This document discusses the evaluation and management of duodenal and pancreatic injuries from trauma. It includes two case scenarios of patients presenting with abdominal trauma and suspected duodenal or pancreatic injuries. It reviews the anatomy, etiology, clinical features, investigations and surgical management of injuries to the duodenum and pancreas. The key investigations discussed are contrast enhanced CT scan and contrast enhanced ultrasound. Surgical techniques for exploring the duodenum like Kocherization and the Cattell-Braasch maneuver are also summarized.

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DuodenoPancreaticInjuries
[RetroperitonealTrauma]
Evaluation and assessment
Dr Debmoy Ghatak
Senior Resident
MCh Trauma Surgery and Critical Care
JPNATC
AIIMS New Delhi

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Objectives
• Anatomy
• Discuss organ specific injuries
• What to look for and how to assess
• How to proceed

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• Case scenarios
• Clinical / Surgical anatomy
• Region & Organ wise discussion
• Etiology
• Clinical Features
• Investigations
• Surgical implications
• Take home message

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Case Scenario 1
• 12/F a/h/o Fall from bicycle with handle
bar injury over abdomen 48 hrs prior
• Blunt abdominal injury ?
• 98% sat, 98/66mmhg , 134 bpm HR,
abdomen tender
• IV Fluids, first aid
M
I
S
T
Primary Survey-
Class II shock
FAST- Reported POSITIVE
Secondary Survey-
Abrasion over upper abdomen
Abdominal tenderness
MRCP Done outside
CECT Torso-
Grade III Pancreatic Injury with 80%
parenchymal transection at the junction of
Body and tail of pancreas
Surgery-
Spleen preserving distal Pancreatectomy
under GA
Amylase done on POD 4- 211 (Kit UL 115)

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Case Scenario 2
• 23/M, a/h/o self inflicted penetrating
injury epigastrium,
• Penetrating abdominal injuries
• 98%, 136bpm, 98/62 mmhg, Abdomen
tender
• IV fluids and first aid
M
I
S
T
Primary Survey-
Class II Shock
FAST – positive in HR
Secondary Survey-
Stab site 8 CMS below the xiphisternum.
CT Torso-
Fluid in HR pouch and pelvis. There is
periduodenal fluid -D2 with B/L perirenal
fat stranding.
Surgery-
Intra OP- Aortic rent of 0.5 cm was noted
in anterior wall of infrarenal aorta after
exploring the zone 1 hematoma. Primary
repaired. No rent on posterior wall of
aorta.
Discharged uneventfully

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Intra OP
• Post Kocherisation looking from the right
to left
Pr

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Zone I Zone II
Zone III Zone IV
Retroperitoneum
4

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Zones of retroperitoneum- Organs to consider
Zones Organs
I • Abdominal Vascular Injury- [Great Vessels and their
branches]
• Duodenum
• Pancreas
II • Kidney Injury
• Ureteric Injury
• Adrenal Injury
III • Pelvic Bone #
• Iliac Vessel Injury
IV • Portal Structures
• Retrohepatic IVC

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Duodenum

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Anatomy

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Etiology
• Adults-1
• Penetrating trauma (53 to
90%)
• Pediatric population-
• Blunt- Handle bar injury –
inappropriately applied seat
belt.
• Resultant-
• Submucosal or subserosal
hematoma, usually in D2,
extensive hematomas
involving both D2 and D3
occur.
• Distribution-2
• D2 (36 %)
• D3 portion (18 %)
• Multiple portions (18 %)
• D4 portion (15 %)
• First portion (13 %)
36 %
18 %
13 %
1. Coccolini F et al. WSES-AAST Expert Panel. Duodeno-pancreatic andextrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;
2. García Santos E et al. Duodenal injuries due to trauma: Review of the literature. Cir Esp. 2015 Feb;

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Mechanism of Blunt
trauma
• Crush
• Occur with a direct force applied to the
abdominal wall, transferred to the duodenum
which is pushed posteriorly against the spinal
column
• Shear
• Occur when the mobile and nonfixed
portions of the organ accelerate and
decelerate forward and backward
respectively
• Burst
• Force is applied to a gas and fluid-filled filled
duodenum against a closed pylorus and
acutely flexed duodenojejunal angle . Boyle’s
law comes into action.
P1 x V1= nRT = P2 x V2

