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1
9
10
1
Right side
3
Incision
1. Inferior vena cava
2. Aorta
3. Right adrenal gland
4. Left adrenal gland
5. Right adrenal vein
6. Left adrenal vein
7. Right renal vein
8. Left renal vein
9. Right inferior phrenic artery
10. Left inferior phrenic artery
11. Right adrenal artery
12. Left adrenal artery
Foramen of Winslow
11
2
3
7
Right kidney
4
5
4
12
6
8
2
Left kidney
Caudate lobe
Vena cava
Tumor
Duodenum
Adrenal gland
Duodenum
Renal vein
5
Vena cava
313
Adrenal gland
Renal vein
Kidney
PLATE
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147
DETAILS OF PROCEDURE Usually, the principal adrenal vein
is rst identi ed and then doubly ligated with silk (figure 6). e surgeon then cautiously works about the medial and inferior edges of the gland
and ligates the principal artery or accessory arteries in a similar manner.
e many minor vessels encountered must also be either carefully ligated
or secured with clips.
e approach to the le adrenal via the transabdominal route may take
either of two courses, as demonstrated in figures 7 through 10. e usual
approach is shown in cross section in figures 7 and 8. e abdominal contents are carefully packed toward the surgeon and then, carefully grasping
the spleen, the surgeon divides the avascular splenorenal ligament so that
the spleen is mobilized somewhat toward himself or herself. With blunt
dissection, it is then possible to dissect above Gerota’s fascia but beneath
the pancreas and primary splenic artery and vein. is dissection may be
carried medially as far as the superior mesenteric vein, which will give a
degree of mobilization as shown in figure 11. e surgeon then incises
the Gerota’s fascia over the le kidney (figure 8) and, with blunt dissection, clears the superior pole of the le kidney and comes upon the adrenal,
which is shown here in a somewhat medial and inferior location. e le
lobe of the liver is also identi able, but it is usually not necessary to mobilize or retract it. e same general principles of exposure apply to the le
adrenal gland except that the prominent adrenal vein (figure 11) is shown
being secured rst. e surgeon then works about the periphery of the
gland, ligating all prominent vessels. is is o en slow, meticulous work,
but—if in doubt—it is safer to ligate or clip each suspicious vascular area.
Many surgeons have found it useful to approach the le adrenal
through the transverse mesocolon, a er mobilizing the inferior border
of the body and tail of the pancreas (figure 9). is is accomplished by
rst removing most of the greater omentum from its attachment along
the transverse mesocolon and carefully securing any bleeding points in
this generally avascular area. Care must be taken to preserve the middle
colic vessels, since the omentum is sometimes closely blended with the
mesocolon, and these vessels therefore are liable to damage during the
procedure. An incision is then made along the distal or inferior margin
of the pancreas from the tip of its tail back along the body to the region
of the inferior mesenteric vein [danger point (central arrow), figure 9].
is allows the surgeon to mobilize the distal pancreas with blunt nger
dissection so that it may be elevated in a cephalad manner and to expose
the Gerota’s fascia directly over the le kidney, whose midportion is usually directly exposed by this approach. is fascia is then incised and the
B A
dissection carried about the superior pole of the kidney, where the adrenal can be identi ed (figure 12). Its lateral edge is then approached and
its removal performed as in the procedure described above.
CLOSURE e incision is closed in the routine manner. However, reten-
tion sutures are recommended in hypercortisolism, as poor wound healing
is a known complication.
POSTOPERATIVE CARE Blood losses must be replaced carefully, and
patient observation and blood pressure monitoring must be unfailingly frequent, preferably by an intra-arterial line. Should blood pressure continue
to fall in the recovery area or during closure despite adequate endocrine
replacement, retroperitoneal hemorrhage from an unsecured vessel must be
strongly suspected. In patients who have had a pheochromocytoma removed
and for whom adequate uid and blood replacement has been accomplished,
a postoperative vasopressor in the form of norepinephrine is usually necessary for to hours, a er which time it is gradually tapered as tolerated.
Propranolol hydrochloride (Inderal) and lidocaine hydrochloride (Xylocaine) may be needed to control tachycardia and cardiac arrhythmias.
