The surgical manoeuvres described above are based on precise anatomical and embryologic grounds, allowing the dissection

to proceed along specific ontogenetic planes with full respect of all organs and tissues.

Duodeno-pancreatic mobilization As decribed by Lane and Kocher the head of pancreas and duodenum are mobilized from the posterior plane of IVC. The right flexure of the colon is mobilized, the peritoneum is divided along the right margin of the duodenum up to lower margin of Winslows foramen; the pre-duodenal laminae of Fruchaud, fixing the first part of the duodenum to the posterior abdominal wall, are divided. In this way the plane between retropancreatic fascia (Treitz) and Gerotas fascia is exposed. Kochers manoeuvre can be extended to the midline to fully expose the IVC, the renal veins, the aorta and the SMA (supramesocolic access according to Borelly). The duodenal loop and the head of pancreas turned over medially and to the left show their posterior surface allowing full access to the retropancreatic and choledocal LN, in the so called Qunu quadrilateral (Wiart and Vautrin manoeuvre).

De-rotation of the intestine This manoeuvre was independently developed by such great surgeons as Cattell, Braasch, Valdoni and Couinaud in the 1950s, based on the anatomical and embryological studies of Toldt, Treitz, Gerota and Fredet carried out at the beginning of the century. Cattell-Braaschs and Valdonis techniques are virtually identical and consist in the derotation of the common mesentery or middle intestine or umbilical loop.

CATTEL-VALDONI MANOEUVRE MOBILIZATION OF ASCENDING COLON

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The manoeuvre includes the following steps: 1. mobilization of ascending colon along Toldts fascia. The right ureter and gonadal vessels are in this way separated from the mesocolic plane. 2. the secondary root of the mesentery is separated from the posterior abdominal wall up to the third part of duodenum, just below the superior mesenteric vessels. 3. mobilization of hepatic flexure and right half of transverse colon along the planes of preduodeno-pancreatic fascia of Fredet and supramesocolic omental fascia: this step exposes the anterior surface of pancreas and second part of duodenum. 4. duodeno-pancreatic mobilization (Kochers or Wiarts manoeuvres). 5. separation of greater omentum from transverse colon and mesocolon. After separation of the transverse colon the dissection can proceed in two ways: either by dividing the posterior lamina of greater omentum to enter the lesser sac, or continuing the dissection within the supramesocolic fascia of posterior lamina of greater omentum. 6. the fourth part of duodenum and duodenojejunal junction are mobilized by dividing the muscle of Treitz. Attention should be paid to the SMV and vascular arch of Treitz. 7. de-rotation according to Valdoni: all the intestine loops, corresponding to the primitive umbilical loop, are freed from their developmental adhesions to the posterior peritoneum and hang from its vascular peduncle. To derotate, the bowel loops must be turned clockwise and moved to the right, remaining below the SMA. In so doing the second, third and fourth parts of duodenum and first jejunal loop will sit in a para-medial sagittal line to the right of superior mesenteric vessels. The remaining small bowel loops will go to the right, while the right and transverse colon will move to the left. As a consequence the SMA will move to the right of SMV.

CATTELL-VALDONI MANOEUVRE MESENTERIC ROOT DIVIDED

Bile duct

Renal a. Renal v.

Inferior vena cava Ureter Gonadal vein

CATTELL-VALDONI MANOEUVRE KOCHERS MANOEUVRE

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Laparoscopic Gastric Surgery - Hscher Surgical Anatomy - F. Ruotolo, A. Mereu, C. Ponzano, A. Recher, G. Sgarzini, G. Todde and C. G. S. Hscher

Huschkes fold

Couinauds technique (mobilization of the pancratico-umbilical loop) adds the mobilization of spleen and body-tail of pancreas along the plane of mesogastric fascia to the de-rotation of the middle and posterior intestine and therefore realizes the complete de-rotation of the GI tract which is brought back to its primitive midline location with a dorsal mesentery, as in the first few weeks of embryonic development.

CATTELL-VALDONI MANOEUVRE OMENTAL BURSA OPENED

Spleno-pancreatic mobilization according to Jinnai The mobilization of the spleno-pancreatic complex includes initially the opening of the lesser sac by separation of the greater omentum from transverse colon and mesocolon; the splenic flexure is mobilized by dividing the phreno-colic ligament (sustentaculum lienis) and spleno-colic ligament (Tillauxs ligament); the greater curvature is mobilized by dividing the gastro-splenic ligament. The posterior peritoneum is divided along the inferior margin of body and tail of the pancreas, corresponding to the insertion of the root of transverse mesocolon to the inferior margin of the pancreas. This section starts at the left border of SMV and continues leftwards along the inferior margin of the pancreas and the posterior margin of the spleen, from lower to upper pole. The dissection proceeds by dividing the posterior leaflet of spleno-pancreatic ligament and separating the spleno-pancreatic complex along the plane between the mesogastric fascia investing the pancreatic vessels and posterior abdominal wall. The mobilization continues medially to the confluence of the splenic vein and SMV. The spleno-pancreatic complex is exteriorized allowing the dissection of the splenic artery and the splenic hilar LN with conservation of the spleen. Jinnais manoeuvre and splenic LN dissection are, at the present state too difficult to be done laparoscopically. Maruyamas, pancreas preserving technique is to be preferred: the middle and distal parts of the splenic artery, with its dense network of peri-pancreatic lymphatics are removed with the spleen, resulting in an oncologically satisfactory lymphadenectomy.

CATTELL-VALDONI MANOEUVRE TREITZ MUSCLE DIVIDED

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Laparoscopic Gastric Surgery - Hscher Surgical Anatomy - F. Ruotolo, A. Mereu, C. Ponzano, A. Recher, G. Sgarzini, G. Todde and C. G. S. Hscher

Access to the lesser sac and to mesogastric retroperitoneum Separation of the greater omentum from the transverse colon and mesocolon is the most respectful of embryonic development. The dissection proceeds in the plane of the mesogastric fascia first below, then behind and finally above the pancreas up to the adherent part of gastric fundus. In such a way it is possible to dissect and remove the whole of the mesogastric tissue.

CATTELL-VALDONI MANOEUVRE SMALL BOWEL ROTATED COUNTER-CLOCKWISE

Mattox manoeuvre (left sided) This was developed to expose the suprarenal aorta but can be used to dissect the lymphatic station 16a. All abdominal viscera including the left kidney are mobilized and moved to the right resulting in excellent exposure of the aorta, CA, SMA and renal arteries. A similar access was described by Benjamin-Jackson to expose extraperitoneally the CA and SMA.

CATTELL-VALDONI MANOEUVRE DUODENO-JEJUNAL LOOP DE-ROTATED

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GASTRO-SPLENIC LIGAMENT DIVIDED

CATTELL-VALDONI MANOEUVRE VIEW OF RETROPERITONEUM AFTER DE-ROTATION

POSTERIOR SPLENIC PERITONEAL ATTACHMENTS DIVIDED

ROOT OF TRANSVERSE MESOCOLON DIVIDED FROM INFERIOR BORDER OF PANCREAS

Oesophagus

JINNAIS MANOEUVRE

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SPLENIC ARTERY AND VEIN DIVIDED

PANCREAS DIVIDED AT ISTHMUS

CA SMA

Left renal vein

MATTOX MANOEUVRE

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Laparoscopic Gastric Surgery - Hscher Surgical Anatomy - F. Ruotolo, A. Mereu, C. Ponzano, A. Recher, G. Sgarzini, G. Todde and C. G. S. Hscher