Surgical Anatomy: The duodenum is divided into four sections. The first portion (D1) crosses over the porta hepatis, the second portion (D2), overlies the right kidney and IVC. The third portion (D3) crosses over the aorta and is under the superior mesenteric vessels. The fourth portion (D4) ascends to meet the jejunum at the ligament of Treitz. The head of the pancreas and the 2nd portion of the duodenum derive their blood supply from the pancreaticoduodenal arcades. Dissection in this area may result in duodenal ischemia. Surgical Exposure: The D1, D2, and proximal D3 are mobilized using a Kocher maneuver, dissecting the duodenum off the retroperitoneum, medializing the head of the pancreas. The distal D3 and the D4 can be exposed with the Cattell-Braasch maneuver, which consists of mobilization of the right colon, followed by incision of the retroperitoneum from the ileocecal valve to the ligament of Treitz. The right colon and small bowel are then retracted cephalad and to the left of the patient. The superior mesenteric vessels are no longer crossing the duodenum and the 3rd and 4th portions are fully exposed.. Operative Management: All hematomas discovered intraoperatively should be explored. Most injuries can be repaired primarily with a tension-free transverse repair. Care must be taken with D2 injuries not to injure the ampulla or to devascularize the duodenum with excessive dissection in the plane between the D2 and the pancreatic head. High-grade injuries may require pyloric exclusion and gastrojejunostomy. Pancreaticoduodenectomy is rarely indicated.