Transcript Abdominal_Vascular_Surgery_Revised_

Abdominal Vascular
Surgery
Summary
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Abdominal Vascular Surgery
A&P
Pathology
Diagnostics/Preoperative Testing
Prep & Positioning
Basic Supplies, Equipment, & Instrumentation
Abdominal Aortic Aneurysmectomy
Aorto-Bifemoral Bypass Graft
Resection of Renal Artery Aneurysm
Anatomy & Physiology
Abdominal aorta begins below the
diaphragm
 Multiple arteries between the diaphragm
and the bifurcation all of which supply
oxygen rich blood to the abdominal wall
and the abdominal organs or viscera
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Abdominal Aorta & It’s Arteries
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See Overhead
Celiac
Superior mesenteric
Renal
Inferior mesenteric
Lumbar
Bifurcation >iliacs>internal & external
External >femoral>popliteal>anterior & posterior
tibial
Peroneal is off the posterior tibial
Venous System
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See Overhead
Abdominal & thoracic walls drained by
brachiocephalic and azygos veins>SVC
Hepatic Portal Vein (Hepatic Portal System) >
IVC
Lower Extremities>Superficial and deep groups
Deep have same names as the arteries around
them
Greater Saphenous Vein is the longest vein in the
body
PATHOLOGY
Aneurysms
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True aneurysm=dilation of all layers of the
arterial wall
May find atherosclerosis along with true
aneurysm, but it is not the cause of the
aneurysm
False Aneurysm (pseudoaneurysm)=not an
aneurysm, but a tear that allows blood between
the layers of the artery
Results from trauma, infection or post-arterial
surgery where suture has been disrupted
True Aneurysms
Most often found in the aorta
 Can be in the iliacs, femoral and popliteal
arteries
 Men get more than women
 Generally found in the elderly
 18% have family history
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Aneurysms Continued
Generally occur below the renal arteries
 Are fusiform or tapered at the ends
 Involves weakening of the tunica media
(elastic layer) and intimal layer damage
(atherosclerosis)
 Patients generally asymptomatic and
these are found during routine physicals
 Low mortality (3%) with elective surgical
intervention (AAA Repair)
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Aneurysms Continued
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May extend to the bifurcation of the aorta or
involve the common iliacs as well as the external
and internal iliacs
Aneurysm rupture patients present with severe
back and abdominal pain
Usually rupture is contained in the retroperitoneal
space but can rupture into the peritoneal space
causing certain death from the hemorrhage
Rupture requires immediate intervention as
mortality goes to 80%
Treatment
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Abdominal aortic aneurysm resection or repair
If the iliacs are involved a Y or bifurcated graft is
used
If the iliacs are not involved a straight or tube
graft is used
Graft material can be Knitted polyester dacron,
Knitted velour polyester dacron,Woven polyester
dacron, or PTFE (Gortex)
Knitted polyester requires preclotting, the others
do not
Graft Options
DACRON (Meadox/Boston Scientific)
 1.“Knitted” polyester dacron
 Must be pre-clotted
 2.“Woven” polyester and Knitted velour
polyester
 Do not need to be pre-clotted
 *Both come in a spiral design that is
designed for bends such as in the iliacs or
knee joint
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Graft Options Continued
3. PTFE: polytetrafluoroethylene (Gortex
or Impra)
 Specifically designed for knee joint bends
or popliteal bend
 Not desirable for aortic aneurysm repair
 May be doctor preference
 Come with rigid rings or without
 Rings add support
 Come thin walled or standard walled
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Preoperative Testing & Diagnostics
1. CT Scan
 diagnose an aneurysm
 Extent
 Location of thromboembolytic matter
 Shows whether or not there is leakage
 2. Ultrasound
 Detection
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Preoperative Testing & Diagnosis
3. Angiography
 Follows detection or diagnosis of
aneurysm
 Provides clear picture of aneurysm so that
surgery can be planned
 Will show all of the vessel(s) that are
involved
 Displays areas that are not getting blood
flow as evidenced by the fact that contrast
dye does not reach those areas
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Prep & Positioning
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Arteriogram films should be displayed in the xray box before the surgeon comes into the room
