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G. C. Velmahos
Fig. 50.1 (a) Extended Kocher maneuver. Note that the peritoneal incision starts at the distal ileum, and the entire right colon is reected medially.
(b) The duodenum is fully mobilized, making it possible to inspect the pancreas, inferior vena cava (IVC), and retroperitoneal space
tamination from the duodenal perforation, the denitive
operation should not be planned before the abdomen is
fully explored. It is in this way that the decision is made
to proceed to a long operation versus abbreviating the
procedure along damage-control principles. The extent
of the duodenal injuries, the presence and severity of
other injuries, and the physiologic condition of the
patient will dictate the ultimate intraoperative plan.
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a
b
a
b
Fig. 50.2 (a) Full mobilization of the duodenum revealing the anterior
surface of the head of the pancreas. Note the clamp that closes the laceration temporarily to control contamination. (b) The posterior surface
of the duodenum and head of the pancreas are also easily inspected after
the Kocher mobilization
50.2 Grade-Specic Operative
Management
50.2.1 Grade I
The majority of these injuries are managed nonoperatively with
success. Duodenal hematomas have been reported with a
higher frequency among pediatric than adult patients. They are
usually discovered on CT scan and on occasions are totally
obstructing the lumen. The majority of them are absorbed with
time and the lumen reopens. Two issues need to be claried
when a grade I injury is detected: (a) Is it indeed only a hematoma or is the hematoma covering a full- thickness laceration?
A careful inspection of the CT scan for extraluminal air or oral
contrast resolves the dilemma in most patients evaluated by
new-generation scanners (16- or 64-slice). If not, a formal contrast swallow will show whether the contrast remains within the
duodenal contour or leaks extraluminally. (b) How long should
Fig. 50.3 (a, b) Axial and coronal cut of a massive duodenal hema-
toma. Despite its size, the patient had no complaints except mild epigastric pain and gastric outlet obstruction. He was managed nonoperatively
with nasogastric tube drainage, and the obstruction eventually resolved
on post-trauma day 23
one wait before decompressing a totally occluding hematoma?
There is no clear answer to this question. Most hematomas will
be absorbed—at least partially—within 7–10 days, and the
patency of the bowel lumen will be restored. I certainly consider it acceptable to wait up to 15days with a nasogastric tube
in place before surgical decompression is considered and have
personally waited for 23days before a massive hematoma was
reabsorbed and the lumen became patent again (Fig.50.3).
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50.2.2 Grade II
Such injuries are produced either by very large hematomas
or—more frequently—by simple lacerations of the duodenum that occupy less than 50% of the circumference. The
management of hematomas is not different than what was
described previously. Duodenal lacerations are sutured primarily. Debridement of the rugged edges is important to
make sure that well-vascularized tissue is present. Then,
close the perforation in one layer with interrupted invaginating Gambee stitches (Fig.50.4) using a 3-0 nonabsorbable or
slowly absorbable suture. A two-layer closure—typically
with a running absorbable suture and a second layer of interrupted nonabsorbable sutures—is also acceptable, although I
typically use only one layer in repairing any part of the intestine. It is important that the line of closure is perpendicular to
the axis of the lumen in order to avoid stenosis. Drain the
area per routine. No other procedures are necessary.
50.2.3 Grades III andIV
G. C. Velmahos
Fig. 50.5 Exclusion of the pylorus by ring a TA stapler at the pyloric
ring
There is a debate about the correct management of grade III
injuries which lie in between grades I and II, managed either
nonoperatively or with simple repair, and grades IV and V,
managed usually with more complex techniques. These techniques include pyloric exclusion, serosal patch, duodenojejunal anastomosis, and resection with anastomosis.
