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C.-j. K. Lu and J. A. Marks
and provides clues for the necessity of damage
control surgery.
Indications for trauma laparotomy include
patients with hemodynamic instability, peritonitis, and trajectory suggesting abdominal injury
such as transabdominal penetrating wounds or
abdominal wounds that violate the anterior rectus
fascia. There may be a role for nonoperative management of certain penetrating wounds; however,
such discussion is beyond the scope of this chapter. In general, trajectory determination yields
injury identication and frequently requires
exploration. The unstable trauma patient belongs
in the operating room, and the abdomen is often
the source.
Once the trauma laparotomy is under way, one
of the most challenging aspects is knowing when
to employ damage control techniques. This is a
difcult decision even in the hands of the most
experienced trauma surgeon. Waiting for the
deadly triad to set in is too late. The surgeon must
identify early cues including bowel edema, dusky
serosal surfaces, tissues cold to touch, noncompliant swollen abdominal wall, and diffuse oozing. The three main indications for damage
control surgery include:
1. Exsanguinating, hypothermic, and coagulo-
pathic patient dying on the operating table
2. Inability to control hemorrhage with direct
hemostasis (large liver laceration, ruptured
retroperitoneal hematomas)
3. Inability to close the abdomen (tension due to
visceral edema, noncompliant abdominal
wall) [4]
The goals of damage control laparotomy are
to stop potential life-threatening bleeding, to
identify the injuries, to control contamination,
and to provide temporary abdominal closure [4].
Regardless of the mechanism and extent of injury,
adhering to these basic principles will allow the
surgeon to maneuver through a damage control
surgery in a calm and systematic fashion. This
chapter focuses on key maneuvers of damage
control laparotomy for trauma, potential pitfalls
associated with each maneuver, and available
bailout techniques. The objective is to simplify
each maneuver to its bare essentials so that a
surgeon at any level of training can condently
execute the steps of an exploratory laparotomy
for trauma.
19.2 General Concepts
Successful exploratory laparotomy in trauma
begins with preoperative setup and ends with
transportation to the surgical ICU for continued
resuscitation. This section highlights the general
concepts and key steps to the trauma laparotomy.
The details of specic exposures and maneuvers
for the retroperitoneal vessels and individual
organ systems are discussed in the Technical
Approaches section.
19.2.1 Preoperative Essentials
The team must minimize the “door to cut” time.
The initial resuscitation should follow a fast
orderly tempo that must continue through to the
OR and beyond until surgical control of injury
and physiologic capture has been obtained.
Multiple tasks need to happen simultaneously as
the patient is being transported to the OR. The
blood bank should be alerted of a potential activation of the massive transfusion protocol. The OR
staff is notied to adjust the room temperature to
75–80°F and to ensure the availability of a rapid
transfuser (delivers large volume warm uid and
blood products to the patient) and a cell saver in
the room. Although cell savers are extremely useful in the setting of hemorrhage, intra-abdominal
contamination is a contraindication for their use.
19.2.2 Positioning andPrepping
(Fig.19.1)
Do not delay positioning and prep once the
patient is on the OR table. Remember, minimize
the “door to cut” time! Work concurrently with
anesthesiologists as they secure the airway and
begin preparations for resuscitation. Position the
patient supine with both arms out. This allows
anesthesia access to bilateral upper extremities
for intravenous lines and monitoring purposes
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Fig. 19.1 Patient
positioning and prepping
(supine, arms out, and
areas to prep)
255
and the surgeon access to the chest. Place a Foley
catheter to monitor urine output as well as to triage the genitourinary system. Prep the patient
from the chin to knees and down to the operating
table bilaterally. This permits the surgeon access
to the abdomen for laparotomy, to the chest for
potential sternotomy or thoracotomy, to the groin
for additional central lines, and to the lower
extremities for saphenous vein graft harvest as
vascular conduit. A groin towel is placed to
ensure sterility.
19.2.3 Incision
The trauma laparotomy incision is midline from
the xiphoid to the pubis.
19.2.3.1 Key Maneuvers
• Make a single incision with a #10 scalpel from
the xiphoid to the pubic symphysis.
• The peritoneal cavity should be entered after
three decisive strokes of the scalpel:
– The rst stroke of the scalpel divides the
skin and dermis to expose the subcutaneous fat.
– The second stroke of the scalpel divides the
subcutaneous fat to expose the linea alba of
the midline fascia.
– The third stroke of the scalpel divides the
fascia and opens the peritoneum.
