ome use a jejunal purse string, which is securely tied. (cid:142)(cid:3) Tie the purse string in the oesophageal resection line over the anvil and join the stapler. (cid:142)(cid:3) Close the stapler and fire it after removing the safety catch. (cid:142)(c id:3) Open the stapler two to three turns and then remove it, holding the anastomosis with your left hand and using the buttonhole technique. (cid:142)(cid:3) Confirm that there are two intact fragments (doughnuts) of oesopha- gus and jejunum on the spindle. If necessary r einforce it partially or completely with sutures. STAPLING IN OESOPHAGOJEJUNOSTOMY1 357 (cid:142)(cid:3) If the esophagus is very thick, dissect back the muscular coat as a cuff. Do not include this in the stapler. After stapling, unite the oesophageal muscle to the jej unum with a continuous ring of sutures. Feel the anastomosis through the open jejunum and e nsure that it is intact and that the efferent long loop is open. (cid:142)(cid:3) Close the open jejunum with a linear stapler or by hand using two layers of Vicryl or PDS. Stapling in oesophagojejunostomy CHAPTER 10 Stapling in surgery 358 Stapling technique for transection of bleeding oesophageal varices Indication Consider tran section when varices continue to bleed despite medical therapy, resuscitation, and insertio n of Sengstaken tube. Preparation, anesthetic, position on the table, and incision are the same as for other vari ceal procedures. Procedure (cid:142)(cid:3) Divide the phreno-oesophageal ligament and dissect free the lowe r esophagus. (cid:142)(cid:3) Place an atraumatic sling around it, taking care not to damage the vagal nerves. (cid:142)(cid:3) Pass 2/0 silk or an atraumatic sling around the cleared esophagus before the insertion of the stapling device; otherwise it is technically more difficult and there is risk of damage to the oesophageal wall when the rigid gun is in position. (cid:142)(cid:3) Make a small gastrostomy in a relatively avascular part of the high anterior surface of the stomach. (cid:142)(cid:3) Pass the sizer into the esophagus to determine the largest size of gun hea d that can be slipped into the esophagus without risk of damage. (cid:142)(cid:3) Select the correct size circular end-to-end stapler with adjustments calculated for staple height and tissue thickness. (cid:142)(cid:3) Insert the complete stapler (closed gun) into the esophagus with the safet y catch on making sure that neither the sling nor the encircling ligature around the esopha gus impedes the passage of the gun up the lumen. (cid:142)(cid:3) Advance the gun into the esophagus for 5 \200\2236cm; open the stapler thr ee or four turns so that there is a gap between the anvil and the firing end (3 \200\2234cm ). (cid:142)(cid:3) Tie encircling 2/0 silk or other easily tied braided suture into the gap, thereby inverting the whole circumference of the esophagus into the gun. It takes time to e nsure that the ligature is firmly tied. (cid:142)(cid:3) Close and then fire the gun with a protective hand around the site of anas tomosis. Open the gun two or three turns and rotate it through before removing it with the buttonhole technique. (cid:142)(cid:3) Check the doughnuts and the anastomosis which should be 2 \200\2233cm above the oesophagogastric junction. (cid:142)(cid:3) Close the gastrostomy with a linear stapler or with two layers of Vicryl or PDS. This page intentionally left blank CHAPTER 10 Stapling in surgery 360 Stapling technique for transection of duodenum Linear staple closure of the bowel is safe, haemostatic, and quick to perform. Closure of the duodenum by this method applies equally w ell to closure of other bowel segment. Preparation, anesthetic, position on the table, and incision are as for gastrectomy. Procedure (cid:142)(cid:3) Mobilize the stomach during total or Polya gastrectomy. (cid:142 )(cid:3) Prepare the duodenum for transection. (cid:142)(cid:3) Place a linear stapler (30 or 60mm long) just distal to the proposed transection line. (cid:142)(cid:3) Ensure that the catch is on and that the correct staple heights have been taken into account. (cid:142)(cid:3) Place a crushing clamp (Parker-Kerr or Payrs) adjacent and proximal to the linear stapler. (cid:142)(cid:3) Remove the safety catch and fire the staple. (cid:142)(cid:3) Divide the d uodenum between the stapler and clamp-using knife. (cid:142)(cid:3) Remove the specimen or displace it medially. (cid:142)(cid:3) Open the jaws of the stapler and remove it. (cid:142 )(cid:3) Check the staple line for bleeding. If there is a bleeding vessel, under run it with 2/0 Vicryl. (cid:142)(cid:3) Drainage to cover the risk of blowout is no more necessary than after hand-sewn closure. A new lesser curve to the stomach during distal gastrectomy can be fashioned similarly usin g the longer 90mm linear stapler. Continuity can be re-established with a gastroenterostomy using a