Management of Pancreatic Injuries
Annotation for Point E
It is critical that thorough exploration and examination of the pancreas and duodenum are performed during LAP, particularly when there is a retroperitoneal hematoma, bile staining, fat necrosis, or edema in the supramesocolic region. Intraoperative evaluation of the duodenum and head of the pancreas begins with full mobilization achieved by the Kocher maneuver to the midline with coincident mobilization and medial rotation of the hepatic flexure of the colon. This provides exposure of the anterior and posterior surfaces of the second and third portions of the duodenum as well as the head and uncinate process of the pancreas. The body and tail of the pancreas are examined by a division of the gastrocolic ligament and reflection of the stomach cephalad. Insertion of a curved retractor in the lesser sac allows full inspection of the anterior surface of the pancreas from the head to tail and from superior to inferior surfaces. In cases of extensive hemorrhage in the region of the neck of the pancreas suspected to originate from the juncture of the portal vein behind the pancreas, the pancreas should be divided without hesitation. A stapling device will allow for rapid exposure of the injured vessel and hemorrhage control of the pancreas. Further exposure of the posterior surface of the pancreas is accomplished by division of the retroperitoneal attachments along the inferior border of the pancreas and retraction of the pancreas cephalad. Additional mobilization of the spleen and reflection of the spleen and tail of the pancreas from the left to the midline is a useful technique for further evaluation of the remaining areas of the pancreas. Most injuries sustained in penetrating trauma will be discovered with direct exploration.