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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3749_Библиотеки_им_академика_М_И_Перельмана
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40
Fig. 3.7 Suture line
continued on each side and
the suture is tightened
S. S. Hans
In patients with weakened aortic wall near the neck, it is preferable to divide the
posterior wall aortic neck completely (transection). One may encounter adherent
lumbar veins at this juncture. In such cases, the graft and aortic neck are sutured
using all interrupted mattress sutures starting from the posterior wall, and pledgets
are used to buttress the suture line. A second layer of continuous suturing is done
starting posteriorly and then laterally and completing it anteriorly.
In patients with juxtarenal AAA, a suture technique (two layers) telescoping the
Dacron graft into the aortic neck is taking bites almost near the orices of the renal
arteries (Figs.3.10, 3.11, 3.12, 3.13, 3.14, 3.15, 3.16, and 3.17). After the completion of proximal anastomosis, the retractors should be released to prevent injury to
the SMA as forceful retraction can lead to dissection of the SMA due to intimal
damage.Even before the proximal anastomosis is started, the blades of the selfretaining retractors should be applied in such a manner that adequate exposure is
obtained, but a forceful retraction is not necessary as it may cause injury to surrounding structures and compression of the inferior vena cava resulting in diminished venous return and hypotension. Common iliac anastomosis is constructed in
an end-to-end fashion. Common iliac artery should be divided completely and dissected from the iliac vein. Two sutures are started posteriorly and continued in each
side to be completed anteriorly. Antegrade ow to at least one hypogastric artery
should be preserved to prevent pelvic ischemia. If the origin of the external iliac and
3 Open Repair ofJuxtarenal andInfrarenal Abdominal Aortic Aneurysm
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 3.8 Anterior suture
line continued
41
Fig. 3.9 Anterior suture
line is almost completed
42
Fig. 3.10 A telescopic
proximal anastomosis (all
upper case) for repair of
juxtarenal AAA.In rst
layer of horizontal mattress
sutures between the
Dacron graft and juxtarenal
aorta at 9 o’clock position
Fig. 3.11 Another suture
started at 3 o’clock
position in a similar
fashion
S. S. Hans
3 Open Repair ofJuxtarenal andInfrarenal Abdominal Aortic Aneurysm
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 3.12 Horizontal
mattress suture technique
is continued posteriorly
taking wider bites in the
aorta as compared to the
Dacron graft
43
Fig. 3.13 Second layer of
continuous suture is
performed posteriorly
44
Fig. 3.14 Graft is laid in
its bed and the rst layer of
horizontal mattress suture
is started at 3 o’clock and
continued anteriorly
toward 12 o’clock
S. S. Hans
the hypogastric is quite apart due to the presence of common iliac aneurysm, it is
preferable to anastomose the graft limb to the hypogastric artery, and anastomoses
of external iliac artery end to side to the iliac limb of the graft if it is redundant is
performed; otherwise, an interposition graft between the external iliac artery and the
anastomosed limb to the hypogastric artery is preferred. Before completion of distal
anastomosis, clamps should be released in such a manner to prevent atheromatous
debris embolizing into the lower extremities. Following completion of distal anastomosis, the clamps are released gradually to prevent declamping shock. The anesthesia team should be informed so that the administration of intravenous uids is
increased. Arterial Blood gasses should be obtained. Usually, there is a 15–20mmHg
drop in blood pressure when the graft limb is opened, and failure of the drop in
blood pressure usually indicates inadequate perfusion of the extremity. After completion of iliac anastomosis on one side, there is a distinct possiblity of fresh
3 Open Repair ofJuxtarenal andInfrarenal Abdominal Aortic Aneurysm
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 3.15 Near completion
of the rst layer of
horizontal mattress
suture line
45
Fig. 3.16 Second layer of continuous suture line (over and over)
46
Fig. 3.17 A completed
two-layer telescoping
anastomosis between the
Dacron graft and the
juxtarenal aorta
S. S. Hans
bleeding from the lumbar artery or arteries in the posterior wall of aneurysm sac
which demands immediate attention.
In patients with tube graft clamp, release should be extremely gradual, as
declamping shock can be much more severe as compared to patients undergoing
aortic bi-iliac reconstruction. Doppler signals in posterior tibial and dorsalis pedis
arteries on both sides should be checked and if distal pulses are not palpable. The
inferior mesenteric artery should be reimplanted as Carrel patch in patients with
large IMA with poor back bleeding in patients with associated SMA or celiac artery
occlusive disease (Fig.3.18). Retroperitoneum is sutured by approximately small
bowel mesentery to the sigmoid mesocolon inferiorly and tissue in dividing the
right wall of the aneurysm and descending mesocolon superiorly so that the graft is
not in contact with the small bowel and the abdomen is closed in layers with the
peritoneum and linear abdomen as a single layer with number one PDS suture.