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Diagnosis
• ATLS
• Primary Survey
• Adjuncts
• Secondary Survey
• Adjunts
Clinical Features-
1. Submucosal or subserosal hematoma
versus rupture
2. The presence of associated injuries,
3. The time interval since injury.**
• Minimal or moderate pain
and epigastric tenderness
on the initial physical
examination.
• A blunt rupture-may also
not be diagnosed low
bacterial count of the
duodenum and pancreatic
bicarbonate neutralizes
gastric acid;
• Retroperitonitis - delayed

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Time from injury to the definitive treatment
• Mortality
• 40%; the patients who diagnosed
over 24hr
• 11%; the patients who underwent
surgery within 24hr
Name of the Game
• Clinical Suspicion – High
• Early Diagnosis
• Prompt Management
Lucos C,Ledgerwood A: Factor influencing outcome after blunt duodenal injury. J Trauma 15(10):839-846,1975

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Duodeno-pancreatic and extrahepatic
biliary tree trauma: WSES-AAST guidelines 2019- DIAGNOSIS Part
Duodenum
• The choice of diagnostic technique at admission must be based on the
hemodynamic status. (GoR 1A)
• E-FAST is rapid, repeatable, and effective for detecting free fluid and solid organ
injury.(GoR 1A)
• Ultrasonography is not recommended to routinely diagnose duodeno-pancreatic
trauma. (GoR 2B)
• CT-scan with intravenous contrast is essential in diagnosing duodeno-
pancreatic injuries in hemodynamically stable or stabilized trauma patients.
(GoR 1A)
• Administration of oral contrast material does not improve intravenous contrast-
enhanced CT-scan sensitivity in detecting duodeno-pancreatic injuries. (GoR
2A)

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Duodeno-pancreatic and extrahepatic
biliary tree trauma: WSES-AAST guidelines 2019- DIAGNOSIS
Part- Duodenum
• Exploratory laparotomy is indicated in hemodynamically unstable (WSES
class IV) patients with a positive E-FAST. (GoR 1A)
• During surgical exploration of patients with abdominal trauma, the
duodeno-pancreatic complex must be exposed and explored. (GoR 1A)
• In patients who are clinically suspected of having duodenal-pancreatic
injuries, and are deteriorating clinically, if the imaging is equivocal, a
diagnostic laparotomy should be performed. (GoR 2A)
• Serial clinical examination is an important part of follow-up after biliary and
pancreatic-duodenal trauma. (GoR 2A)
• Abdominal plain films using water-soluble contrast in the early trauma
scenario are not recommended. (GoR 2A)

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How to investigate ?
• “It Depends !”
• Clinical examination and
blood biochemistry fall
short for a definitive
diagnosis.
Hemodynamic
status
Stable
CECT Torso
Transient or
Nonresponder
Laparotomy

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CT Findings suggestive of duodenal injuries
• Extraluminal air, [SN 46% and SF
99% ]
• Duodenal wall thickening
• Peri-duodenal fluid
• Fluid in the right anterior pararenal
space,
• Diminished bowel wall
enhancement of the injured
segment,
• The “sentinel clot” sign
• Extraluminal oral contrast material
[seen in only 19% cases]
1. Mirvis SE, et al Rupture of the bowel after blunt abdominal trauma: diagnosis with CT. AJR Am J Roentgenol 1992;
2. Kunin JR, et al Duodenal injuries caused by blunt abdominal trauma: value of CT in differentiating perforation from hematoma. AJR Am
J Roentgenol 1993;160(6):1221–1223.
3. Orwig D, Federle MP. Localized clotted blood as evidence of visceral trauma on CT: the sentinel clot sign. AJR Am J Roentgenol
Paraduodenal Air Foci

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Nonenhancing D3 D4 with significant hematoma around
Sentinel Clot Sign

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AAST Grading

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Quiz Time ! Hints ?

