(cid:142)(cid:3) Close the subcutaneous tissues below the superficialised vein and close the wound in layers with an absorbable suture after ensuring the presence of a palpable thr ill in the fistula. Lower limb AV fistula The long saphenous vein of >3.5mm diameter in the thigh can be used a s a suitable conduit if there are no suitable veins in the arm. The preferred configuration is a straight transposition onto the anterior thigh. (cid:142)(cid:3) Expose the long saph enous vein in the proximal thigh through a vertical incision along the desired length. CHAPTER 12 Peripheral vascular surgery 458 (cid:142)(cid:3) Transpose the mobilized vein subcutaneously to lie over the distal superficial femoral artery in the mid to distal thigh. (cid:142)(cid:3) Expose the SFA and apply bulldog clips to the artery and fashion a 1.5cm arteriotomy. Now join the spatulated vein end to the arteriot- omy with a continuous 6/0 Prolene and release the occluding SFA clamps. (cid:142)(cid:3) Close the wound in layers. Prosthetic access grafts Indications Synthetic arteriovenous bridge if no adequate vein exi sts. The usual prosthetic material is PTFE. Requirements for a synthetic graft are suit- ab le arterial inflow and a vein to provide adequate venous outflow. A variety of anatomical graft configurations are possible: (cid:142)(cid:3) Straight radiobasilic (cid:142)(cid:3) Brachiobasilic forearm loop (cid:14 2)(cid:3) Brachioaxillary graft (cid:142)(cid:3) Thigh loop (common femoral/femoral vein). Grafts require a brief period of consolidation (7 \200\22310 days) but are prone to infecti on or thrombosis. Brachioaxillary PTFE graft Position Supine with the arm extended on a table with the hand i n a sterile, trans- lucent bag. Procedure (cid:142)(cid:3) Make a transverse incision in the axilla and mobilize the axilla ry vein passing slings around the vessel. (cid:142)(cid:3) Now expose the brachial artery at the elbow either by a vertical incision just below the edge of biceps or by an oblique cubital fossa incision. (cid:142)(cid:3) Mobilize the artery and pass slings around it for control. Using a tunneling instrument fashion a subcutaneous tunnel between the two incisions and pass a len gth of unsupported 6mm or 8mm PTFE graft along the tunnel. (cid:142)(cid:3) Give the patient 5000IU heparin and clamp the axillary vein with bulldog clips. (cid:142)(cid:3) Make a 1.5cm venotomy, tailor the graft obliquely and suture the graft to the venotomy with continuous 6/0 Prolene. Now apply bulldog clips to the brachial artery an d fashion a 1.5cm arteriotomy, anastomosing the graft to the artery in a similar fashion en d to side with 6/0 Prolene. Release the arterial clamps and check for haemostasis at the su ture line then release the clamps on the axillary vein. (cid:142)(cid:3) Close the wounds without drainage in layers. This page intentionally left blank CHAPTER 12 Peripheral vascular surgery 460 Amputations Despite use of embolectomy, arterial bypass surgery and catheter- directed thro mbolysis the annual amputation rate has not decreased, peripheral vascular disease being re sponsible for 90% of amputations performed in England and Wales. Aims Restoration of mobility, relief of pain life saving procedure. Indications Chronic ischaemia flexion contractures or non- Elderly who do not walk with rec onstructable disease (rest pain) and ulceration or gangrene affecting a considerable part o f the weight bearing surface. Acute ischaemia Limb loss following acute ischaemia is 9 \200\22330% with a mortality >18%. Ampu- tation appropriate when ischaemia fails to respond to surgical or medical measures a nd to prevent septicaemia resulting from gross tissue necrosis. Infectious gangrene (diabetics) When gangrene is \200\230dry \200\231 amputation is perfor med when there is a clear line of demarcation established. When \200\230wet \200\231 gangr ene is present, preop- erative control of infection is needed by use of antibiotics. Infect ion is usually polymicrobial and adjunctive treatment with broad spectrum anti- biotics nec essary (cephalosporins/ aminoglycosides/metronidazole).The foot is not salvageable when inf ection has destroyed the plantar architec- ture or if debridement results in no functional weight bearing surface. MRSA is today a likely problem. Level of amputation (see Fig. 12.22) Aim (cid:142)(cid:3) Remove the infected/dead part (ci d:142)(cid:3) Site with good potential for healing (cid:142)(cid:3) Successful rehabilitati on (cid:142)(cid:3) Prosthetic device fitting. Ultimate objective is to identify the most d istal site at which healing will reliably occur. Vascular reconstruction may allow healing at a lower level and better rehabilitation potential. Basic principles (cid:142)(cid:3) Careful, precise surgical technique (cid:142)(cid:3) Bone s transected at comfortable distance above skin flap (no