Monday, October 01, 2007
On a Nobel Prize website, in reference to Theodor Kocher, recipient of the Prize in Medicine in 1909, it says, among other things, "The influence of a devoted mother and later the loving care of a selfsacrificing wife enabled him to pass without interruption through the continuous strait of secondary school and University, and he obtained his doctorate in 1865." Some things, I guess, don't change all that much; in others, he was unique.
In surgical lore, Emil Theodor Kocher is known for many things, as is the case with all those greats of old: innovation, invention, vision. Clarity. Viewers, they were, of the empty spaces between knowledge and action, and seers of ways to fill them. Despite my cognizance of the breadth of his influence, when I think of Kocher three main things come to mind: a big honkin' surgical clamp (curved or straight), the classical gallbladder incision, and his discovery of how to mobilize the duodenum; another of those simple and anatomically-correct tricks that gives the surgeon entry into secret places, and makes a hard job easier. The Kocher Maneuver. What a great thing to have named after oneself. A maneuver.
It's as if the duodenum is the command module of the belly: riding high and hanging back, daunting (one might assume) to the lesser organs, it receives input from the stomach, the liver, the pancreas and distributes it all downstream. With many life-sustaining tubes draining into it, and with as many big and scary blood vessels passing behind, beside, and around it, surgery of the duodenum is tricky, and requires most of the skills a surgeon must have acquired. The simple snip Dr Kocher invented makes the work a little cleaner, and is essential to working on that part of the intestine, on the pancreas, and for much of the surgery of the stomach. In one sense, it's no big deal at all: just a few seconds of scissoring along an imaginary line. In another, it's amazing that there's one person to whom the move is attributed, since it seems anyone working there would see the need to do it. Which makes it all the more noteworthy: when the Kochmeister was poking around in bellies, many of even the most basic concepts were yet to be deduced. I can barely imagine what it must have been like to be a surgeon in those times. Scary, exhilarating, deflating, rewarding. Those guys must have lain awake many nights as their brains buzzed and glowed with ideas. ("Teddy," his wife might have sighed, "Can you stuff a cork in your ear? The light is keeping me awake.") Would they have been barely able to keep from getting up and running to the lab to enflesh their latest inspiration?
I guess you could say there was no downside to what those trailblazers attempted: the conditions against which they were struggling had, until then, only bad outcomes. Either they found new ways, or the patients died as usual. Depending on how you look at it: either unbearably pressure-filled, or completely liberating.
The duodenum is plastic-wrapped to the backside of the abdominal cavity, covered as it is by the posterior parietal peritoneum for most of its length. Looking at the picture above, you can see that after connecting to the stomach, it descends downward and then curves hard to its owner's left. That curve is called the C-loop (or the "second portion," or the "descending duodenum.") The Kocher Maneuver is the process of cutting the C-loop loose, by incising the peritoneum covering its lateral edge. Made a verb, the term is "Kocherize," as in dictating "the duodenum was Kocherized..." Doing so gives just enough mobility to be able to tug the duodenum upward to join the stomach if you happen to have cut part of it (the stomach) away (only so far: the duodenum is, ultimately, tightly tethered by the aforementioned tubes and vessels); or more easily to open the duodenum across the pylorus for any of several reasons. And, most exquisitely, to gain access for your finger to nooger behind the duodenum and pancreas together, all the way to the superior mesenteric vein, after which, among other things, you can extend the Kocher Maneuver downward and to the left. Then you really have the meat of the belly in your hand. Awesome.
On the other hand, maybe you have to be there...