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Training Tips

Vascutek Training Tips

Vascutek Ltd. sponsored the compilation of over 130 "Technical Tips" for Training Vascular Surgeons. These have been contributed by 26 UK-based surgeons and are reproduced by kind permission of Isis Medical Media Ltd. (www.isismedical.com).

We are now able to consider any tips you may wish to submit for inclusion on these pages.

Please contact: Jim Veitch at Vascutek (+44) 141 812 5555 or e-mail:   This email address is being protected from spambots. You need JavaScript enabled to view it.

 

AAA

Training Tips - Abdominal Aortic Aneurysms

Remember to check for a bleeding inferior mesenteric artery orifice after aneurysm repair. The orifice is often hidden by the overhanging edge of the sac and may only start bleeding when pelvic arterial flow has been restored.
(J D Beard)


When performing aortic aneurysm surgery, particularly in an acute situation, prior to completion of the distal anastomosis, gently pass a sterile endotracheal sucker (approximately 18Ch) into the common, external or internal iliac arteries. With a thumb over the side hole, the catheter should be withdrawn, so performing a suction embolectomy of thrombus that may have accumulated during clamp time.
(D C Berridge)


Always try and keep one internal iliac artery perfused to reduce the risk of ischaemic colitis. In the presence of common iliac aneurysm disease, it is often more easy to use a bifurcated graft to the common iliac bifurcation than to go down to the femoral arteries. This is important as there is an association between infected groin wounds and subsequent aortic graft infection.
(P M Lamont)


When the aorta has been clamped from side to side, take great care with suture placement in the posterior midline where it is possible for the clamp to create a deep fold that, if missed, leaves a large defect in the suture line.
(B P Heather)


The vast majority of Abdominal Aortic Aneurysms can be replaced by tube grafts even when the iliac vessels are ectatic. Discrepancies can be corrected by sculpturing the lower end of the tube with a disposable cautery pencil. Diameter is increased by suturing a 'V' shaped gusset. Stenosis is corrected by a tongue shaped graft extension as an angioplasty for the iliac orifice.
(C V Ruckley)


If it is necessary to close the bifurcation of the aorta in order to prevent back bleeding this should be prior to aorto-femoral bypass. A plug of Surgicell or even a portion of thrombus from an aneurysm pushed down the common iliac orifice helps to occlude it to get a good seal for the suture line.
(B R Hopkinson / P W Wenham)


Bleeding from the median sacral artery can often be stopped by placing the points of the diathermy forceps into the orifice. Good suction to prevent dissipation of the generated heat usually allows cauterisation of the vessel without need for sutures.
(S D Parvin)


Suture hole bleeding can sometimes be controlled by a single 5/o prolene inserted into the adventitia around the suture hole. In so doing, it is not necessary to reclamp the aorta.
(S G Darke)


Buttress sutures can be made from fragments of discarded Dacron and are therefore cheaper but just as effective as Teflon pledgets.
(J J Earnshaw)


A very friable aorta is encountered not infrequently and extreme difficulty is found in retention of sutures with tearing of the aortic wall and subsequent major haemorrhage. A further complication can be haemorrhage from the clamp site once the aortic clamp has been removed at the end of the anastomosis. In this situation, haemostasis can be readily achieved by using interrupted polypropylene sutures buttressed with a Teflon pledget. The needle should first be placed through one side of the pledget rectangle, then through the aortic wall and back out again, encompassing the split or tear and then passed through the opposite side of the pledget rectangle. Once this has been done the pledget can be snugged down securely onto the tear and tied.
(G Hamilton)


If the top suture line is not dry posteriorly, consider transecting the posterior wall of the aorta to gain a better view. The cause is sometimes a small aortic tear above the suture line and can be sealed with a 5/0 prolene suture over a pledget. If not, the anastomosis can be wrapped in a Dacron sleeve.
(R N Baird)


For the occluded aorta at the level of the renal arteries, dissect around the aortic wall to allow insertion of an aortic clamp but do not close it. With the open clamp in place make an elliptical incision in the anterior aortic wall. Remove the plug of thrombus/atheroma with Desjardins forceps. When pulsatile flow is restored, the clamp can be closed thus minimising renal embolisation.
(D C Berridge)


With a large AAA, the side of the sac sometimes falls in, obscuring the neck. The use of a self retaining retractor (eg. Travers or Norfolk and Norwich) keeps the neck clear.
(R B Galland)


If faced with a calcified or heavily atheromatous aneurysm neck, never perform an endarterectomy of the proximal aorta. There will be little aorta left and that which is, will be incapable of holding an anastomosis.
(W G Tennant)