tension) (cid:142)(cid:3) Nerves d ivided sharply (nerve catheters for analgesia) (cid:142)(cid:3) Avoid mass ligatures (cid:1 42)(cid:3) Haemostasis essential (closed system suction drains). Foot Digital amputations The flaps may be fish mouth, plantar based, dorsal based or circul ar but should be tension free to allow closure over the bone stump. Never AMPUTATIONS1 461 Amputation sites Skin flaps Transmetatarsal amputation Fig. 12.22 Amputations in the lower limb CHAPTER 12 Peripheral vascular surgery 462 carry out amputation by disarticulation through a phalangeal joint, but rather transect the proximal phalanx leaving a button of bone. Ray amputation (cid:142)(cid:3) Use a racquet incision with the vertical component on the d orsum of the foot to expose the metatarsal head and carry out incision distally to encircle the toe. (cid:142)(cid:3) Divide the distal metatarsal shaft at its neck and all the attached ten- dons and nerves. Secure haemostasis. (cid:142)(cid:3) Approximate the skin flaps are approximated accurately and without tension using non absorbable sutures. Transmetatarsal amputation Indications (cid:142)(cid:3) Gangrene of foot confined to the to es (cid:142)(cid:3) The plantar skin of the foot must be healthy. Procedure (cid:142)(cid:3 ) Make a slightly curved dorsal incision from one side of the foot to the other just distal to the anticipated point of bone division in the middle portion of the metatarsal shafts. Extend the incision at the base of the toes across the plantar surface of the foot in the m etatarsophalangeal crease. Deepen the dorsal incision down to the metatarsal shafts. (cid:1 42)(cid:3) Excise the plantar flap from the metatarsal shafts and divide the meta- tarsal bones with a Gigli or oscillating saw. The bone ends are smoothed with a rasp and th e plantar flap tailored, thinned, and redundant muscle excised. (cid:142)(cid:3) Approximate the flap and skin edges by a tension free skin closure using interrupted sutures. Postoperatively (cid:142)(cid:3) No weight-bearing for 7 \200\22310 days (cid:142)(cid:3) N o specific prosthesis required but shoe modification. Lisfranc forefoot amputation Similar to above but makes use of a short dorsal and along pla ntar flap, the bones being divided along the base of the metatarsals. Symes amputation Seldom indicated for the truly ischaemic limb but may be applicable in dia betics with forefoot gangrene. Not greatly favored by prosthetists or patients (BKA better) . A healthy heel pad is a prerequisite. Procedure (cid:142)(cid:3) The incision creates a long posterior flap incorporating the hee l pad the dorsal incision extending across the ankle from the medial to lateral malleolus. Make the plantar incision at 90(cid:13) angle to the dorsal incision and extend it in the p lantar aspect of the foot distal to the heel cutting all layers to the bone (take care not to cut the posterior tibial artery on the sole). (cid:142)(cid:3) Enter the capsule of the tibiotalar joint. Divide the tibialis posterior and plantar flex the foot forcibly to allow division of the ligaments and AMPUTATIONS1 463 dislocate the talus. Dissect the calcaneus sharply from the heel pad and divide the Achille s tendon at its insertion. Divide the malleoli flush with the joint surface. (cid:142)(cid:3) Swing the posterior heel pad flap forwards and tailor its length and affect a tension free closure with interrupted Nylon sutures. Below knee amputation This is the best amputation for rehabilitation and mobility but is co ntra- indicated when there is extensive lower limb infection or gangrene close to the tibia l tuberosity or involving the posterior calf skin. There should be no flexion contracture o f the knee and it is contraindicated in those with no prospect of walking. Two principle ty pes: (cid:142)(cid:3) Burgess flap (cid:142)(cid:3) Skew flap. Burgess flap used most often and less complicated than skew flap procedure. Burgess flap (see Fig. 12.23) Procedure The level of tibial transection is 10 \200\22312cm (approx. a hand \200\231s breadth) below the tibial tuberosity. (cid:142)(cid:3) Make a ski n incision at this level for two thirds of the circumference of the leg down to the tibia and exposing the muscles of the lat- eral/anterior compartment an d extend it on either side inferiorly to the limits of healthy calf skin. Divide the muscle s of the anterior compartment and isolate the anterior neurovascular bundle. Divided and se parately ligated allowing the divided nerve to retract superiorly. (cid:142)(cid:3) Transect the fibula using a Gigli saw 1 \200\2232cm proximal to the point of tibial division. Now divide the tibia with a steep 45(cid:13) bevel anteriorly. (cid:142)(cid:3) Expose and divide the posterior tibial and peroneal neurovascular bundles. (cid:142)(cid:3) Fashion the posterior myocutaneous flap leaving the gastrocnemius and sole us muscles as a base and