Blood should be available in the room prior to
incision
A foley catheter is placed upon induction of
anesthesia
Patient is supine with arms tucked or on padded
armboards
Pillow under head or headrest
Foam or gel pads may be used on the heels
Foam or gel pad for the OR bed
Prep and Positioning Continued
Patient should be shaved nipples to knees
in pre-op unless is emergent and must be
shaved in the room
 Prep is nipples to knees
 Prep starts at the abdomen where the
incision will be and works outward to the
groins and the pubis is prepped last
 Separate prep sticks should be used for
the legs working outward to the bed and
prepping the groins and pubis last
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Drape Sequence
Groin towel, towels x 6 (at sides, across
knees, across chest)
 Drying towels
 Ioban
 Drape (universal sheets or laparotomy
sheet)
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Basic Supplies, Instruments, and
Equipment
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Supplies
1” penrose, long polyester tapes, silicone vessel
loops, cotton umbilical tapes (*Surgeon
preference) for isolating the aorta and iliacs
2-0, 3-0, 4-0 SH or MH Prolene suture for sewing
the proximal portion of the aortic graft
5-0 or 4-0 RB-1 or C-1 Prolene for the iliacs
2-0, 3-0, 0 Silk or Nurolon for oversewing the
lumbars
Supplies Continued
Silk ties or reels 0, 2-0, 3-0, 4-0
 Laparotomy or universal pack
 #20,#10, #11, #15 blades
 Major Basin Pack
 Custom CV Tray (contains kittners, rubber
shods, umbilical tapes, cytal, kidney basin,
bowl, blades, foley catheter, towels)
 Ioban
 Drains (JP, Blake, or Snyder)
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Supplies Continued
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Clips (small, medium, or large)
Dacron graft straight or bifurcated
Syringes (30cc)
Doppler probe
Fish or Viscera Retainer
Closing Suture (varies by surgeon) #1 or 0 PDS,
Prolene, Novafil for fascia/0, 2-0, 3-0 CTX Vicryl
for subcutaneous (may do two layers), Stapler or
4-0 Monocryl or Vicryl for skin or subcuticular
Binder (with obese patient)
Dressing sponges (xeroflo or telfa, 4x4s, ABD
post final count
Basic Supplies, Instrumentation, and
Equipment
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Instruments
CV Tray complete with variety of aortic clamps and vascular
clamps
Extra-long instruments should be available
(debakey forceps, long metz, long NHs, long tonsils, kellys,
and right angles)
Hand-held abdominal retractor tray (richardsons deavers,
& Harrington/Sweetheart)
Self-retaining retractor tray (balfours x 2, omni-tract, or
bookwalter) *Surgeon preference
Micro instuments (Vascular NH, scissors, forceps)
Standard and Long Clip Appliers (small, med & large)
Tunneler
Basic Supplies, Instrumentation, And
Equipment
Equipment
 ESU/Bovie
 Suction/Cell Saver
 Headlight for the surgeon
 Bair hugger for patient (upper body)
 Doppler box
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Medications
Saline irrigation with antibiotic of surgeon
choice (should be in a warmer)
 Heparin saline (1,000ut/250ml NS) can
keep warm in warmer
 Contrast available
 Topical hemostatics available (Gelfoam,
Thrombin, Surgicel, Avitene)
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Procedures
Abdominal Aortic Aneurysm
 Aorto-Bifemoral Bypass Graft
 Aorto-Iliac Bypass Graft
 Resection of Renal Artery Aneurysm
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Abdominal Aortic Aneurysmectomy
Repair of the portion of the aorta between
the renal arteries and the bifurcation of
the iliac arteries
 Aneurysm will be 6cm or greater in
diameter
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AAA Procedure
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Incision starts with a #10m blade, incision is
made below the xiphoid process and to the left
and ends at the umbilicus
Provide hand cautery, debakey forceps
Will proceed through various layers, provide
hand-held retractors; may use/set up the omni,
bookwalter, or balfour retactor (provide moist
laps to go under blades be they hand-held or
self-retaining
Offer metz as needed with bovie as go deeper be
prepared to change the cautery for a longer tip,
longer debakeys, and longer metz
Isolate bowel and place in an intestinal bag/wrap
in a moist sponge
AAA Continued
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Isolate aorta (may go around aorta with a vessel loop and
clamp with a rommel tourniquet or long polyester or cotton
tape passed from a ligature passer)
Surgeon will ask CRNA to heparinize patient