In AAA repair, it can be difficult to secure haemostasis of the lumbar vessels if the posterior wall is heavily calcified. 'Endarterectomy' comprising stripping the atheroma from around the lumbar vessel ostia allows sutures to be placed easily through the remaining aneurysm wall.
(R B Galland)


Consider ligation or suture of the inferior mesenteric artery (IMA) before opening the aneurysm sac. It should reduce blood loss. Only do this if the internal iliac arteries are normal otherwise a re-implantation of the IMA in an aortic patch may be required.
(S D Parvin)


There is always the outside chance of having to reimplant the IMA. Place a small clamp (ring handle or bulldog) on the IMA before opening the aneurysm sac. If there is no flow or good back bleeding then it can be ligated.
(S G Darke)


Bleeding from an accessory renal artery below the top clamp may be troublesome but can be controlled with a bulldog clamp. If not, a 5 French umbilical feeding catheter with its cap on, inserted into the orifice can stem the flow. This technique can also be used for bleeding from the median sacral artery.
(J J Earnshaw)


What should be done about those nasty little lumbar arteries that always seem to bleed just below the top clamp? To overrun them can sometimes distort the subsequent suture line. It is possible to suture through a pool of blood but, an alternative is to divide the aorta and put a small straight clamp onto the lumbar vessels, behind the aorta. This does not get in the way of the anastomosis.
(S G Darke)


If a Foley catheter is not readily to hand, insert a swab mounted on sponge holding forceps (swab-on-a-stick) into the aorta. This can be palpated more easily and a clamp applied to a sponge as it is slowly withdrawn.
(S G Darke)


In haemodynamically unstable patients with a leaking AAA and large retroperitoneal haematoma, a conventional approach to the infra renal neck can be difficult because of obscured vision. If the haematoma extends into the lesser sac, control at the diaphragmatic hiatus can lead to tears of the liver and damage to other structures. Through an incision in the lesser sac, the aorta can be compressed against the vertebral column. If an assistant takes over, the surgeon can then mobilise the infra-renal aorta with enough time to identify important structures.
(S T R MacSweeney)


Do not divide the inferior mesenteric vein unless absolutely necessary. Running with this is often the marginal artery of Drummond which is a crucial blood supply to the left colon.
(S G Darke)


The aortic clamp applied during surgery is best secured by wrapping a sling around it and fixing this to the towels. The clamp is then kept steady and reduces the possibility of damage from twisting.
(J R Nash)


When confronted with a short neck to an aneurysm, use a multipurpose DeBakey clamp put on antero-laterally and then rotated through 90 degrees clockwise. The aneurysm can then be pulled down with the fingers of the left hand while the clamp is pushed up to butt against the renal arteries. The iliac arteries ought to be clamped first to reduce the risk of athero-emboli.
(S G Darke)


Faced with a large AAA in which the renal vein is stretched over the neck, mobilise the caecum and ascending colon upwards and to the left. This manoeuvre exposes the whole vena cava and termination of the left renal vein. Division of the latter is therefore made more easy and safer than exposure by the 'conventional' approach between the duodenum and transverse mesocolon.
(C W Jamieson)


If the aneurysm itself is close to the renal arteries, division of the left renal vein with preservation of the lumbar branch, will allow access to the aorta immediately above the renal arteries. By clamping the vessel here after appropriate renal protection with Mannitol etc. the graft can be sewn to the edge of the normal aorta exactly where the renal arteries are attached.
(P R F Bell)


If urgent control is required in a ruptured or leaking AAA, the most expedient and effective manner is to open the aneurysm sac and place a thumb into the aortic neck. This manoeuvre usually occludes the lumen. A 30F Foley catheter passed alongside the thumb can then be inflated in the aorta to stop the haemorrhage. It is important to place a large clamp across the lumen of the catheter!
(G Hamilton)


When application of an infra-renal clamp is potentially difficult, a balloon placed above the renals from the groin or arm under radiological guidance can act as a safety control.
(T Loosemore)


If the aortic neck above an aneurysm is inadequate for clamping, it is best to divide the renal vein in the first instance. This will allow access to sufficient length of neck to proceed. If this is not the case, then an incision needs to be made along the left of the colon so that it, the spleen and pancreas can be mobilised to the right. This manoeuvre gives good access to the aorta above the renal vessels where safe clamping can be done. If re-implantation of the renal arteries is required, this can be done easily.
(P R F Bell)