side-to-side stapler (Polya) or an end-to-end stapler to the duodenum (Bilroth I). This page intentionally left blank CHAPTER 10 Stapling in surgery 362 Stapling technique for gastroenterostomy Stapled gastroenterostomy using a side-to-side tec hnique is easy and rapid to perform in distal gastric resection or palliative proximal bypa ss for unresectable antral cancer. Procedure (cid:142)(cid:3) After resecting the distal stomach or realizing that the antral cancer cannot be resected, bring up a loop of jejunum ante or retrocolically so that it rea ches the stomach without tension. (cid:142)(cid:3) In palliative surgery exclude the distal stomach (the 90mm linear stapler is ideal for this). (cid:142)(cid:3) Position the jejunal loop with the afferent loop to the lesser curve so th at the proposed stoma lies in the most dependent part of the stomach. (cid:142)(cid:3) Plan the position of the stomach and jejunal loop for stapling to ensure that vessels in the gastric arcade and jejunal mesentery are not embarrassed. (cid:142)(cid:3) Hold the proposed suture lines adjacent with four Babcock \200\231s forcep s. Make two enterotomies opposite each other in the duodenum and stomach with diathermy. (cid:142)(cid:3) These should admit the jaws of a side-to-side stapler and be approxi- mate ly 1cm across. Insert the open jaws of the stapler fully into each viscus and approximate t he proximal end first. (cid:142)(cid:3) Ensure that the vessels and other structures are not incorporated and fire the stapler. Open the stapler and remove it. (cid:142)(cid:3) The anastomosis can be inspected for completeness and bleeding through the now single enterotomy. (cid:142)(cid:3) Close the enterotomy with two layers of continuous 2/0 Vicryl or with a linear stapler. (cid:142)(cid:3) It is not necessary to reinforce the staple line, but a Vicryl suture placed seromuscularly at each end of the anastomosis may take the strain off it. This page intentionally left blank CHAPTER 10 Stapling in surgery 364 Stapling technique for bowel resection and functional end-to-end anastomosis After bowel re section, e.g. right hemicolectomy, an end-to-end anasto- mosis can be fashioned quickly usi ng the side-to-side stapler. Preparation, anesthetic, position on the table, and incision are the same as conventional h and-sewn anastomosis. Procedure (cid:142)(cid:3) After right hemicolectomy line up the distal ileum and transvers e colon with their open lumina adjacent using Babcock \200\231s tissue forceps. (cid:142)(cid:3) En sure that the mesentery of each viscus is as far away from the proposed anastomosis as possible. Ideally the staple line should run along the antimesenter ic border. (cid:142)(cid:3) Insert the open jaws of the stapler down each bowel limb, close and fire. (cid:142)(cid:3) Open and remove the stapler and inspect the long side-to-side join. (cid:1 42)(cid:3) Close the open ends of the ileum and colon with two layers of con- tinuous 2/0 Vicryl or by using a linear stapler. (cid:142)(cid:3) A similar palliative gastroenterostomy bypass can be fashioned quickly for an unresectable cancer by lining up two loops of bowel as in gastroenterostomy. Stapling can be justified when operative procedures can be undertaken more quickly and easi ly. Stapling further facilitates other more complex operations. Such operations include sma ll bowel pelvic pouches and Koch reservoir ileostomy, vertical banded gastroplasty (for obe sity) and reverse gastric tubes. Oesophageal replacement using stomach, colon, or small bow el is also quicker using stapling techniques. This page intentionally left blank CHAPTER 10 Stapling in surgery 366 Stapling technique for prolapse and hemorrhoids This operation involves excision, pulling u p and anchoring of excess rectal mucosa using a circular stapler. The technique has been sh own in several randomized trials to shorten anesthetic time and in-patient stay, reduce pai n scores and analgesic requirements allowing more rapid return to normal activities. Sympto m control and functional outcome are comparable at 3 months follow up. Position Prone. Jackknife that allows good visibility and access. Equipment 33mm haemorrhoidal circular stapler, suture threader, circular anal dilator, purs e-string anoscope. Procedure (cid:142)(cid:3) Insert the circular anal dilator and remove the obturator. This device allows easy introduction of the instruments and protects the internal sphincter. (cid:142)(cid:3) Suture the dilator to the anoderm. (cid:142)(cid:3) Identify the dentate l ine. Some surgeons infiltrate marcaine with adrenaline 0.5% into submucosa to contribute to analgesia and haemostasis. (cid:142)(cid:3) Introduce the purse-string suture anoscope through the anal dilator. Place 2/0 Prolene/Monocryl purse-string suture containing only rectal mucosa. (cid:142)(cid:3) R otate the purse-string suture anoscope to allow the placement