smooth the bone ends with a rasp. Tailor the myocutaneous flap rem oving excess muscle and approxi- mate it over a suction drain to the anterior tibial fascia and the tibial periosteum with absorbable sutures. (cid:142)(cid:3) Close the skin with interrupted Nylon sutures or a subcuticular absorbable suture (4/0 PDS). Postoperative Postoperative analgesia can be facilitated by the insertion of a tibial nerve catheter for infusion of analgesic. Ensure the patient practices extension and flexion of the knee joint such that the joint can be straightened. A flexion contracture makes fitting of a prosthesis impossible. CHAPTER 12 Peripheral vascular surgery 464 Skew flap (see Fig. 12.23) Procedure The length of the stump measured to the point of bone division is 10 \200\22315 cm from the tibial plateau. (cid:142)(cid:3) Draw a circumferenti al line on the skin at the defined level of bone division. On this line mark a point 2cm la teral to the subcutaneous tibial crest to identify the junction point of the anteromedial a nd pos- terolateral flaps. Draw on the skin a fourth circumference arc to mark the minimal distance of the flaps. Along this circumference incise the skin, subcutaneous tissue, fat a nd periosteum. (cid:142)(cid:3) Divide and ligate the long and short saphenous veins. (cid:142)(cid:3) Dee pen the incision through the anterior tibioperoneal muscles divid- ing the anterior tibial nerve and allowing it to retract. Ligate the ante- rior tibial vessels separately and expos e the tibia and fibula on the interosseus membrane. Divide the fibula with a Gigli saw and the tibia with an anterior bevel. Having divided the bones, expose the posterior tibial and peroneal vascular bundles and ligate them separately. (cid:142)(cid:3) Dissect the skin flap on the distal leg distally to reveal the gastrocne- mius/soleus mass which is extricated from the distal leg. (cid:142)(cid:3) Fashion a myoplastic flap and thin it leaving only aponeurosis over the di stal few millimeters (bleeding from the soleus venous plexus and small arteries will requir e control or oversewing. Trim excess muscle and smooth the bone ends with a rasp. Wash the site out with saline and fold the flap upwards and suture it to the anterior tibial fascia and tibial periosteum over a suction drain using an absorbable suture. (cid:142)(cid:3) App roximate the skin and fat with interrupted nylon or an absorbable subcuticular suture. Through knee amputation Most commonly performed for trauma, provides a long stump for balan ce if bilateral amputee Flaps/incisions (cid:142)(cid:3) Long anterior flap (cid:142)(cid:3) Equal length anterior and posterior flaps (cid:142)(cid:3) Sagittal equal length anterior/posterior flap \200\224 most common in ischaemia. Position Supine with a \200\230bump \200\231 in the operating table to elevate the thigh, and with the knee flexed. Procedure (cid:142)(cid:3) Outline skin flaps with a skin marker and incise. Dissect anteri or to the insertion of the patellar tendon and divide it. Continue the dissection medially to divide the four hamstring tendons. Laterally divide the biceps femoris and iliotibial ba nd. AMPUTATIONS1 465 Skew flap 10 \200\22315cm 2cm 2cm 1/4 circumference Burgess flap \200\230Rule of thirds \200\231 10 \200\22312cm 2/3 circumference 1/3 circumference Fig. 12.23 Below knee amputation CHAPTER 12 Peripheral vascular surgery 466 (cid:142)(cid:3) Enter the knee joint from the front and cut the cruciate ligaments. Locate the popliteal vascular bundle and ligate it and divide it. Divide the tibial and per oneal nerves and allow them to retract. Place the patellar tendon in the intercondylar notc h and sew it to the cruciates with an absorbable suture and similarly the semitendinosus an d biceps tendon. A drain is optional. (cid:142)(cid:3) Close the skin without tension using an absorbable subcuticular suture. Above knee amputation 3 levels \200\224supracondylar/mid thigh/high thigh. The longer the femoral shaft the greater the mechanical advantage regarding transfer, balance etc. Incision Fish mouth or circumferential. Procedure The proximal extent of the incision is at the intended level of femoral division and the length of the flap is approximately half the anteroposte- rior diameter (ensure no tension \200\224better a loose flap than an ischaemic flap). (cid:142)(cid:3) Incise throug h the skin, subcutaneous tissue, and fascia and identify the femoral vessels in the subsart orial canal, separately ligate and divide them. (cid:142)(cid:3) Divide and retract all anterior and posterior muscles. Isolate the sciatic nerve and divide it under tension and allow it to retract. Insert a sciatic nerve catheter and anchor it with an absorbable suture. Transect the femur at a higher level than the fla p and smooth the edges with a rasp. Test closure to ensure it is tension free \200\224if no t shorten the