In both civilian and wartime trauma, pancreatic and duodenal injuries are fortunately relatively uncommon, presumably due to their protected retroperitoneal locations. In both civilian and wartime trauma, pancreaticoduodenal injuries are most often the result of penetrating trauma . The majority of pancreatic penetrating injuries are associated with major vascular injury. In general, the patient with penetrating abdominal trauma and pancreaticoduodenal injuries will have nonspecific indications for trauma laparotomy (shock, peritonitis, positive FAST , or diagnostic peritoneal lavage (DPL ), etc.). If it is not initially obvious upon entering the abdomen, the only diagnostic study required to identify these injuries is a complete, thorough trauma laparotomy exploration; subtle bile staining may be the only initial clue that there is a pancreaticoduodenal injury. Free bleeding and/or bile or enteric contamination into the peritoneal cavity from the right upper quadrant may herald the diagnosis. You may see an ominous right upper abdominal hematoma in the region of the pancreas, which heralds not only pancreaticoduodenal trauma but the possibility of one or more large blood vessel injuries. Moreover, you may see a combination of free bleeding and contained expanding or non-expanding hematoma.

With the advent of body-armor and heavily armored mine-resistant ambush protected (MRAP ) vehicles decreasing the amount of penetrating trauma cases, you may also see patients with pancreatic and/or duodenal injuries from blunt trauma to the abdomen in the wartime environment. Patients with a history of blunt or blast trauma with direct trauma to the upper abdomen, especially with an associated lumbar spine fracture, are at risk for these notoriously hidden but deadly pancreaticoduodenal injuries. Identification of such injuries in this setting requires a high index of suspicion. These patients can be very difficult to assess as they may have no obvious indication for urgent trauma laparotomy, especially in the far-forward setting without a CT scanner and robust lab capabilities. These patients can be very challenging to diagnose even in the civilian setting, despite robust capabilities (endoscopic retrograde cholangiopancreatography (ERCP ), CT scans, etc.), because even these sophisticated capabilities are not sensitive enough in a significant percent of cases. Serial amylase measurements are of limited value in the civilian setting to diagnose pancreatic injuries and you should not even think of using them in the deployed setting. In addition to simply not being available, not being particularly sensitive or specific, it is challenging to track serial measurements across echelons of care.

In the far-forward setting, you are limited in your evaluation of blunt trauma to your understanding of the mechanism of injury, vital signs, physical exam, FAST , DPL , urine output, and/or rudimentary labs. While a focused abdominal sonogram for trauma (FAST) is not sensitive, it may provide evidence for free intraperitoneal fluid. In the hemodynamically stable patient, especially for whom an abdominal exam is not obtainable or reliable due to sedation or central nervous system injury, a diagnostic peritoneal lavage (DPL) remains an important tool in the far-forward setting. Even in the face of a negative or equivocal FAST, DPL may reveal subtle bile staining or other indication of injury. In the absence of these nonspecific indications for trauma laparotomy, the combination of mechanism of injury and high index of suspicion should allow you to focus on a select group of patients for closer observation.

In general, you should have a low threshold to consider an exploratory laparotomy on wounded patients in the deployed setting. A positive FAST exam in an injured patient in the deployed setting equals a trip to the operating room for a trauma laparotomy, no matter what the mechanism of injury was (e.g., blunt) or the hemodynamic stability of the patient. Although the civilian literature is replete with the nonoperative management of selected pancreatic and other solid organ injuries, there is, in general, limited role for the nonoperative management of trauma in the wartime setting, as we simply do not have the advanced adjunctive tools, resources, personnel, or continuity of care in our echelon of care, severely resource-limited environment.

If your evacuation times are short (e.g., around 30 min), carefully selected, hemodynamically stable patients who sustained blunt trauma with negative FAST exams and no clear indication for trauma laparotomy but for whom you maintain a concern for pancreaticoduodenal and other intra-abdominal injuries can be evacuated to higher echelons of care where CT scanner capability can be used for further assessment. This plan obviously requires a functioning CT scanner and qualified CT scan interpreter (e.g., radiologist) to exist at the next echelon. However, if the transport time is long, and/or requires at least one additional stop to transfer to another helicopter (“tail to tail”), or the conditions (weather and/or combat) are poor for transport, your continued observation may result in a less favorable situation for the patient if they have an undrained pancreatic and/or duodenal injury. The tissue damage from an untreated leak may significantly limit options for the patient. So if your clinical evaluation is suspicious, especially if the patients has any evidence of a worsening clinical picture overall, the patient may be better served with an exploration to preserve future options. The trauma laparotomy is the deployed wartime surgeon’s CT scan.