Provide the aortic clamp of the surgeons choice
Iliacs will be clamped with straight or angled vascular
clamps such as peripheral debakeys or patent ductus
clamps
Aorta will be incised with a knife (long handle) or scissors
Plaque will be removed if present
Other involved arteries with backup arteries to oxygenate
their respective organs (inferior mesenteric and lumbers),
are clipped, tied, or sewn off with non-absorbable suture
Involved arteries without back-up circulation are reimplanted into the graft using smaller lumened Dacron
grafts (renals, superior mesenteric, celiac)
AAA Continued
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Prepare graft
Graft sizers prn (may pass on a long tonsil or kelly
Irrigate inside aorta before grafting with heparinized saline
Start with proximal anastamosis (have long vascular NH,
loaded with 3-0 SH double ended, long debakey forceps,
long suture scissors, rubber shod)
Usually sew ½ way around tag and begin with the other
needle coming the other way
Surgeon may want his hands wet with saline when he ties
to keep suture from sticking to his hands
AAA Continued
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Graft will be measured to its distal end and cut
with either a knife or scissors
Distal anastamosis will follow the same sequence
as the proximal
Surgeon will slowly remove the aortic clamp,
observing for leaks
Leaks will be repaired with pledgeted or nonpledgeted 3-0 or 4-0 prolene suture
Topical hemostatic agents may be applied
Distal clamps will be removed, leaks will be
repaired using the same type of suture
Topical hemostatics may be applied
AAA Continued
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Abdomen will be irrigated with antibiotic saline
Aneurysm sac will be sewn to prevent the intestine from
adhering to the graft usually with a 0 Vicryl on a CT-1
needle with a long NH
Remove all laps do first count
Return bowel to their normal position and pull greater
omentum back over the bowel
Place a fish or viscera retainer over the abdominal organs
and close the peritoneum, fascia, and muscles with a heavy
0 or #1 PDS, Novafil, Ethibond (Ticron) or Prolene (usually
done as one layer)
Do second count
Close subcutaneuos layer with 0, 2-0, or 3-0 vicryl on CTX
or CT-1 tapered needle
Close subcuticular with 4-0 vicryl on PS-1, Monocryl or
staplers
AAA Continued
Dress with xeroflo or telfa, 4x4s, ABD pad
and tape
 May need an abdominal binder with the
obese patient
 Pedal pulses should be checked at the end
of the procedure by the surgeon
 Keep table sterile until patient safely out
of the room
 Clean up per policy
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Aorto-Bi-Iliac Bypass Graft
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Procedure is the same as an Abdominal Aortic Aneurysmectomy
with following changes:
Aorto-Iliac Bypass Graft
Will need: a bifurcated graft
May require a heavier vascular clamp such as a straight or angled
patent ductus clamp (surgeon preference)
Will need smaller prolene suture for the iliac anastamoses such as
5-0 or 4-0 on a smaller needle (still need rubber shods)
May cut down the groin areas using weitlanders for retractors or
gelpis depending on patient anatomy
Will use standard length instuments when working in the groin
Will isolate the iliacs with tapes or vessel loops
Will need two layers of closing suture for groins when done
Will need dressings for the groins post surgery
Aorto-Bi-Femoral Bypass Graft
Same as Aorto-Bi-Iliac with following
differences:
 Definitely will cut down groins
 Will need: a bifurcated graft, short
tunneler (may use long kelly or aortic
clamp)
 Will isolate femoral artery with cotton
tapes or vessel loops (using right angle
and debakey forceps/may use rommel
tourniquet)
 Will use peripheral debakey clamps to
clamp femoral arteries
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Resection of Renal Artery Aneurysm
Renal artery aneurysm repair
 Function of renal artery is to supply
kidneys with oxygenated blood
 Renal artery arises from the abdominal
aorta
 This is an arteriosclerotic aneurysm and
classified as a “true aneurysm”
 Resection indicated for: symptomatic,
renal artery stenosis, pregnant women or
those women considering pregnancy
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Renal Artery Aneurysm Resection
Patient Preparation and Prep
Shaved nipples to top of thighs
 Prep soap betadine nipples to knees and
betadine paint nipples to knees (use drip
towels)
 Supine with arms tucked or on armboards
and padding to prevent ulner and brachial
nerve damage (pay attention to areas
where post for abdominal retractor will be