Be ready to encounter a gush of blood as
the abdominal tamponade is released.
Do not forget to communicate with the
anesthesiologists prior to releasing the
abdominal tamponade so that they can prepare their resuscitation.
19.2.3.2 Potential Pitfalls
A trauma patient with multiple previous abdominal procedures presents as a challenge due to a
potentially hostile abdomen. Midline incisions in
these circumstances may not permit the rapid
access needed and may cause additional damage
to underlying structures due to dense adhesions.
An alternative approach is the bilateral subcostal
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incision through which most of the abdomen still
can be explored.
19.2.4 Hemorrhage Control:
Packing theFour Quadrants
oftheAbdomen
Once the abdomen is entered, the next move is
eviscerating the small bowel and packing the
abdomen to help control hemorrhage.
19.2.4.1 Key Maneuvers
• Pack the four quadrants of the abdomen with
folded, radiopaque laparotomy pads in a
clockwise fashion starting in the right upper
quadrant.
• Packing the right upper quadrant and liver
(Fig.19.2):
– Divide the falciform ligament between two
Kelly clamps and ligate with 0-silk sutures.
– Surgical assistant retracts the abdominal
wall upward and away from the liver.
– Position your non-dominant hand over the
liver to protect and retract it inferiorly.
– Use your dominant hand to position dry
packs above the liver.
– Reposition your non-dominant hand under
the liver to retract it superiorly, and position packs below the liver.
Falciform
lig.
Fig. 19.2 Packing of the RUQ—liver packing
C.-j. K. Lu and J. A. Marks
Fig. 19.3 Packing of the LUQ—spleen packing
– The liver is now compressed anteriorly and
posteriorly to achieve hemostasis.
• Packing the left upper quadrant and spleen
(Fig.19.3):
– Surgical assistant retracts the left abdomi-
nal wall outward away from the spleen.
– Position your non-dominant hand over the
spleen to protect and elevate it toward the
midline.
– Use your dominant hand to position dry
packs posterior to the spleen.
– Release the spleen and place dry packs
anterior to the organ.
• Packing the left lower quadrant and pelvis:
– Surgical assistant retracts the abdominal
wall laterally and away from the colon.
– Sweep the small bowel and left colon
superomedially.
– Pack the left paracolic gutter and pelvis
with dry packs.
• Packing the right lower quadrant and pelvis:
– Surgical assistant retracts the abdominal
wall laterally and away from the colon.
– Sweep the small bowel and right colon
superomedially.
– Pack the right paracolic gutter and pelvis
with dry packs.
• Once the four quadrants are packed and hemorrhage is temporarily controlled, inform
theanesthesiologist and allow adequate resuscitation before proceeding.
• Abdominal retractors such as Bookwalter,
Thompson, or Balfour should be set up at this
time to assist in abdominal wall retraction.
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19.2.4.2 Potential Pitfalls
In terms of packing, quality is more important
than quantity! Under-packing results in continued hemorrhage, while over-packing can compress the inferior vena cava (IVC), cause decrease
in venous return, and result in hypotension.
19.2.5 Hemorrhage Control:
Identifying Retroperitoneal
Hematomas (Fig.19.4)
The retroperitoneum is divided into three zones,
each containing vital structures that may require
exploration during a trauma laparotomy:
• Zone 1 encompasses the central region of the
retroperitoneum and extends from the diaphragm to the aortic bifurcation. It contains
the abdominal aorta, celiac axis, superior mesenteric artery (SMA), IVC, proximal renal
vasculatures, pancreas, and portions of the
duodenum.
Table 19.1 Exploration of retroperitoneal hematomas
Zone
1 (central) Explore Explore
2 (perinephric) Explore Observe if not
3 (pelvic) Explore Observe if not
Penetrating
injury Blunt injury
pulsatile/expanding
pulsatile/expanding
• Zone 2 encompasses the lateral regions of the
retroperitoneum and contains the renal hilum
vasculature, kidney, adrenal gland, ureter, and
colon.
• Zone 3 is the pelvic retroperitoneum containing the iliac vessels and portions of the colon
and rectum.
Indications for exploration vary with each
zone and the mechanism of injury (Table19.1).
In general, all penetrating, pulsatile, and expanding hematomas require exploration. All zone 1
retroperitoneal hematomas are explored regardless of mechanism of injury. The vascular surgery
tenet of obtaining proximal and distal control
remains true during exposure and exploration of
retroperitoneal hematomas.
