Laparoscopic hepatic flexure mobilisation

Abstract

Ann R Coll Surg Engl 2012; 94: 359-372Many lower extremity, pelvic and acetabular fractures require traction as first aid management prior to definitive fixation. While skin traction and Thomas splints are generally available, weights to provide countertraction are often missing or in parts of the hospital remote to the emergency department. A sharps bin (Sharpsguard ® orange 11.5; Daniels, Oxford, UK) filled two-thirds with tap water and tied via its bucket handle to skin traction (Fig 1) provides approx 8kg of traction. This can effect reduction and temporary traction until weights are available. We describe a simple method to help identify the correct plane for hepatic flexure mobilisation while simultaneously protecting the duodenum during a laparoscopic right hemicolectomy. The placement of a swab or nasal pack on top of the duodenum after medial to lateral dissection below the ileocolic pedicle and right mesocolon (Fig 1) allows clear identification of the hepatic flexure from above. This can then be divided safely with the Harmonic ® scalpel (Ethicon EndoSurgery, Cincinnati, OH, US) protecting the duodenum from thermal injury (Fig 2).