PMC4275811_01
Drawing of the modified retrograde decompressing tube duodenostomy performed as last step of the procedure. Approximately 15 cm distal to the ligament of Treitz, the antimesenteric border of the proximal jejunum was brought to the upper left lateral parietal peritoneum. A seromuscular triangular pursestring suture was then placed in the selected site of the proximal jejunum and the rubber tube was entered retrograde into the duodenal lumen via a small enterotomy in the center of the pursestring. Before passing the catheter into the duodenal lumen, multiple side holes were added to the intraluminal portion of the catheter to ensure effectual function. The pursestring was tied around the tube and the rubber tube was externalized through a tunnel in the left lateral abdominal wall. The pursestring suture was finally continued as a continuous circumferential stich approximating the bowel wall and the parietal peritoneum, extraperitonealizing the entry site of the catheter into the bowel lumen. In order to avoid proximal jejunum volvulus its part immediately aborally to the duodenostomy, was sutured for a length of 5 cm to the left lateral parietal peritoneum.
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Multidetector CT scan depicted efferent and afferent limp obstruction and findings suggestive of a DDS (Fig. 1a-d).
(a) Multidetector CT scan shows excessive dilatation of the afferent and efferent limps to the jejunojejunal anastomosis. The afferent limp is opacified by oral contrast while the jejuno-jejunal anastomosis was intact with no leak of positive oral contrast. (b) Multidetector CT scan depicting a right subhepatic fluid collection surrounding the duodenal stamp's staple line infiltrated with air densities (white arrow) suggestive of a DDS. (c) The right subhepatic fluid collection surrounding the DS staple line (black arrow) corresponding to the extravasated oral contrast which is extruding (white arrow) through a small dehiscence in the upper pole of the upper midline surgical wound. (d) The dilated efferent loop is depicted to have a transition point to collapsed jejunum at approximately the level of jejunoileal junction.
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Copious and challenging dissection in a field of dense adhesions between the Roux limp, transverse colon-mesocolon, visceral surface of the liver, gallblader and hepatoduodenal ligament enabled identification of a completely blown duodenal stump (Fig. 2).
Copious and challenging dissection in a field of dense adhesions between the Roux limp, transverse colon-mesocolon, visceral surface of the liver, gallblader and hepatoduodenal ligament enabled identification of a completely blown duodenal stump.
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An extended Lane-Kocher maneuver was performed followed by meticulous detachment of the remaining first and proximal second part of the duodenum from the pancreatic head by ligating small vessels and "fibrous" connections (Fig. 3).