General Abdomen: Maneuvers & Retroperitoneal Exposure

Mattox Maneuver

• “Left-Sided Medial Visceral Rotation” Mn
• Procedure:
  • Mobilize Descending Colon at White Line of Toldt
  • Extend Incision Lateral Around the Spleen
  • Using Hand Sweep from Below-Up and Medial
    • Dissection Plane Directly on the Posterior Abdominal Wall
  • Rotate All Structures to the Midline
• Visualize:
  • Entire Abdominal Aorta
  • Proximal Celiac Axis & SMA
  • Left Renal Artery
  • Limits IVC Exposure
• Risk: Splenic Injury or Avulsion of Left Descending Lumbar Vein off Renal Vein

Inframesocolic Division

• Used in Vascular Surgery as the Preferred Operative Approach for a Transperitoneal Open AAA Repair
• Procedure:
  • Reflect Transverse Mesocolon Cephalad
  • Eviscerate Small Bowel to Right
  • Incise Retroperitoneum Along Midline
    • From Ligament of Treitz, Left of Aorta
    • Extend Caudally to the Right of the Aorta
• Visualize:
  • Inframesocolic Aorta
    • More Targeted/Limited Than Mattox if Supramesocolic Access is Unnecessary
• Pitfalls:
  • IMV Injury with Initial Cut
  • IMA/Sigmoid Mesentery Injury

Kocher Maneuver

• Procedure:
  • Incise Posterolateral Peritoneal Attachments of Duodenum
  • Place Hand Behind Duodenum/Pancreatic Head and Retract Medially
• Visualize:
  • Duodenum (D1, D2, Proximal D3) & Pancreas
  • Suprarenal IVC
  • Right Renal Hilum
• Risk: Right Gonadal Vein Injury

Cattel-Braasch Maneuver

• “Right-Sided Medial Visceral Rotation” Mn
• 3-Stages:
  • 1. Kocher Maneuver
  • 2. “Extended” Kocher Maneuver
    • Extend Incision Caudally to the White Line of Toldt
    • Fully Mobilize the Ascending Colon
  • 3. “Super-Extended” Kocher Maneuver
    • Extend Incision Around the Cecum
    • Retract Bowel to the Right and Superiorly
    • Incise the Mesentery Attachment to the Posterior Peritoneum from the Medial Cecum to the Ligament of Treitz
• Visualize:
  • Panoramic View of Entire Inframesocolic Retroperitoneum
  • Includes Distal D3 & D4
• Risk: SMV Injury
  • Right Colon Hangs by Mesentery Alone
  • An Inadvertent Pull Will Avulse Right Colic Vein off SMV

Pringle Maneuver

• Compression of Portal Triad Mn
• Stops Hepatic Inflow (Artery & Portal Vein)
• Does Not Stop Backflow from Hepatic Vein Bleed