Division of the left renal vein is rarely required and should be avoided because left kidney function can be affected. It should be possible to mobilise the vein, and move it up and down, by using a moistened sling. Dissection should continue carefully through the peri-aortic fibrous tissue, consisting of lymphatics that can be ligated or coagulated with diathermy, from the level of the renal arteries up to the base of the superior mesenteric artery. A suitable length of sub-superior mesenteric aorta can then be dissected to allow a clamp to be placed. An aortic graft can then be anastomosed into the sub-renal aortic wall with good views of the renal orifices, so avoiding the creation of a stenosis. It is perfectly possible to achieve this anastomosis without undue haste within 20-30 minutes without significantly affecting renal function.
(G Hamilton)


If the aneurysm is close to the renal arteries and the left one is lower, apply the aortic clamp transversely and obliquely above the left renal artery. This will allow the sutures to be placed close to the orifice of the left renal artery without encroaching it.
(R N Baird)


Avoid dissection and placement of slings around the iliac arteries, as there can be a high incidence of iliac vein haemorrhage. Simply expose enough of the anterior and side walls of the common iliac artery to be able to apply a clamp across it vertically.
(P M Lamont)


A Yankeur sucker is an excellent tool for exposing the neck of a ruptured aneurysm without damaging the renal vein and tributaries.
(J D Beard)


When faced with an enormous AAA, it is a good manoeuvre to extend a midline incision upwards to the left and into the chest so as to expose the lower thoracic aorta just above the diaphragm and prepare it for clamping. With the clamp in place, ready to be applied as a life-saver, the dissection of the neck can be accomplished with more confidence and less tremor.
(B R Hopkinson)


If an aneurysm has ruptured and the neck cannot be safely dissected, abandon the operation. Electively, avoid the situation by careful pre-operative investigation of the patient.
(W C Jamieson)


When the neck of an AAA cannot be safely dissected or clamped, the first essential is that a surgeon knows their own limitations and when they should back off. If the left renal vein needs to be mobilised for access, it is important not to do so until the gonadal and lumbar tributaries on the left side of the neck have been individually dissected out and ligated. If this is done, it is surprising how far the left renal vein can be mobilised.
(C V Ruckley)


When approaching the neck of a ruptured AAA there is sometimes a tendency to ’go too high’, so risking damage to renal vein tributaries and other structures, Find the aneurysm sac and pass a hand over its surface, often backwards and inferiorly from the upper most part of the sac. This will lead to the neck of the aneurysm.
(W B Campbell)


When faced with an AAA of such size that the neck cannot be safely dissected, ask your assistant to place a swab on the aneurysm and gently pull down. If this does not provide sufficient room, lowering of the blood pressure by the anaesthetist may make this technique easier.
(D J A Scott)


Dissection of iliac aneurysms in the presence of a more proximal aortic aneurysm can be difficult because of the pulsation of the iliac vessels. If the aorta is cross-clamped above the aortic aneurysm first, further iliac dissection can be continued more easily.
(S D Parvin)


Abandon vertical incisions for aortic surgery and instead use a transverse incision situated approximately 1-2cm above the umbilicus. In complex aneurysms requiring good access to the abdomen and the pelvis make a roof-top incision, extending from just above each anterior superior iliac spine upwards into the epigastrum. This combined with an Omnitract retractor gives much better exposure than a full length paramedian incision or midline incision and allows the bowel to fall naturally out of the abdomen rather than the incision becoming deeper, the more it is retracted.
(C W Jamieson)


When implanting an aortobifemoral graft, use transverse skin crease incisions for exposure of the femoral vessels. These heal better, especially in patients with 'overhanging' abdomens.
(W G Tennant)


When opening the retroperitoneum at the start of an aortic grafting procedure, leave 1 or 2cm of peritoneum to the left of the duodenum. This flange facilitates closure of the retroperitoneum at the end of the operation.
(W B Campbell)


Do not try and remove the duodenum from the sac of an inflammatory aneurysm, simply cut into the sac medial to the duodenum and peel off a layer like an onion skin. The sac is usually thick at the front and this process of peeling can be carried out from the top to bottom without causing any harm and making an approach to the neck and iliac vessels more simple.
(P R F Bell)


All training tips provided in this series were submitted by Consultant Vascular Surgeons as indicated in brackets.

Vascutek is grateful for all submissions within this series and welcomes any new submissions.