1
2
3
Fig. 19.4 Retroperitoneal hematoma zones 1, 2, and 3
2
19.2.6 Injury Identication
19.2.6.1 Key Maneuvers
• Remove packs one quadrant at a time, starting
from t.ctive bleeding, retroperitoneal hematomas, bile staining, succus leakage, and diaphragmatic injuries.
• Running the small bowel:
– Identify the ligament of Treitz by lifting up
the transverse colon and following the
transverse mesocolon to its base.
– Flip the small bowel back and forth
between your hands to evaluate the bowel
wall and its mesentery.
– Examine the entire small bowel from the
ligament of Treitz to the terminal ileum.
• Assessing the colon:
– Identify the cecum and examine the ascend-
ing, transverse, descending, and sigmoid
colon for bowel wall and mesocolon
injuries.
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C.-j. K. Lu and J. A. Marks
– Follow the sigmoid colon to the rectosig-
moid junction and evaluate the intraperitoneal rectum.
– A digital rectal exam and rigid proctosig-
moidoscopy should be performed in all
patients with high index of suspicion for
rectal injury (pelvic fractures, truncal gunshot and stab wounds, penetrating wounds
of the lower abdomen, buttocks, or
perineum).
• Diaphragmatic injuries are difcult to diagnose and must be repaired once identied:
– Reduce any abdominal contents from the
intrathoracic cavity.
– Surgical assistant retracts the liver or spleen
inferiorly to provide diaphragmatic
exposure.
– Reapproximate the diaphragmatic defect
with hemostats.
– Primarily repair the diaphragm with run-
ning or interrupted nonabsorbable sutures
over a red rubber catheter inserted into the
pleural space.
– Place the catheter to suction to evacuate the
pneumothorax.
– The assistant removes the catheter as the
surgeon ties down the suture repair.
– Insert chest tube on injured side.
19.2.6.2 Pitfalls
Do not forget to evaluate the gastroesophageal
junction, the anterior and posterior aspects of
the stomach, and the pancreas via the lesser sac.
Expose the gastroesophageal junction by dividing the left triangular ligament of the liver and
retracting the left lobe of the liver laterally. To
enter the lesser sac, rst retract the stomach
superiorly and the greater omentum inferiorly.
Make a transverse incision in the thin portion of
the omentum with Bovie cautery just inferior
and parallel to the greater curvature of the stomach. The posterior aspect of the stomach is
assessed through the lesser sac. The anterior
surface of the body and tail of the pancreas can
be visualized and palpated through the lesser
sac as well.
19.2.7 Contamination Control
The goal is to limit the amount of intra- abdominal
contamination as quickly as possible and plan
for denitive repair at a later time. Bowel injuries can be controlled and contained via several
techniques:
• Grasp and close opposing bowel walls with
Babcock or Allis clamps.
• Suture closure (interrupted or running) the
bowel injury with any suture on a non-cutting
needle.
• Skin staples to reapproximate the bowel edges.
• Tie off the proximal and distal ends of the
injured bowel with umbilical tape (effectively
isolating the area of injury).
• Resect the injured bowel segment with a gastrointestinal anastomosis (GIA) stapler, and
leave the bowel in discontinuity.
19.2.8 Temporary Abdominal
Closure
At this point of the operation, ongoing hemorrhages are halted, major injuries are identied, and
intra-abdominal contaminations are controlled. It
is time to determine whether the patient is stable
for denitive repair or unstable and requires damage control procedures. Contraindications to
immediate reconstruction include hemodynamic
instability; physiologic derangements including
hypothermia, acidosis, and coagulopathy (be vigilant during the operation and look for these signs
before they actually appear); and multisystem
injuries. Competing priorities such as concomitant
head injury may require an abbreviated damage
control operation. In addition, visceral edema,
abdominal noncompliance, and the need for a second-look laparotomy preclude denitive abdominal closure in trauma patients.
A few common techniques for temporary
abdominal closure are listed below, and a more
detailed analysis of such techniques is offered in
Chap. 20:
Cattell-Brasch
e
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• Rapid skin closure with towel clamps sequentially applied to skin edges 1–2cm apart [4]
• Negative pressure/vacuum-assisted closure
(such as the ABThera system, KCI Medical)
• Bogota bag or mesh closure
19.2.8.1 Potential Pitfalls
Abdominal compartment syndrome (ACS) can
occur in the setting of an open abdomen! ACS
is dened as intra-abdominal pressure
≥20mmHg with organ dysfunction [5]. Signs
include elevated peak airway pressure, hypotension, oliguria, and bowel ischemia. Treat
ACS by removing the temporary abdominal
closure device and releasing the pressure via a
laparotomy. In some instances, tight or excessive intra-abdominal packings may also need
to be removed.
