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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3748_Библиотеки_им_академика_М_И_Перельмана
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7 Repair ofAortoenteric Fistula
91
removal or excision of all the remaining graft material. Complete excision of the
preexisting graft is mandatory. The time spent excising any grossly infected or
inammatory tissue is a critically important component of in-line replacement
therapy and should not be accomplished in haste. This often requires a debridement of the aortic wall up to the level of the inferior vena cava. Following this, the
anastomoses are performed to each uninvolved iliac artery, preferably beyond the
prior graft anastomosis.
If the graft does extend down to the femoral arteries, the groin incisions are
accomplished rst with exposure of the femoral arteries and the graft. The native
arteries are exposed proximal and distal to the site of the prior anastomosis. A twoteam approach is benecial to expedite the operation. Access to the retroperitoneal
tunnels down to the level of the femoral arteries is maintained within umbilical tape;
laparotomy pads can be passed through the tunnels accomplishing some additional
debridement while maintaining access. Due to the signicant retroperitoneal adhesions that are typically encountered, creation of a new tunnel is difcult with a signicant risk of iliac vein injury. It is useful to divide the graft limb just above the
anastomosis to allow for perfusion through the common femoral profunda–femoralsupercial femoral artery circuit, thereby limiting limb ischemia. The author has
also placed a Sundt shunt through the end of the cryopreserved or Rifampin-soaked
Dacron graft limb and the other end into the distal graft above the anastomosis; this
maintains perfusion to one limb, while the other limb will be sewn to the distal
artery. Once the distal anastomosis is ready to be performed, the arteries proximal
and distal to the graft are clamped, any remaining graft material is completely
excised, and the distal anastomosis is now performed. In most instances, when
doing the groin reconstruction, the author attempts to preserve retrograde ow.
However, in practice, many of the groin anastomoses are accomplished in an endto- end fashion. Providing coverage of the groin anastomoses, the rotational sartorius muscle is useful and performed when possible. The skin of the groin wound is
left open with the application of a VAC dressing.
Following both distal anastomoses, ow is completely restored, and attention
turns toward the duodenal defect. The defect is typically closed in a transverse fashion (Fig.7.7). If the duodenal defect is large, a segmental resection with end-to-end
anastomosis is performed. Finally, a segment of the omentum is mobilized and
wrapped around the recently placed cryopreserved arterial allograft or Rifampinsoaked Dacron graft (Fig.7.8). The omental pedicles are created by dividing the
omentum perpendicular to the omental arteries, typically using the right or left
omental arteries as the inow to the wrap.
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Fig. 7.7 The duodenal
defect closed in a
transverse fashion
T. J. Nypaver
7 Repair ofAortoenteric Fistula
93
Fig. 7.8 Schematic representing the omental wrap based upon the right omental artery
Use oftheCryopreserved Arterial Allograft
When time allows, this is our preferred treatment method for in-line repair of
AEF.The graft and appropriate sizes of the aortic allograft are determined to be
available. The graft is prepared as the operation ensues as there is a dened manufactural de-thawing process in the preparation of the cryopreserved allograft. The
thawing process averages approximately 30–40min. Slits to enlarge the circumference of the proximal portion of the graft may have to be performed to accommodate
the anastomosis due to the size discrepancy. Rather than using a single opening in
the allograft, incisions are made into the allograft both 3 o’clock and 9 o’clock
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Fig. 7.9 Preparation of the cryopreserved graft with the graft rotated with the lumbar arteries
oriented anteriorly. Insert: the lumbar branches are oversewn with 4-0 Prolene sutures, typically
with a gure-of-eight suture
T. J. Nypaver
positions for appropriate sizing. The graft is rotated so that the lumbar orices are
positioned anteriorly—each lumbar artery is to be oversewn with interrupted sutures
of 4-0 Prolene (rather than just tying off the branch). Any additional holes or leaks
in the allograft are also suture ligated (Fig.7.9).
Fill a 50cc syr
(total 50cc)
t
7 Repair ofAortoenteric Fistula
95
Use oftheRifampin-Impregnated (Soaked) Dacron Graft
The most used agent for antimicrobial impregnation of prosthetic grafts is soaking
the graft in the antibiotic solution of Rifampin. Prosthetic grafts form an ionic bond
with the Rifampin primarily through the gelatin that is used in the sealant process.
The antibiotic is released locally and gradually for a period of up to 5 days
(Fig.7.10).
40cc sterile saline
inge with
Reconstitute 600mg of
Rifampin with 10cc
of diluent provided
Draw up this 10cc
Rifampin solution
into the syringe
with the 40cc saline
Inject the 50cc Rifampin solution thru
lid of blister containing the Dacron graf
Fig. 7.10 Preparation sequence for the Rifampin-soaked Dacron graft
Allow 5 minutes
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T. J. Nypaver
Complications
This is an extensive operation, one which has a signicant physiologic insult to the
patient. Complications are generally related to the systemic response (early) and the
potential for additional infectious complications (late). Appropriate antibiotic coverage should be sustained for a minimum of 6months and potentially lifetime.
