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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_630_Библиотеки_им_академика_М_И_Перельмана
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151
V A, P P,
I J V
INDICATIONS e most common indication is for the administration
of chemotherapy or long-term parenteral nutritional support. For these
purposes, a port is usually used. For short-term therapies, alternatives
include a tunneled central venous catheter or a peripherally inserted central catheter (PICC).
PREOPERATIVE PREPARATION e procedure is usually performed as
an outpatient. Electrolytes and clotting studies should be checked prior to
the procedure. If the patient has had previous central catheters, a careful
history should be obtained, as this will help with site selection. Transcutaneous ultrasound can assist with vein localization. A single dose of preoperative antibiotics provides for prophylaxis.
ANESTHESIA Moderate sedation and local anesthesia is preferred.
POSITION e patient is placed in the supine position. Fluoroscopy should
be available. e arms are tucked at each side.
OPERATIVE PREPARATION e hair is removed with clippers. e cho-
sen side of the neck/upper thorax are prepped and draped using the maximum sterile barrier technique.
DETAILS OF PROCEDURE
INTERNAL JUGULAR VEIN ACCESS e internal jugular vein may be
safer than subclavian venous access. e internal jugular vein is located
posterior to the sternocleidomastoid mastoid muscle (figure 1). It is usually accessed by a percutaneous route. e plate demonstrates a right internal jugular cannulation.
Preliminary ultrasound of the right side of the neck is done in order to
document the patency of the internal jugular vein. With real-time ultrasound guidance and employing a modi ed Seldinger technique, a small
incision is made in the skin of the neck with a blade and the internal
jugular vein is cannulated with a small diameter needle (figure 2a). A er
removing the syringe, the surgeon places a exible guidewire (figure 2b).
e needle is removed, and over this wire, a -French dilator is placed to
create a track (figure 3). A - to -cm transverse incision is made on the
upper right thorax two ngerbreadths below the clavicle and a hemostat
is passed to create a tunnel between the two incisions (figure 4). Blunt
dissection is done to create a subcutaneous pocket on top of the pectoralis
muscle fascia for the reservoir (figure 4). e Silastic catheter is advanced
through the subcutaneous tissues from the upper thoracic subcutaneous
pocket to the neck incision (figure 4). e -French dilator is exchanged
over a wire for an introducer with a peel-away sheath (figure 5). e
dilator and wire are removed from the introducer. e Silastic catheter
is advanced through the peel-away sheath (figure 6) and is positioned
under uoroscopy with its tip in the right atrium (figure 7). Keeping the
catheter in place with a forceps (figure 6), the sheath is “peeled away” by
pulling it apart laterally until it is completely split and out. e catheter is
cut to length at the pocket and the slide-on boot is placed over the catheter. e catheter is pushed onto the chamber hubs (figure 8a), and the
boot is slid down over the catheter in order to secure its attachment to the
hub (figure 8b). Immediately following placement, each of the ports is
aspirated and ushed to verify patency. If any resistance is encountered,
then obstruction of the catheter in the vein insertion site, the tunnel, or
at the junction of the catheter with the reservoir should be suspected.
ese sites should be inspected. e position of the catheter with its tip
in the right atrium should be veri ed by uoroscopy. e reservoir is then
secured with nonabsorbable mono lament suture to the pectoralis fascia.
e subcutaneous tissues of the reservoir pocket are closed using interrupted - absorbable suture. e port must be easily palpable, and in very
obese patients, the subcutaneous fat may need to thinned directly above
the port. e skin edges are approximated using a continuous subcuticular
- absorbable suture. e neck incision is closed using a single subcuticular - absorbable suture and the port is checked for ow in both infusion
and aspiration a er which it is loaded with a dilute heparin solution. e
nal con guration is shown in figure 9 and all personnel who access the
port must remember to use the special needles that do not cut or core out
a segment of the Silastic access dome as they are inserted into the port.
