A Technic of Exposure for Diverticula of the Third and Fourth Parts of the Duodenum

Abstract

The technics of exposure utilized in the operative treatment of diverticula of the third and fourth parts of the duodenum have apparently changed little since the publication of the classic case reports of Forssell and Key (I9I5), Basch (I917) and Maclean (I927). Access to the duodenum has ordinarily been sought through the transverse mesocolon or through the gastro-colic omentum and the lesser omental sac. Diverticula occurring in anterior locations have then generally been dealt with by simple dissection, but procedures which have led to duodenal mobilization or elevation of the pancreas have almost invariably been used in the search for diverticula not at once exposed to view.The mobilization of the duodenum in the latter instances has been achieved by recourse to a method commonly attributed to Kocher. Here the duodenal segments are reflected medially and thus restored to the position in which they lie before rotation during embryonic life. Additional technics of mobilization which have also been suggested are not known to have been used in the treatment of these lesions. A medial approach had been proposed by Clairmont and Schinz (I920), but in the review by Morton (I940) this procedure was considered difficult and ill-advised. A method used by Vautrin and Fourche (I923) for other lesions in the region of the proximal duodenum was thought suitable for diverticula of the distal segments by Kellogg and Kellogg (I93I).A portion of the transverse colon was turned down in this procedure, and the duodenum was reflected with the pancreas medially. Subsequent reference to these methods has been limited because the surgical treatment of diverticula has not often been advised.We wish to call attention at this time to a technic of duodenal mobilization which we have not found emphasized in any previous report. TECHNICThe duodenum is exposed by turning the transverse colon, mesocolon and great omentum upwards. An incision is begun in the posterior layer of the parietal peritoneum, just below and parallel to the inferior duodenal edge, and from this point it is extended, medially and laterally, until it underlies the third and fourth parts of the duodenum. The superior mesenteric vessels are retracted towards the patient's right, and by means of sharp dissection which