Maneuvers and Retroperitoneal Exposure

Maneuvers and Retroperitoneal Exposure

David Ray Velez, MD

Table of Contents

Approach to Retroperitoneal Exposure

Maneuvers:

Approach to Retroperitoneal Exposure

There is Significant Overlap with Maneuvers and They Should be Tailored to the Individual Patient to Keep Retroperitoneal Exploration Targeted and Limited

Exposure of the Inferior Vena Cava (IVC)

  • Suprarenal IVC: Kocher Maneuver
  • Infrarenal IVC: Right-Medial Visceral Rotation
    • Distal IVC and Iliac Bifurcation May Require Transection of Right Iliac Artery to Access

Exposure of the Aorta

  • Suprarenal Aorta: Left-Medial Visceral Rotation
  • Infrarenal Aorta: Transperitoneal Inframesocolic Exposure

Exposure of Arterial Branches

  • Celiac Axis: Left-Medial Visceral Rotation
  • Superior Mesenteric Artery (SMA):
    • Proximal SMA: Left-Medial Visceral Rotation
    • Body/Distal SMA: Transperitoneal Inframesocolic Exposure
  • Inferior Mesenteric Artery (IMA): Transperitoneal Inframesocolic Exposure

Exposure of the Duodenum

  • Proximal (D1, D2, and Proximal D3): Kocher Maneuver
  • Distal (Distal D3 and D4): Right-Medial Visceral Rotation

Retroperitoneal Zones

Maneuvers to Access the Retroperitoneum: 1. Mattox, 2. Transperitoneal Inframesocolic Exposure, 3. Kocher*, 4. “Extended” Kocher*, 5. “Super-Extended” Kocher*, *#3-5 Together Compose the Cattell-Braasch Maneuver

Kocher Maneuver

Mobilization of the Duodenum

Procedure

  • Incise the Posterolateral Peritoneal Attachments of the Duodenum
  • Place Hand Behind the Duodenum/Pancreatic Head and Retract Medially
  • Duodenum (Along with the Superior Mesenteric Vessels) is Mobilized Off the IVC and Aorta

Visualization

  • Duodenum (D1, D2, Proximal D3) – Distal D3 and D4 are Not Visualized
  • Head of the Pancreas
  • Suprarenal IVC
  • Right Renal Hilum

Notable Pitfalls: Right Gonadal Vein Injury

Duodenum

Right-Sided Medial Visceral Rotation (Cattel-Braasch Maneuver)

Mobilization of the Right Colon

Procedure: 3-Stages

  • Stage 1. Kocher Maneuver – *See Above
  • Stage 2. “Extended” Kocher Maneuver
    • Extend the Incision Caudally Along the Hepatic Flexure and Right White Line of Toldt
    • Fully Mobilize the Ascending Colon
  • Stage 3. “Super-Extended” Kocher Maneuver
    • Extend the Incision Around the Cecum
    • Retract Bowel to the Right and Superiorly
    • Incise the Mesenteric Attachment to the Posterior Peritoneum from the Medial Cecum to the Ligament of Treitz
  • Some Prefer to Perform the Kocher Maneuver After Right Colon Mobilization

Visualization

  • Panoramic View of Entire Inframesocolic Retroperitoneum
  • Infrahepatic Inferior Vena Cava (IVC) – Not the Retrohepatic IVC
  • Inframesocolic Aorta
  • Duodenum – Entire Duodenum Including D3 and D4
  • Head of the Pancreas
  • Right Kidney and Ureter
  • Ascending Colon

Only Two Areas of the Retroperitoneum are Inaccessible: Retrohepatic IVC and Supramesocolic Aorta

Notable Pitfalls: Superior Mesenteric Vein (SMV) Injury – Right Colon Hangs by the Mesentery Alone and an Inadvertent Pull Will Avulse the Right Colic Vein off the SMV

Retroperitoneum

Left-Sided Medial Visceral Rotation (Mattox Maneuver)

Mobilization of the Left Colon

Procedure

  • Incision Along the Left White Line of Toldt to Mobilize the Descending Colon
  • Extend Incision Lateral Around the Spleen
  • Using Hand Sweep from Below-Up and Medial
    • Dissection Plane is Directly on the Posterior Abdominal Wall
  • Rotate All Structures to the Midline

Modified Mattox Maneuver: The Left Kidney is Left Behind and is Not Mobilized During the Maneuver

Visualization

  • Entire Abdominal Aorta
  • Proximal Celiac Axis
  • Proximal Superior Mesenteric Artery (SMA)
  • Proximal Inferior Mesenteric Artery (IMA)
  • Left Renal Artery/Vein
  • Left Kidney and Ureter
  • Descending Colon
  • Minimal IVC Exposure

Notable Pitfalls: Splenic Injury or Avulsion of Left Descending Lumbar Vein Off the Renal Vein

Transperitoneal Inframesocolic Exposure

*There are No Well-Established Names for the Maneuver

Incision Directly Over the Aorta Below the Transverse Mesocolon

Used in Vascular Surgery as the Preferred Operative Approach for a Transperitoneal Open AAA Repair

Procedure

  • Reflect the Transverse Colon Cephalad
  • Eviscerate the Small Bowel to the Right
  • Incise the Retroperitoneum Along Midline
    • Start Incision at the Ligament of Treitz to the Left of the Aorta
    • Extend the Incision Caudally to the Right of the Aorta – Avoid IMA/IMV Injury

Visualization

  • Inframesocolic Aorta

More Targeted/Limited Than a Mattox Maneuver if Supramesocolic Access is Unnecessary

Notable Pitfalls: Inferior Mesenteric Vein (IMV) Injury with the Initial Incision

Inframesocolic Aorta