Upper limb
•Arm – make a longitudinal incision laterally from deltoid insertion to lateral epicondyle. Identify the intermuscular septum and divide fascia anterior and posterior to this, decompressing both compartments. The radial nerve crosses the septum posterior to anterior halfway down the arm.
•Forearm – make an incision longitudinally across the wrist and divide the carpal tunnel. Extend this incision transversely down to the ulnar border of the wrist, run up the ulnar border of the forearm and then transversely across the cubital crease. Divide the bicipital aponeurosis as necessary. To release the dorsal compartment, make a longitudinal incision down the length of the forearm.
Lower limb
•Thigh – Make an incision from the greater trochanter to the lateral condyle of the femur and incise the iliotibial tract. Reflect the vastus lateralis off the intermuscular septum and incise the septum longitudinally the whole length of the septum. To decompress the medial compartment a separate incision is required.
•Leg – Two incision technique.
oMake an incision longitudinally through skin and fascia centred between the fibula and the tibial tuberosity. Decompress the anterior compartment in line with tibialis anterior. Identify the lateral septum and superficial peroneal nerve and decompress the lateral compartment.
oMake a second incision longitudinally, 2cm medial to the subcutaneous medial border of the tibia. Release the superficial compartment and the deep compartment over the FDL. Identify tibialis posterior and release its fascia.
Popliteal artery relations
AVN(posterior tibial) from medial to lateral, NVA in lower part.
Showing posts with label Vascular. Show all posts
Showing posts with label Vascular. Show all posts
Monday, October 1, 2007
Below knee amputation
1.Position the patient supine with foot wrapped in drape/crepe.
2.Make an incision (Burgess) a hands-breadth or 10cm below the tibial tuberosity. Ligate the long saphenous vein.
3.Divide through anterior compartment with anterior tibial artery and deep peroneal nerve situated on the interosseus membrane. Ligate large vessels and nerves. Divide through lateral compartment ligating superficial peroneal nerve in the substance of peroneus longus.
4.Define the level of transection of bone with a periosteal elevator. Divide the fibula at a more proximal level (at least 1.5cm) using bone cutting forceps. Transect the tibia with a Gigli saw and bevel the edges round.
5.Divide through posterior compartment (On entering the popliteal fossa, in the upper part the relationship is AVN(tibial) from medial to lateral whence it arches laterally midway and in the lower part of the fossa reassumes its previous relationship i.e. NVA and crosses the soleal arch) ligating posterior tibial artery and tibial nerve medially with peroneal artery adjacent to the medial aspect of the fibula on the posterior surface of tibialis posterior.
6.Create a long posterior myocutaneous flap, consisting of muscular fibres of gastroecnemius NOT tendon, supplemented with soleal fibres if needed. Ligate short saphenous vein and sural nerve in the subcutaneous tissue at the inferior apex of the flap.
7.Place an epineural catheter near the stump of the tibial nerve and infiltrate bupivacaine.
8.Close in layers using 3/0 vicryl/monocryl.
2.Make an incision (Burgess) a hands-breadth or 10cm below the tibial tuberosity. Ligate the long saphenous vein.
3.Divide through anterior compartment with anterior tibial artery and deep peroneal nerve situated on the interosseus membrane. Ligate large vessels and nerves. Divide through lateral compartment ligating superficial peroneal nerve in the substance of peroneus longus.
4.Define the level of transection of bone with a periosteal elevator. Divide the fibula at a more proximal level (at least 1.5cm) using bone cutting forceps. Transect the tibia with a Gigli saw and bevel the edges round.
5.Divide through posterior compartment (On entering the popliteal fossa, in the upper part the relationship is AVN(tibial) from medial to lateral whence it arches laterally midway and in the lower part of the fossa reassumes its previous relationship i.e. NVA and crosses the soleal arch) ligating posterior tibial artery and tibial nerve medially with peroneal artery adjacent to the medial aspect of the fibula on the posterior surface of tibialis posterior.
6.Create a long posterior myocutaneous flap, consisting of muscular fibres of gastroecnemius NOT tendon, supplemented with soleal fibres if needed. Ligate short saphenous vein and sural nerve in the subcutaneous tissue at the inferior apex of the flap.
7.Place an epineural catheter near the stump of the tibial nerve and infiltrate bupivacaine.
8.Close in layers using 3/0 vicryl/monocryl.
Above knee amputation
1.Position the patient supine with the leg wrapped in drape/crepe.
2.Make a fish-mouth incision at the level of intended amputation (supracondylar, diaphyseal or sub-trochanteric) usually a hands-breadth or 10cm above the upper border of patella, ligating the long saphenous vein medially.