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Kocherisation
• Devised by Kocher
himself
• D2-D3
• Left Renal Vein
Extended
Kocherisation
Reverse
Kocherisation
• Modification
• Whipples
• SMA
• Modification based on
Oncologic clearance
• “Artery First Approach”
• Laparoscopic
• Medial to lateral
1. Georgescu, et al (2014). Hind Right Approach Pancreaticoduodenectomy: From Skill to Indications. Gastroenterology research and practice.
2. Nagai, Hideo. (2003). Configurational anatomy of the pancreas: Its surgical relevance from ontogenetic and comparative-anatomical viewpoints. Journal of Hepato-Biliary-Pancreatic Surgery.

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How to surgically
explore all portions of
duodenum?
• Kocherisation-
• Should be able to
palpate the head of the
pancreas to the level of
the mesenteric vessels
• Be able to visualize the
anterior and posterior
aspects of the D2, the
head of the pancreas
and the infrarenal IVC

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Cattell & Braasch Manoeuvre 1960
aka- Super Extended Kocher Manoeuvre
• Technique for exposure of 3rd and 4th
portion of the duodenum
• Incise the avascular line of Toldt
• Mobilize the ascending colon and the
hepatic flexure
• Sharply incise the retroperitoneal
attachments of the Small bowel from the
RLQ to the DJF
• Reflect the Small bowel out of the
abdominal cavity
• Gives excellent exposure to retroperitoneum
CATTELL RB, BRAASCH JW. A technique for the exposure of the third
and fourth portions of the duodenum. Surg Gynecol Obstet. 1960

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Division of
ligament of treitz
• Exposes the 4th part of
duodenum

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Surgical findings that raises suspicion of
duodenal injury
• Crepitus along the duodenal
sweep
• Bile staining of paraduodenal
or adjacent tissues
• Documented bile leak
• Right-sided retroperitoneal or
periduodenal hematoma

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Pt in ED with Suspected
Pancreaticoduodenal Inuries
PS and Resuscitation ATLS
Assess Hemodynamic status
Hemodynamic
status
Stable or
Stabilised
CECT abdomen
with IV contrast
Unstable
Exploratory
Laparotomy
• Suspicious findings
• Manoeuvres to expose
• D2- Kocherization
• D3- CBM
• D4- Treitz Takedown
• Pitfalls
EL
• Specific findings
CECT

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Pancreas

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Clinical Anatomy
• “The pancreas
• cuddles the left kidney,
• tickles the spleen,
• hugs the duodenum,
• cradles the aorta,
• opposes the inferior vena cava,
• dallies with the right renal pedicle,
• hides behind the posterior parietal
peritoneum of the lesser sac and
• wraps itself around the superior
mesenteric vessels.”
- Durmen
Sir Alfred Cuschieri , George B Hanna - Essential Surgical Practice Higher Surgical Training in General Surgery

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Etiology
• Blunt Injury- 5% - BTA : Penetrating injury- Low vel-2% -Stab : High vel-6%
GSW
• Indian Data- 92.7 % blunt , 7 % penetrating
• Retroperitoneal- other organs are involved- isolated- rare
• Blunt ? Duodenum Liver Spleen
• Penetrating ? Stomach vascular structures liver colon spleen duodenum
• Blunt –
• Anteroposterior direct compression force – MVC
• Acceleration –deceleration injury- shearing injury between body (fixed) tail (mobile)
– resultant injury at the neck
• Pediatric age group- MCC Major Pancreatic Injury- Handle Bar Injury
1. Akhrass R, Yaffe MB, Brandt CP, et al. Pancreatic trauma: a ten-year multi-institutional experience. Am Surg 1997;63: 598–604
2. Sutherland I, Ledder O, Crameri J, et al. Pancreatic trauma in children. Pediatr Surg Int 2010;26:1201–1206.
3. Devi Bavishi, Kapil Dev Soni, Martin Gerdin Wärnberg, Management of pancreatic trauma in urban India: A multicenter study,Annals of Medicine and Surgery, Volume 78,2022.

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Distribution
• Two thirds of blunt pancreatic
injuries occur in the pancreatic
body, with the remainder
occurring with equal frequency
in the head, neck, and tail.
• Complete pancreatic rupture as
a result of traumatic transection
usually occurs in the line of the
superior mesenteric vein at the
neck of the gland.
66%
11%
11%
11%
Wilson RH, Moorehead RJ. Current management of trauma to the pancreas. Br J Surg 1991;78(10): 1196–1202.