of purse- string suture aroun d the entire circumference. Apply the suture at least 5cm above the dentate line. Pull the end gently to confirm mobility of the mucous membrane and to ensure no muscle bites have be en taken. (cid:142)(cid:3) Apply KY Jelly to head of gun to allow easy insertion through purse-stri ng. (cid:142)(cid:3) Open the circular stapler fully and position its head proximal to the purse-string. Tie with one throw loose enough to allow tissue to slip down the shaft when t raction is applied. (cid:142)(cid:3) Pull the ends of the suture through the lateral holes of the stapler and t ie the knot externally. Introduce the cartridge housing of the stapler in the anal canal an d confirm that the upper rim of staples is at least 2cm above the dentate line using cm mar king. (cid:142)(cid:3) With moderate traction on the purse-string draw the prolapsed mucous membrane into the casing. (cid:142)(cid:3) Close the stapler tight enough to optimize haemostasis before firing. Open the circular stapler and extract the head. Examine the staple line using the purse-str ing suture anoscope. (cid:142)(cid:3) Apply any additional stitches if needed. (cid:142)(ci d:3) Diclofenac (100 mg) and/or paracetamol (1g) suppositories can be inserted post-procedure and topical GTN 0.2% cream applied to ano- derm, to reduce iatrogen ic anal fissures and sphincter spasm. (cid:142)(cid:3) Bleeding has been observed in approx imately 20% of patients on stapler extraction: in 10% of cases haemostasis occurs spontaneously (within 5min), the rem ainder of patients will require the insertion of a 2/0 Vicryl suture to the bleeding point. Chapter 11 367 Hernias F. Di Franco, G. R. McLatchie, David J. Leaper Inguinal hernia 368 Repair of femoral hernia 372 Adult umbilical hernia (Mayo \200\231s \200\230vest over pants \200\231 repair) 374 E pigastric hernia 376 Incisional hernia 378 CHAPTER 11 Hernias 368 Inguinal hernia Indications (cid:142)(cid:3) Elective: all symptomatic hernias need operati on, particularly if indirect. (cid:142)(cid:3) Emergency: irreducible or strangulated herni as. Preoperative preparation (cid:142)(cid:3) Elective: can be performed as a day case in patie nts fulfilling the criteria. Antibiotic prophylaxis if planning to perform a mesh repair. (cid:142)(cid:3) Emergency: IV fluids, antibiotic prophylaxis, and NG suction are required. Emergency situations associated with intestinal obstruction. Position of patient Supine. Incision (cid:142)(cid:3) Make a curved inguinal incision in skin crease approximately 2cm above the medial two-thirds of the inguinal ligament. (cid:142)(cid:3) Incise fat and Scarpa \200\231s fascia, ligating the superficial epigastri c veins which cross the line of incision. Procedure (cid:142)(cid:3) Identify the external ring. Divide the external oblique aponeuro sis along the line of its fibers over the inguinal canal. Open the external ring. (cid:142)(cid:3) Pay attention to the ilioinguinal nerve, which exits the external ring and the iliohypogastric nerve, which is superior. (cid:142)(cid:3) Apply artery forceps to the edges of the external oblique. Turn back the e dges and identify the internal oblique and the conjoint tendon above the cord and inguinal ligament below. In the Shouldice repair divide the cremasteric muscle and open the fascia t ransversalis. Indirect hernias (cid:142)(cid:3) Identify the sac after picking up the cord at its medial end. Split its investing fibers in the line of the cord and dissect the sac to its origin, avoiding injury to the vas deferens. Transfix the sac at its base and excise it, except when there is a sl iding hernia in which case the sac should be reduced. (cid:142)(cid:3) Repair the transversalis fascia margins of the internal ring and repair th e posterior wall of the inguinal canal with non-absorbable sutures. Direct hernias Push the sac inwards and repair the posterior wall. If the sac is very large divide the sac near its origin and leave the distal portion open. Lichtenstein \200\230mesh \200\231 repair (see Fig.11.1) This is now a popular procedure. (cid:142)(cid:3) Tailor the mesh as shown (made of Prolone or Marlex). (cid:142)(cid:3) Pla ce the mesh over the conjoint tendon/internal oblique with the two limbs around the cord. I t should overlap the pubic tubercle and the conjoint tendon and be adjacent to the inguinal ligament. INGUINAL HERNIA1 369 (cid:142)(cid:3) By using monofilament stitches, suture the mesh to the inner surface of the inguinal ligament and conjoint tendon. (cid:142)(cid:3) Suture the tail ends of the mesh to one another around the cord. (cid:142) (cid:3) The mesh allows reinforcing the posterior wall of the inguinal canal in a \200\230tension free \200\231 fashion. Shouldice repair (see Fig.11.2) (cid:142)(cid:3) Suture the lateral flap of the fascia tran sversalis to the under-surface of the medial flap. (cid:142)(cid:3) Suture