19.2.9 Transport fromtheOR
totheSICU
This is a crucial yet often overlooked and
underrated step of trauma laparotomy [4]. The
transportation process should be a well-orchestrated event with constant communication
between the surgeon, anesthesiologist, OR
staff, and SICU team. Prior to leaving the con-
trolled setting, ensure the availability of an ICU
bed, monitoring devices, Ambu bag, blood
products, and vasopressor medications. A thorough sign-out from the surgeon and anesthesiologist and a clear understanding of the patient’s
condition are keys to a successful ICU
resuscitation.
19.3 Technical Approaches
19.3.1 Exposing theIVC
19.3.1.1 Key Maneuver: CattellBraasch Maneuver (Fig.19.5)
• Right-sided visceral medial rotation with the
surgeon positioned on the patient’s left side.
• Retract the right colon medially with your left
hand to expose the white line of Toldt.
• Holding the cecum in your left hand, bluntly
dissect the white line of Toldt with your left
index nger, and travel superiorly from the
cecum to the hepatic exure (the correct plane
consists of loose areolar tissue that should easily divide).
• Continue mobilization of the right colon
medially and superiorly to the transverse
colon until the IVC, right kidney, and iliac
vessels are visualized.
Fig. 19.5 CattellBraasch maneuver
Kocher Maneuver
Extended
Kocher
Maneuver
Maneuver
White lin
of Toldt
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C.-j. K. Lu and J. A. Marks
19.3.1.2 Potential Pitfalls
The correct plane of dissection can be more difcult to identify in the presence of a retroperitoneal hematoma. However, hematomas often
create a dissection plane and may help guide your
maneuver. Dissecting in a plane deep to the white
line of Toldt will result in elevation of the right
kidney. Identify and protect the duodenum as it is
exposed with the mobilization of the hepatic exure of the colon.
19.3.1.3 Key Maneuver: Kocher
Maneuver
• Medial visceral rotation of the duodenum to
expose the posterior aspect of the pancreatic
head.
• The c-loop of the duodenum is exposed after
the hepatic exure is mobilized.
• Gently retract the duodenum medially with
your left hand.
• Using a combination of blunt and sharp dis-
section, divide the peritoneal attachments to
the lateral wall of the duodenum with your
right hand from the rst portion, and move
inferiorly to the third/fourth portion.
• The maneuver is complete when the aorta is
visualized.
19.3.2 Exposing theAbdominal
Aorta
19.3.2.1 Key Maneuver: Mattox
Maneuver (Fig.19.6)
• Left-sided visceral medial rotation with the
surgeon positioned on the patient’s right side.
• Retract the left colon medially with your left
hand to expose the white line of Toldt.
• Bluntly dissect the white line of Toldt with
your right index nger and travel superiorly
from the sigmoid colon to the splenic
exure.
• Identify the spleen, retract the spleen medially
in your left hand, and divide the peritoneal
attachments to the spleen with your right
hand.
• Rotate the left colon, spleen, tail of the pancreas, and stomach medially and superiorly to
expose the abdominal aorta and the iliac
vessels.
Fig. 19.6 Mattox
maneuver
Maddox Maneuver
White lin
of Toldt
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19.3.2.2 Potential Pitfalls
The Mattox maneuver may be too time- consuming
for patients who require immediate supraceliac
aortic control in the setting of an expanding retroperitoneal hematoma. To expose the aorta above
the celiac axis, retract the stomach laterally, and
sharply divide the gastrohepatic ligament vertically. Retract the distal esophagus/proximal
stomach laterally and the left hepatic lobe to the
right (the left triangular ligament may need to be
divided) to expose the left crus of the diaphragm.
Use your dominant index nger to bluntly dissect
the loose tissue around the aorta superiorly and
inferiorly until an aortic clamp can be placed along
the aorta. An orogastric tube placed by theanesthesiologist will help differentiate the esophagus
from the potentially accid, empty aorta.