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Diagnosis
• Clinically-
• Sign symptoms are vague
• High index of suspicion- b/o
MOI, Clinical features.-
seatbelt mark, steering
wheel / handle bar injury
• Early- mild epigastric pain
• Delayed?- Peritonitis
• Missed ?- Acute
peripancreatic collection/
pseudocyst
• Biochemically-
• Amylase + Lipase-
• Nonspecific
• Not raised in 1/3rd with
significant injury
• Raised in other causes of
acute abdomen? Duodenal
perforation
• Nondiagnostic in first 6
hours
• Poor Negative predictive
value
• Wisner DH, Wold RL, Frey CF. Diagnosis and treatment of pancreatic injuries: an analysis of management principles. Arch Surg 1990;125: 1109–
1113

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CEUS- Contrast Enhanced Ultra Sound
• Contrast agent was SonoVue (Bracco,
Milan, Italy)
• Stabilised microbubbles containing inert
gas (sulphur hexafluoride, 8 lL/mL of
solution), and is covered by a
phospholipid membrane.
• It is reconstituted with 5 mL of normal
saline for a few seconds and is
immediately administrable.
• No fasting- repeatable inj.

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CEUS- Contrast Enhanced Ultra-Sound
• Imaging-
• Pancreatic disruption or lacerations appear as
anechoic and/or hypoechoic perfusion defect
area in arterial and parenchymal phases, ideally
with separated structures, which can be
missed on conventional US images.
• Reason?
• It may be the difference in blood supply, which
makes it possible for CEUS to have a better
view of pancreas and peripancreatic
microcirculation perfusion .
CEUS can be
performed using
• Contrast Pulse
Sequencing (CPS)
• Pulse Inversion
Harmonic
• Energy-modulated
Technique At Low
Acoustic Power.
Lv F, Tang J, Luo Y, et al. Emergency contrast-enhanced ultrasonography for pancreatic injuries in blunt abdominal trauma. Radiol Med 2014;119:920–9

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CEUS

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CEUS- Contrast Enhanced Ultra Sound
Advantages
• Pancreas parenchyma and
capsule with excellent imaging
features.
• Portable,
• Timely, with a room time 5 min.
• Can be simultaneously
performed while performing
other physical examination or
resuscitation procedures.
• Useful in pediatric or pregnant
population as better yield than US
Disadvantages
• Similar limitations to
conventional US, such as
patient obesity, subcutaneous
emphysema, etc. Moreover,
lacks the panoramic quality of
CT.
• Indirectly diagnosed
pancreatic ductal injury on the
basis of a lesion involving more
than 50 % of the thickness of
pancreas, and the diagnostic
accuracy is lower.

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CECT Abdomen / MDCT Abdomen with IV
Contrast

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MDCT- Multi Detector Contrast Enhanced CT
Abdomen
• A multi-slice CECT scan of the
abdomen represents the best non-
invasive diagnostic method for the
detection of pancreatic injury.
• Teh et al reported a sensitivity and
specificity of 91%.
• At our center we achieved a
sensitivity of 94.7% and a specificity
of 100% of MDCT
Teh SH, Sheppard BC, Mullins RJ, et al. Diagnosis and management of blunt pancreatic ductal injury in the era of high-resolution computed
axial tomography. Am J Surg 2007;193:641–643.
[Panda A, Kumar A, Gamanagatti S, et al. Evaluation of diagnostic utility of multidetector computed tomography and magnetic resonance
imaging in blunt pancreatic trauma: a prospective study. Acta radiol 2015;56:387–396.

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CECT Findings
Gordon et al evaluated 53
patients with pancreatic injury
and reported simple
peripancreatic fluid as most
sensitive for
ductal injury (100%) while
active hemorrhage within
pancreatic parenchyma was
most specific for ductal injury
(100%). Laceration >50% was
found to have a specificity of
95.1%.
Fluid separating the splenic vein from
posterior aspect of pancreas **

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CECT Findings in CT

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AAST Grading- Pancreatic Trauma
• grade I: haematoma with
minor contusion or
superficial laceration without
duct injury
• grade II: major contusion or
laceration without duct injury
• grade III: distal transection or
deep parenchymal injury with
duct injury