placed
 Pillow under head and knees
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Equipment
Warming blanket or Upper Body Bair
Hugger
 Cell saver
 Extra suction
 ECU
 Headlamp
 Warmer for irrigants
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Instruments
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Major tray with cardiovascular clamps (aortic
clamps)
Cardiovascular tray
Major vascular tray
Extra Long Instruments
Surgeon’s specialty instruments
Abdominal retractor (Bookwalter, Omni-Tract, or
Balfour retractors x 2)
Medium and large long clip appliers
Heparin needle
Supplies
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Foley and urimeter
Medium and large clip cartridges
Rumels
#16 or #18 red rubber catheter for rumel
tourniquet
Fogarty inserts if using fogarty aortic clamp
Vessel loops, long umbilical tapes, or dacron
polyester tapes
Peanuts or Kittners
Rubber shods
Sponge on a stick x 2 available
Draping
Groin towel
 Towels x 6
 Drying towel
 Ioban
 Universal drapes
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Procedure
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#10 blade on #3 knife handle for vertical midline incision
(base of xiphoid to around umbilicus to the pubis)
Cautery/metz dissect through subcutaneous, fascia,
muscle, and peritoneal layer
Moist laps available for placement under hand-held or selfretaining retractors to protect abdominal organs
Long metz, long kittner, clips, ties available to dissect
through the omentum
Isolate renal artery and renal vein
May use rumel tourniquet or vessel loop or umbilical tapes
around renal artery, vein and vena cava
May need to retract pancreas and duodenum for optimal
exposure
Heparinize patient (CRNA)
Procedure Continued
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Cooley clamps or peripheral debakey clamps
available to clamp renal artery and any other
arteries in close proximity to renal artery
Excise aneurysm
Repair with short piece of Hemashield graft
material or just do simple closure of arterial
defect with prolene suture
Remove clamps allowing release of blood to
dispel air
Reversal of anticoagulated state with Protamine
Sulfate by CRNA
Hemostasis achieved
Irrigate with antibiotic saline
Procedure Continued
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Close retroperitoneum with 0 Vicryl on CT-1
tapered needle
Return bowel to anatomical position remove all
packs, retractors
Initiate first count
Close peritoneum, fascia, and muscles as single
or individual layer (surgeon choice) using
nonabsorbable or absorbable suture
Perform final count
Close skin with subcuticular stitch or staples
Cleanse prep solution from skin
Dress per surgeon preference (telfa, 4x4s, ABD
pads, tape)
Complications
Bleeding/hemorrhage
 Impaired renal function
 Infection
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ENDOVASCULAR
Repair Of Abdominal
Aortic Aneurysm
Anatomy & Physiology of AAA
 An aneurysm refers to a bulge or balloon that forms
in the wall of a blood vessel
 If an aneurysm forms in the part of the aorta that
extends past the diaphragm, it is called an abdominal
aortic aneurysm (AAA)
 Result of true or false aneurysm
 Over time, the vessel wall loses elasticity and the
force of normal blood pressure in the aneurysm can
lead to bursting or rupture of the vessel
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 The abdominal aorta is the most common site for an
aneurysm development
 The exact cause (AAA) is unknown
 Risks associated with AAA include: atherosclerosis
(accumulation of fatty deposits on the vessel wall),
hypertension, smoking, trauma to the arterial wall,
infection, peripheral vascular disease,
arteriosclerosis, and congenital defects of the artery
wall
 Most AAA occur below the level of the renal artery and involve
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the bifurcation of the aorta as well as the proximal ends of the
iliac arteries
Stasis of blood can lead to thrombus formation along arterial
wall
Peripheral emboli can develop causing arterial insufficiency
Once an aneurysm forms it often increases in size and
consequently the chances of rupture also increase
Aneurysm rupture can lead to hemorrhage and death
Presentation of AAA
 Most patients present without a symptomatic pulsatile
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abdominal mass
The aortic bifurcation is located just above the
umbilicus
An overlying mass (pancreas or stomach) may be
mistaken for an AAA
An abdominal bruit is nonspecific for a nonruptured
aneurysm
Patients with popliteal artery aneurysms have a high
incidence of AAAs (25-50%).
