Prevention of Aortoduodenal Fistula by Duodenal Reflection
Don FL Miller, AB, MD, Irvine, California
Although the incidence of aortoduodenal fistula after vascular grafting of the abdominal aorta is small, the associated mortality from this complication is uniformly high. Although there is some controversy over the exact etiologic factors involved, the intimate contact of the duodenum with the graft or, more commonly, with the anastomosis of the aorta and the graft is consistently present. The constant pulsatile irritation of the ridge of the suture line or graft material may eventually erode the duodenum. Some surgeons advocate placing an additional cuff of graft material or tissue between the anastomosis and the duodenum to prevent contact between the two. By simply moving the duodenum away from the graft, contact is avoided and the potential for fistulization is reduced. Technique
The third portion of the duodenum normally crosses the aorta, ascends on the left side of the aorta, and turns sharply at the level of the second lumbar vertebra, where it is fixed by the ligament of Treitz which is continuous with the left leaf of the mesentery. This normal relation is frequently displaced by large aortic aneurysms. The incision in the base of the left leaf of the mesentery, which is usually used to expose the subrenal aorta, skirts the left side of the duodenum, which is then reflected to the right From the Department of Surgery, University of California, Irvine. College of Medicine, Irvine, California. Reprint requests should be addressed to Don R. Miller, MD, Department of Surgery, University of California, Irvine, Irvine, California 92717.
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(Figure 1). This is comparable to kocherization of the second portion of the duodenum. The completed proximal aorta to graft anastomosis will of necessity underly the third and fourth portions of the duodenum and will be in intimate contact with the posterior duodenal wall when the mesentery is reperitonealized by the conventional method (Figure 2). Interposing additional tissue between the anastomosis and the duodenum may increase the tension under which the duodenum is drawn toward the pulsating ridge of the suture line by reperitonealization. Reports on aortic grafting fail to stress that the duodenum need not be returned to its original retroperitoneal position in contact with the aorta but may be left intraperitoneally, displaced to the right with some distance between it and the graft (Figure 3). There are usually sufficient remnants of the layers of the aneurysmal wall and fatty connective tissue to sew over the graft and anastomosis, which should be approximated anteriorly as the first and second layers. The lateral edge of the divided peritoneal opening is then sewn to connective tissue at the base of the mesentery, over and to the right of the aorta or graft, taking care to avoid mesenteric vessels in the superficial suture bites. The closure is extended to ‘the inferior end of the mesenteric incision using a continuous absorbable suture, which is then retraced as a second layer peritonealizing the base of the mesentery by inbricating the lateral surface of the opposing mesentery to the medial cut edge of the mesentery. However, this is continued only to the duodenum which is not peritonealized and is displaced to the right (Figure 3). This suture is contin-
The American Journal of Surgery
Duodenal Reflection
Figure 1, left. The intimate relation of the third and fourth portions of the duodenum and an underlying aortic aneurysm are shown. The usual incision in the posterior parietai peritoneum used to expose the aorta is shown; this releases the duodenum, which is then retracted to the right. Figure 2, center. After the grafthg pmcedure, conventionai reperitoneaiization returns the duodenum to the anatomic iocation, which restores intfmate contact of the aorta to graft anastomotfc line and sets up the potential for aortoduodenai fistuia. Figure 3, right. Diagram of the present method of reperitoneaiixation in which the third and fourth portions of the duodenum remain intraperitoneaiiy, reflected to the right and out of contact with the anastomosis. The graft has been covered by remnants of the aortic wail, subperitoneal fat, connective tissue, and parietai peritoneum which is sutured posteriorly and to the right of the aorta.
ued superiorly, approximating the lateral peritoneum to the connective tissues medial to the anastomosis and posterior and to the left of the duodenum. This leaves two or three layers of tissue between the anastomosis and the fourth portion of the duodenum, but of utmost importance, the duodenum is not in
Volume 139, August 1979
contact with the anastomosis or graft or under tension against it. Although I do not claim originality for the technique, I have used this method or a slight variation of it routinely for many years, and it has been possible in all end-to-end or end-to-side anastomoses in this area.
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