Take-Home Points
1. This is a complex operation, technically difcult and challenging. Cryopreserved
graft with in-line replacement is the procedure of choice in patients who are not
prohibitive risk.
2. The cryopreserved graft will need to be prepared with suture ligation of lumbar
vessels with the graft positioned so that the sutures ligatures (4-0 polypropylene)
appear on the anterior surface (to easily allow repair if needed after restoration
of ow).
3. Debridement of surrounding inammatory aortic tissue is critically important to
the long-term success of the operation; this is especially true when one is using
Rifampin-soaked Dacron graft. This debridement can be accomplished after the
proximal anastomosis is completed, thereby limiting visceral and renal ischemia.
4. One needs to ascertain that the cryopreserved graft is long enough to reach to the
anticipated distal anastomotic site—this is critically important when going to the
femoral levels. One also needs to make sure that the main body of the allograft
is not too long as to be compressed in the retroperitoneal tunnels. Rather, the
bifurcation needs to remain above where the retroperitoneal tunnels start.
Chapter 8
Open Repair ofRuptured Abdominal
Aortic Aneurysm
SachinderSinghHans
Patients with a ruptured abdominal aortic aneurysm (AAA) typically presents in
hypovolemic shock due to signicant blood loss unless the rupture is contained.
Hypovolemic shock is treated by volume replacement, but in patients with ruptured
AAA, restricting uid resuscitation and accepting lower systolic blood pressure
(permissive hypotension) have been shown to be benecial. Early transportation to
the emergency room of the hospital, prompt diagnosis (ultrasound/CTA), and immediate proximal control have a positive impact in the outcome of patients with ruptured AAA.In most patients, there is time to obtain an emergency CTA of the
abdomen and pelvis with 1mm cuts to conrm the diagnosis and plan either endovascular or open repair depending on the anatomy of the AAA.In patients with a
free rupture, CTA imaging may not be possible, and immediate transfer to the operating room is the best option.
Operative Technique
Patient is prepped from the nipple line to midthigh. To avoid cardiovascular collapse, anesthetic induction and intubation should be withheld until the surgeon is
ready to make the incision, as induction of the anesthesia can lead to profound
hypotension due to elimination of sympathetic tone. A rapid transfusion protocol is
activated. Cell saver (autologous blood recovery system) and body warmer are both
S. S. Hans (*)
Vascular and Endovascular Services, Henry Ford Macomb Hospital,
Clinton Twp, MI, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_8
97
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S. S. Hans
necessary. In most patients, a midline transabdominal incision from xiphoid process
to symphysis pubis is made. In few selected patients with ileostomy, urinary diversion, and contained rupture from leaking type IV thoracoabdominal aneurysm, a left
ank approach through tenth intercostal space is preferable. The incision extends
from the lateral border of the rectus abdominis muscle between symphysis pubis
and umbilicus and extends upward and laterally into the tenth intercostal space with
position of the table described in Chap. 3.
Proximal Control
In most hemodynamic stable patients, with associated small- to moderate-sized retroperitoneum hematoma, following mobilization of the ligament of Treitz with the
help of nger dissection around the aortic neck, proximal control can be obtained
with cephalad retraction of the left renal vein and proximal aortic clamp is applied
(Figs.8.1 and 8.2). In patients with extensive retroperitoneal hematoma and shock,
supraceliac control is preferable. If severe hypotension develops during nger dissection, then proximal control can be obtained by inserting the index and middle
nger of the operator’s hand into the aorta and guiding a number 28 Foley catheter
with a 30cc balloon, which is inated in the lower thoracic aorta.
8 Open Repair ofRuptured Abdominal Aortic Aneurysm
Fig. 8.1 Showing nger
dissection of the ruptured
AAA with the index nger
of the right hand just
behind the left renal vein
making the plane between
the aortic neck and the
surrounding tissue.
Proximal vascular clamp is
shown
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Fig. 8.2 Finger dissection
with the index nger in the
anterior wall so that the
aortic neck and on both
sides are separated from
the surrounding tissues
S. S. Hans
Exposure oftheSupraceliac Aorta
The left lobe of the liver is retracted toward the right following division of the left
triangular ligament. The peritoneal reection over the gastroesophageal junction is
divided and retracted to the left by a Penrose drain. This is usually aided by an NG
tube in the esophagus. Deep blades of the self-retraining retractor (Bookwalter III)
should be applied and gastrohepatic omentum is opened through a longitudinal
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