Provided as a service to medicine by VASCUTEK, a TERUMO Company 2004

Carotid

TRAINING TIPS - Carotid Surgery

After completion of a carotid endarterectomy but prior to closure of the vessel with a patch, the arteriotomy should be extended 5 mm distally. This will ensure that any step in the intima or (heaven forbid) any flap, will lie in a portion of the artery widened by the patch rather than at the apex of the arteriotomy. The suture line around the patch will also tend to tack down the intima, further reducing the chances of post operative thrombosis or embolism.
(S Brearley)


Consider irrigation with Dextran and heparin rather than saline/heparin during carotid surgery. The combination avoids the formation of small thrombi from vasa vasora.
(W G Tennant)


While very tortuous internal carotid arteries require resection and re-anastomosis, a larger dissection is needed and there is a risk of bleeding from the extra-anastomotic suture line. A tortuous carotid nearly always bulges laterally such that the medial wall is shorter. A simple plication suture that progressively everts the arterial wall from medial to lateral side will straighten the artery. This technique has the advantage of permitting incorporation of the distal intimal flap following endarterectomy.
(J D Beard)


If a Javid shunt is used, move the distal clamp 1 to 2 cm up the internal carotid after it has been inserted. This will allow the arteriotomy to be extended so that it is well clear of the distal feathering of the endarterectomy.
(R N Baird)


Good exposure of the carotid artery can be obtained by using a mastoid type self-retaining retractor with the pointed part facing into the facial vein. This provides good retraction and does not damage the jugular vein.
(P R F Bell)


Specially engineered cone retractors with blunt tips can be used to hold back the jugular vein providing beautiful exposure of the carotid artery without damaging the vein. Exposure to the upper end is produced by a retractor held by a Wascherle device known at St Thomas's as a 'Medical Student'.
(K Burnand)


It is not necessary to place a self retaining retractor on the internal jugular vein. Place the jaws of the retractor on the sternomastoid muscle next to the internal jugular vein and this does the trick just as well as having the retractor on the vein.
(P M Lamont)


When faced with a high carotid bifurcation, exposure of normal internal carotid artery above the stenosis can be difficult. Division of the posterior belly of the digastric muscle can give better access. Be cautious of heavy retraction in this area after division of the muscle, as it is easy to produce a neuropraxia of the glossopharyngeal nerve.
(P M Lamont)


When dissecting up the internal carotid towards the hypoglossal nerve, proceed by pushing away the structures with slightly opened McIndoe scissors. This facilitates the dissection without risking damage to the nerve.
(S G Darke)


Always expose the hypoglossal nerve so that you know where it is during the course of the operation. If it is in the way, dissect up laterally to it when it will fall medially away from the internal carotid artery.
(P M Lamont)


Male patients can find postoperative numbness in the neck, after carotid endarterectomy, a difficulty when shaving. To prevent this, the cranial end of the skin incision should be at least two finger-breadths behind the angle of the mandible to avoid damage to the cervical branch of the facial nerve. The greater auricular nerve often lies in the line of the skin incision at this point and can be dissected out and retracted posteriorly.
(P M Lamont)


The risk of post-operative haematoma of the neck can be reduced if aspirin is stopped a few days before admission. It should be restarted after surgery.
(R N Baird)


All training tips provided in this series were submitted by Consultant Vascular Surgeons as indicated in brackets.

Vascutek is grateful for all submissions within this series and welcomes any new submissions.

Peripheral

TRAINING TIPS - Peripheral Surgery

When the normal sources of vein graft have been used or have been found to be unsuitable, the superficial femoral vein can be harvested without significant morbidity, provided the profunda vein is left intact.
(S G Darke)


When tying knots at the completion of an anastomosis, fine sutures such as 5/o and less, can catch on dried blood covering surgical gloves. This can be annoying or result in breakage of the suture. If both hands are moistened with saline (two or three squirts from a flush syringe) then the sutures do not snag.
(S T R MacSweeney)


Side branches of an in situ vein can be detected using a flowmeter at the top of the graft after completion of the proximal anastomosis. Any flow at this stage must be due to incompetent tributaries. Digital occlusion of the long saphenous vein proximal to each incompetent tributary will reduce the flow and allow accurate localisation. The tributaries can then be ligated via small skin incisions. This technique also saves time as the assistant can be dealing with the tributaries whilst the surgeon is completing the distal anastomosis.
(J D Beard)


If a vein graft needs to be tunnelled across the interosseous ligament to reach the anterior tibial artery, it may become squashed, particularly in young patients. A short segment of reinforced thick walled PTFE graft on the outside of the vein graft provides protection and, if properly done, a smooth and kink-free path.
(W G Tennant)


When reversing vein grafts, complete the proximal anastomosis first and allow some blood to pass through so that it assumes an untwisted position. Pass the graft through the tunneller, allow two or more squirts of blood to pass through, remove the tunneller and allow two or three more squirts to ensure that the strength of pulsation is similar to that before tunnelling.
(K G Callum)