the medial flap of the fascia transversalis to the anterior surface of the lateral flap. (cid:142)(cid:3) Suture the conjoint tendon to the inguinal ligament. (cid:142)(cid:3) The external oblique is closed anterior to the cord. (cid:142)(cid:3) Use non-absorbable monofi lament sutures for the repair. Bassini repair (see Fig.11.2) This is no longer recommended because of the high risk of rec urrence. (cid:142)(cid:3) It is performed by suturing the conjoint tendon to the inguinal ligament using a non-absorbable suture. Fig. 11.1 Lichtenstein mesh repair CHAPTER 11 Hernias 370 Closure (cid:142)(cid:3) Approximate the external oblique with an absorbable suture. (cid:1 42)(cid:3) Close the wound in layers with clips or a subcuticular suture to skin. (cid:142) (cid:3) Inject local anesthetic at wound site and apply adhesive strips. Complications (cid:142)(cid:3) Acute urinary retention (cid:142)(cid:3) Haematoma (cid:142) (cid:3) Wound infection (cid:142)(cid:3) Infection of the mesh (cid:142)(cid:3) Exacerbatio n of prostatic symptoms (cid:142)(cid:3) Chronic pain (trapping of the ilioinguinal nerve) (cid:142)(cid:3) Recurrence. INGUINAL HERNIA1 371 Bassini repair Rectus muscle lliohypogastric nerve Aponeurosis of transversus abdominis Tanner slide Inguinal ligament Inguinal ligament Shouldice repair External oblique Inguinal ligament Transveralis fascia Transveralis fascia First suture Second suture Inguinal ligament Closure of external oblique aponeurosis Third suture Fig. 11.2 Inguinal hernia CHAPTER 11 Hernias 372 Repair of femoral hernia (see Fig.11.3) There are several approaches to the repair of femor al hernia which are all safe, but the operator must witness all of them and decide which pr ocedure suits his/her needs most. Position of patient Supine, regardless the approach used. McEvedy approach Incision Oblique vertical or transverse over the femoral canal with the lo wer part of the incision over the sac. Procedure (cid:142)(cid:3) First isolate the sac by a preperitoneal approach through the ex ternal oblique aponeurosis and conjoint tendon. (cid:142)(cid:3) Open the transversalis fascia and dissect between it and the peritoneum to the neck of the sac. The inferior epigastric vessels may have to be divided i n this plane. (cid:142)(cid:3) Reduce the sac by manipulating it from above and below. Then isolate and o pen it, ensure that it is empty, and transfix, ligate and divide it. (cid:142)(cid:3) Carry out the repair of the hernia by uniting the inguinal and pectineal ligaments for a distanc e of 0.5 \200\2231cm laterally without constricting the femoral vein. Use monofilament Nylo n. (cid:142)(cid:3) Retract the vein laterally with an index finger, insert the stitch into th e inguinal ligament, have your assistant retract the ligament upwards; take a large bite of the pectineal ligament. A single stitch may be all that is required. If not, insert a furt her stitch. High approach Incision Inguinal incision about 1cm above the medial two-thirds of the ingui nal ligament. Procedure (cid:142)(cid:3) Identify the external oblique aponeurosis. Split it as for the a pproach to an inguinal hernia repair and then displace the cord or round ligament upwards. (cid:142)(cid:3) Incise the transversalis fascia in line with the incision to identify the neck of the sac and the external iliac vein. (cid:142)(cid:3) Gently isolate the sac, open it, and empty it. Then transfix, ligate, and divide it. (cid:142)(cid:3) Affect this by placing non-absorbable sutures between the pectineal ligame nt and the inguinal ligament, not constricting the femoral vein. Low approach (not recommended for strangulation) Incision 5 \200\22310cm long in the line o f the groin crease, centered between the anterior superior iliac spine and the symphysis pu bis. REPAIR OF FEMORAL HERNIA1 373 Repair of femoral hernia Procedure (cid:142)(cid:3) Deepen the incision to identify the her nial sac. Ligate veins as necessary. (cid:142)(cid:3) Clean the sac, open and empty its contents, transfix, ligate and divide it, then carry out the repair as above. Closure Close the skin wounds with subcuticular sutures to the skin. High approach Examine sac Low approach Twist and transfix Fig. 11.3 Repair of femoral hernia CHAPTER 11 Hernias 374 Adult umbilical hernia (Mayo \200\231s \200\230vest over pants \200\231 repair) Position o f patient Supine. Incision Horizontal elliptical (with excision of stretched skin). Procedure (cid:142)(cid:3) Deepen the incision to reach the rectus sheath. Expose the neck of the sac. Open it in proximity of its neck. Return any protruding bowel to the peritoneal cavity. (cid:142)(cid:3) Any protruding omentum may be excised to reduce the volume of contents to be reduced. Remove the whole sac. (cid:142)(cid:3) Use non-absorbable mattress stitches. (cid:142)(cid:3) Suture the lower ed ge of the rectus behind the upper