Surgical Procedures 1: Quiz 17 Review

What kind of patients would not be candidates for insertion of a greenfield filter

Contraindicative for patients on anticoagulants

During an amputation what is done to prevent phantom nerve pain

the Sciatic Nerve is crushed with a Kocher above where the leg is being removed

Where is the most common area for aneurysms

Below the renal artery

What is a Greenfield Filter and how is it inserted

- A filter that is placed in the inferior vena cava that prevents clots from going into heart and lungs - Incision is made into either the Femoral or Jugular vein. Right flank is lifted with bolster then filter is then put in under Fluoroscopy

What is an Endovascular AAA and how is it done

- AKA EVAR - Endovascular Aneurysm Repair - Done on patients that are too sick to be totally opened - Graft inside a Catheter is inserted into the Femoral Artery under Fluoroscopy - Once at Aneurysm site Graft is released and pushes plaque away - More dangerous than open approach due to there being a chance the Guide wire rupturing the aneurysm when being put in or when graft is released

What is a Portacaval shunt and what is it used for

- AKA Portal Systemic Shunt - Palliative Procedure done for Patients who have Portal Hypertension caused by cirrhosis of the liver - Shunts Portal vein and systemic venous system - Portal vein is bypassed to the Inferior Vena Cava - End to side or side to side anastomosis of the portal vein and inferior vena cava

What is a Axillofemoral Bypass and how is it done

- Blockage in Iliac artery - Graft is put in from the Axillary Artery to the femoral artery to restore blood flow - Incision is made in the axilla fist then in the groin - Long graft is tunneled and put in with 4-0 Prolene

What is a Femeropopliteal Bypass and how is it done

- Blockage in femoral Artery is bypassed with patients own vessel (Saphenous Vein) or a Long Gortex graft to restore circulation to the leg - 2 Incisions - Groin (Femoral Artery) and Knee (Popliteal Artery) - Graft is tied to the Tunneler and passed sub Q through the leg - Proximal part of the graft is anastomosed end to side with 4-0 Prolene on a Double Arm suture - Distal part is Anastomosed with 5-0 Prolene on a double arm suture - Doppler is used to make sure there is good blood flow - Incision is closed

What is a AV Loop Fistula/Loop Fistula Graft and why is it done

- Communicating an artery and vein using a Gortex Loop Fistula Graft - Graft will be punctured during hemodialysis instead of their vessels

What is a Vena Cava Ligation/Interruption and how is it done

- Done for patient where the greenfield filter does not work - Flank incision is made and Vena Cava is partially occluded with heavy silk sutures so that any large emboli cannot get through

What is a Femorofemoral Bypass and how is it done

- Done on patients that have very large blockage in their Iliac Artery - Blood needs to be shared between the Femoral arteries - Graft from one femoral artery to another is put in - Can make a flap incision or can be tunneled through 2 smaller incision

What is an AV Shunt and why is it done

- External Communication between artery and vein done for very sick patients undergoing hemodialysis - temporary due to limited life span

What equipment is needed for insertion of an Internal Fistula, AV Loop Fistula, or a AV Shunt

- Garret Dilators - Hand Table - Tunneler - Sitting Stools - Fogarty Catheters - AV Fistula Tray - Heparinized Saline - Different sized Gortex Grafts - MAC - Monitored Anesthesia Care. - Extremity Prep and Drape

What are the steps to a Carotid Endarterectomy

- Incision over Carotid - External, Common, and Internal Carotid are identified - External Carotid is clamped first, then Common Carotid is clamped (If shunt is not used), Finally internal Carotid is clamped - Artery is opened and Plaque is then cleaned - Carotid is closed with a patch and 5-0 Prolene - Common Carotid is unclamped first, Then External Carotid is unclamped, and finally the internal Carotid is unclamped - Doppler is used to check for blood flow - Incision is closed (Jackson Pratt Drain may be used)

What is needed for a AAA

- Major Tray with Bookwalter or other table mounted retractor - Hemostatic Agents (Gelfoam, Thrombin, BioGlue) - Major Vascular Tray - Synthetic Grafts (Bifurcated and Tubular) - Patients blood type available - Prolene suture (2-0 for aorta and 3-0 if Iliac Arteries if involved) - Freer Elevator or Penfield to remove plaque

What is a Mesocaval Shunt

- Mesenteric vein to the Inferior vena cava to stop the blood from entering the liver

What is a False Aneurysm

- Occurs from MVA or other Trauma and makes a clot that pulsates and can rupture - on the outside of the artery

What are some complications for a Carotid Endarterectomy

- Peripheral Nerve Deficits - Facial paralysis or numbness - CVA - Stroke

What is an Internal Fistula and why is it done

- Radial artery is sown to the Cephalic Vein - Done on patients who are undergoing hemodialysis and their vessels are collapsing from being punctured Repeatedly

What are the steps to an Open AAA

- Routine Laparotomy to get in - Dissection down to the aorta through the peritoneum - Heparin is given by anesthesia and wait 3 min - Aorta is cross clamped (One above Aneurysm and one on each Iliac Artery) - 11 blade on a 7 blade handle is used to cut into aorta - Cell Saver is on hand ready to suck up blood - Plaque is cleaned out with a blunt instrument (Freer and Penfield) or by hand - Graft is sized - Dacron Bifurcated graft is used if Iliac Arteries are involved otherwise Dacron Tubular Graft is used - Graft is sown into aorta first with 0/2-0 and then one Iliac Artery 3-0/4-0 - Vascular Clamps are then SLOWLY released to avoid Phenomena - 2nd Iliac Artery is then sown with same suture - Aneurysm sack is then sown around the graft with 2-0 Prolene to give strength to the graft and to prevent adhesions - Pulse is taken with doppler - Peritoneum is closed, Intestines are moved back, and incision is closed

What position is a patient in for a Carotid Endarterectomy

- Supine with Arms tucked to the sides so we can get to the neck - Neck is extended and turned so the effected side is up

What are Dissecting Aneurysms

- Tear in the intima causes blood to flow between the layers of the artery - Caused by build up of plaque - Builds up until artery explodes

What are True Aneurysms and what are the 2 types

- Weakness in any Layers of an Artery. Usually occurs from plaque build up - Fusiform - Bulge is even on each side. (Most common) - Saccular - Aneurysm looks like a cyst hanging off the artery

What kind of dressings are used for an amputation

Bulky Dressing and compression is applied post op which helps with swelling and allows a proper Prosthesis fit

What is the indication for patients undergoing hemodialysis

End Stage Renal Disease (ESRD)

What is divided in a AKA

Femur, Femoral artery, Femoral vein and sciatic nerve are divided

What incisions can be used for an Open AAA

Full Midline or Left paramedian incision

What drains are put in after an amputation

Jackson Pratt drain for Vascular Surgeon and Hemo-vac drain is used for Ortho

What is the indication for Insertion of Greenfield Filter

Patients that have Venous Thromboembolism Disease

What incisions can be used when inserting a Portacaval shunt

Right subcostal or Right transabdominal

How is the patient prepped and draped for an amputation

Routine prep and drape for an extremity. Mayo stand cover is put over the limb so that once it is removed it is covered

During an Carotid Endarterectomy why is the internal Carotid unclamped last

So that if any debris from the plaque detaches it does not go to brain

What is divided in a BKA

Tibia, Fibula, Popliteal artery and vein and sciatic nerve are divided

During an Amputation how is the bone cut through

Vascular Surgeon use a Gigli saw and Ortho Surgeon use a sagittal saw.

What is done in an endovascular Carotid Endarterectomy

a metal stent is put into the Common Carotid. Plaque can break off during this and cause a CVA