Mark vein grafts with methylene blue along one surface to ensure that they do not twist when placed through a tunnelling device.
(K Burnand)


When a vein graft is pressurised with fluid, it is less likely to twist. If sufficient vein graft is available, place a clip on one end of the graft, inflate it with warm blood and then seal the end with a second clip. This produces a near rigid tube that can be passed through a tunnelling device.
(W S Moore)


When inserting a reversed vein graft through a tunneller, a useful way of showing that it is not twisted is to place a syringe on the end distal to that being pulled through the tunneller and inflate with saline so that the graft is fully distended before being pulled through the tunnel. Once through, intermittent squirts confirm that a twist has not occurred.
(P R F Bell)


Prevention of a twist in a reversed vein graft can be accomplished by letting the vein lie in its normal anatomical path. This method makes the vein easy to identify for duplex follow up assessment and more easy to correct if a patch angioplasty is subsequently needed.
(T Loosemore)


Short areas of varicose vein can be dealt with by surrounding the vessel with an appropriate piece of PTFE or Dacron to compress the varicosity. In this way, even varicose veins can be used for femoropopliteal bypass.
(P R F Bell)


An accidental twist in a reversed vein graft can be a real nuisance and is easily done. One solution is to do the distal anastomosis first. After preparation, connect the proximal end of the graft to a Stoke on Trent catheter and pass up the tunnelling device into the femoral wound. Distend the graft with heparinised saline so that the pressure removes any twists.
(S T R MacSweeney)


Completion angiography gives important information about the quality of a distal reconstruction. Unfortunately contrast leaks through the suture holes of PTFE grafts. This can be avoided by side clamping the final part of the proximal anastomosis with a Glover clamp to let the graft run for ten minutes before suturing is completed. Once the lower anastomosis is blood tight, the side clamp is removed and an umbilical catheter inserted down the graft for hand injection of a small volume of contrast.
(C V Ruckley)


It can be remarkably difficult to prevent blood entering a PTFE graft, prior to completion of an anastomosis, even if the graft is clamped. Clots that form can be difficult to wash out and may therefore cause distal embolisation. The problem can be prevented by filling the graft with heparinised saline before carrying out the anastomoses.
(S Brearley)


There are two common sites of narrowing of the anastomoses of femoro-tibial reversed vein bypass grafts. These are in the vein just distal to the heel of the femoral anastomosis, and within the tibial artery just distal to the toe of the lower anastomosis. These problems can be resolved by cutting the vein so that the heel of the femoral anastomosis is at the site of a branch (Figure 1). To prevent stenosis of the tibial artery, the vein graft should be cut slightly square. When the anastomosis is done, the sutures at the toe should be closer together in the artery than they are in the vein, (Figure 2). This technique opens the artery and reduces the risk of stenosis.
(K G Callum)

Figure 1Figure 1

 

Figure 2Figure 2


Before performing any vascular anastomosis, cover all the instrument handles around the operative field with a green towel to stop sutures from snagging. These green towels are called 'FP's' as they protect the nursing staff from exclamations of dismay by the surgeon.
(W B Campbell)


Sew a gusset of vein into the toe of an anastomosis before attaching a prosthetic graft to a small vessel. Irrespective of haemodynamics, it makes for accurate suturing.
(P W Wenham)


When performing a distal anastomosis at the knee, the graft usually lies posterior to the proximal clamp, this gives a good view for completion of the upper side of the anastomosis. When completed, replace the proximal clamp posterior to the graft so that its shaft lifts the graft upwards, to give a better view of the lower side of the anastomosis.
(S G Darke)


Above knee patency rates are much better than below knee. Consider on table balloon angioplasty of a more distal stenosis in the popliteal artery. This can be readily performed through an above knee popliteal arteriotomy and allows the distal anastomosis of the bypass graft to be kept above the knee.
(P M Lamont)


Avoid placing clamps on small vessels during distal bypass surgery. Instead, use a Lovquist roll-on tourniquet on the upper calf after the proximal anastomosis has been done and the graft tunnelled down the leg.
(C V Ruckley)


To improve flow down a bypass graft onto a single vessel, inject 1-1.5mg of Reserpine (ganglion blocker) into the graft lumen. This provides a sympathectomy for 24-28 hours. The same effect can be obtained with papaverine but is often longer lasting. These vasodilators do not normally have any clinically significant systemic effect.
(J J Earnshaw)


When dissecting out one of the tibial or peroneal vessels for distal bypass, prevent spasm of the artery by injecting a small amount of Papaverine (40mg/ml) using a fine (25G) needle, into the peri-adventitial tissue. If it is in the correct layer, a "bleb" will be seen running the distance of the artery that has been exposed. The subsequent anastomosis should be easier with a dilated vessel.
(K G Callum)