19.3.3 Liver Injuries
Hepatic injuries range from small parenchymal
lacerations that are easily treated with pressure and
hemostatic agents to large avulsions or retrohepatic
vena cava hemorrhage that require full liver mobilization and vascular control. Regardless of the
extent of the injury (and you likely will not know
the full extent initially), the rst step is to pack the
liver. Hemorrhage not well controlled by packing
will require further mobilization and exploration.
Three commonly utilized techniques for treating
liver injuries/bleeding are discussed below. Several
additional techniques are listed, but detailed
descriptions are beyond the scope of this chapter.
19.3.3.1 Key Maneuver: Hepatic
Packing
• Recreate the anatomy by packing above and
below the liver.
• Anterior hepatic packing:
– Divide the falciform ligament as previously
described.
– Retract the liver inferiorly with one hand,
and place packs over the retracting hand
between the anterior surface of the liver
and the diaphragm.
• Lateral hepatic packing:
– Retract the liver medially one hand, and
place packs over the retracting hand
between the right lateral surface of the liver
and the abdominal sidewall.
Posterior hepatic packing:
•
– Retract the liver superiorly with one hand,
and place packs under the retracting hand
between the posterior surface of the liver
and the infra-hepatic structures.
• If bleeding stops after packing, leave the packs
in place! Premature removal of the packing
may result in further bleeding from peeling
the packs off the injured parenchyma.
• To remove the packing, slowly irrigate with
water to loosen the packs.
•
Localize and control residual areas of
bleeding.
19.3.3.2 Potential Pitfalls
Excessive packing can compress the IVC and
jeopardize venous return. Too much packing can
also limit diaphragmatic movement and cause
increase peak airway pressure and hypoventilation. Full mobilization of the liver by dividing the
triangular and coronary ligaments may improve
exposure of the injury and allow more effective
packing. However, if a retrohepatic injury is suspected, mobilization of the right liver lobe may
unroof the tamponade and cause severe
hemorrhage.
19.3.3.3 Key Maneuver: Pringle
Maneuver
• Retract the anterior edge of the liver superi-
orly and to the right.
• Insert the left index nger into the foramen of
Winslow.
• Pinch the thumb on top of the index nger to
control the portal triad (hepatic artery, portal
vein, common bile duct).
• A vascular clamp can replace the ngers for
long-term control.
• Release the clamp intermittently to limit total
ischemia time.
19.3.3.4 Potential Pitfalls
The Pringle maneuver is ineffective in patients
with a replaced left hepatic artery (most commonly off the left gastric artery) or injuries to the
hepatic veins and retrohepatic IVC.A replaced
right hepatic artery (off the SMA) commonly
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C.-j. K. Lu and J. A. Marks
travels posterior to the portal vein. Feel for a pulsatile structure posterior to the portal vein to help
identify this vessel. Be careful not to injure the
artery when placing a vascular clamp during the
Pringle maneuver.
19.3.3.5 Key Maneuver: Suture Repair
• Reapproximate the liver parenchymal lacerations with sutures (0-chromic) on a large blunt
needle.
• Take large bites incorporating the uninjured
liver parenchyma and capsule.
• Place gure-of-eight or horizontal mattress
sutures.
19.3.3.6 Potential Pitfalls
Taking too small of a bite of the liver parenchyma
can cause the suture to tear through and result in
more bleeding. When tying down the sutures,
apply just enough tension to reapproximate the
lacerated edges. Excessive tension during knot
tying will further avulse the liver and exacerbate
the injury.
19.3.3.7 Additional Hemostatic Agents
andTechniques
Learn the available topical hemostatic agents
available at your institution. Commonly utilized
topical agents include thrombin Gelfoam,
Surgicel, Combat Gauze, and brin glue. Argon
beam coagulator can be used for hemostasis by
creating an eschar on the bleeding liver surface.
Omental packing is useful in deep liver lacerations and needs to be secured with sutures.
Through-and-through liver injuries can be controlled via balloon tamponade by using a
Blakemore tube or a homemade balloon constructed from a Penrose drain over a hollow rubber catheter. A hepatotomy can be performed
after adequate vascular inow control with the
Pringle maneuver. Using the nger fracture
technique, parenchymal defects are opened to
expose the injured vessels/ducts. Bleeding vessels are then controlled with direct suture ligation, clips, or electrocautery. Atrial caval shunts
and hepatic venovenous bypass are rarely used
(and also rarely successful) and beyond the
scope of this chapter.
