Kocher manoeuvre

1. Indications

• Exposure of the posterior wall of the first and second parts of the duodenum
• Exploration of the retroduodenal and intrapancreatic common bile duct (CBD)
• Pancreatic head surgery → pancreaticoduodenectomy (Whipple), assessment of the head
• Bleeding posterior duodenal ulcer → laxity for duodenotomy closure
• Pyloroplasty (Heineke–Mikulicz, Finney) and Jaboulay gastroduodenostomy
• Tension-free Billroth I anastomosis
• Duodenal trauma → inspection of the posterior wall
• Exposure of the inferior vena cava (IVC) and right renal vein → portacaval shunt, right adrenalectomy

2. Contraindications

• No absolute contraindications
• Dense retroperitoneal inflammation or tumour fixed to the IVC → plane unsafe

3. Preparation and positioning

• General anaesthesia with endotracheal intubation
• Supine
• Upper midline or right subcostal incision; laparoscopic approach possible
• Surgeon on the patient's right
• Hepatic flexure retracted downward and medially

4. Steps

1. Identify the middle colic vessels over the second part of the duodenum
2. Incise the parietal peritoneum lateral to the second part, from the epiploic foramen downward
3. Grasp the duodenum in the left hand and reflect it medially
4. Sweep the peritoneum off the duodenum by blunt dissection
5. Develop the avascular plane behind the duodenum and pancreatic head
6. Divide the white avascular bands between the second and third parts and the posterior wall
7. Continue medially until the IVC and aorta are exposed
8. Palpate the pancreatic head and distal CBD between finger and thumb

Extensions

1. Cattell manoeuvre → right colon reflected medially; line of fusion of the small bowel mesentery incised → third part exposed proximal to the superior mesenteric vessels
2. Cattell–Braasch manoeuvre → Cattell plus Kocher extended below the paraduodenal fossa → whole duodenum exposed
3. Division of the ligament of Treitz → further mobilisation of the fourth part

5. Layers encountered

1. Parietal peritoneum lateral to the second part of the duodenum
2. Loose areolar fusion plane behind the duodenum and pancreatic head
3. IVC
4. Right gonadal vein and right renal vein
5. Left renal vein and aorta

6. Complications

• Injury to the middle colic vein → when the manoeuvre is extended along the third part
• Bleeding from the communicating vein between the right gastroepiploic and middle colic veins
• IVC, right gonadal or right renal vein injury
• Inferior mesenteric vein (IMV) injury → when incising the peritoneum at the duodenojejunal flexure
• Injury to the duodenal wall or pancreatic head