Patients will experience a drop in the level of circulating corticosteroids a er removal of a hyperfunctioning tumor or a er subtotal or total
adrenalectomy. erefore they must have cortisone support before, during,
and a er surgery. Cortisone acetate in the dose of mg is given intravenously the evening before and on the morning of surgery. Supplemental intravenous hydrocortisone is given during the operation as needed.
A nal dose of mg cortisone acetate is given intravenously in the
evening a er surgery, with a total dose of approximately mg being
given the day of surgery. is is gradually tapered down over the next to
days to approximately mg per day, which may be given in divided
doses. It is felt that to mg per day of oral cortisone represents reasonable maintenance therapy. However, it may be necessary to add an active
mineralocorticoid to this if maintaining sodium and potassium balance is
di cult. In the immediate postoperative period, however, the major problem is to ensure adequate cortisone replacement, as it is easy to undertreat
but almost impossible to overtreat with cortisone.
e postoperative ileus and return to alimentation should be handled
the same as for any laparotomy. Wound healing, however, will be impaired
in patients with hypercortisolism, and infection is a possibility, as many of
these patients also have extensive furunculosis. Last, it is important that
the patient’s long-term medical management and follow-up and endocrine
replacement be clearly de ned. ■
314
6
Adrenal vein
Superior
mesenteric vein
Vena cava
7
Adrenal
gland
Left side
Kidney
Spleen
8
Spleen
Pancreas
Gerota’s fascia
Adrenal gland
11
Liver
Renal vein
9
Pancreas
Adrenal gland
12
Spleen
Pancreas
Colon
Line of incision
10
Incision in
Gerota’s fascia
Spleen
Kidney
Adrenal gland
Renal vein
Forceps under
adrenal vein
Pancreas
Kidney
315
PLATE
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148
INDICATIONS e presence of cortical or medullary tumors of a benign
nature is a well-established indication for unilateral laparoscopic adrenalectomy. ese tumors may be functional and produce cortisol, aldosterone, catecholamines, and rarely testosterone and other sex hormones. In many cases the
tumors are nonfunctional and are removed because of the concern for cancer.
In these situations the adrenal mass is frequently found during abdominal imaging done for unrelated indications. ese so-named adrenal “incidentalomas”
should be removed if they have a cross-sectional diameter cm or greater or if
they are proven to be functional. Patients with nonfunctional adrenal masses
less than cm should be followed with periodic imaging to monitor changes
in the size of the mass. A benign adenoma on CT is typically a homogeneous
mass with a low attenuation value (less than HU). It is recommended that
patients with an incidentaloma should have a -mg dexamethasone suppression
test and a measurement of plasma-free metanephrines. In addition, patients
with hypertension should have determinations of serum potassium and plasma
aldosterone concentrations to plasma renin for an activity ratio. Surgery is considered in all patients with functional adrenal cortical tumors. All patients with
biochemical evidence of pheochromocytoma should undergo surgery except
in rare instances. Although size is not an absolute contraindication to laparoscopic adrenalectomy, the procedure may be di cult on lesions greater than
cm. Open adrenalectomy with en bloc excision is the mainstay for primary
and recurrent adrenocortical carcinoma due to the lack of e ective adjuvant
therapy and the di culty of maintaining oncologic principles with laparoscopy.
PREOPERATIVE PREPARATION e most important preoperative proce-
dure is to establish a rm diagnosis. Accordingly, the reader should refer to
current texts on diagnostic endocrinology for the required procedures. When
adrenalectomy is decided upon, the surgeon should investigate and, if possible,
correct many of the secondary systemic and metabolic e ects that are the direct
result of the altered functional activity of the adrenal. e management of the
hypertension and its cardiovascular sequelae is the major problem with pheochromocytomas. Preoperative treatment with an alpha-receptor antagonist such
as phenoxybenzamine hydrochloride and volume expansion is necessary in
patients with pheochromocytoma in order to control the associated hypertension. is may take two weeks or more. Beta-blockers are reserved for patients
with tachycardia or cardiac arrhythmias. Problems associated with hypercortisolism have been reviewed in the section on bilateral adrenalectomy.
ANESTHESIA Preoperative consultation and communication among endo-
crinologist, surgeon, and anesthesiologist are necessary. A type and screen is
acceptable for small tumors. Autologous donation or type and cross to ensure
the availability of blood products is recommended for tumors greater than
cm. General anesthesia with endotracheal intubation is preferred in all cases.