ALTERNATIVELY e central venous system may be accessed via the sub-
clavian vein as shown in Plate . In this operation the subclavian skin
entrance site is opened a few millimeters and a tunnel is created with a
small hemostat to the port site pocket. e subcutaneous fat at the entrance
may require some spreading so as to allow the Silastic catheter to round this
corner without an obstructing angulation. e remainder of the procedure
is the same except for the need to close this skin incision with a few absorbable subcuticular sutures followed by adhesive skin strips. e port is then
aspirated, checked for free ow in both directions, and nally loaded with
a dilute heparin solution. ■
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V A, C V
C, S V
INDICATIONS e most common indication is for the short-term ( to
days) administration of uids, electrolytes, antibiotics, or other concentrated parenteral medications that are not well tolerated in peripheral
veins. Absence of suitable peripheral veins and patient comfort are alternative indications, as is the inability to place a peripherally inserted central
catheter (PICC).
PREOPERATIVE PREPARATION e procedure may be performed at the
bedside, in the operating room, or in an outpatient ambulatory setting.
Electrolytes and clotting studies should be checked prior to the procedure.
If the patient has had previous central catheters, a careful history should be
obtained, as this will help with site selection. Transcutaneous ultrasound
can assist with vein localization.
ANESTHESIA Moderate sedation and local anesthesia is preferred.
POSITION e patient is placed in the supine position, and the arms are
tucked at each side. Fluoroscopy should be available.
OPERATIVE PREPARATION e hair is removed with clippers. e cho-
sen side of the neck and upper thorax are prepped and draped using the
maximum sterile barrier technique.
DETAILS OF PROCEDURE figures 1 and 2 show the relevant anatomy of
the subclavian vein. It may be cannulated on the right or the le side. e
plate shows cannulation on the right side. On the right, the subclavian vein
courses behind the medial third of the clavicle and joins the internal jugular vein to drain into the superior vena cava. It lies anterior and inferior
to the subclavian artery. e dome of the right lung lies behind the vessels.
Ultrasound is used to con rm the patency of the vein and location. e same
modi ed Seldinger technique is used as described in Plate . e patient is
placed in a supine position. A rolled towel or sheet is placed in the interscapular area to allow the shoulder to drop to the side away from the infraclavicular
site (figure 1). e patient is placed in a -degree Trendelenburg position
(head down) in order to minimize the risk of air embolism and increase the
size of the vein. e head is turned slightly to the opposite side. A er installation of local anesthetic to include the periosteum of the clavicle, the subclavian vein is cannulated with a small caliber needle (figure 3). Ultrasound
guidance may be used to provide assistance. A key landmark is the point one
ngerbreadth lateral to the junction of the middle and medial thirds of the
clavicle. e needle is inserted at this point and passed along a straight line
toward the sternoclavicular joint on a plane parallel to the chest wall. A exible guidewire is inserted into the needle (figure 4), and if any arrhythmia is
noted, the wire is withdrawn until the electrocardiogram returns to its usual
pattern. e position of the wire is uoroscopically veri ed. e triple lumen
catheter is thread over the guidewire (figure 5). Topical antiseptic and a dry
sterile dressing are placed over the entrance site. e catheter hub and wings
are secured to the chest skin with ne nonabsorbable sutures (figure 6). A
chest x-ray is obtained to verify the position of the catheter and exclude complications such as a pneumothorax. ■
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INDICATIONS Aneurysms of the abdominal aorta occurring below the
renal vessels should, in general, be replaced. is is particularly true if they
are enlarging and producing pain or if there is evidence of impending or
actual rupture. In poor-risk patients with small aneurysms less than cm
in diameter, observation may be the better course. Many aneurysms are
corrected by endovascular techniques, but an open operative approach is
acceptable and sometime necessary alternative. Although the operation is
of considerable magnitude, anticipated mortality associated with spontaneous rupture and exsanguination from an aneurysm is such as to warrant the
risk of surgery in the great majority of patients. Emergency operations may
o er the only chance of a patient’s survival if there is evidence of leakage or
rupture of the aneurysm. A past history of coronary artery disease is not a
contraindication to surgery.
