Step-by-Step Process of Kocherization
Kocherization is a surgical maneuver that involves mobilization of the duodenum and head of the pancreas by incising the lateral peritoneal attachments to expose these structures for surgical access. This technique is essential for procedures involving the duodenum, pancreas, and related structures 1.
Anatomical Basis
- Kocherization takes advantage of the embryological development of the duodenum and pancreas, which allows for mobilization of these structures by dividing their peritoneal attachments 1
- The duodenum is partially retroperitoneal, with the second and third portions fixed to the posterior abdominal wall, requiring careful dissection to mobilize 2
Equipment Required
- Standard laparotomy or laparoscopic instruments including:
- Electrocautery device
- Tissue forceps
- Scissors
- Retractors
- Gauze for blunt dissection 3
Step-by-Step Procedure
1. Patient Positioning and Access
- Position patient supine with arms extended (for open surgery) or in modified lithotomy position (for laparoscopic approach) 2
- For open surgery, perform a midline incision or right subcostal incision 1
- For laparoscopic approach, establish appropriate port placements 3
2. Initial Exposure
- Retract the liver superiorly to expose the porta hepatis and duodenum 2
- Identify key landmarks: gallbladder, porta hepatis, first portion of duodenum, and hepatic flexure of colon 1
3. Peritoneal Incision
- Make an incision in the lateral peritoneal reflection along the right side of the duodenum, extending from the foramen of Winslow superiorly to the inferior border of the third portion of the duodenum 1
- The incision should be made in the avascular plane, staying close to the duodenum to avoid injury to retroperitoneal structures 3
4. Mobilization of the Duodenum
- Using a combination of sharp and blunt dissection, carefully separate the duodenum and head of the pancreas from their posterior attachments 2
- Place gauze between the fingers for blunt dissection to create a plane between the duodenum and retroperitoneal structures 3
- Continue dissection medially, identifying and preserving important structures including the inferior vena cava and right kidney 1
5. Extended Mobilization
- For complete Kocherization, continue the dissection medially until the left lateral border of the aorta is visualized 2
- The dissection can be extended inferiorly to include the third and fourth portions of the duodenum if needed for the specific procedure 4
- In some cases, a "semi-Kocherization" may be performed, which involves limited mobilization sufficient to perform the intended procedure 3
6. Identification and Preservation of Key Structures
- Throughout the dissection, identify and preserve:
7. Completion and Verification
- Once mobilized, the duodenum and pancreatic head can be rotated medially to expose the retroperitoneal structures 4
- Verify hemostasis throughout the dissected area 2
- For specific procedures like duodenojejunostomy, the mobilized duodenum can now be brought into position for anastomosis 3
Alternative Approaches
- For tumors in the second and third portions of the duodenum, a transmesocolic approach may be considered as an alternative to extensive Kocherization 2
- A modified "reversed Kocherization" can be performed in conjunction with intestinal derotation for pancreaticoduodenectomy to facilitate mesopancreas excision 4
- An inframesocolic approach provides direct access to the second and third segments of the duodenum without requiring complete Kocherization, which can be advantageous in minimally invasive procedures 5
Common Pitfalls and Considerations
- Excessive traction during dissection can lead to duodenal tears or injury to retroperitoneal structures 1
- Bleeding from small vessels in the retroperitoneum should be controlled with careful electrocautery 2
- Incomplete mobilization may not provide adequate exposure for the intended procedure 3
- Care must be taken to avoid injury to the common bile duct and portal structures at the superior aspect of the dissection 4