3 Open Repair ofJuxtarenal andInfrarenal Abdominal Aortic Aneurysm
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
47
Fig. 3.18 Reimplantation of the inferior mesenteric artery with a disc of aortic wall ready to be
implanted into the left limb of the aortoiliac graft as Carrel patch
Retroperitoneal Approach
Patient Position
Patient is placed in a modied right lateral decubitus position with the shoulders at
70 degrees to the operating table and the hips more posteriorly. This is helpful if
groin incisions become necessary. Patient is also placed in a jackknife position in a
vacuum “beanbag” to open the left ank. The table is tilted toward the right. The
mid-point between the patient’s right costal margin and right iliac crest is centered
over the break of the table (jackknife position). For infrarenal aneurysm repair, the
incision extends from the lateral margin of the left rectus sheath from a point midway between the symphysis pubis and umbilicus extending laterally and upward
into the eleventh intercostal space for 10–12cm. In patients undergoing a repair for
juxtarenal or pararenal aortic aneurysm, the incision extended into the tenth intercostal space (Fig.3.19). The muscles of the abdominal wall and intercostal muscles
are divided in the line of the incision, and extraperitoneal space is entered at the tip
of the 12th rib. The peritoneum along with the transversalis fascia is separated from
the abdominal wall muscles anteriorly. In the inferior part of the dissection, the
peritoneal sac and its contents are retracted anteriorly and medially (Fig.3.20). In
48
Fig. 3.19 Left ank
incision for retroperitoneal
incision. (a) Infrarenal
AAA. (b) Juxtarenal AAA
S. S. Hans
A
B
A - Infrarenal AAA
B - Juxtarenal AAA
Fig. 3.20 Retroperitoneal
exposure of AAA. The
plane of dissection is
behind the left kidney.
Proximal aortic clamp is
above the superior
mesenteric artery for repair
of pararenal AAA
patients with infrarenal AAA, dissection can be performed anterior to the left kidney and kidney left in its bed (Fig.3.21). In patients with juxtarenal or pararenal
aortic aneurysms, the dissection plane is developed behind the kidney. The left kidney and ureter are reected medially and anteriorly. Inferiorly, distal abdominal
aorta and left CIA are dissected. The left renal artery is exposed. The posterior
3 Open Repair ofJuxtarenal andInfrarenal Abdominal Aortic Aneurysm
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 3.21 Retroperitoneal
exposure with the left
kidney in a bed. This
technique is necessary in
patients with retroaortic
left renal vein
49
lumbar branch of the left renal vein is present just below the origin of the left renal
artery and aids in its identication. In patients with retroaortic left renal vein, as
determined on preoperative CTA images, the dissection should be performed anterior to the left kidney. The periaortic fascia and lymphatics around the neck of the
aorta are ligated and divided exposing the posterior and lateral wall of the aneurysm. Heparin is adminstered by the anesthesia team with monitoring of
ACT. Placement of the aortic cross-clamp is the next step as in transperitoneal exposure. Like in transperitoneal exposure, circumferential dissection of the aorta is not
necessary.
For exposure of the suprarenal aorta, the dissection proceeds cephalad dividing
the left crus, identied as a rm tendinous band crossing the aorta just proximal to
the origin of the left renal artery. The origin of the left renal artery is exposed with
a Kittner dissector or with a gentle nger dissection, anterior and posterior to the
aorta. Silver clips are applied to the lumbar arteries at this time. Fibers of the left
crus will need to be divided for another 5cm proximally and the fascia around the
aorta is carefully divided to expose the supraceliac aorta, which is often a better site
for proximal aortic clamping than placing the clamp at the suprarenal level. In
patients necessitating supraceliac control, incision should be made in the tenth
intercostal space, and the peritoneal sac is reected medially from the left iliac forceps carefully mobilizing the ureter and peritoneal sac. Exposure of the left CIA and
its bifurcation is excellent from the left ank approach, but the right CIA can only
be exposed in its proximal one third. Division of the IMA and further mobilization
of the peritoneal sac medially improve the exposure of the right CIA.If a vascular
clamp cannot be safely applied to the right CIA, then endoluminal control with a
large Fogarty catheter or a Pruitt occlusion baloon catheter or a large Garrett dilator
(Teleex) can help control retrograde bleeding. Distal right CIA can be exposed by
extending the left ank incision to the midline, but this may result in inadvertent
entry into the peritoneum. Though challenging, the right lower quadrant incision,
3–4cm above the right inguinal ligament with rotation of the table to the left, can
help in extraperitoneal exposure of the right CIA bifurcation and proximal right
external iliac artery. For femoral anastomosis (in patients with associated occlusive
disease), groin incisions can be made by rotating the table. Exposure of the right
renal artery is inadequate with this approach. Further steps for aortic graft
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