An arterial clamp can be kept free of the operative field by passing it through a small incision in the skin before the artery is engaged. The skin hole can be used at the end of the operation for a vacuum drain.
(R N Baird)


When applying slings to arteries, always try to place them beyond a nearby arterial branch. This prevents them from sliding down into the operative field. It is particularly helpful in the groin always to place the proximal sling above either the inferior epigastric or superficial circumflex iliac artery.
(W B Campbell)


In some circumstances, especially revision surgery, it may not be easy to find the common femoral artery. It is much easier to find the SFA in the distal part of the femoral triangle near its apex than it is adjacent to the inguinal ligament.
(CV Ruckley, S G Darke)


All training tips provided in this series were submitted by Consultant Vascular Surgeons as indicated in brackets.

Vascutek is grateful for all submissions within this series and welcomes any new submissions.

Venous

TRAINING TIPS - Venous Surgery

It may be safest to double ligate fragile or inaccessible veins in continuity before dividing them. It can however be difficult to place the second tie far enough away from the first to ensure an adequate stump after vessel division. Place a single haemostat between the two ligatures before the second one is tied to ensure sufficient spacing before division.
(S Brearley)


The wounds made by stab avulsions will close more readily with steristrips if the incisions have been made along the line of the skin creases (Langer's Lines).
(P M Lamont)


Gross varicose veins, especially when recurrent, are best avulsed using a Lovquist or Esmarch tourniquet to exsanguinate the leg. If the long saphenous vein needs stripping, a stripper usually passes easily under the thigh tourniquet.
(J D Beard)


Patients with Klippel-Trénaunay syndrome and a degree of lymphoedema, or those with congenital lymphoedema, are at risk of a lymphatic leak or further compromise to their already inadequate lymphatic drainage following surgery. A vertical incision over the common femoral vein, preferably marked by duplex examination, should reduce the risk of such complications.
(S G Darke)


For any major venous haemorrhage, apply Allis forceps with tiny teeth, to the edges of the hole. Pass a suture across the defect as many times as seems necessary, then remove the forceps, holding the suture fairly tightly to close the hole before tying it. In general use a large diameter needle - if a small needle is passed into a large vein and pressure on that vein is released then the suture can be lost within the vein lumen - this presents a difficult situation!
(W B Campbell)


Pass balloon catheters (30F) into an IVC tear and inflate proximally and distally to facilitate suturing.
(G Hamilton)


If a hole has been made inadvertently in the IVC, tip the patient head down and apply pressure. Pressure can be applied circumferentially around the bleeding point and the hole sutured. Most mistakes are made by people trying to deal with this too quickly.
(C V Ruckley)


A hole in the IVC requires downward compression with two fingers on either side of the hole, pushing backwards against the lumbar spine. The assistant sucks over the hole and a 5/o or 6/o prolene can be easily inserted while the vein is compressed. Two bites are taken through the edges of the defect and tied. Do not try to apply clamps.
(K Burnand)


Control vena cava bleeding with a finger or swab and after sweeping a finger behind the IVC above and below the tear, pass a moistened nylon tape behind it. By pulling the tape, blood loss can be controlled.
(G Hamilton)


Haemorrhage from a hole in the vena cava is torrential and often audible! Place a lubricated 2/o silk suture across one end of the laceration without tying it. Put a clip on one end and hold both ends up under tension. Suture along the tear to the other end and apply a second clip to it without tying. This gives either complete or more often partial control of haemorrhage to allow a more definitive exposure of the tear and more accurate suturing with prolene. The silk suture is not removed, the ends are simply cut once control has been achieved.
(G Hamilton)


If a hole is made inadvertently in the inferior vena cava, put a finger on the hole followed by several small swabs to control the haemorrhage and lower your own blood pressure. Ideally, move to another part of the wound to carry on with dissection. If that is not possible, leave the wound packed and go for coffee. On return, with appropriate 4/o or 6/o sutures to hand, repair is relatively simple. Doing it in the heat of the moment against a rush of black blood is a sure combination for disaster.
(B R Hopkinson)


If a hole has been made in the vena cava, place a swab on a stick on each side of the hole, pick up part of the hole with one stitch and then using a side-occluding clamp to include the rest of the defect, suture the tear.
(C W Jamieson)


If a defect in an iliac vein causes serious haemorrhage that is difficult to control, consider dividing the overlying iliac artery, reflecting its ends and obtaining good exposure of the vein. When the vein has been repaired, the artery can be re-anastomosed, used as the recipient site for a graft, or bypassed.
(W B Campbell)