19.3.4 Splenic Injuries
Indications for splenectomy in a trauma patient
include active bleeding, hemodynamic instability, and concurrent moderate to severe brain
injury that can exacerbate with ongoing hypotensive episodes. Due to its posterior location, the
spleen must be mobilized to the midline to allow
better exposure and control. Splenorrhaphy is
rarely performed during a trauma laparotomy.
When in doubt, the spleen should come out!
19.3.4.1 Key Maneuver: Splenectomy
• Surgeon is positioned on the patient’s right
side.
• Place the left hand posterior to the spleen and
retract the spleen medially and anteriorly.
• Medial retraction of the spleen exposes the
retroperitoneal splenic attachments.
• Dissect and divide (blunt, sharp, or cautery)
the superior lienophrenic, lateral lienocolic,
and posterior lienorenal attachments with the
right hand.
• Lift the spleen off the right kidney and toward
the abdominal midline.
• Place laparotomy pads posteriorly in the
splenic fossa to prevent the spleen from falling
back into its original position.
• Divide the short gastric vessels (suture ligation, stapler, energy device) to expose the
splenic hilum.
• Ligate and divide the hilar vessels:
– Individually dissect out the splenic artery and
vein, place two hemostats on each vessel,
divide between the hemostats with scissors,
and suture ligate the two ends with 2-0 silk ties.
– An alternative is to divide the artery and
vein with a vascular stapling device.
19.3.4.2 Potential Pitfalls
Excessive retraction during mobilization can tear
the splenic capsule and cause more bleeding.
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Identify and protect the tail of the pancreas to
prevent pancreatic leak and stulas. Protect the
stomach during division of the short gastric vessels. Care must be taken to ensure thatall ofthe
short gastric vessels are adequately ligated to prevent postoperative bleeding.
19.3.5 Pancreatic andDuodenal
Injuries
The pancreas and duodenum are surrounded by
numerous vital structures. Adequate assessment
of these two organs requires multiple maneuvers,
and detection of any pancreatic and duodenal
injuries should raise suspicion for associated
injuries to adjacent structures.
19.3.5.1 Key Maneuver: Exposure
oftheDuodenum
• The rst portion is inspected by following the
distal stomach to the pylorus and continuing
distally.
• The second and third portions are exposed
with the Kocher maneuver, which also allows
examination of the posterior aspect of the
c-loop.
• The fourth portion is exposed by dividing the
ligament of Treitz.
• The third and fourth portion of the duodenum
can be further mobilized with a Cattell-
Braasch maneuver by carrying the dissection
to the root of the small bowel mesentery.
19.3.5.2 Key Maneuver: Exposure
ofthePancreas
• Expose the superior border of the pancreas by
dividing the gastrohepatic ligament.
• Exposing the anterior surface:
– Open the lesser sac and retract the stomach
superiorly.
– Sharply incise and divide the peritoneal
covering of the pancreas to examine its
anterior surface.
– Continue the dissection to the right of the
patient to expose the entire anterior aspect
of the pancreas from the tail to the head.
Exposing the posterior surface:
•
– A Kocher maneuver exposes the posterior
aspect of the head and neck of the pancreas.
– Medial mobilization of the spleen by divid-
ing the lienocolic and lienorenal ligaments
exposes the posterior aspect of the body
and tail of the pancreas.
19.3.6 Kidney Injuries
Renal injuries are most commonly identied on
CT scan during a trauma work-up. Indications for
exploration include active bleeding, hemodynamic instability, expanding or pulsatile hematoma, and injury to the ureters or bladder. Renal
salvage is rarely indicated if the patient has a normal contralateral kidney.
19.3.6.1 Key Maneuver
• Exposure of the right kidney:
– Perform a right-sided medial visceral rota-
tion to mobilize the right colon.
– Perform a Kocher maneuver to mobilize
the duodenum.
• Exposure of the left kidney:
– Perform a left-sided medial visceral rota-
tion to mobilize the left colon, spleen, and
distal pancreas.
• Vascular control:
– Obtain proximal renal vascular control
prior to entering Gerota’s fascia.
– Lift the transverse colon and follow the
mesocolon to its base.
– Sharply open and enter the retroperitoneum
at this level.
– Extend the opening from the ligament of
Treitz to the aortic bifurcation to allow full
exposure of the renal vessels.
– Identify the right renal vein as it enters the
right lateral edge of the IVC, and isolate it
with a vessel loop.
– Retract the right renal vein superiorly to
expose the underlying right renal artery,
and isolate the artery with a vessel loop.
– Identify the left renal vein as it crosses the
aorta laterally and enters the left lateral
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