Pyloric exclusion aims to divert all supraduodenal secretions from the repair, not only to prevent distention by the
volume of uids but also to avoid activation of pancreatic
enzymes by gastric contents. Before pyloric exclusion, the
duodenal laceration must be sutured, per the techniques
described above. Then, exclude the pylorus by either ring a
TA stapler at this level (Fig.50.5) or opening the stomach at
Fig. 50.6 Exclusion of the pylorus by making a gastrotomy in the near
vicinity and placing a suture at the pyloric ring level
Fig. 50.4 Closure of simple duodenal laceration (after debridement of
the edges) with a Gambee suture
the antrum and suturing the pylorus from the inside
(Fig. 50.6). The gastrotomy should be placed at the most
dependent position of the stomach in order to serve as the
site of the gastrojejunostomy. Through the gastrotomy, grasp
the pylorus with an atraumatic clamp to bring it close to the
gastrotomy. Then, place either a purse-string or an interlock-
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Fig. 50.7 Standard gastrojejunal anastomosis (preferably retrocolic)
by using the gastrotomy site of the pyloric exclusion
ing running suture using nonabsorbable or slowly absorbable
material. It has been suggested that nonabsorbable sutures
are allowed because the pyloric exclusion almost always
opens with time under the continuous peristaltic force of the
stomach. In any case, leave a long tail on your suture, so that
it can be identied, grasped, and cut via gastroscopy, if this
is deemed appropriate in the future. Following the pyloric
exclusion, a jejunal loop is brought at the gastrotomy site to
function as the new gastric outlet (Fig.50.7). A retrocolic
gastrojejunostomy is performed per routine (Fig.50.8).
In large injuries of the duodenum, primary closure of the
defect may be undesirable because it produces stenosis or
places the suture line under great tension. In this situation,
the defect can be sealed by bringing a loop of jejunum and
suturing its serosal surface on the debrided duodenal wound
(Fig.50.9). This is commonly referred to as a Thal patch. A
second circumferential line of interrupted seromuscular
sutures is placed between the jejunum and duodenum all
around the rst line of repair in order to diminish the tension
at the rst suture line and prevent leaks.
On occasions, even a Thal patch may produce stenosis at
the injury level. Under these circumstances, a loop of jejunum may be brought and opened to create a side-to-side
Roux-en-Y duodenojejunal anastomosis (Fig. 50.10).
Finally, for extensive injuries of the fourth or even the third
portion of the duodenum, resection and primary end-to-end
Fig. 50.8 Completed pyloric exclusion with gastrojejunal
anastomosis
anastomosis are possible (Fig.50.11). This is easier done at
the fourth portion which is more mobile after dissection of
the ligament of Treitz. It becomes more challenging in the
third portion, as adequate mobilization of the medial portion of the duodenum to provide a tissue margin for anastomosis can be hard. The duodenum is attached to the
pancreas, and dissection of its medial side requires ligation
of small vessels, which may compromise the blood supply
to the anastomotic line. The feasibility of resection and a
safe anastomosis clearly relies on careful intraoperative
assessment of the anatomical conditions and the proximal
extent of the injury.
When a complex repair is necessary, strongly consider
adding a pyloric exclusion to offer extra protection at the
injury repair suture line. Also, consider a feeding jejunostomy, as the complication rate is substantial and enteral
feeding may not be possible, if not directed distally to the
repair.
In desperate situations, the duodenal injury is so large that
it simply cannot be repaired. Then, a pancreatoduodenectomy (Whipple procedure) may be appropriate and will be
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G. C. Velmahos
Fig. 50.9 (a, b) Serosal
patch on large duodenal
perforation by suturing a loop
of uninvolved bowel to the
edges of the laceration
a
discussed below. If the patient is not stable for such an extensive procedure, the insertion of a large-bore mushroomtipped tube in the duodenal lumen and closure around the
tube with a purse-string suture may be the only remaining
choice, even if far from optimal (Fig.50.12). The tube is
brought out through the skin to create a directed lateral duodenal stula. Drains should be placed around the area, as the
leak rate after this procedure is high.
As mentioned, there are no clear guidelines about using
simple repair or complex techniques. It has been shown that
as the grade of injury increases, complex techniques should
be used more liberally to prevent complications. I tend to
manage the majority of grade III injuries with a simple
repair, whereas grade IV injuries usually require complex
techniques.