Stripping the long saphenous vein (LSV) is important but can produce a thigh haematoma. This can be prevented by attaching a 2 cm wide ribbon gauze soaked in 0.25% Bupivicaine with adrenaline to the stripper head instead of a stripper olive. If the LSV is stripped early in the procedure, the gauze can be left down the full length of the 'strip track' whilst the avulsions are done. The end of the gauze can be pulled from the groin wound, thus removing it, the stripper and the LSV and so avoiding a large incision at the knee.
(J J Earnshaw)


In the event of difficult venous bleeding in the groin during sapheno-femoral vein surgery, do not grasp blindly with forceps or apply crude sutures. Tip the head of the table down and compress the area until it is dry. Then place fine vascular sutures accurately or call for help.
(C V Ruckley)


A quick exposure of the sapheno-femoral junction can be done through a relatively small groin incision, the lateral end of which is placed over the femoral pulse. Cut down with a scalpel until the anterior surface of the long saphenous vein (LSV) is seen. Use a gauze swab on the end of a finger to sweep proximally and distally along the surface of the LSV. With a retractor in the cranial part of the wound, the tributaries can be easily identified ready for ligation, all without the need for extensive sharp dissection.
(S D Parvin, P M Lamont)

 

Miscellaneous

TRAINING TIPS - Miscellaneous Surgery

Abdominal pain or back pain in the presence of an abdominal aortic aneurysm is because the aneurysm has leaked until proven otherwise.
(S D Parvin)


If in doubt about operating for chronic arterial disease then do not. Quite a few ischaemic limbs remain stable or improve and you can always change your mind.
(W B Campbell)


If you suspect that an arterial bypass graft has blocked post-operatively, then it almost always has.
(W B Campbell)


Patients who need amputations for skin ulceration often have an ulcer on the contra-lateral leg. Harvest of skin from the amputated leg, with storage in a refrigerator for later application to the debrided ulcer can accelerate healing and reduce the morbidity associated with skin graft donor sites.
(J J Earnshaw)


A cup of coffee takes longer to drink than blood does to clot. If it oozes, pack it and take a twenty-minute break. (This break is sometimes known as the Tea or Rothmans test!).
(P W Wenham)


When suturing a fragile anastomosis it may be useful to incorporate a 1cm cube of fat graft in the suture line to act as a buttress.
(B R Hopkinson)


Whenever suturing to control a bleeding point, a single stitch is rarely sufficient. A cross stitch is much more effective in controlling bleeding and less likely to cut out.
(B R Hopkinson)


For insertion of an iliofemoral graft through the obturator foramen, find the obturator membrane by pushing a finger into it from above the inguinal ligament. Use a tunnelling device from below and using the stereotactic skills that most vascular surgeons have, press the tip of the tunneller against the membrane. Use a tapping motion until the tunneller can be felt by the finger after which it can be pushed through safely. Extensive dissection of the obturator membrane can therefore be avoided.
(P R F Bell)


False femoral aneurysms can be dealt with under local anaesthesia. Control of the lesion is essential. This can be achieved by making a small finger sized incision above the inguinal ligament followed by dissection down to the iliac artery. The index finger pressed through this wound controls the situation adequately to allow repair of the aneurysm.
(P R F Bell)


In the rare event of an iliac false aneurysm, control can be obtained by passing an angioplasty balloon above the lesion via an ipsilateral femoral artery puncture. The aneurysm can then be opened from a retroperitoneal approach, without the need for further dissection of the common iliac artery.
(P W Wenham)


Lignocaine is safe for infusion in limited quantities into peripheral arteries. When doing an embolectomy under local anaesthesia instil 10ml of 0.5% Lignocaine into the vessel after the first pass of the embolectomy catheter. This manoeuvre reduces pain during further balloon withdrawals and helps the patient to keep still.
(W B Campbell)


In the rare event that a bypass graft needs to be done to arm vessels, use the cephalic vein in situ. Do not disturb it from its bed, any branches can be divided through small incisions and the valves destroyed in the usual way. The distal end can be sutured to the arm artery wherever it is patent. Proximally, there will not be enough length to attach it to the subclavian artery but an extra piece of vein taken from elsewhere should be used to connect the cephalic vein and subclavian artery. These grafts work much better than trying to tunnel the graft alongside the vessel.
(P R F Bell)


