What are the steps of Kocherisation (mobilization of the duodenum and the head of the pancreas) and extended Kocherisation in a patient undergoing abdominal surgery, such as cholecystectomy (gallbladder removal)?

Kocherisation and Extended Kocherisation: Surgical Steps

Kocherisation is a fundamental surgical maneuver that mobilizes the duodenum and pancreatic head by incising the lateral peritoneal reflection of the duodenum and dissecting the retroperitoneal attachments, while extended Kocherisation continues this dissection medially to expose the inferior vena cava and aorta. 1

Standard Kocherisation Technique

Initial Steps

• Incise the lateral peritoneal reflection along the right border of the second portion of the duodenum, extending from the hepatic flexure superiorly to the third portion of the duodenum inferiorly 1, 2
• Mobilize the hepatic flexure of the colon downward to provide adequate exposure of the duodenum 2
• Dissect the retroperitoneal attachments between the duodenum and the underlying retroperitoneal structures using blunt and sharp dissection 1

Key Anatomical Landmarks

• Identify and preserve the right ureter and gonadal vessels posteriorly during the dissection 1
• Expose the anterior surface of the inferior vena cava (IVC) as the medial limit of standard Kocherisation 1, 3
• Mobilize the duodenum medially to allow palpation of the pancreatic head and visualization of structures posterior to the duodenum 1

Extent of Mobilization

• Standard Kocherisation provides adequate exposure of the first, second, and third portions of the duodenum and the head of the pancreas 2
• This maneuver allows complete mobilization of the portal and superior mesenteric veins from the uncinate process, which is essential for pancreatic head resections 4

Extended Kocherisation Technique

Additional Dissection Steps

• Continue the medial dissection beyond the IVC to expose the aorta and the origin of the superior mesenteric artery 1
• Dissect the retroperitoneal tissue between the IVC and aorta to achieve maximal mobilization 1
• Skeletonize the lateral, posterior, and anterior borders of the superior mesenteric artery to maximize uncinate process exposure and radial margin clearance 4

Specific Indications

• Extended Kocherisation is particularly useful for pancreatic head tumors requiring assessment of superior mesenteric artery involvement 4
• This technique facilitates evaluation of vascular involvement (portal vein, superior mesenteric vein, and superior mesenteric artery) during pancreatic resections 4
• It provides access for radical lymphadenectomy around the origins of the celiac and superior mesenteric arteries, though this is not routinely recommended 5

Alternative Approaches

Inframesocolic Approach

• Dissect the fusion between the duodenum and transverse mesocolon from below, termed "semi-Kocherisation" 6
• This approach provides ready access to the second and third segments of the duodenum through virgin territory with advantages in exposure and operative time, particularly useful in reoperative surgery 7, 2
• Open the transverse mesocolon and mobilize the duodenum through this opening 6

Left-Sided Approach (Modern Minimally Invasive Technique)

• Flip the transverse mesocolon upward and excise the anterior side of the mesojejunum to expose the first jejunal artery 3
• Expose the left sides of the superior mesenteric artery and Treitz ligament, then dissect the Treitz ligament completely 3
• Proceed with dissection along the anterior wall of the IVC to complete mobilization of the pancreas head from the left side 3

Critical Caveats

Common Pitfalls

• Inadequate dissection of the uncinate process can lead to positive margins and decreased survival in oncologic resections 4
• Failure to identify vascular involvement during extended Kocherisation can result in incomplete resection 4
• Injury to the right ureter or gonadal vessels can occur if posterior dissection is not performed carefully 1

Safety Considerations

• Avoid excessive traction on the duodenum to prevent injury to the pancreatic head or duodenal wall 1
• Identify and preserve the gastroduodenal artery during dissection around the pancreatic head 4
• In trauma settings, damage control surgery should be strongly considered rather than definitive reconstruction if the patient is physiologically deranged 5