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Laparoscopic drainage of an intramural duodenal haematoma: a novel technique and review of the literature
© Nolan et al; licensee BioMed Central Ltd. 2011
Received: 19 July 2011
Accepted: 20 December 2011
Published: 20 December 2011
Intramural Duodenal Haematoma (IDH) is an uncommon complication of blunt abdominal trauma. IDH's are most often treated non-operatively. We describe laparoscopic treatment of an IDH after failed conservative management. To our knowledge, successful laparoscopic drainage of an IDH in an adult has not been described previously in the literature.
Literature review of interventions for Intramural Duodenal Haematomas
N° of Cases
Days to Drainage
Benieghbal et al .
Laparoscopic drainage and omental patch
Discharged day 3 post-surgery. Normal barium meal at 4 weeks. Asymptomatic at 6 months follow-up.
Hanish and Pappas 
Percutaneous CT guided drainage
Discharged day 1 post-procedure. CT 10 days after discharge showed complete resolution.
Desai et al 
Laparotomy and drainage
No duodenal stricture or fistula on follow-up.
Takishima et al 
Laparotomy and evacuation of haematoma
Radiologic resolution on CT on the 40th postoperative day.
Maemura et al 
Laparoscopy converted to open to repair duodenal perforation
Discharged day 16 post-surgery.
Jewett et al 
24: evacuation of haematoma
Mean hospital stay 14.2 days.
Jewett et al 
65: evacuation of haematoma
18: bypass procedure*
Mean hospital stay 16 days.
On day ten a progress CT scan was performed showing no change in size of duodenal haematoma. On day thirteen, the gastric outlet obstruction had not resolved. The risks of surgery including haemorrhage, duodenal leak and fistula formation were weighed against the ongoing conservative approach with an extended period of TPN and the potential for duodenal structuring. The non-operative approached was abandoned.
Two days after surgery the NGT and Jackson-Pratt drain was removed and a free fluid diet commenced. The T tube was removed three days after surgery. The patient was discharged home on a normal diet four days after surgery. He had an uneventful recovery and no issues at follow-up.
Non-operative management of IDH is often successful. It represents the mainstream treatment of IDH unless active bleeding or bowel perforation is diagnosed and emergency laparotomy therefore required. In the majority of patients the gastric outlet obstruction secondary to IDH resolves after conservative measures including TPN and NGT treatment [6, 8–10]. Only when these measures fail surgery is advocated.
The trend toward minimally invasive procedures has influenced the surgical management of IDH. Successful ultrasound or CT guided drainage has been reported IDH [11, 12]. After 2 weeks from injury the haematoma is usually lysed and easier to aspirate . Laparoscopic drainage of IDH has been described in the literature only twice. Banieghbal described a four port approach, similar to laparoscopic cholecystectomy, in an 11 year old child. An omental patch was applied on the serosa opening . Maemura described an IDH in a 21 year old man following blunt abdominal trauma who required surgery due to evolving biliary obstruction . The laparoscopic procedure was abandoned due the finding of a duodenal wall perforation, which required a laparotomy with formal repair and pyloric exclusion.
There are a number of points to detail about our laparoscopic approach. Firstly, the inframesocolic route allows a direct approach to the haematoma without need for a Kocher manoeuvre. The approach allows the entire clot to be evacuated and introduction of a laparoscope in the cavity allows limited assessment for mucosal lacerations. The T-tube assists decompression of the cavity should more bleeding occur or serum accumulate in the haematoma cavity. It also allows the development of a controlled fistula if a mucosal perforation has been missed at exploration of the cavity. We believe the technique is robust and simple and can be applied in most cases where conservative measures fail and facilitates early recovery and discharge from hospital.
IDH is an uncommon injury after blunt abdominal trauma. Most patients can be treated conservatively with NGT decompression and TPN. When conservative management fails and drainage is required this can be safely achieved with a laparoscopic technique.
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
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