50.2.4 Grade V
These are the worst possible injuries as they involve the pancreas and quite frequently other peripancreatic vessels and
structures. The surgical strategy for this type of injuries
obeys in the rule of “all or nothing.” If the patient’s intraoperative hemodynamic condition allows and in the presence of
violation of the ampulla or the major pancreatic duct, a formal pancreatoduodenectomy may be necessary. This is the
“all” approach. Start, as always, with the wide Kocher
maneuver. Identify the injury of the major pancreatic duct
and/or ampulla of Vater. This is not always easy. A variety of
b
techniques have been described, including cannulating the
ampulla or cannulating the cystic duct (after cholecystectomy) and injecting contrast. The sensitivity and specicity
of these techniques are completely unknown. I believe that
they are not much better than a careful dissection and inspection of the structures. If in doubt, err toward doing less. If not
in doubt about injury to one of the abovementioned structures, proceed! Divide the antrum and proximal jejunum
with a stapler and the distal common bile duct sharply.
Elevate the specimen off the retroperitoneum and divide the
pancreas distal to the injury, saving as much pancreatic mass
as possible (Fig.50.13). Three anastomoses follow, including the pancreaticojejunal, biliary-jejunal, and gastrojejunal
suture lines (Fig. 50.14). Numerous techniques have been
described for each one of these anastomoses, and the detailed
description of these techniques goes beyond the scope of the
chapter. I prefer a telescoping two-layered pancreaticojejunal anastomosis, a one-layered biliary-jejunal anastomosis
after “sh mouthing” the usually narrow common bile duct
(no stents are placed in the anastomosis), and a standard gastrojejunal anastomosis.
On the other hand, a hemodynamically unstable patient
should never have a Whipple procedure. Instead, one should
have an abbreviated damage-control operation. This I call
the “nothing” approach only to contrast it with the timeconsuming pancreatoduodenectomy but with no intent to
minimize its lifesaving potential. Such a patient should have
only temporary closure of all the perforations and ligation
or shunting of the major bleeding sites. Then, the patient
Jejunum
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Fig. 50.11 (a, b) Resection and primary anastomosis of the third/
fourth part of the duodenum. This technique is not performed for proximal duodenal injuries
Fig. 50.10 Duodenojejunal anastomosis to treat a large perforation of
the duodenum, which would produce stenosis of the lumen if closed
primarily
Fig. 50.12 Directed duodenocutaneous stula by insertion of large
tube into duodenal perforation
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Fig. 50.13 Gunshot wound injury through the head of the pancreas
and pancreatoduodenectomy specimen
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G. C. Velmahos
ing recommendations can be considered, even if not applicable, to all patients:
1. Grade I injuries are almost always managed nonopera-
tively. Be patient if there is obstruction from a hematoma.
Most will open up with time and nasogastric tube
decompression.
2. Grade II injuries are almost always managed by simple
repair. Debride the edges of the wound and close it
primarily.
3. Grades III and IV injuries require careful intraoperative
evaluation. Most grade III injuries are amenable to simple
repair. Most grade IV injuries require a more complex
procedure, which usually is a pyloric exclusion.
4. Grade V injuries fall under the “all or nothing” rule. You
will either need to do a Whipple procedure after suspecting major pancreatic duct injury on a hemodynamically
stable patient or a damage-control procedure on an unstable patient. If in doubt, prefer to do the minimal required.
You can then reevaluate the patient under more controlled
conditions and offer the denitive operation at a later
stage.
Fig. 50.14 (a, b) Pancreatoduodenectomy
should be packed and returned with an open abdomen to the
intensive care unit for resuscitation. The denitive repairs
can be done in follow-up procedures, as described above.
50.3 Conclusions
DIs are rather infrequent injuries which may prove to be particularly challenging in terms of intraoperative selection of
the correct procedure according to the extent of the injury
and the patient’s hemodynamic status. The existing evidence
does not elevate above Level III, and therefore, universally
accepted guidelines are hard to nd. In general, the follow-
Important Points
• The majority of duodenal injuries can be sufciently
managed by primary repair only.