You must understand the anatomy of the complex right upper quadrant to be able to control both hemorrhage and contamination. The heat of battle in the operating room is not the time to brush up on your anatomy. You must also have an understanding of how to manage multifocal bleeding. For example, if you see free bleeding into the peritoneal cavity, control that first before you unroof or explore any retroperitoneal hematoma . Do not explore a retroperitoneal hematoma without ensuring that you and your team are ready to provide rapid blood replacement for the patient. Use a combination of packing, manual pressure, judicious clamping, hemostatic sutures, and the Kocher and the Cattell-Braasch maneuvers to control bleeding in the right upper quadrant. If the patient is in extremis and/or you cannot control the bleeding, ligating the portal vein is a bailout option.

The head of the pancreas and duodenum sit on top of the inferior vena cava and right renal vessels. The proximal portion of the duodenum is anterior to the neck of the pancreas; the neck of the pancreas sits right on top of the confluence of the superior mesenteric vein, splenic vein, and inferior mesenteric vein as they become the portal vein after the confluence joins and heads cephalad. Bleeding in these locations is not controllable until you open up the correct surgical planes. To at least initially control superficial head of pancreas bleeding and control of portal-mesenteric vein bleeding with manual pressure, you must perform a wide Kocher maneuver . This maneuver will lift the head of the pancreas complex out from being on top of the vena cava, and you will be able to squeeze the head of the pancreas from above and below in between your fingers and thumb.

While taking out an anatomy atlas can be useful in the deployed setting when encountering injuries in locations you do not normally operate, it is best if you have done this review well in advance, ideally on your typically long trip to get to your deployment location. However, taking out an atlas while trying to control multifocal large blood vessel bleeding in the right upper quadrant is a clear recipe for failure. Review the anatomy now. You should know the basic maneuvers to expose the pancreas and the critical surgical anatomy of the pancreas and duodenum (Fig. 9.1). This is an area that is often relatively unfamiliar to general surgeons, so spend some time reviewing it and mentally rehearsing maneuvers before you deploy.

The Kocher maneuver is the most important maneuver to both explore the head of the pancreas and duodenum for trauma as well as help control bleeding from the pancreaticoduodenal arcade, portal and mesenteric veins, and superior mesenteric artery. Extension of the Kocher maneuver into the Cattell-Braasch maneuver with a right medial visceral rotation allows you to address vena cava injuries as well.

While many argue that exposure of the head of the pancreas and the second/third portion of the duodenum should be done by first mobilizing the hepatic flexure of the colon inferiorly and medially (Fig. 9.2a), it is preferable to attack with a Kocher maneuver first and lift the second portion of the duodenum out of the retroperitoneum (see Fig. 9.2a) and divide the posterolateral attachments of the duodenal C-loop as you retract it anteriorly and medially. If you simply continue to pull the distal duodenum toward the patient’s right, you can expose the infra-pancreatic superior mesenteric vein without mobilizing the colon. Be mindful that the C-loop of the duodenum is sitting right on top of the vena cava as you begin this maneuver. Slide your hand behind the head of the pancreas and bluntly mobilize and palpate it to assess for injury, if it is not obvious after mobilizing it. With this extended Kocher maneuver, you should be able to lift the head of the pancreas and duodenum out of the retroperitoneum. Starting with this Kocher maneuver first is especially important if you have brisk bleeding or a retroperitoneal hematoma in this location, as it will help you gain control with manual pressure.

If a Cattell-Braasch maneuver with right medial visceral rotation is required, either for visualization or to control deeper bleeding from the vena cava and/or renal pedicle, you should sharply open the white line of Toldt along the ascending colon and continue this around the flexure, retracting the colon inferiorly and the gallbladder superiorly. Once that first layer is opened, the rest can usually be rapidly done with blunt finger dissection and bovie. If you have not already performed an extended Kocher maneuver , you can follow the colon mesentery to the base and this will lead directly to the C-loop of the duodenum. Once the right colon is mobilized, you have exposed the anterior surface of the duodenum and pancreatic head. Some argue that if this appears completely normal, no further mobilization is required. In combat trauma, it is preferable to have complete visualization and mobilization, so if you have not already performed a Kocher maneuver, rapidly but carefully divide the posterolateral attachments of the duodenal C-loop as you retract it anteriorly and medially, as previously described above. Exposure of the body of the pancreas is easily obtained by opening the gastrocolic ligament and retracting the stomach superiorly and anteriorly (see Fig. 9.2b). You can also visualize most of the tail of the pancreas through this window in the lesser sac. To fully mobilize the tail and splenic hilar vessels, the lateral attachments of the spleen are divided, and the spleen and pancreas are mobilized to the midline together (see Fig. 9.2c). Further exposure of the posterior pancreas and the fourth portion of the duodenum can be obtained by opening the retroperitoneum along the inferior border of the pancreas and dividing the ligament of Treitz.