AAA

Patient supine.
Prep from lower chest to mid thighs
Check status of lower limb pulses preoperatively

Large midline incision
2.Place a self-retaining Buchwalter retractor and reflect the transverse colon upwards and SB to the right in a bowel bag. Have assistant hold the colon or pack intra-abdominally
3.Mobilize to some degree the D3 and D4 off the aorta.
Incise the peritoneum jst to the left of the duodenum
4.The inferior mesenteric vein is usually a barrier to continued division of peritoneum, although this can usually be divided, it is close to the upper limit of direct vision anyway as the inferior border of the pancreas comes into view.
5.The left renal vein is then seen to cross the front of the aorta. This is dissected to provide access to the aorta up to the renal artery origin (L2) below which clamps can be placed to obtain proximal control following administration of heparin 5000U.
6.Distal control is achieved with clamps after dissecting (not encircling) the distal CIA on both sides mindful of the common iliac veins lying deeper and to the right, as well as the ureter. Also be mindful of the parasympathetics overlying the left CIA. Clamp CIA first.
7.The peritoneum overlying the aneurysm can then be opened and the aneurysmal sac entered to the right of the midline. Suction clot away.
8.All posterior parietal branches and IMA (L3) may continue to back bleed and these must be suture ligated.
9.A suitable aortic/bifurcate graft (Dacron, 20mm wide) is placed and sutured to normal proximal aorta using a continuous 4/0 prolene (double ended). This is done always starting at the posterior wall using a parachute technique, working around diameter and closing anteriorly.
10.Clamps can then be let down to test patency. Further bleeding points on the anastomoses can be reinforced with sutures. If there is general ooze, Surgicel can also be used. If haemostasis is satisfactory then move the clamps distally and place them on the graft itself.
11.Similarly anastomose the distal end of the graft to healthy distal aorta or common iliac if bifurcate. Ensure the anastomosis is posterior to the ureters. Release iliac arteries sequentially after informing anaesthetist
12.The aneurysm sac is then closed over the graft using vicryl.
13.The small intestine is removed from the bowel bag and viability confirmed.
14.The abdomen is lavaged to remove stagnant blood/clot and a closed suction drain placed along the posterior abdominal wall.
15.Close in layers.


Special comments for ruptured AAA
Do not induce anaesthetic until patient prepped and draped.
If unstable, or free intra abdominal bleeding, or haematoma extends to the level of the renal vein, then apply supracoeliac clamp.

Supracoeliac clamp
Avascular portion of the gastrohepatic ligament is incised.
Large bore NGT inserted
+/- retract left lobe of liver
Manually control aorta
Blunt finger dissect through crura
Place aortic clamp superior to fingers
You now have control but you also have a visceral ischaemic time
Alternative is to place Foley catheter with 30ml balloon through incision in aneurysm and inflate