flap. (cid:142)(cid:3) Carry the upper flap down to overl ap the lower flap. Closure Close the skin either with clips or a subcuticular suture. Complications (cid:142)(cid:3) Rise in the intra-abdominal pressure due to the return of me sentery, bowel and omentum into the abdominal cavity. (cid:142)(cid:3) This may affect venous return and diaphragmatic movements leading to both circulatory and respiratory problems. (cid:142)(cid:3) Recurrence. Mesh repair is preferable in large umbilical hernias. This page intentionally left blank CHAPTER 11 Hernias 376 Epigastric hernia Indications (cid:142)(cid:3) Symptomatic (cid:142)(cid:3) >2cm in diamete r Position of patient Supine. Incision Vertical midline. Procedure (cid:142)(cid:3) Deepen the incision around the margin of the hernia until health y linea alba is identified. (cid:142)(cid:3) Then dissect towards the free edges of the sac. Excise the sac and repair the defect in the linea alba with non-absorbable sutures. Closure Close the skin either with clips or a subcuticular suture. This page intentionally left blank CHAPTER 11 Hernias 378 Incisional hernia Aim (cid:142)(cid:3) To close the abdominal wall defect and prevent recur rence. (cid:142)(cid:3) Carry out either a side-to-side suture of healthy aponeurosis, over lap of the defect edges, or interposition of a prosthetic patch or mesh. Position of patient (cid:142)(cid:3) Supine. Most hernias are midline. Procedure (cid:142)(cid:3) Excise the old scar and deepen the incision around the margins o f the hernia until healthy aponeurosis is identified. (cid:142)(cid:3) Dissect towards the free e dges of the defect. (cid:142)(cid:3) Return the sac, intact if possible, to the peritoneal cavity and suture its margins together. (cid:142)(cid:3) Clean the edges of the defect so that they are easily approximated. Options 1. If the defect edges come together easily, suture them with continuous (mass type closure) or interrupted Nylon sutures. 2. Create a two-layer closure by incising along the edges of the muscular defect. Suture the opposing sides together in two layers. 3. Overlap the edges of the defect in two layers of sutures. Do this only if no tension is created. 4. The \200\230keel \200\231 repair involves inversion of the sac with suture of its mar- gins followed by several layers of sutures to invert the edges of the defect. 5. If the defect is large or if there is only tension caused by approxima- tion, use a mesh (Marlex or Prolene) or a patch (Teflon) to close the defect. Suture the pr osthesis all the way round the palpable margins of the defect. Closure (cid:142)(cid:3) Close the skin with clips, or interrupted, or subcuticular Nylon s utures. (cid:142)(cid:3) Bring a suction drain through a separate stab wound. When using a prosthesis give prophylactic antibiotics. (cid:142)(cid:3) Large defects can be closed with 2 layers of mesh, inlay and onlay, to the musculofascial margins of the defect. Chapter 12 379 Peripheral vascular surgery A. E. Clason Arterial anastomosis 380 Exposure of major blood vessels 386 Profundaplasty 39 6 Endarterectomy 398 Carotid endarterectomy 400 Excision of carotid body tumor 404 Aneurysm al internal carotid artery repair 406 Sympathectomy 408 Repair of abdominal aortic aneurysm 416 Embolectomy 422 Aortoiliac occlusive disease 428 Extra-anatomic bypass 432 Infrainguin al bypass 440 Popliteal artery entrapment syndrome 446 Peripheral aneurysms 448 Pseudoaneur ysms 452 Fasciotomy 454 Renovascular access surgery 456 Amputations 460 Varicose veins 468 CHAPTER 12 Peripheral vascular surgery 380 Arterial anastomosis Aim The aim of arterial anastomosis is to achieve a watertight closure /join between the conduits concerned without tension and without compro- mise of the lumen. This is facilitated by first excising the adventitia. The intimal surface should be protec ted from damage. Gentleness at all times is mandatory and it is a vital principle of all an astomoses that the edges should always be everted to allow apposition of the intima of the artery with the graft lining. Materials Vascular sutures are usually produced with a needle at each end and polypropylene (Prolene) of various gauges is the commonest used. In general 3/0 Prolene is used for the aorta, whilst 4/0, 5/0, or 6/0 are used for smaller vessels. 