PREOPERATIVE PREPARATION CT scan best de nes the size and con-
tour of these aneurysms. Transabdominal ultrasound is a good screening
tool, but CT best de nes size and proximal and distal extent. Aortography
is carried out if there is a question about the extent of the aneurysm, if distal
occlusive disease is present, and when renal vascular disease or mesenteric
insu ciency is suspected. A thorough cardiac evaluation with an electrocardiogram, echocardiogram, and imaging stress test is performed.
In elective resection of an aneurysm, the preoperative preparation consists of emptying the large intestine by administering a mild cathartic. A
uid load of “crystalloid” is given at approximately to mL per hour
beginning the evening before operation. Intravenous antibiotic coverage is
started on call to the operating room. A nasogastric tube is inserted, and
constant bladder drainage is initiated to follow accurately the hourly output
of urine, especially during the immediate postoperative period. Catheters
are placed for central venous and arterial monitoring, while a Swan-Ganz
catheter may be useful in complex cardiac cases.
ANESTHESIA General anesthesia with endotracheal intubation is rou-
tine. e arterial line permits instantaneous evaluation of blood pressure
changes, and blood gas sampling can be done when required. Several largebore (-gauge) catheters should be placed intravenously for adequate control of uid and blood replacement.
POSITION e patient is placed in a slight head-down position to aid
in natural retraction of the small intestine from the region of the lower
R A A A
abdomen. Intravenous catheters are secured in place in both arms and adequately protected from dislodgement. e urethral catheter is connected to
a constant bladder drainage bottle. Since the presence of pulsations of the
dorsalis pedis must be veri ed a er the prosthesis has been inserted, some
type of low support should be provided over the feet and lower third of the
legs to assist in evaluating the presence of arterial pulsations.
INCISION AND EXPOSURE A long midline incision is made from xiphoid to
pubis (figure 1). Many surgeons use a large open ring retractor for exposure.
is retractor is secured to the side rail of the operating table and allows for the
placement of multiple individual curved or angled adjustable retractors.
DETAILS OF PROCEDURE A er rapid palpation and visualization of the
aorta and con rmation of the diagnosis of aneurysm, steps are taken to
empty the abdominal cavity of small intestine. Unless the abdominal wall
is quite thick, the greater portion of the small intestine can be retracted
upward and to the right and inserted into a plastic bag, the mouth of which
can be partly constricted by a tape (figure 2). Saline is added to the plastic
bag to keep the intestine moist. A sterile gauze pad is inserted into the neck
of the plastic bag to avoid undue constriction and prevent the escape of the
small intestine from the bag. It may be advisable (if the aneurysm is sizable and involves the right common iliac) to mobilize the appendix, terminal ileum, and cecum and to retract the right colon upward. e small and
large bowels are retracted laterally and superiorly using multiple adjustable
retractors. Additional exposure can be gained by dividing the peritoneum
about the ligament of Treitz to permit further retraction of the small intestine upward and to the right (figure 2). What at rst may appear to be
an inoperable aneurysm eventually may prove to be rather easily resectable,
since the aneurysm tends to bulge anteriorly and seems to extend up so high
as to suggest involvement of the renal vessels (figure 3). e bulk of the
aneurysm tends to come forward from under the le renal vein. e incised
peritoneum over the anterior surface of the aneurysm is re ected by blunt
and sharp dissection until the le renal vein is visualized. Blunt and sharp
dissection frees the le renal vein from the underlying aorta (figure 4). e
le renal vein is retracted upward with a retractor (figure 5) to gain additional space for the application of the occluding clamp to the aorta above the
aneurysm. e le renal vein can be divided, if necessary, to gain the nal
exposure. It does not need to be reanastomosed if the adrenal and gonadal
vessel veins are intact.