3.Divide through the anterior compartment and contained quadriceps, sartorius and subsartorial canal with ligation of femoral vessels and saphenous nerve. Deep to the quadriceps and on adductor magnus, adjacent to the femur ligate the profunda femoris vessels. Bevel the muscle down to the femur proximally.
4.Divide through the posterior compartment and ligate the sciatic nerve.
5.Transect the femur with a Gigli saw and bevel the edges round with a rasp.
6.Place an epineural catheter near the stump of the sciatic nerve and infiltrate bupivacaine.
7.Close in layers using 3/0 vicryl/monocryl.
2.Make a fish-mouth incision at the level of intended amputation (supracondylar, diaphyseal or sub-trochanteric) usually a hands-breadth or 10cm above the upper border of patella, ligating the long saphenous vein medially.
3.Divide through the anterior compartment and contained quadriceps, sartorius and subsartorial canal with ligation of femoral vessels and saphenous nerve. Deep to the quadriceps and on adductor magnus, adjacent to the femur ligate the profunda femoris vessels. Bevel the muscle down to the femur proximally.
4.Divide through the posterior compartment and ligate the sciatic nerve.
5.Transect the femur with a Gigli saw and bevel the edges round with a rasp.
6.Place an epineural catheter near the stump of the sciatic nerve and infiltrate bupivacaine.
7.Close in layers using 3/0 vicryl/monocryl.
Brachial embolectomy
1.The arm is usually more resistant to critical ischaemia therefore hand remains viable and surgery can be performed at earliest convenience not emergency.
2.Make a transverse incision 1cm distal to cubittal skin crease over the medial side of the forearm.
3.Make a longitudinal incision through fascia and bicipital aponeurosis
4.Identify the brachial artery (N(median)AV from medial to lateral) and venae comitantes.
5.Isolate the brachial artery proximally and sling to allow control, then follow the brachial artery distally to expose bifurcation into ulnar and radial (note may be trifurcation with deep interosseus artery) and sling distally.
6.Administer IV heparin at 100units/kg and then pull up and clip slings to drapes – no clamps on small arteries.
7.Make a transverse arteriotomy just proximal to bifurcation and assess inflow and backflow.
8.Perform a Fogarty balloon embolectomy proximally (size 3 or 4 proximally) until two clear passes and reassess inflow.
9.Similarly, perform a distal embolectomy (size 3) down each branch until two clear passes.
10.Flush with heparinized saline and assess resistance to flow.
11.Close the arteriotomy with 6/0 prolene continuous (begin at each apex and tie in middle). Release slings prior to tying to ensure do not narrow the artery
12.Drain and close
2.Make a transverse incision 1cm distal to cubittal skin crease over the medial side of the forearm.
3.Make a longitudinal incision through fascia and bicipital aponeurosis
4.Identify the brachial artery (N(median)AV from medial to lateral) and venae comitantes.
5.Isolate the brachial artery proximally and sling to allow control, then follow the brachial artery distally to expose bifurcation into ulnar and radial (note may be trifurcation with deep interosseus artery) and sling distally.
6.Administer IV heparin at 100units/kg and then pull up and clip slings to drapes – no clamps on small arteries.
7.Make a transverse arteriotomy just proximal to bifurcation and assess inflow and backflow.
8.Perform a Fogarty balloon embolectomy proximally (size 3 or 4 proximally) until two clear passes and reassess inflow.
9.Similarly, perform a distal embolectomy (size 3) down each branch until two clear passes.
10.Flush with heparinized saline and assess resistance to flow.
11.Close the arteriotomy with 6/0 prolene continuous (begin at each apex and tie in middle). Release slings prior to tying to ensure do not narrow the artery
12.Drain and close
Femoral Embolectomy
1.Position the patient supine.
2.Prepare the entire limb on the involved side only.
3.Make a vertical incision over the mid-inguinal point and insert a self-retaining retractor (Weitlander).
4.Dissect down to the femoral artery/profunda trifurcation. Administer 5000u of heparin and then encircle the vessels with vascular slings.
5.Make a longitudinal arteriotomy at the trifurcation with a clamp on the patent vessels.
6.Insert a Fogarty balloon catheter (size 4 or 4mm calibre) and perform an antegrade embolectomy to beyond the popliteal trifurcation if possible. If there is an occlusion beyond which the catheter will not pass it may be at the adductor hiatus (try again with the tip bent) or because of atheroma. Similarly, perform a retrograde embolectomy (using a size 5 catheter).
7.Remove clot ahead of the embolectomy balloon with a vascular sucker, with a right angled clamp at the ready. If there is steady back bleeding, conclude the embolectomy.