8/0 to 10/0 sutures may be use d in the formation of micro vascular anastomoses. Taper cut needles allow easier penetratio n of atheromatous vessels. Arteriotomy This is best fashioned longitudinally for several reasons: (cid:142)(cid:3) Lon gitudinal easier to close than transverse (cid:142)(cid:3) Easier to extend if necessary (c id:142)(cid:3) Transverse more difficult as intima tends to retract away from the edges. Incise the artery wall with a 15 blade knife and extend the arteriotomy incision with Potts scissors taking care not to create any intimal flaps. Techniques Anastomosis may be end-to-end or end-to-side. Insert the sutures from inside to outside the artery and from outside to inside the graft. This avoids displacement of the in tima and creation of intimal flaps that may occlude the vessel. End-to-end (see Fig. 12.1A) (cid:142)(cid:3) Insert one of the double-ended needles from in side to outside the proximal end of the artery at the center point of the back wall and the other similarly fro m inside to outside of the distal end, tying the knot on the outside. (cid:142)(cid:3) Take each needle and suture round the circumference of the vessel with an over-and-over stitch till you reach the center of the front wall and tie both ends of the suture together on the outside of the artery. Avoid tension on the anastomosis and i ntimal damage. A continuous suture is appropriate in large vessels but interrupted (either simple or everting mattress) may be more suitable for smaller vessels. (cid:142)(cid:3) Whe n it is possible to rotate the vessel the anastomosis may be facilitated by dividing the circumference into three with stay sutures and rotating the ves sel by gentle traction on the stay sutures. ARTERIAL ANASTOMOSIS1 381 Interrupted Fig. 12.1A End-to-end arterial anastomosis CHAPTER 12 Peripheral vascular surgery 382 (cid:142)(cid:3) In the case of end-to-end suture of a graft to a large vessel, use a polypropylene suture and place the first four or five sutures before pulling down the gra ft, thus facilitating careful placement of sutures in the back wall (see Parachute techniqu e). It is not necessary to cut the vessel completely across but approximately halfway or tw o thirds, so that it is opened like the leaves of a book. It is important to take an adequa te bite of the posterior wall of the artery and pull it up. Then snug the graft down by pul ling both ends of the suture at right angles to the artery wall and complete the suture lin e by a continuous over-and-over stitch till the sutures meet tying the knot externally. (ci d:142)(cid:3) Wherever smaller vessels are to be anastomosed, cut the vessel ends obliquely . This increases the length of the suture line and reduces tension and the risk of stenosis . (cid:142)(cid:3) Pass two double-ended polypropylene sutures through the opposing ends of t he vessel. Tie one end and hold the other in a rubber-shod mosquito forceps. Use one end of the tied suture to sew over and over to the other corner. On completion of one side rotate the vessel and complete the second side similarly. End-to-side (see Fig. 12.1B) This is the standard form of anastomosis used for bypass proce dures. (cid:142)(cid:3) Use a double ended vascular suture and pass the needles from outside \200\224in on the graft side \200\224out on the artery. (cid:142)(cid:3) Fashion an arteriotomy as above and cut the graft obliquely tailoring the length of the oblique cut to match the arteriotomy and spatulating the end by an \200 \230S \200\231 shaped cut to form a \200\230cobra head \200\231. (cid:142)(cid:3) Place a double-ended stitch from outside to inside in the heel of the graf t and then pass both needles from inside to out at the proximal apex of the arteriotomy and tie the knot on the outside. Either anchor the toe of the graft to the distal apex of the arteriotomy with a separate double ended suture or leave it free (the latter allows clearer view of the inside of the anastomosis). Run the suture down each side of the anastomosis t o beyond the mid point and retain the ends in rubber shod forceps. (cid:142)(cid:3) Now either take one suture around the lowermost part of the anastomosis to meet the second or alternatively insert a further stitch in the toe of the g raft at the lower apex and complete either side, tying the knots on the outside of the arte ry. ARTERIAL ANASTOMOSIS1 383 Fig. 12.1B End-to-end arterial anastomosis CHAPTER 12 Peripheral vascular surgery 384 Variation: parachute technique (see Fig. 12.1C) With the graft and the recipient artery sep arated, place a number of running stitches from outside the graft to inside the apex of the arteriot- omy at the heel, beginning from the mid point of the faraway wall and continuing around the heel without tying the knot (ensure no snagging). Then gently pull the suture e nds at right angles to the artery wall as the vessels are approximated. Then complete the s uture line as above. Patch angioplasty (see Fig. 12.1D) If the vessel being opened is <4mm in diameter or if it is desired to widen the lumen of a stenosed vessel (see Profundaplasty) then achieve closur e of the vessel by patch angioplasty. (cid:142)(cid:3) Use a patch of autologous vein for s mall vessels (never sacrifice the proximal end of the long saphenous vein but rather harves t the vein patch from the ankle or a tributary). For larger vessels use a patch of Dacron o r PTFE. (cid:142)(cid:3) Shape the patch to match the arteriotomy/defect and fix either end