CONTINUES
328
1
Incision
Aneurysm
2
Ligament of Treitz
Duodenum
Left
renal
vein
3
Inferior
mesenteric artery
Aneurysm
Blood clot
Lumen
Lumbar arteries
5
Left
4
renal vein
Inferior
vena cava
Aorta
Aneurysm
Inferior
mesenteric
artery
Aneurysm
Right common
iliac artery
329
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154
DETAILS OF PROCEDURE e inferior mesenteric artery
is clamped (figure 6). e aortic side may be divided and ligated from
without or, conversely, oversewn from within a er the aneurysm is opened.
Usually, this vessel is small and sclerotic, in which case its sacri ce is of little
consequence. In some instances, it is large and serves as a major contributor to the le colon blood supply, especially if internal iliac and mesenteric
occlusive disease is present. In such cases the vessel will be patent but will
not exhibit back bleeding. Reimplantation of this vessel into the aortic gra
may be required to protect the colon.
e common iliac arteries then are exposed on their anterior, lateral,
and medial surfaces in preparation for clamp placement. It is not necessary
to encircle these vessels completely, and dissection posteriorly can result
in troublesome hemorrhage from the underlying iliac veins. During the
iliac artery exposure the ureters are identi ed and protected from injury
throughout the procedure (figure 6).
In the past, certain gra s required preclotting; however, this is not necessary with woven gra s, knitted gra s sealed with collagen or gelatin, or
expanded polytetra uoroethylene gra s.
R A A A
Heparin is then injected systemically or directly into the aneurysm
to provide protective anticoagulation for the extremities during aortic
clamping.
Angled vascular clamps are applied to the distal common iliac arteries.
An aortic clamp is used to occlude the aorta proximal to the aneurysm
and distal to the renal arteries. A careful identi cation of the position of
the renal arteries is mandatory before clamp application. e aneurysm is
then opened through a linear arteriotomy (figure 7). e mural throm-
bus is extracted (figure 8). Bleeding from the paired lumbar arteries is
controlled with full-thickness mattress or gure-of-eight nonabsorbable
suture ligatures (figure 9). e aortic cu is next prepared by dividing
all but the posterior wall. Leaving this portion attached prevents troublesome bleeding from lumbar veins o en found in this area (figure 10).
e iliac arteries are prepared in similar fashion; the posterior wall is
undisturbed to protect the iliac veins (figure 10). Alternatively, some
surgeons prefer to completely transect the proximal aorta and the distal
iliac arteries so as to provide free circumferential cu s for gra anastomoses.
CONTINUES
330
6
Right ureter
Inferior
mesenteric artery
Right
common
iliac artery
Aneurysm
7
Inferior
mesenteric
Incision
artery
8
10
Ligated
lumbar arteries
Clotted blood
Aneurysm
Aorta
9
331
Common
iliac arteries
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DETAILS OF PROCEDURE A gra of appropriate size is then
stretched and tailored to t the aortic defect (figure 11). Suturing of the
gra begins in the midline posteriorly with a double-arm swedged or
nonabsorbable suture usually made of mono lament nylon or polypropylene. e initial stitch begins by passing both needles from outside
inward on the gra and from inside outward on the aorta. is suture is
then tied (figure 12). Over-and-over suturing is then carried from the
midline position, proceeding from outside the gra to inside the aorta. At
the midline anteriorly, this suture is again tied (figure 13).
R A A A
Vascular clamps are temporarily applied to the iliac limbs of the gra ,
and the aortic clamp is momentarily released to check the proximal suture
line for hemostasis and the preclotting of the gra . Should leaks be noted in
the anastomosis, they can be controlled by individual mattress sutures.
e iliac anastomoses are done in the same manner as that of the aorta
(figure 14). Just before completion of the anastomosis, the aortic clamp is opened
momentarily to ush any clots that may have accumulated in the aorta or gra
(figure 15). is ushing out greatly lessens the incidence of subsequent thrombosis in either extremity and justi es a considerable loss of blood.
CONTINUES
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