• Always put drains at the area of repair.
• Concomitant injury to the head of the pancreas increases
morbidity and mortality.
• Pyloric exclusion can be considered in high-grade
injuries.
• Grade V duodenal injuries usually require damage control
or pancreatoduodenectomy or both.
Suggested Reading
Degiannis E, Boffard K. Duodenal injuries. Br J Surg.
2000;87(11):1473–9.
Degiannis E, Krawczykowski D, Velmahos GC, Levy RD, Souter I,
Saadia R. Pyloric exclusion in severe penetrating injuries of the
duodenum. World J Surg. 1993;17(6):751–4.
Lopez PP, Benjamin R, Cockburn M, Amortegui JD, Schulman CI,
Soffer D, Blackbourne L, Habib F, Jerokhimov I, Trankel S, Cohn
SM.Recent trends in the management of combined pancreatoduo-
denal injuries. Am Surg. 2005;71(10):847–52.
Seamon MJ, Pieri PG, Fisher CA, Gaughan J, Santora TA, Pathak
AS, Bradley KM, Goldberg AJ. A 10-year retrospective review:
does pyloric exclusion improve outcome after penetrating duo-
denal and combined pancreatoduodenal injuries? J Trauma.
2007;62(4):829–33.
Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA,
Berne TV, Demetriades D.Complex repair for the management of
duodenal injuries. Am Surg. 1999;65(10):972–5.
Penetrating Trauma tothePancreas
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MartinD.Smith, DietrichDoll, andEliasDegiannis
51
The pancreas is likened to the base player in a band; no one
ever knows the name of the base player, but when he is not
there, the band falls terribly at. This rather innocuous gland
situated posteriorly in the retroperitoneum is only really
taken seriously when it gives trouble, and when it gives trouble, it requires experience and a good knowledge of anatomy
and surgical techniques to solve the problems. Penetrating
trauma to the pancreas is not very common. Due to its anatomical location and relationship to major vessels, isolated
injury to the pancreas is even more rare, and it is usually the
associated injuries, often aggravated by the consequences of
the pancreatic injury, that result in the fairly high morbidity
and mortality associated with pancreatic trauma.
Blunt pancreatic trauma is more often isolated and due to
the often insidious nature of the clinical picture is difcult to
diagnose. Much has been written about the role of biochemical markers and imaging studies to diagnose pancreatic trauma
in the absence of an acute abdomen or in the hemodynamically unstable patient. In penetrating trauma, the diagnosis is
often only made intraoperatively, and it is, therefore, very
important to recognize the subtle intraoperative ndings.
Identication often requires extensive mobilization of the
pancreas, but in general, the management requires less
aggressive surgery. There are two guiding principles: iden-
M. D. Smith
Department of Surgery, University of the Witwatersrand Medical
School, Johannesburg, South Africa
Hepatopancreaticobilary Unit, Chris Hani Baragwanath Academic
Hospital, University of the Witwatersrand Medical School,
Johannesburg, South Africa
e-mail: martin.smith@wits.ac.za
D. Doll
Medical Faculty Saarland University, Homburg, Germany
Department of Colorectal Surgery, St. Mary’s Hospital, Vechta,
Germany
E. Degiannis (*)
Department of Surgery, University of the Witwatersrand Medical
School, Johannesburg, South Africa
e-mail: degiannis@yebo.co.za
tify the extent of the parenchymal injury, and, second, the
injury to the main pancreatic duct (MPD) needs to be identied and quantied.
The general rules that apply to the management of penetrating trauma also apply to injury of the pancreas. Full
resuscitation including the primary and secondary survey is
followed, and the decision to proceed to surgery is based on
the accepted criteria and protocols. There are those patients
who remain unstable who require urgent transport to the
OR.The stable patient with an acute abdomen requires surgery and should be fully resuscitated and then taken to the
OR.The patient who has limited abdominal signs should be
investigated further and observed as per accepted protocols.