with a double ended stitch passing both needles from outside the patch to inside and inside to out side of the artery wall at the apex. Complete the suture line with a running stitch but do not finish at the apex, rather go round either side to the middle. ARTERIAL ANASTOMOSIS1 385 (C) Parachute technique (D) Vein patch Fig. 12.1C and D Arterial anastomosis techniques CHAPTER 12 Peripheral vascular surgery 386 Exposure of major blood vessels Carotid (see Fig. 12.2A) Position Supine with the neck exte nded (place a pad between shoulder blades and support the head in rubber ring). Turn the he ad to the contralateral side. Incision Along the anterior border of sternomastoid extending from 2cm below the angle of t he jaw to just above the clavicle. Procedure (cid:142)(cid:3) Divide the platysma and incise the deep fascia, divide the commo n facial vein and retract the internal jugular vein posteriorly. (cid:142)(cid:3) Mobilize the common carotid, superior thyroid, external and internal carot id arteries and control them with slings. The ansa cervicalis lies anterior to the vessels and leads superiorly to the hypoglossal nerve whilst the vagus nerve lies lateral to and po sterior to the vessels. The carotid sinus nerves lie in the bifurcation above the artery. (cid:142)(cid:3) Divide the stylohyoid and digastric muscles if greater access to the internal carotid is required, as in the case of high bifurcation of the vessels. Vertebral (see Fig. 12.2A) Position As for carotid. Procedure (cid:142)(cid:3) Make an oblique incision lateral to sternomastoid, expose the in ternal jugular vein and retracted laterally to expose the vagus nerve. (cid:142)(cid:3) Dissect ou t the carotid artery and retract it medially and continue dissection in the angle between t he artery and vein to expose the vertebral artery and vein crossed by the cervical sympathe tic chain. Expose the lower part of the vertebral artery and the origin of the subclavian b y downward dissection dividing the sympathetic chain and the vertebral vein. Subclavian (see Fig. 12.2B) Position As for carotid. Procedure (cid:142)(cid:3) Make a 10cm incision above medial half of clavicle and lateral t o the insertion of sternomastoid muscle. Deepen the incision by dividing clavicular head of sternomastoid, platysma and deep fascia to expose omohyoid and fat pad with lymph node whi ch is displaced superiorly. (cid:142)(cid:3) Identify the phrenic nerve lying in the anterior aspect of scalenus anterior and passing downward and medially, and protect it. Identify the brachial plexus an d protect it laterally. (cid:142)(cid:3) Divide scalenus anterior over a blunt instrument to reveal the subclavian artery and the suprascapular and internal mammary branches. EXPOSURE OF MAJOR BLOOD VESSELS1 387 (A) Hypoglossal nerve and ansa cervicalis Superior thyroid artery Carotid Common carotid art. ECA Vertebral Stump of facial vein Internal carotid art. Int. jugular vein (B) Phrenic nerve Divided scalenus ant. Subclavian Axillary Subclavian art. Fig. 12.2 Exposure of carotid and subclavian arteries CHAPTER 12 Peripheral vascular surgery 388 Distal subclavian/axillary artery (see Fig. 12.2B) Position As for Carotid. Procedure (cid:142)(cid:3) Expose the distal subclavian artery as for Subclavian extending the incision over the clavicle, divide the clavicle if necessary. (cid:142)(cid:3) Approach the proximal axillary artery via a 10cm incision below the middle third of the clavicle. (cid:142)(cid:3) Incise the skin and deep fascia to expose the fibers of pectoralis major, split them and insert a self retaining retractor. Define the axillary artery in the depth o f the wound. Exposure of the vessel may be aided by division or detachment of pectoralis mi nor from the coracoid process, the acromioclaviclar branches, if necessary, to allow full m obilization. Brachial artery (see Fig. 12.2C) Position Supine with the arm on table and the hand isolate d in a sterile translu- cent bag. Procedure (cid:142)(cid:3) In the upper arm by an incision placed along the medial border, just behind biceps muscle. Divide skin and deep fascia and retract biceps anteriorly and tr iceps posteriorly. The median nerve lies anterior and superior to the artery. (cid:142)(cid:3) Achieve exposure of the brachial artery at the elbow by an S-shaped incisi on in the anticubital fossa. Expose the bicipital aponeurosis and divide it to expose the b rachial artery and its bifurcation to radial and ulnar arteries, passing between brachiorad ialis and the flexor muscles. The median nerve and basilic vein are posteromedial to the ar tery. Radial artery (see Fig. 12.2C) Procedure (cid:142)(cid:3) Expose the radial artery via a ve rtical incision in the anterior aspect of the forearm. (cid:142)(cid:3) Expose it proximally by dissection between brachioradialis medially and flexor carpi radialis. (cid:142)(cid:3) Expose it at the