8.Perform an on-table angiogram to determine patency of vessels.
9.If flow is still inadequate leave a catheter in situ for a urokinase infusion.
10.Close the arteriotomy with double armed 4/0 prolene.
11.Close wound in layers.
2.Prepare the entire limb on the involved side only.
3.Make a vertical incision over the mid-inguinal point and insert a self-retaining retractor (Weitlander).
4.Dissect down to the femoral artery/profunda trifurcation. Administer 5000u of heparin and then encircle the vessels with vascular slings.
5.Make a longitudinal arteriotomy at the trifurcation with a clamp on the patent vessels.
6.Insert a Fogarty balloon catheter (size 4 or 4mm calibre) and perform an antegrade embolectomy to beyond the popliteal trifurcation if possible. If there is an occlusion beyond which the catheter will not pass it may be at the adductor hiatus (try again with the tip bent) or because of atheroma. Similarly, perform a retrograde embolectomy (using a size 5 catheter).
7.Remove clot ahead of the embolectomy balloon with a vascular sucker, with a right angled clamp at the ready. If there is steady back bleeding, conclude the embolectomy.
8.Perform an on-table angiogram to determine patency of vessels.
9.If flow is still inadequate leave a catheter in situ for a urokinase infusion.
10.Close the arteriotomy with double armed 4/0 prolene.
11.Close wound in layers.
Varicose Veins
1.Obtain a pre-operative US of incompetent perforators and have them marked on the skin. Mark individual varicosities with a permanent marker with the patient standing.
2.Position the patient supine, exsanguinate the limb with an Esmarch bandage and prepare the entire lower limb from groin downwards.
3.Make an oblique groin incision in line with a skin crease over the site of the SFJ (3.5cm below and lateral to the pubic tubercle) measuring 4-5cm.
4.Dissect down to the SFJ and delineate tributaries to be divided once SFJ has been identified. The tributaries are superficial circumflex iliac, superficial epigastric, superficial and deep external pudendal, a deep vein that pierces the fascia over adductor longus, anterolateral and posteromedial (accessory saphenous) thigh veins.
5.Dissect the SFJ and divide between artery forceps having clearly identified the femoral vein and ensured there is not a deep external pudendal vein entering the femoral vein as this can lead to recurrent vulval varicosities. Transfix the SFJ using 3/0 vicryl. Then individually ligate tributaries.
6.Insert a vein stripper without the bulky head attachment into the cut end of the saphenous vein and run it down as far as the upper third of the tibia if possible. Below this level the saphenous nerve is closely associated with the vein and a subsequent greater incidence of neuralgia. Make a 1cm incision over the site of the stripper pointing and extract it. Suture the end of the stripper at the cut superior end and strip the length of the vein with an assistant putting pressure on the thigh.
7.Perform haemostasis of the groin wound and close in layers.
8.Perform stab avulsions over the marked individual varicosities via 5mm incisions and small Kocher forceps.
9.Close the stab wounds with steristrips and dress with gauze, velban and crepe from ankle to groin (leave intact for 1-2 days then discharge home or arrange RDNS home visit at 1-2 days for removal of dressing and application of full length graduated compression stockings).
2.Position the patient supine, exsanguinate the limb with an Esmarch bandage and prepare the entire lower limb from groin downwards.
3.Make an oblique groin incision in line with a skin crease over the site of the SFJ (3.5cm below and lateral to the pubic tubercle) measuring 4-5cm.
4.Dissect down to the SFJ and delineate tributaries to be divided once SFJ has been identified. The tributaries are superficial circumflex iliac, superficial epigastric, superficial and deep external pudendal, a deep vein that pierces the fascia over adductor longus, anterolateral and posteromedial (accessory saphenous) thigh veins.
5.Dissect the SFJ and divide between artery forceps having clearly identified the femoral vein and ensured there is not a deep external pudendal vein entering the femoral vein as this can lead to recurrent vulval varicosities. Transfix the SFJ using 3/0 vicryl. Then individually ligate tributaries.
6.Insert a vein stripper without the bulky head attachment into the cut end of the saphenous vein and run it down as far as the upper third of the tibia if possible. Below this level the saphenous nerve is closely associated with the vein and a subsequent greater incidence of neuralgia. Make a 1cm incision over the site of the stripper pointing and extract it. Suture the end of the stripper at the cut superior end and strip the length of the vein with an assistant putting pressure on the thigh.
7.Perform haemostasis of the groin wound and close in layers.
8.Perform stab avulsions over the marked individual varicosities via 5mm incisions and small Kocher forceps.
