At laparotomy you find a large oedematous mass at the back of the patient’s upper abdomen, displacing his hepatic flexure downwards to the left.
Find the triangle of peritoneal tissue which lies, with its apex pointing medially, between his colon and his duodenum. Explore any haematoma at the base of his mesocolon, or over the convexity of the second part of his duodenum.
Divide the bloodless fold of peritoneum above and lateral to the hepatic flexure of his colon. Draw this downwards and medially; if necessary, use a sponge stick.
You should now see his duodenum, except for its distal part underneath his mesenteric vessels.
If there is no injury on the front of his duodenum, move to the left side of the table. Incise the peritoneum lateral to the second part of his duodenum. Put your hand under it and under the head of his pancreas, and reflect them forwards. Look for staining with bile and blood, and dissect gently to reveal the tear. This is usually in its second or third parts.
Look carefully at the last part of the patient’s duodenum, and at his duodeno–jejunal flexure. if necessary, reflect the peritoneum off it with blunt–tipped scissors.
BRUISING OF THE DUODENUM Don’t try to suture a bruised duodenum. Instead, leave it and insert a drain.
A SMALL TEAR OF THE DUODENUM Suture this with nonabsorbable sutures as a single layer. If it is longitudinal, don’t try to sew it up transversely. Stitch omentum over the tear and drain the area for several days.
A LARGE TEAR OF THE DUODENUM If the tear is too large or too ragged to suture, there are three possibilities:
If you are skilled, you can close the hole by bringing a loop of gut up onto it, so as to make a duodeno–jejunostomy.
If you are less skilled, repair the tear, and do a gastroenterostomy.
Alternatively, drain the patient’s duodenum through a large bore Foley catheter, with two extra holes cut near its tip. Pass it down into the tear. Partly inflate the balloon, to keep it in place. Bring it out through a stab wound in his flank to provide dependent drainage. if possible, apply continuous suction. Drain the retroperitoneal area. Two weeks later deflate the balloon, and slowly withdraw it over several days. The fistula will usually dry up within a month.
If stenosis develops, the patient will need a feeding jejunostomy.
COMPLETE TRANSECTION AT THE DUODENO–JEJUNAL FLEXURE You may be able to do an end–to–end anastomosis.
If the anastomosis breaks down, it will at least convert the leak into a fistula instead of a spreading peritonitis.
DRAINS The suture line may leak, so always insert a drain through a separate stab wound in the patient’s right flank.
POSTOPERATIVE CARE For all lesions do a feeding jejunostomy (9.6a), except when you have already done a gastroenterostomy. You will have to feed the patient through his injured duodenum. The ileus that follows duodenal lesions can last for several weeks.