A catheter should be placed in the urinary bladder for monitoring urine output.
e stomach should be decompressed with an orogastric or nasogastric tube.
For patients with nonfunctional tumors, there are no special considerations for
anesthesia. Patients with hyperaldosteronism should have the blood pressure
controlled preoperatively, but rarely have life-threatening intraoperative hypertension. Patients with hypercortisolism should have correction of the metabolic
abnormalities and be given a stress dose of steroids.
Patients with pheochromocytoma should have an ar terial line and central line
placed. In some patients with associated hypertensive cardiomyopathy, a pulmonary artery catheter may be helpful. During the procedure the anesthesiologist should be prepared to control hypertension with an intravenous infusion of
sodium nitroprusside (Nipride). A er the pheochromocytoma is removed and
ensuring that adequate uid and blood replacement has been accomplished, an
infusion of norepinephrine (Levophed) may be necessary to treat hypotension.
Propranolol hydrochloride (Inderal) and lidocaine hydrochloride (Xylocaine)
may be needed to control tachycardia and cardiac arrhythmias.
ANATOMY e surgeon must rst be aware of the anatomic di erences of the
two adrenal glands (see Plate , figure 2). e le adrenal is in proximity
to the aorta medially, the renal vein inferiorly, and the superior pole of the le
kidney. It may be located near the renal hilum. Its main arterial supply comes
directly from the aorta (), but the main le adrenal vein () usually comes
from the le renal vein (). In contrast, the right adrenal is close to the superior pole of the kidney, the vena cava medially, and the right lobe of the liver
superiorly. Its main arterial supply comes directly to its medial edge from the
aorta (
figures 2, 12), and the main right adrenal vein () comes directly from
the inferior vena cava in a parallel manner. Both adrenal glands, however, have
many arterial twigs from both the inferior phrenic arteries ( and ) and both
renal arteries. Both adrenal glands are within gerota’s fascia.
POSITION An adjustable vacuum beanbag should be placed on the operating
table prior to bringing the patient into the room. e patient is positioned with
the bag being at the level of their ank below the ribs and above the iliac crest
A, L L
over the break position of the table so as to allow a “jack knife” extension that
may be useful in obese patients.
For a le adrenalectomy the patient is placed in a lateral position with the
le arm crossing the chest and supported on a padded arm board (figure 1).
e right arm is placed on a separate arm board and an axillary roll is used. Liberal padding is used between and around both arms. e abdomen and ank
area should be exposed and the le knee exed, with a padding of blankets or
pillows between the legs.
OPERATIVE PREPARATION e patient’s hair should be removed with elec-
tric hair clippers with minimal trauma to the skin.
INCISION AND EXPOSURE For a le adrenalectomy the surgeon stands on
the patient’s right side (figure 1a). e camera operator stands to the le of the
surgeon and the assistant on the le side of the patient. A -mm -degree laparoscope is placed either above the umbilicus or in the le lateral midsubcostal
position in the mid-clavicular line just above the level of the umbilicus using
the open technique of Hasson as described in Plate . e abdominal space is
in ated to cm of pressure, the laparoscope is introduced, and all four quadrants of the abdomen are examined for abnormalities, safety of other planned
port sites, and evidence of any metastatic disease. A -mm port is placed in the
far le lateral subcostal position and a -mm port is placed just to the le of the
midline through the upper rectus muscle sheath just to the le of the round ligament. is reduces the chance of lacerating the epigastric artery, which might
require suture ligation. ese ports are in a line about two ngerbreadths or so
below the edge of the costal margin. A third -mm port is placed in the anterior
axillary line midway between the costal margin and the iliac crest
DETAILS OF PROCEDURE e operative exposure of the le adrenal is
shown rst. e splenic exure of the colon is mobilized using an ultrasonic
device so as to expose the kidney. e dissection is continued cephalad and the
lesser sac is entered by separating the greater omentum from the splenic exure
and transverse colon (
e lesser sac is entered and the pancreas identi ed (figure 2). e retroperitoneun is exposed to show the kidney and posterior surface of the pancreas
(
figures 2 and 3). Gerota’s fascia is incised and opened to expose the upper
pole of the kidney (figures 2 and 3). Dissection is continued under gerota’s
fascia while the assistant li s the tail of the pancreas anteriorly (figure 3).
is dissection should be continued as far cephalad as possible. e inferior
pole of the adrenal gland will be seen as a bright yellow organ and the adrenal
tumor exposed
excessive retroperitoneal fat. If one cannot identify the le adrenal, it is usually because the operative eld is too caudad and more superior dissection is
needed. In these cases, identifying the le renal vein will allow the identi cation of the le adrenal vein that may be traced to the adrenal gland
It is usually necessary to place a retractor device under Gerota’s fascia and the
tail of the pancreas in order to expose the operative eld (figure 3).