Once in the OR, a midline laparotomy is performed, and
again the usual guidelines as to how to manage penetrating
trauma to the abdomen is followed. Often following the tract
of the bullet or knife may indicate an injury to the pancreas.
This is not always the case, and as such, certain features may
suggest the presence of a pancreatic injury like the following: uid collection in the lesser sac, bile staining of retroperitoneal tissues, presence of fat necrosis of the omentum or
the retroperitoneum, or a hematoma overlying the pancreas.
It is essential to remember that the most important factor
in the outcome for the patient is the presence or absence of a
main pancreatic duct (MPD) injury. In the acute situation of
pancreatic (especially penetrating) trauma, there is no place
for the pre-operative evaluation of the injury by radiology or
ERCP.Intraoperative observation is the only method used to
detect ductal damage, based on the intraoperative criteria of
the main pancreatic duct injury described by Heitsch etal.
These include direct visualization of ductal violation, complete transection of the pancreas, laceration of more than half
the diameter of the pancreas, central perforation, and severe
maceration of the gland. Further intraoperative decisionmaking can be assisted by the grading of the injury and the
standard guidelines for the management of each grade. There
are numerous classication systems, and they all have in
common a measure of the extent of the parenchymal and
main ductal injury. We prefer the American Association for
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_51
427
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M. D. Smith et al.
the Surgery of Trauma (AAST) Committee on Organ Injury
Scaling classication.
To accurately grade the injury the injured region of the
pancreas must be fully mobilized. Exposure of the head of
the pancreas requires kocherization of the head of the pancreas. Retract the inferior surface of the liver superiorly;
retract the transverse colon including the hepatic exure
inferiorly. Your assistant should place their hand over the
head of the pancreas and the second part of the duodenum
and retract the head toward the left. The role of the assistance
retracting the duodenum to the left cannot be underestimated,
because it is this maneuver that exposes the correct dissection plane. This maneuver exposes the lateral aspect of the
retroperitoneal portion of the duodenum. Incise the peritoneal reection being careful not to damage the serosa of the
duodenum. The IVC is identied posterior to this plane.
Using a combination of blunt and sharp dissection, we use
the diathermy knife to achieve this dissection, and the duodenum is mobilized to the left until the aorta is identied. There
is a branch of the IVC that runs inferiorly to the right of the
IVC that is easily torn in this maneuver. The duodenum is
freed from the retroperitoneum as far superiorly as the foramen of Winslow that identies the tunnel that passes behind
the portal triad. Inferiorly the duodenum is mobilized distally by carefully identifying the tissue that holds the transverse mesocolon and the lateral aspect of the junction
between the second and third parts of the duodenum. This
plane is identied by the surgeon holding the head of the
pancreas and duodenum in his left hand, while the assistant
holds the transverse colon and mesentery upward and into
the incision. Dividing this tissue opens up the head of the
pancreas and mobilizes the uncinate process up to the right
lateral edge of the superior mesenteric vein. Be prepared to
mobilize the head of the pancreas as far medially as the aorta.
At this point, the head of the pancreas is easily examined
both anteriorly and posteriorly.
If there is suspicion that the distal pancreas has been
injured, this should be visualized by opening the lesser sac.
The surgeon performs this from the patient’s right side, and
opens the lesser sac. This is achieved by detaching the greater
omentum from the transverse colon along the bloodless line
or dividing the gastrocolic vessels in the omentum using an
energy devise or between serially placed artery forceps.
There are times that the greater omentum and the transverse
mesocolon are “stuck” together, and it is difcult to separate
them with this approach without risking damage to the transverse mesocolon and its corresponding vasculature. If the
surgeon nds himself or herself in this situation, they should
proceed with the following maneuver: The surgeon lifts up
the stomach by grasping the anterior surface with his/her
right hand and breaks the lesser omentum with the ngers of
the left hand making sure that one does not damage the vasculature of the lesser curvature of the stomach. Then, the surgeon’s whole left hand is inserted along the back of the
stomach, ngers pointing caudally, and by moving the whole
palm in a transverse and caudal plane, one will easily open
the potential lesser sac space by separating the greater omentum from the transverse mesocolon. The surgeon should
make sure that the opening of the lesser sac is generous and
so should proceed with the division of the greater omentum
up to the inferior short gastric vessels.
