Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_663_Библиотеки_им_академика_М_И_Перельмана

eral perpendicular extensions at the inferior, diaphragmatic part of the pericardial incision. This should give the pericar­diotomy the shape of an inverted “T” which usually provides the best exposure. Manually evacuate the pericardial content causing the tamponade, and assess cardiac contraction and rhythm status. If asystole or ventricular brillation is present, internal cardiac massage should be maintained until a per­fusing rhythm and adequate cardiac lling volume can be established. Communicate closely with the anaesthetic team with appropriate administration of resuscitation drugs like Adrenalin throughout. Internal debrillation paddles can be used to debrillate a non-perfusing ventricular rhythm but should be avoided in asystole. Find the bleeding laceration on the ascending aorta, and control it with digital compres­sion or a side-biting clamp (Satinsky or large Wiley “J” clamp). Once temporary haemostasis is achieved in this manner, use limited (but well-spent) time with attention to exposure and planning the repair. Pericardial retraction sutures improve access to the ascending aorta. Negotiate mentally whether repair underneath a digitally compressing nger or a carefully applied side-biting clamp will be most effectively performed. If a side-biting clamp is used, ensure adequate residual patency of the underlying aorta for proper ejection of the heart to perfuse the head and neck vessels. Consider the type of injury or defect and appropriate repair­ing strategy using 3.0 or 4.0 monolament nonabsorbable sutures. If a small pinpoint penetrating hole is encountered, a pledgeted “U” suture (autologous pericardial or Teon felt pledget) is most effective for repair. In a larger defect (but where the edges can be approximated), a lateral aortorrhaphy will sufce using direct suturing with a double layer of rst a horizontal mattress suture technique, ensuring that the endothelium is caught with every suture in order to traverse the full-thickness aortic wall and especially the strong adven­titial layer with the suturing needle. This technique should ensure a full thickness of 2–3mm of the aortic wall in the rst layer, which is then followed with a second layer of over-and-over suturing while ensuring that the bites of the second layer are just fractionally more supercial than the rst layer in order to avoid creating new suture holes. A larger defect where edges cannot be approximated should be repaired with the use of an autologous pericardial patch or prosthetic material (e.g. Dacron or Gore-Tex). The pericar­dium can easily be harvested from the pericardiotomy site and should be used untreated (kept moist in a saline-soaked Ratex swab after harvesting) with the smooth aspect of the pericardium applied to the internal aspect of the aorta. While sutures are tied on the aorta, it is ideal that the systolic blood pressure should be carefully lowered. A skilled anaesthetist may be able to perform this formidable task in an unstable trauma patient, but the easiest way is usually to manipulate the head-up bed position for a few seconds prior to tying a suture in order to achieve temporary but very reversible mild