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AAST Grading- Pancreatic Trauma
• grade IV: proximal transection or
deep parenchymal injury involving
the ampulla (and/or intrapancreatic
common bile duct)
• grade V: massive disruption of the
pancreatic head ("shattered
pancreas")

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Wong et al Scoring
• A simpler method for grading severity on CT in pancreatic injury
proposed by Wong et al. is:
• grade A: pancreatitis or superficial laceration only
• grade B
• BI: deep laceration involving pancreatic tail
• BII: complete transection of pancreatic tail
• grade C
• CI: deep laceration involving pancreatic head
• CII: complete transection of pancreatic head

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MRCP
• MRCP can noninvasively delineate the
pancreatic parenchyma and the morphology
of the pancreatic duct.
• The modality is of value in cases in which
findings of MDCT are equivocal about ductal
integrity .
• In a study of 7 patients with confirmed
pancreatic injury, Soto et al found that MRCP
was able to delineate the site of pancreatic
disruption and also the part of the duct
located beyond the site of duct disruption.
The MRI/MRCP protocol –
• AxialT1- and T2-weighted MR
images,
• Axial and coronal fast spoiled
gradient-echo imaging with
steady-state free precession
and single-shot fast spin-echo
T2-weighted MRI sequence,
• Heavily T2-weighted three-
dimensional MRI sequences
for MRCP.
• Contrast enhanced T1-
weighted fat-saturated MRI
also may aid in delineating
pancreatic parenchymal
injuries and associated fluid
collections.
Soto JA, Alvarez O, Munera F, et al. Traumatic disruption of the pancreatic duct: diagnosis with MR
pancreatography. Am J Roentgenol 2001;176:175–178

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ERCP
• The most accurate method for -
physiologically stable patient-
extravasations of contrast medium from
the pancreatic duct system.
• With raised serum amylase level,
persistent abdominal pain, and
questionable abdominal CT findings, who
are being considered for non-operative
management (NOM), should have the
integrity of the duct system demonstrated.
• It also has therapeutic role as pancreatic
ductal stenting and transgastric
cystoenterostomy can be performed, thus
supplementing NOM

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Case- With distal pancreatic injury with leak in ERCP

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Diagnosis

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Duodeno-pancreatic and extrahepatic
biliary tree trauma: WSES-AAST guidelines 2019- DIAGNOSIS
Part -Pancreas
• Repeated and combined measurement of serum amylase and
lipase levels, starting from 3to 6 h after the initial injury, is a
useful tool to support clinical evaluation in suspicion of
pancreatic injury. (GoR 1B)
• FAST and CEUS- Non specific – no specific recommendation.
• A repeat CT-scan within 12–24 h from the initial injury should be
considered in hemodynamically stable patients [clinical
suspicion for duodeno-pancreatic injury or pancreatic ductal
injury with negative CT-scan or non-specific CT findings on
admission imaging, and/or elevated amylase and lipase, or
persistent abdominal pain.] (GoR 2A)

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Duodeno-pancreatic and extrahepatic
biliary tree trauma: WSES-AAST guidelines 2019- DIAGNOSIS Part -
Pancreas
• (MRCP) can be considered a 2nd line non-invasive diagnostic
modality to definitely rule out pancreatic parenchymal and
pancreatic ductal injuries. (GoR 1B)
• In hemodynamically stable or stabilized adults and pediatric
patients, (ERCP) can be used for both diagnosis and treatment
even in the early phase after trauma.(GoR 1B)
• In pediatric and pregnant women, to detect pancreatic
parenchymal or pancreatic duct lesions, MRI is preferred if
available in the emergency setting. (GoR 2A)

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Duodeno-pancreatic and extrahepatic
biliary tree trauma: WSES-AAST guidelines 2019- DIAGNOSIS Part -
Pancreas
• Hepatobiliary scintigraphy is not recommended for detection of
biliary leak in patients with suspected gallbladder and biliary
injuries in the trauma setting. (GoR 2B)
• During exploratory laparotomy, when biliary injury is suspected
but not identified, an intraoperative cholangiogram is strongly
recommended. (GoR 2A)