Presentation of Ruptured AAA
 Ruptured may present in many ways
 Most typical presentation is abdominal or back pain
with a pulsatile abdominal mass
 Symptoms may be vague and therefore overlooked
 Symptoms may include groin pain, syncope,
paralysis, or flank mass
 The diagnosis may be confused with renal calculus,
diverticulitis, incarcerated hernia, or lumbar spine
disease
What is an Endovascular Stent
Graft?
 A woven polyester tube externally supported
by a tubular metal web that expands to a preestablished diameter when placed intraluminally in the artery
Endovascular Repair
Advantages:
Significantly lower
number of
complications
Fewer deaths
Shorter hospital stay
 Disadvantages:
 Increase in health care
costs
 Is manufacturer
competitiveness
currently that is slowly
decreasing costs
How Does the Stent Graft Work
 The stent graft excludes the aneurysm from
the circulation and thus prevents continued
pressurization and possible rupture of the
aneurysm
 The stent graft is placed inside the aneurysm
using a delivery catheter
Endovascular repair appears to have
augmented treatment options rather than
replaced open surgical repair for patients with
AAA
Patients who previously were not candidates
for repair because of medical co-morbidity
may now be safely treated with endovascular
repair
Graft options
 Manufacturers:
 Surgeon preference
 WL Gore (Gore-tex)
 Some companies are trying
“Excluder”
 Medtronic “Aneuryx”
 Cook “Zenith” Allows for
AAA that goes up beyond
the renal arteries, but does
not include aneurysmal renal
artery involvement
to modify their product to be
used in ever increasing
situations
 These changes take years of
FDA trials to receive
approval to come on the
market
Diagnosis
 During a routine physical exam a doctor may
feel a throbbing mass in the middle or lower
part of your abdomen
 However, most aneurysms are identified
when diagnostic imaging ( X-ray, CT, MRI,
arteriogram) is performed for other reasons
Indications for Use
 Adequate iliac / femoral access
 Infra-renal , non-aneurysmal neck length greater than 1 cm at
the proximal & distal ends of the aneurysm & an inner diameter
10-20% smaller than the labeled device diameter (Exception
currently “Zenith”)
 Morphology suitable for endovascular repair
 Aneurysm diameter > 5 cm
 Aneurysm diameter of 4-5 cm which has also increased in size
by 0.5 cm in the last 6 months or which is twice the diameter off
the normal infra-renal aorta
Pre-op testing
 CBC (complete blood count)
 BMP (basal metabolic panel)
 PT, & PTT /c INR ( clotting factor)
 Type & cross for blood
 EKG
 Chest x-ray
Prep and positioning
 Patient warm with silver hat, warm blankets,
or ideally bair hugger
 Position patient supine, arms tucked at sides,
legs slightly apart, head on headrest, upper
body bair hugger (nipples up)
 Foley catheter
 Scrub & paint betadine nipples to knees,
lateral to sides bedsheet to bedsheet
Drape sequence
 Drying towels
 Groin towel, square off using entire area
nipples to knees
 Ioban drape/may need two if larger or longer
patient
 Universal drapes
Basic supplies,instruments &
equipment
 Cell saver ( available )
 Omni retractor or Bookwalter (surgeon
preference) available
 Fluid warmer available
 C-arm ( fluoroscopy )
 Lead aprons
Supplies & Instruments
 Major vascular tray
 Dr’s special instruments
 Universal drape pack
 Major basin pack
 Cardiovascular Pack
 Sutures (surgeon preference card)
 Deployment device per manufacturer
Anesthesia
 General anesthesia primarily
 Spinal anesthetic along with MAC in case of
increased risk of complications (COPD)
 Local anesthetic and MAC
Medication (on sterile field)
 Heparin / saline
 Antibiotic / saline (Ancef, other)
 Contrast
 0.25 % marcaine plain
Procedures
 Abdominal aortic aneurysm stent grafting
 Aorto bi-iliac
 Aorto uni-iliac
 Aorto bi femoral
 Aorto uni-femoral
 FDA has approved trial of stent grafts for
thoracic aneurysms
Summary
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Abdominal Vascular Surgery
A&P
Pathology
Diagnostics/Preoperative Testing
Prep & Positioning
Basic Supplies, Equipment, & Instrumentation
Abdominal Aortic Aneurysmectomy
Aorto-Bifemoral Bypass Graft
Resection of Renal Artery Aneurysm
Endovascular AAA Repair