, and other organs

A pancreaticoduodenectomy, also known as a Whipple procedure, is a major surgical operation most often performed to remove cancerous tumours from the head of the pancreas. It is also used for the treatment of pancreatic or duodenal trauma, or chronic pancreatitis. Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the duodenum, proximal jejunum, gallbladder, and, occasionally, part of the stomach.

<span class="mw-page-title-main">Common bile duct stone</span> Medical condition

Common bile duct stone, also known as choledocholithiasis, is the presence of gallstones in the common bile duct (CBD). This condition can cause jaundice and liver cell damage. Treatments include choledocholithotomy and endoscopic retrograde cholangiopancreatography (ERCP).

<span class="mw-page-title-main">Pringle manoeuvre</span> Surgical technique

The Pringle manoeuvre is a surgical technique used in some abdominal operations and in liver trauma. The hepatoduodenal ligament is clamped either with a surgical tool called a haemostat, an umbilical tape or by hand. This limits blood inflow through the hepatic artery and the portal vein, controlling bleeding from the liver. It was first published by and named after James Hogarth Pringle in 1908.

<span class="mw-page-title-main">Pancreatic duct</span> Duct associated with the human pancreas

The pancreatic duct, or duct of Wirsung, is a duct joining the pancreas to the common bile duct. This supplies it with pancreatic juice from the exocrine pancreas, which aids in digestion.

<span class="mw-page-title-main">Lesser omentum</span>

The lesser omentum is the double layer of peritoneum that extends from the liver to the lesser curvature of the stomach, and to the first part of the duodenum. The lesser omentum is usually divided into these two connecting parts: the hepatogastric ligament, and the hepatoduodenal ligament.

<span class="mw-page-title-main">Greater omentum</span> Fat sheath under abdominal wall

The greater omentum is a large apron-like fold of visceral peritoneum that hangs down from the stomach. It extends from the greater curvature of the stomach, passing in front of the small intestines and doubles back to ascend to the transverse colon before reaching to the posterior abdominal wall. The greater omentum is larger than the lesser omentum, which hangs down from the liver to the lesser curvature. The common anatomical term "epiploic" derives from "epiploon", from the Greek epipleein, meaning to float or sail on, since the greater omentum appears to float on the surface of the intestines. It is the first structure observed when the abdominal cavity is opened anteriorly.

<span class="mw-page-title-main">Hepatic plexus</span>

The hepatic plexus is a sympathetic and parasympathetic nerve plexus that provides innervation to the parenchyma of the liver as well as contributing innervation to some other abdominal structures.

<span class="mw-page-title-main">Hepatoduodenal ligament</span>

The hepatoduodenal ligament is the portion of the lesser omentum extending between the porta hepatis of the liver and the superior part of the duodenum.

<span class="mw-page-title-main">Hemosuccus pancreaticus</span> Medical condition

Hemosuccus pancreaticus is a rare cause of hemorrhage in the gastrointestinal tract. It is caused by a bleeding source in the pancreas, pancreatic duct, or structures adjacent to the pancreas, such as the splenic artery, that bleed into the pancreatic duct, which is connected with the bowel at the duodenum, the first part of the small intestine. Patients with hemosuccus may develop symptoms of gastrointestinal hemorrhage, such as blood in the stools, maroon stools, or melena, which is a dark, tarry stool caused by digestion of red blood cells. They may also develop abdominal pain. It is associated with pancreatitis, pancreatic cancer and aneurysms of the splenic artery. Hemosuccus may be identified with endoscopy (esophagogastroduodenoscopy), where fresh blood may be seen from the pancreatic duct. Alternatively, angiography may be used to inject the celiac axis to determine the blood vessel that is bleeding. This may also be used to treat hemosuccus, as embolization of the end vessel may terminate the hemorrhage. However, a distal pancreatectomy—surgery to remove of the tail of the pancreas—may be required to stop the hemorrhage.

<span class="mw-page-title-main">Major duodenal papilla</span>

The major duodenal papilla is a rounded projection in the duodenum into which the common bile duct and pancreatic duct drain. The major duodenal papilla is, in most people, the primary mechanism for the secretion of bile and other enzymes that facilitate digestion.

<span class="mw-page-title-main">Hepatoportoenterostomy</span>

A hepatoportoenterostomy or Kasai portoenterostomy is a surgical treatment performed on infants with Type IVb choledochal cyst and biliary atresia to allow for bile drainage. In these infants, the bile is not able to drain normally from the small bile ducts within the liver into the larger bile ducts that connect to the gall bladder and small intestine.

<span class="mw-page-title-main">Hepatic lymph nodes</span> Lymph nodes on the common hepatic artery

The hepatic lymph nodes consist of the following groups:

<span class="mw-page-title-main">Roux-en-Y anastomosis</span> Type of surgery

In general surgery, a Roux-en-Y anastomosis, or Roux-en-Y, is an end-to-side surgical anastomosis of bowel used to reconstruct the gastrointestinal tract. Typically, it is between stomach and small bowel that is distal from the cut end.

<span class="mw-page-title-main">Omental foramen</span> Part of the human abdomen

In human anatomy, the omental foramen, is the passage of communication, or foramen, between the greater sac, and the lesser sac.

The cystic node is the sentinel lymph node of the gall bladder. It is located within the cystohepatic triangle.

<span class="mw-page-title-main">Choledochoduodenostomy</span>

Choledochoduodenostomy (CDD) is a surgical procedure to create an anastomosis, a surgical connection, between the common bile duct (CBD) and an alternative portion of the duodenum. In healthy individuals, the CBD meets the pancreatic duct at the ampulla of Vater, which drains via the major duodenal papilla to the second part of duodenum. In cases of benign conditions such as narrowing of the distal CBD or recurrent CBD stones, performing a CDD provides the diseased patient with CBD drainage and decompression. A side-to-side anastomosis is usually performed.

References

  1. 1 2 3 4 5 6 Livani, Anastasia; Angelis, Stavros; Skandalakis, Panagiotis N; Filippou, Dimitrios (2022-09-21). "The Story Retold: The Kocher Manoeuvre". Cureus. 14 (9): e29409. doi: 10.7759/cureus.29409 . ISSN   2168-8184. PMC   9586190 . PMID   36304342.
  2. 1 2 3 4 5 6 "Surgical Maneuvers". Archives of Surgery. 134 (8): 823. 1999-08-01. doi:10.1001/archsurg.134.8.823. ISSN   0004-0010.
  3. 1 2 3 4 Acta Obstetricia et Gynecologica Scandinavica. 45 (3). January 1966. doi:10.1111/aog.1966.45.issue-3. ISSN   0001-6349 http://dx.doi.org/10.1111/aog.1966.45.issue-3.{{cite journal}}: Missing or empty |title= (help)
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