Brachial embolectomy should nearly always be done using local anaesthesia. It is not essential to mobilise the radial and ulna arteries, as there is seldom thrombus within them. A size 2 or 3 Fogarty embolectomy catheter is normally sufficient to restore circulation. Always use a transverse arteriotomy and repair with 6/o prolene. Exploration of radial or ulna arteries can be reserved for the situation when distal pulses do not immediately reappear or Doppler signals are damped.
(J J Earnshaw)


For completion angiography after embolectomy an olive-ended Tibbs cannula can be snugged into the superficial femoral artery with a silastic sling.
(J D Beard)


In the absence of good arterial images, use contrast to inflate the balloon of the embolectomy catheter. Use of image intensification can show the level of a vessel stenosis or residual thrombus, as the balloon can be seen to indent at that level.
(S D Parvin)


An angiogram should always be done at the end of an embolectomy. If there is significant residual thrombus then intra-operative thrombolysis is indicated. Place an umbilical or neonatal feeding catheter through the arteriotomy to the level of the occlusion. Infuse 100,000 units of Sstreptokinase or 15mg tissue Plasminogen Activator in 20ml of normal saline over 30 minutes with the inflow clamped.
(J J Earnshaw)


Putting a slight bend on the end of a Fogarty embolectomy catheter can help in directing it down each of the calf vessels. Pressure on the posterior and anterior-tibial arteries at the ankle will give an idea as to which vessel the catheter has passed through.
(S D Parvin)


The completion of a small vessel anastomosis can be difficult. Before insertion of the final two sutures, release the bottom clamp and pull gently on the two suture ends, thus filling the anastomotic hood by back bleeding. There is seldom sufficient pressure to produce excessive bleeding through the anastomosis. Final sutures can then be inserted with much more ease into the now dilated graft and host vessel.
(S G Darke)


Always prepare the whole leg when doing a femoral embolectomy to allow palpation of ankle pulses during the procedure. If clear, alcoholic solution is used then skin colour can easily be assessed at the end of the procedure.
(S D Parvin)


When passing a needle through a calcified vessel, wiggle the needle slightly to find a defect. If this does not work, place the needle more deeply where soft vessel can often be found.
(A H Davies)


Passing a needle through a calcified vessel is often difficult. If a 20cc needle does not work alone, make a hole with pointed towel clips before the needle is passed through.
(A H Davies)


Needles will almost always be successfully inserted through the arterial wall if placed at right angles to a calcified vessel with a short distance between needle tip and needle holder, and application of gentle prolonged pressure with some counter pressure. If this does not work then an endarterectomy is indicated to remove the calcified plaque.
(K Burnand)


Massive pelvic venous bleeding can be difficult to control. Cross clamping the aorta will reduce the pelvic inflow and hence the outflow.
(J D Beard)


Use three fingers to examine a femoral pulse - this gives some assessment of size and makes it quicker to find in the obese patient. If both groins are examined simultaneously, a comparison of the two can be made.
(W B Campbell)


It is easier to palpate the popliteal pulse if the knee is not flexed. Extension of the knee throws the artery into prominence and makes it easier to feel.
(W B Campbell)


If a popliteal pulse cannot be felt easily, palpate different parts of the popliteal fossa, particularly where the artery crosses the tibia.
(S D Parvin)


The presence of an easily palpable popliteal pulse should demand an ultrasound examination to exclude aneurysmal disease.
(D C Berridge)


When a popliteal aneurysm is suspected, do not forget to palpate the thigh above the popliteal fossa. Sometimes there is a large aneurysm at this site when the pulse in the conventional position can be quite normal. It is surprisingly easy to miss a gross and significant finding.
(S G Darke)


During Doppler assessment of the arteries at the ankle, always listen for the peroneal. If the other two are absent or diminished, the peroneal may be the best, especially in diabetics.
(W B Campbell, S G Darke)


When trying to locate the ankle arteries using a Doppler probe in a very ischaemic limb, use a large amount of jelly and avoid pressure on the skin. If a continuous flow is heard which disappears when the foot is squeezed gently then it is an artery. If the flow increases, it is a vein.
(W B Campbell)


If there is uncertainty that a foot is ischaemic, stand well back from the end of the bed and look at both feet from a distance. A difference in colour should then be much clearer (just like a chest x-ray).
(W B Campbell)


Remember that 6/o prolene comes with different needle sizes. An 8mm needle is much easier to use under magnification. If anastomoses are done without loupes, then a 13mm needle is better.
(P M Lamont)


Pick winners!
(R N Baird)


All training tips provided in this series were submitted by Consultant Vascular Surgeons as indicated in brackets.

Vascutek is grateful for all submissions within this series and welcomes any new submissions.

Provided as a service to medicine by VASCUTEK, a TERUMO Company 2004

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