If there is suspicion that the injury may involve the distal
tail of the pancreas near the hilum of the spleen, the lienosplenic, splenocolic, and splenorenal ligaments are incised
and the spleen mobilized, by rotating it medially and lifting
it upward toward the incision but being careful not to damage the short gastric arteries. This will allow inspection of
the anterior as well as the posterior aspects of the tail of the
pancreas. The same maneuver can be used in visualizing the
body and the tail, but because it requires signicant mobilization of the spleen and the pancreas from the retroperitoneal
space, it can lead to signicant oozing especially in the coagulopathic patient. An alternative approach to visualizing the
body of the pancreas is by incising the avascular peritoneal
attachment of the transverse mesocolon to the pancreas and
exposing the inferior border of the pancreas. This is done by
sharp dissection with Metzenbaum scissors or using a diathermy needle knife. As the peritoneum is divided, 2 or 3mm
of retroperitoneal fat is seen bulging at the line of division
between the lower border of the pancreas and incised mesocolon. There are very few vessels in this space, and if they
are cut, they can easily be controlled using diathermy. This
incision is extended as far laterally as possible toward the
spleen. Then, the surgeon should start mobilizing the pancreas anteriorly up by inserting the index and middle nger
of the right hand, facing upward, in the retroperitoneal space
behind the pancreas. The surgeon bluntly dissects the posterior surface of the pancreas from the retroperitoneum using
their ngers till they reach the superior border of the pancreas. The peritoneum exposed along the superior border of
the pancreas is then incised. One must not worry about the
veins along the posterior surface of the pancreas in this anatomical area as it is largely avascular and the tissues easily
separated. On the other hand, the surgeon must always keep
in mind that the splenic artery is running at the upper border
of the pancreas, so when dividing the peritoneum along the
upper border of the pancreas, the artery is not damaged. This
will now allow cephalad rotation of the pancreas and inspection of the posterior surface and bimanual palpation
(Fig.51.1).
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Fig. 51.1 Rotation of the body and the tail of the pancreas for the inspection of its posterior aspect
The Organ Injury Scaling (OIS) Committee of the American Association
for the Surgery of Trauma (AAST) for pancreatic trauma
Grade Criteria
I Simple contusion of the pancreas
II Major contusion or laceration without tissue loss or
involvement of the main pancreatic duct
III Complete transection of the pancreas or a parenchymal
injury with involvement of the major duct to the left of
the SMV
IV Ductal transection or a major parenchymal injury to the
right of the SMV
V Massive disruption of the head of the pancreas
The rst step to perform resection of the mobilized distal
pancreas should be to ligate the splenic artery and vein to
decrease the possibility of extensive bleeding during the
resection. Ligation of both vessels about 2cm to the right of
the injury site is performed so that they are not inadvertently
damaged during the transection of the parenchyma. In the
same way, the surgeon should continue the mobilization of
the pancreas also for 2cm to the right to the site of the proposed resection line. The surgeon then takes a soft bowel
clamp and applies it on the pancreas as proximally as possible and divides the parenchyma with a scalpel or a modern
electrocautery device. By intermittently releasing the soft
For minor parenchymal injuries without ductal disruption
(grades I and II), we do not suture the gland but would leave
a drain onto the site of the injury. We use soft silicone suction
drains.
If the parenchyma is signicantly divided or the main
pancreatic duct (MPD) disrupted, for injuries to the left of
the PV/SMV, we advocate a distal pancreatectomy.
bowel clamp, one will identify the superior and inferior pancreatic arteries and overrun them with a 5-0 Prolene gureof-eight stitch. The bites of the needle are as close as possible
to the bleeding vessel, including minimal pancreatic tissue.
If it is applied further away from the vessel, there is a good
possibility that the thin stitch will cut through the parenchyma while applying tension on throwing the knot causing
small irritating bleeding. Linear stapling devices when avail-
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