wrist by a vertical incision beginning at the radial sty- loid. The cephalic vein lies above the deep fascia and the radial artery below it. (cid:142)(cid:3) Incise the deep fascia to expose the artery and its accompanying veins. Ulnar artery (see Fig. 12.2C) (cid:142)(cid:3) Expose the ulnar artery likewise via vertica l forearm incisions. (cid:142)(cid:3) Expose it proximally by dissection of pronator teres and the brachio- radialis laterally and the flexor digitorum. The artery is found between them. (cid:142)(cid:3) For exposure at the wrist make a similar vertical incision medial to flexo r digitorum and the ulnar styloid. The ulnar artery lies slightly deeper than its radial co unterpart, expose it as it passes below the flexor retinaculum. EXPOSURE OF MAJOR BLOOD VESSELS1 389 Divided biceps tendon Brachial art. Median nerve Radial art. Basilic vein Ulnar art. Fig. 12.2C Exposure of brachial artery CHAPTER 12 Peripheral vascular surgery 390 Exposure of the abdominal aorta (see Fig. 12.2D) Position Supine. Incision Long midline skirting umbilicus, transverse, or retroperitoneal. Procedure (cid:142)(cid:3) Place self retaining retractors (Balfour, Finochetti, Omnitract) in the wound. Lift the transverse colon out of the wound or pack it under the upper abdomen/lower thorax. Displace the small bowel to the right and wrap it in moist packs in a gut bag. (cid:142)(cid:3) Expose the coeliac axis after opening the lesser omentum to identify the diaphragmatic crura. Divide them to reveal the aorta and origin of the coeliac axis. Su pracoeliac approach can be used to gain rapid con- trol of the aorta in the case of aortic rupture. (cid:142)(cid:3) Expose the splenic artery by dividing the greater omentum along the lower border of the stomach. Retract the stomach proximally to expose the upper margin of the pan creas and the splenic vessels. (cid:142)(cid:3) Expose the superior mesenteric artery by careful caudal dissection along t he aorta utilizing the supracoeliac approach as described above. An alternative and quicker approach to the SMA is via the root of the small bowel mesentery. Displace the transverse colon upwards and, with the small bowel to the right, expose the SMA in the small bowel mes entery using the point at which the middle colic artery ascends in the transverse mesocolon as a guide. (cid:142)(cid:3) To expose the infrarenal aorta, renal arteries, and the aortic bifurcation identify the peritoneum overlying the aorta and divide it over the bifurcation upwards to the right of the inferior mesenteric artery, mobilizing the duodenum to the right (you may need to divide the inferior mesenteric vein to gain access). Identify the left renal vein a nd carefully mobilize it passing a sling around it. The vein can be lifted or divided to ex pose the renal vessels. (cid:142)(cid:3) To expose each common iliac, lift the overlying peritoneum and divide it t aking care to preserve the ureters and iliac veins (often adherent to the artery) and conti nue the exposure to the iliac bifurcation and origin of the internal iliac. Common/external iliac artery (see Fig. 12.2E) Incision Oblique incision in iliac fossa late ral to edge of rectus sheath. Procedure (cid:142)(cid:3) Deepen the incision and divide the abdominal wall muscles to exp ose the peritoneum which is displaced medially identifying the ureter and the iliac vessels . (cid:142)(cid:3) Insert deep self-retaining retractors to allow access. Expose the inter- nal iliac by encircling the common and external iliac arteries with slings and pulling the vessel laterally to allow exposure of the origin of the internal iliac. EXPOSURE OF MAJOR BLOOD VESSELS1 391 (D) Abdominal aorta (a) (b) (c) (E) Iliac vessels Internal iliac art. Common iliac art. External iliac art. Fig. 12.2 Exposure of (D) abdominal aorta and (E) iliac arteries CHAPTER 12 Peripheral vascular surgery 392 Common femoral/profunda femoris arteries (see Fig. 12.2F) Incision The surface marking for the common femoral artery is the mid inguinal point, halfway between the anterior superior iliac spine and the pubic tubercle. Make 10 \200\22312cm vertical incision two fingerbreadths lateral to pubic tu- bercle exten ding one third above and two thirds below the inguinal ligament or over the palpable femora l pulse. Feel for the pulsation with your fingers. If exposure of the long saphenous vein i s required use a lazy S incision curving medially over the vein. Procedure (cid:142)(cid:3) Incise the fat and fascia and insert a Travers retractor. Do not cut across lymph nodes and ligate lymphatics. Feel for the pulse and expose the femoral sh eath and incise longitudinally. (cid:142)(cid:3) Mobilize the artery using sharp dissection, ligating and dividing any small veins to allow exposure of the common femoral and the superfi- cial femoral arteries. Pass a Lahey clamp under each vessel and draw a sling around each.