Once the gland is identi ed, dissection is begun with the ultrasonic device
along the inferior pole working medially. e adrenal vein is dissected with a
Maryland dissector so as to visualize its entire circumference.
on the patient side using a -mm clip applier (figure 4). e vein is cut sharply
leaving a longer stump on the renal vein side. e ultrasonic device is used to dissect around the adrenal gland beginning medially. Clips may be used to secure
prominent blood vessels (
seals small arterial vessels that enter the adrenal gland like the spokes of a wheel. In
some patients it is necessary to dissect the entire lateral border of the adrenal gland
in order to mobilize it and retract the gland superiorly, thus permitting identi cation of the adrenal vein. e inferior attachments are divided. Finally
lateral and superior attachments are dissected (figure 7). e gland is now free
for extraction in a laparoscopic retrieval bag (figure 8). e technique for extraction is described under laparoscopic right adrenalectomy (see Plate ).
e tumor bed is then inspected for any evidence of bleeding and any additional hemostasis obtained.
returned to its normal position.
POSTOPERATIVE CARE If the patient does not have a pheochromocytoma,
the orogastric tube and Foley catheter are removed in the postoperative recovery
area. Intravenous uids are administered and a clear liquid diet is ordered. Antibiotics are discontinued within hours. Vital signs are monitored every hours.
e hemoglobin is checked on postoperative day one and the diet advanced. e
patient is discharged on postoperative day to . If the patient has a pheochromocytoma, the patient will usually be in the ICU. Monitoring of urinary output with
a urinary Foley catheter is required. In addition blood pressure is monitored with
an arterial line. e patient is transferred from the ICU when stable and the diet
advanced. For patients with a functional tumor, discussion with the endocrinologist about resumption of preoperative medications is helpful.
(figure 3). It may be di cult to identify in obese patients with
figure 2). It is not necessary to mobilize the spleen.
figures 5 and 6). e ultrasonic dissector e ectively
e retraction on the pancreas is released and it is
(figure 1b).
(figure 3).
It is doubly clipped
the avascular
■
316
317
PLATE
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149
INDICATIONS e indications are as previously described for laparoscopic
le adrenalectomy.
PREOPERTIVE PREPARATION e same steps in preparation are taken as
described for the laparoscopic le adrenalectomy.
ANESTHESIA e anesthetic considerations as described for the le
adrenalectomy are followed.
ANATOMY See Plate .
POSITION A vacuum-assisted beanbag should be placed on the operating
table prior to bringing the patient into the room. e patient is positioned
with the bag being at the level of their ank below the ribs and above the
iliac crest over the break position of the table so as to allow a “jack knife”
extension that may be useful in obese patients.
For a right adrenalectomy the patient is placed in the right lateral position with the right arm crossing the chest and supported on an arm board
(figure 1a). e le arm is placed on an arm board and an axillary roll
used. In general the le and right positions are mirror images of each other.
A er the patient is positioned, the air is suctioned from the beanbag in
order to secure the position. In addition, the patient is secured across the
chest and hips to the table with wide adhesive tape, as the operating room
table will be tilted. Some surgeons may prefer to improve tape adhesion
with a skin preparation.
INCISION AND EXPOSURE For a right adrenalectomy the surgeon stands
on the patient’s le side (figure 1a). e camera operator stands to the
surgeon’s le and the assistant on the patient’s right. A -mm -degree
laparoscope is inserted using the aforementioned technique either in a
supraumbilical position or the right lateral subcostal position in the midclavicular line just above the level of the umbilicus. A -mm port is placed in
the right lateral subcostal area in the anterior axillary line and another -mm
port is placed just to the right of the midline and the right of the round
ligament. A third -mm port is placed on the right side in the anterior axillary line midway between the costal margin and the iliac crest (figure 1b).
Additional ports or larger ports may be placed depending on the preference
of the surgeon, the size of the tumor, and the shape and size of the patient.
e patient is then placed in a reverse Trendelenburg (head-up) position.