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Surgical Exposure
• Ideally whole of the pancreas
should be exposed where there
is a suspicion of pancreatic
contusion.
• Blunt laceration more commonly
seen at the neck
• Steps
• Surgical exposure
• Assess ductal integrity
The intra-operative clues of pancreatic
injuries include
• peripancreatic hematoma,
• peripancreatic edema,
• blood stained peripancreatic fluid,
• presence of retroperitoneal bile,
• hematoma at the base of transverse
mesocolon
• Central retroperitoneal hematoma
• omental saponification (a late sign),

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Operative Signs
“Intra-operative evidence of
laceration/contusion/hematoma in
the lesser omentum just around the
pyloroantral region along the lesser
curvature of the stomach in blunt
traumatic injuries suggesting
potential injury to the neck or
around the neck of the pancreas”

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Steps- Surgical Exposure
• Step 1- Extended Kocherization[Allow visualization of head ant post
surf, inferior border of the neck]
• Step 2- Division of Gastrocolic omentum [anterior aspect of the body]
• Step 3- Division of retroperitoneal attachments and carefully
preserving the IMV SMV- Bimanual Gentle Palpation of the Body.
• Step 4- Aird Manoeuvre -Division of lienorenal Ligament and
sweeping of distal pancreas to midline.
Juan A. Asensio, Demetrios Demetriades, et al A unified approach to the surgical exposure of pancreatic and duodenal injuries, The
American Journal of Surgery, Volume 174, Issue 1, 1997,

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Step 1-
• Extended
Kocherization
• Allow visualization of
head ant post surface,
upper border neck]
Juan A. Asensio, Demetrios Demetriades, et al A unified approach to the surgical exposure of pancreatic and duodenal injuries, The
American Journal of Surgery, Volume 174, Issue 1, 1997,

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Step 2
• Division of Gastrocolic
omentum
• Anterior aspect of the body
Juan A. Asensio, Demetrios Demetriades, et al A unified approach to the surgical exposure of pancreatic and duodenal injuries, The American Journal of Surgery,
Volume 174, Issue 1, 1997,

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Step 3
• Division of retroperitoneal
attachments and carefully
preserving the IMV SMV
• Bimanual gentle Palpation of
the Body
Juan A. Asensio, Demetrios Demetriades, et al A unified approach to the surgical exposure of pancreatic and duodenal injuries, The American Journal of Surgery,
Volume 174, Issue 1, 1997,

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Step 4- Aird Manoeuvre
• Aird and Helman described a maneuver
that involves -
• Take down the splenic flexure of the
colon
• Exposure of the splenic hilum by
mobilizing the lienosplenic, splenocolic,
and splenorenal ligaments
• Followed by mobilization of the spleen
from a lateral to a medial position.
• This allows for visualization of the
posterior aspect of the tail of the
pancreas
BMJ 1955

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Division of Gastrohepatic Ligament
• Superior surface of neck and boby
of pancreas can also be explored
through the gastrohepatic
ligament – lesser omentum
• Mishra’s sign is a telltale sign of
upper portion of neck and body
injury in pancreas

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Steps to assess ductal integrity
ATOM Manual Cinemed USA Mattox Trauma 9th Edition

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How SHOULD we assess ductal injury?
A. Intraoperative cholangiopancreatogram (C-Arm)
B. Dye study using methylene blue (Direct Visual)
• A #5 IFT -into cystic duct [Mattox]/ 18 G
angiocatheter inserted in neck of GB [ATOM
Manual].
• After Inj Fentanyl to cause spasm of the sphincter
of Oddi.
• Standard cholangiogram contrast or 1 Amp of MB
solution in 200 mL normal saline is injected
through the feeding tube.
• Finding-
• Obvious leakage in cholangiogram
• Obvious staining in the pancreatic surface
• Disadvantage - Cholecystectomy after the cystic

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Things we SHOULD NOT do !
Trans-duodenal X X Retrograde X X

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Pt in ED with Suspected
Pancreaticoduodenal Inuries
PS and Resuscitation ATLS
Assess Hemodynamic status
Hemodynamic status
Stable or
Stabilised
CECT abdomen with
IV contrast.
Hard Signs
Soft Signs
MRI MRCP ERCP CEUS
Unstable
Exploratory
Laparotomy
Suspicion
Manoeuvres
Pitfalls

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End of Part One
Questions ?

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