1914 Journal of the American Medical Association  
The anatomic relations of the retroperitoneal portion of the duodenum are such that this organ may be injured during operations for the removal of the right kidney. Such injury, however, can only occur if there be infiltration about the pedicle which has caused close adhesion to the duodenum. The duodenum in its descending course overlies the pedicle of the right kidney and a considerable portion of the lower half of that organ on the inner side (Fig. 1) . As this portion of the duodenum is
more » ... operitoneal and more or less fixed in position one can readily understand how the accident might occur under such circumstances. The exact relationship of the duodenum to the right kidney depends on the mobility of the latter organ which lies somewhat lower than the left kidney and is more or less movable normally. The extent of this mobility depends on a number of factors. As shown by Harris,1 the shape of the lower thorax, to a large extent, determines its posi¬ tion ; a loose attachment of the ascending colon to the posterior parietes permits a wider range of motion. Under ordinary circumstances, during a right nephrectomy, the pedicle is loosened until it can be well sur¬ rounded with the fingers, clamped with forceps or tied, and as long as this method is followed the duodenum will not he injured. But in those cases in which, on account of infiltration, such a pedicle cannot be formedî t not infrequently happens that the \ressels are torn with a resultant sudden gush of blood, or, after the removal of the kidney, the pedicle retracts from the forceps or ligature with sudden hemorrhage, necessi¬ tating active hemostasis. As shown by Gerster,2 if the artery is cut first the veins may tear with consequent hemorrhage. In the effort to check this sudden hemor¬ rhage by grasping the vessels with forceps having strong biting jaws and teeth at the end, the duodenum may he seized. As a rule, the injury to the duodenum is not manifested for several days. The injured part becomes necrotic and a duodenal fistula of a most distressing type results which will often, if not usually, cause the death of the patient. I have known of three such injuries to the duodenum, the first many years ago when I was assisting a surgeon 1. who was following a nephrotomy by a nephrectomy. Heavy biting forceps were left or. the pedicle. On the fourth or fifth day a copious discharge began of biliary and pancreatic secretions, with food discharged almost as quickly as taken. The patient became rapidly exhausted and died in two weeks. The second case was one of my own and the injury occurred in the removal of a carcinoma of the pelvis of the kidney, the result of a chronic irritation due to a large branched stone. The pedicle was extremely rigid from earcinomatous infiltration and in the attempt to remove it, the vessels were torn across in the infiltrated tissues. With considerable difficulty these vessels were caught by heavy, toothed forceps which Avere left in situ. On the fifth day a duodenal fistula showed itself. Biliary and pancreatic secretion and intestinal juices were passed in great quantities. The patient, already in a most serious condition, developed acute nephritis in the remaining kidney and died from asthenia on the tenth day. Necropsy showed a large fistulous opening in the descending portion of the duodenum. The third case was one of duodenal fistula following nephrectomy seen in consultation. The pedicle had been infiltrated with inflammatory products, the kidney had torn loose. The injury to the duodenum was undoubtedly inflicted by the application of heavy for¬ ceps. In this case the fistula was small at first, but grad¬ ually increased in size, and the patient died two weeks after the operation. One feature in all these cases was the action on the skin of the escaping secretions. Large areas of the neighboring integument became scalded, painful and irritated. In one patient this set up a rapidly spreading eczema and in a week a great part of the skin of the body was affected. From the fatal issue in these three cases, it would seem that accidental injury to the duodenum in con¬ nection with right nephrectomy is an exceedingly seri¬ ous occurrence, and although after a somewhat careful examination of the literature, I have not found cases reported, I can only believe that this accident is more common than the records show, and that some of the cases in which fistulas have formed following right nephrectomy, while supposedly in other portions of the intestinal tract, have really been duodenal. It will be noted that in the three cases herein mentioned, duodenal injury took place during attempts to check hemorrhage, and probably all. of them were due to forceps. In this connection I would say that in the same man¬ ner the vena cava is even more frequently injured. When the pedicle is infiltrated, the renal veins may tear away from the vena cava and the latter be grasped in forceps in the attempt to stop the bleeding. On the left side the vena cava is not thus exposed to injury,
doi:10.1001/jama.1914.02560300001001 fatcat:jmu3tecejvbzvm5bspjhvmmjau