DETAILS OF THE PROCEDURE On the right side, the hepatic exure of
the colon is mobilized from the lateral gutter using the ultrasonic device.
Any adhesions about the lateral liver or even the gallbladder may need to
be incised with sharp dissection (figure 2). A Kocher maneuver is done to
expose the inferior vena cava in its position directly posterior to the second
portion of the duodenum and possibly the right renal vein as it is essential to know the location of these structures before entering Gerota’s fascia (figure 3). e right lobe of the liver should be mobilized by dividing
posterior and lateral attachments until the diaphragm is exposed so as to
gain a better exposure of the right adrenal (figures 2 and 3). A retractor is
placed to hold the liver superomedially (figures 2 and 3). is may require
an additional port—either a -mm or a -mm one depending upon which
A, R L
retractor device is used. e peritoneum lateral to the duodenum is then
incised, and it is mobilized in the usual Kocher maneuver manner by using
a blunt tip dissector or the ultrasonic device (figure 3). is area is then
cleared to show the right renal vein. Gerota’s fascia is incised and the superior pole of the right kidney is located (figure 3). e adrenal is identi ed
by its characteristic yellowish color, lobulated appearance, and its clearly
de nable blunt lateral edge.
e surgeon should bear in mind that the vascular attachments are usually on or near the medial and superior edges of the gland rather than on
its broad surfaces. (See Plate ). A er initial lateral and inferior mobilization, the adrenal gland may be retracted laterally. It is helpful to identify the
retrohepatic inferior vena cava (figure 4) and then the right adrenal vein.
e right adrenal vein is identi ed and doubly clipped proximally and distally using a -mm clip applier and divided (figures 4 and 5). e superior
attachments of the adrenal gland are then divided and the superior arterial
supply clipped or coagulated freeing the gland. Next the inferior portion of
the gland is further dissected exposing the adrenal artery arising from the
right renal artery. is is doubly clipped (figure 6). e generally avascu-
lar lateral area is then incised and additional exposure and mobility of the
adrenal gland may be obtained by gentle blunt dissection directly posterior
and lateral to the gland (figure 7). e suction tip is an excellent tool for
this blunt dissection. e gland should be free at this point for extraction
(figure 8). e tumor bed is inspected for bleeding and any additional
hemostasis obtained.
EXTRACTION OF THE ADRENAL GLAND e same technique is used
to remove either the right or the le gland from the peritoneal cavity.
e -mm laparoscope is removed, and the videocamera is mounted
on a -mm laparoscope. is is inserted through the most inferior -mm
trocar. A clear plastic specimen retrieval bag device is inserted into the
peritoneal cavity through the -mm Hasson port. e bag is opened and
the adrenal gland is grasped by some peri-adrenal fat or connective tissue. e gland is delivered into the bag (figure 8). e bag is closed and
separated from its insertion device. Using gentle traction, the bag with
the adrenal gland is pulled from the abdominal cavity through the Hasson
insertion site. e incision may need to be enlarged for larger tumors. It
is not necessary to fragment the adrenal gland into pieces as it is so and
pliable, permitting it to be removed through a relatively small opening.
e camera is then placed back on the -mm laparoscope and the bed of
the adrenal gland is irrigated and inspected for bleeding, which may be
controlled by electrocautery, the harmonic scalpel, or clips.
CLOSURE e Hasson trocar site is closed with interrupted absorbable
sutures. In the patient with hypercortisolism, nonabsorbable sutures may
be necessary. For Hasson incisions in the lateral abdomen or ank, the use
of a ompson closure device may be helpful. e skin is closed with subcuticular absorbable sutures or staples.
POSTOPERATIVE CARE e general principles are the same as those for open
adrenalectomy and those speci c to laparoscopic adrenalectomy are described
in the section on laparoscopic le adrenalectomy (see Plate ). ■
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VASCULAR PROCEDURES
PLATE
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150 V A, A F
INDICATIONS e most common indication for creation of an arterio-
venous (AV) stula is renal failure requiring chronic hemodialysis. It is
preferable to create a native stula, although prosthetic material may be
needed if a suitable vein is not available.
