Technical note Operative techniques in pancreatic trauma—A heuristic approach Tugba Han Yilmaz a , Thorsten J. Hauer b,c, *, Martin D. Smith c , Elias Degiannis c , Dietrich Doll c,d a Baskent University, Department of Surgery, Izmir, Turkey b Military Hospital Ulm, Department of Surgery, Ulm, Germany c Chris Hani Baragwanath Academic Hospital, Trauma Directorate, University of the Witwatersrand, Johannesburg, South Africa d St. Marienhospital Vechta, Department of Surgery, Vechta, Germany Patients who sustain trauma to the pancreas can in certain cases, if they are physiologically stable, be transferred to a dedicated trauma unit. On the other hand, some of these patients will be physiologically unstable and need to be managed by the locally available surgeon, who may be unfamiliar with the operative management of trauma to the pancreas. The surgeon can, if time is not critical, refer to an operative surgical book and attempt to master this type of surgery. Reading the techniques from an unfamiliar operative textbook is frequently not sufficient to enable performance of the actual operation. It is the small points – the ‘‘tricks of the trade’’ – that make the difference to the ‘‘uninitiated’’: it is the heuristics, the ‘‘rule of the thumb’’ that doctors doing these procedures frequently learn through experience. We describe some of these techniques (heuristics) of the operative management of pancreatic trauma. Suspicion/detection of pancreatic injury The surgeon must be aware that most patients with pancreatic trauma will have concomitant or associated injuries that will themselves require a laparotomy. This is particularly true in cases of penetrating as well as less commonly in blunt trauma. In many cases, the patient is taken to theatre without extensive preopera- tive workup, due to haemodynamic instability or the presence of an acute abdomen. The surgeon proceeds with a long midline incision as this is the approach providing optimal exposure in pancreatic trauma. The bleeding and the ongoing contamination are controlled, and when the patient is physiologically stable, the surgeon proceeds to the next step, that is to detect the presence of a pancreatic injury. There are certain clues suggesting pancreatic injury: fluid collection in the lesser sac, bile staining of retroperitoneal tissues, presence of fat necrosis of the omentum or the retroperitoneum, or a haematoma overlying the pancreas. In penetrating trauma, the surgeon tries to follow the penetrating track for its entire length. The surgeon must remember that the most important factor in the outcome for this 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 evaluation of the injury by radiology or ERCP. Intraoperative observation is the only method to used to detect ductal damage, based on the intraoperative criteria of main pancreatic duct injury described by Heitsch et al. 1 These include, direct visualisation 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. To identify these criteria, the injured area must be fully mobilised, which is the next step that we are going to describe. Mobilisation of the pancreas In the injury to the head of the pancreas, intraoperative evaluation must determine the integrity of the MPD, the presence of a devitalised pancreatic head or duodenum, the extent of duodenal injury, the integrity of the ampulla and bile duct and whether a concomitant vascular injury is present. To achieve this, the surgeon must have good visualisation of the pancreas. In injury to the head of the pancreas the surgeon proceeds to full mobilisation of the head. The surgeon positions themselves to the patient’s left in order to get the transverse colon off the anterior aspect of the duodenum and the head of the pancreas. This is achieved by mobilising the hepatic flexure of the colon. The assistant retracts the colic flexure and the proximal colon caudally and thereby visualising the second part of the duodenum in front. By having an abdominal swab under one’s left hand and applying gentle traction to the duodenal loop the surgeon then divides with his/her scissors the peritoneal attachment along the lateral portion of the second part of the duodenum (Kocher manoeuvre) and inserts the left index finger behind the lateral duodenal ligament which attaches the second part of the duodenum to the Gerota’s fascia. The surgeon then divides this ligament over his/her index finger and continues the line of dissection towards the third portion of the duodenum till the point is reached where the superior mesenteric vein crosses the third part of the duodenum. Special attention must be paid during this manoeuvre as excessive Injury, Int. J. Care Injured 44 (2013) 153–155 A R T I C L E I N F O Article history: Accepted 23 September 2012 * Corresponding author at: Military Hospital Ulm, Department of Surgery, Oberer Eselsberg 40, 89081 Ulm, Germany. Tel.: +49 731 17101205. E-mail address: thorstenhauer@bundeswehr.org (T.J. Hauer). Contents lists available at SciVerse ScienceDirect Injury jo ur n al ho m epag e: ww w.els evier .c om /lo cat e/inju r y 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.09.020