9.Close the stab wounds with steristrips and dress with gauze, velban and crepe from ankle to groin (leave intact for 1-2 days then discharge home or arrange RDNS home visit at 1-2 days for removal of dressing and application of full length graduated compression stockings).
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
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
Saturday, September 29, 2007
Infusaport
1. Position patient in Trendelenberg, on head ring and sandbag between shoulder blades.
2. Infiltrate LA at marked sites of port and subclavian access.
3. With arm pulled down cannulate (pink needle?12G) subclavian vein at junction of lateral third and medial two third of clavicle. Once vein is entered advance guide-wire which is kept at the ready.
4. Use Image Intensifier to confirm satisfactory placement of guide-wire.
5. Make a transverse incision at site of port placement on anterior pectoral wall. Dissect down to allow an appropriate thickness of skin flap, as well as incising the guide-wire insertion site.
6. Create a pocket in the subcutaneous plane large enough to accommodate the port by dissecting inferiorly.
7. Place stay sutures of 3/0 prolene on either side of the catheter attachment and hold these in artery forceps.
8. Thread the sutures into the port at the pre-formed holes and tie them to secure the port in place (ensure port is primed with heparinized saline).
9. Tunnel an artery forcep of appropriate length into the created pocket via the guide-wire insertion site and hold the catheter to bring it out via the guide-wire site.
10. Adjust the length of the catheter by measuring to the sternal angle and excise redundant length.
11. Use dilator and sheath provided to widen channel for catheter in subcutaneous plane and in the vein itself.
12. Remove guide-wire and dilator only, leaving sheath in place and feed catheter into sheath.
13. Once catheter is completely inserted gradually remove sheath.
14. Use II to confirm satisfactory placement, as well as aspirating the port with the special provided needle (bent at tip) and then priming with heparinized saline.
15. Close both incisions in two layers using vicryl and monocryl.
2. Infiltrate LA at marked sites of port and subclavian access.
3. With arm pulled down cannulate (pink needle?12G) subclavian vein at junction of lateral third and medial two third of clavicle. Once vein is entered advance guide-wire which is kept at the ready.
4. Use Image Intensifier to confirm satisfactory placement of guide-wire.
5. Make a transverse incision at site of port placement on anterior pectoral wall. Dissect down to allow an appropriate thickness of skin flap, as well as incising the guide-wire insertion site.
6. Create a pocket in the subcutaneous plane large enough to accommodate the port by dissecting inferiorly.
7. Place stay sutures of 3/0 prolene on either side of the catheter attachment and hold these in artery forceps.
8. Thread the sutures into the port at the pre-formed holes and tie them to secure the port in place (ensure port is primed with heparinized saline).
9. Tunnel an artery forcep of appropriate length into the created pocket via the guide-wire insertion site and hold the catheter to bring it out via the guide-wire site.
10. Adjust the length of the catheter by measuring to the sternal angle and excise redundant length.
11. Use dilator and sheath provided to widen channel for catheter in subcutaneous plane and in the vein itself.
12. Remove guide-wire and dilator only, leaving sheath in place and feed catheter into sheath.
13. Once catheter is completely inserted gradually remove sheath.
14. Use II to confirm satisfactory placement, as well as aspirating the port with the special provided needle (bent at tip) and then priming with heparinized saline.
15. Close both incisions in two layers using vicryl and monocryl.
Friday, September 14, 2007
Varicose Veins
ANATOMY
Saphenofemaoral junction 1cm below and 4cm lateral to pubic tubercle and 2.5cm below inguinal ligament
Tributaries of the saphenous vein:
Accessory saphenous, superficial epigastric, superficial external pudendal, superficial circumflex iliac
Great saphenous vein may lie anterior or posterior to superficial external pudendal artery
Insertion of short saphenous highly variable
Saphenous opening is fossa ovalis
PROCEDURE
Note variations: Inguinal tributaries can enter femoral vein directly, saphenous vein can enter femoral 5cm below saphenous opening
Short saphenous runs with sural nerve
Saphenofemaoral junction 1cm below and 4cm lateral to pubic tubercle and 2.5cm below inguinal ligament
Tributaries of the saphenous vein:
Accessory saphenous, superficial epigastric, superficial external pudendal, superficial circumflex iliac
Great saphenous vein may lie anterior or posterior to superficial external pudendal artery
Insertion of short saphenous highly variable
Saphenous opening is fossa ovalis
PROCEDURE
Note variations: Inguinal tributaries can enter femoral vein directly, saphenous vein can enter femoral 5cm below saphenous opening
Short saphenous runs with sural nerve
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