PREOPERATIVE PREPARATION e goal is to place an AV stula prior
to the patient starting dialysis. e day of surgery, electrolytes should be
checked to verify the absence of hyperkalemia. Many of the patients are
diabetic and close monitoring of blood glucose levels during the procedure is warranted. Antibiotic prophylaxis is administered within one
hour of the incision. A single dose is usually su cient. In patients with a
poorly de ned super cial venous system, venous mapping may be done
preoperatively to de ne the anatomy.
ANESTHESIA e patients requiring chronic hemodialysis are poor risks
for general anesthesia. An axillary block on the side that is to be used provides excellent regional anesthesia. If regional anesthesia cannot be done,
local anesthesia is a valid option.
POSITION e patient is placed in the supine position. e arm to be used
for the stula is placed on an arm board (figure 1). e opposite arm may
be tucked with a sheet or placed on an arm board.
OPERATIVE PREPARATION Hair is removed with clippers. e arm is
prepped circumferentially from the ngers to the axilla (figure 2). A er
draping, a sterile knit stocking is placed over the arm. is covers the ngers and arm to the axilla.
DETAILS OF PROCEDURE e surgeon palpates the radial pulse. e loca-
tion of the incision is planned (figure 3). A vertical incision is made in the
forearm close to the wrist and lateral to the radial pulse (figure 4). Once
the incision is carried to the deep subcutaneous tissue, self-retaining retractors are placed. Sharp and blunt dissection are used to identify the cephalic
vein. e vein is skeletonized for a distance of to cm. It is encircled with
vessel loops proximally and distally. Side braches of the vein are ligated with
- silk (figure 5). e radial artery is then dissected for a distance of to
cm. ere is a vein on either side of the radial artery that may be ligated or
freed from the artery. e artery is encircled with vessel loops proximally
and distally. Side braches are ligated as necessary with - silk. Both vessels
must be freely mobilized to enable a tension-free anastomosis. e artery
and vein are then encircled with a single vessel loop both proximally and
distally to allow alignment of the structures (figure 6).
A longitudinal venotomy is made in the cephalic vein with a number
blade and extended for cm with Iris scissors. e vein is dilated to size
. mm and a Silastic catheter is passed cephalad to ensure patency of the
vein. e vein is irrigated with heparinized saline (figure 7).
e patient is administered intravenous heparin. Fine curved or straight
bulldog clamps are placed proximally and distally on the radial artery. A
longitudinal arterotomy of cm is made. In some cases the artery may be
much calci ed and it will be necessary to probe the artery proximally to
ensure patency. Once patency is established, the proximal bulldog clamp
is reapplied. e artery and vein are aligned. A side-to-side anastomosis
is then created between the cephalic vein and the radial artery using running - nonabsorbable mono lament sutures. e needle on the arterial
side must be passed from the endothelial surface outward, ensuring the
endothelium is tacked down (figures 8 and 9). Needle B (figure 8) is
passed back into the lumen and then run continuously on the back wall—
always beginning into the arterial intima. At the end, it is tied externally
to one arm of suture A (figure 10). Once the anastomosis is nearly complete, the proximal bulldog clamp is released transiently to ensure in ow
and to ush out any clot. e distal bulldog is likewise released to ensure
back-bleeding and clear any clot and debris (figure 11). e suture is then
tied. e vessel loops are released on the vein and the distal and proximal
bulldog clamps are removed from the radial artery. e vein proximal to
the anastomosis is then palpated for a thrill to determine patency. Absence
of a thrill may indicate a technical problem and the anastomosis should be
re-explored. is is done by making a small venotomy in the cephalic vein
distal to the anastomosis and a dilator is used to explore the anastomosis
as well as the artery and vein. It is important to ligate the cephalic vein
distal to the anastomosis, usually with double - silk (figure 12). A er
ligation, the vessel is transacted, as this releases any tension on the anastomosis and reduces the incidence of venous hypertension of the hand.
e presence of a thrill is re-veri ed. Hemostasis is achieved and the subcutaneous layers are closed with interrupted - absorbable suture. e
skin is closed with a running subcuticular - absorbable suture. A sterile
dressing is then placed.
POSTOPERATIVE CONSIDERATIONS e patient is discharged the day
of the procedure. If needed, dialysis is continued by the temporary access
achieved prior to the operation. Occasionally, a venous side branch creating
diversion of ow may need ligation. It usually takes six weeks for the arteriovenous stula to mature and be ready to be used for hemodialysis. ■
322
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