Retroperitoneal air:
- represents a duodenal injury until proven otherwise
- repeat the CT with a po contrast agent
Examining the pancreas:
- Mobilize the duodenum and pancreas:
- Kocher, take down lig of Trietz
- open lesser sac
- incise the peritoneum above and below the pancreas
- you must get to the posterior surface of the pancereas
- classic missed injury is a posterior disruption of the pancreas where the anterior surface looks normal but if you slip your finger behind the pancreas is fractured where it lies over the spine.
Duodenal Injuries:
- EEM closes the duodenum with a 1 layer continuous suture
- duodenal injuries: most can close primarily unless the ampulla is involved
- if there is extensive blowout of the duodenum options include bringing up a R-en-Y limb and plugging it into the blowout
- ? duodenal diverticulization
- Wide drainage is an option with pyloric exclusion
- should not need to do a Whipple's for duodenal injuries
Pancreatic Injuries:
- Stents in neck of pancreatic duct; better than performing a 90% pancreatectomy with risk of leak
- if do distal pancreatectomy should be able to leave the spleen
- if need to can take splenic artery, just be sure you leave the short gastrics as you are opening the lesser sac
- can also perform intraoperative ERCP - even after having done Kocher - just clamp bowel @ LT and help guide scope down
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