femur. (cid:142)(cid:3) Secure haemostasis and suture the anterior and poster ior muscles over the femoral end. (Suction drain optional, brought out through healthy skin remote from amputation site.) (cid:142)(cid:3) Approximate the anterior and posterior layers of deep fascia with interrupted absorbable sutures and the skin closed with interrupted or subcuticular stitche s. This page intentionally left blank CHAPTER 12 Peripheral vascular surgery 468 Varicose veins Varicose veins occur in the long and short saphenous systems secondary to va lvular incompetence possibly as a consequence of degenerative fibrosis of the vein wall and /or valve ring. They may also be secondary to perforator vein incompetence usually after de ep vein thrombosis. Indications (cid:142)(cid:3) Relief of symptoms \200\224chronic ache, night cramps, itching , restless legs (cid:142)(cid:3) Complications \200\224varicose eczema, ulcer, recurrent ph lebitis (cid:142)(cid:3) Cosmetic. Preoperative preparation The groin and leg are shaved (especially in men). The veins are ma rked on the skin, with the patient standing, using a felt pen prior to surgery. Points of i ncompetence and sites of perforators are marked. In the case of recurrent varicose veins or where there is doubt as to the sites of major incompetence a preoperative Duplex scan asse ssment is man- datory and vein mapping immediately prior to surgery may be helpful. Trendelenberg procedure Position Supine with the legs abducted and the knee flexed. The ski n of the lower abdomen legs and groin is prepared. Incision Medial to the femoral pulse and approximately 5cm long below and parallel to the i nguinal ligament (in the obese this may be above the skin crease). Procedure (see Fig. 12.24) (cid:142)(cid:3) Insert a West \200\231s self retaining retracto r to spread the skin edges apart. Identify the long saphenous vein and ligate and divide al l its tributaries (the anatomy is variable, but tributaries include; superficial epigastric , superficial and deep external pudendal, and superficial circumflex iliac veins). (cid:142)(cid:3) Divide the long saphenous vein after clear identification of its junction with the femoral vein at the cribiform fascia (the junction is usually crossed inferiorly b y a small artery branch from the adjacent femoral artery). Then transfix and ligate the pro ximal end with 3/0 Vicryl, the needle of the transfixion suture entering the long saphenous vein approximally one half of the long saphenous vein diameter away from the saphenofemora l junction so that the transfixion suture will lie flush with the femoral vein and any cons triction of the femoral vein is avoided. VARICOSE VEINS1 469 (A) (B) Long saphenous vein Femoral art. CFV Cribriform fascia Saphenofemoral junction (C) (D) Stripper wire Long saphenous vein Long saphenous vein CFV CFV Edge of cribriform fascia Ligated saphenofemoral junction Fig. 12.24 Trendelenburg operation (saphenofemoral disconnection) CHAPTER 12 Peripheral vascular surgery 470 (cid:142)(cid:3) Pass a vein stripper distally to the below knee level. Extract the strippe r through a small stab incision at that site and pull distally until the small knob at its upper end is flush with the cut end of the vein. Then ligate it with a long (one meter) le ngth of 2/0 thread, firmly anchoring the stripper wire in the vein. The long length of thre ad is left intact so that when the stripper wire passes through and extracts the invaginate d long saphenous vein, the thread remains in the track of the long saphenous vein. Should t he full length of the long saphenous vein not have been removed, traction on either end of the thread tents the skin and allows a stab incision to be made to reach the residual segme nt which can be grasped with its contained thread. Then pull a tape soaked in 0.5% bupivaca ine and 1:200 000 adrenaline through the track of the extracted long saphenous vein and lea ve it in situ till the operation is complete and then removed (this reduces post operative haematoma and aids analgesia). (cid:142)(cid:3) Then identify any other marked varicosities and deliver them through 3mm stab incisions made in the long axis of the leg penetrating the dermis only by using fi ne mosquito forceps or a Mueller vein hook. Pull the vein to the surface and deliver it as a loop and divide it between forceps. Apply gentle traction until a segment of vein is deli vered with each forcep, apply- ing another forcep close to the skin as the further segment of vein emerges. Continue this process until the vein breaks off. Make a new inci- sion fur ther down the marked vein to pick up the vein again and repeat the process until the entire length of the marked varicosity is removed. (cid:142)(cid:3) Infiltrate the edges of the groin wound with 0.5% bupivacaine and approximate the subcutaneous tissues with an absorbable deep suture. (cid:142)(cid:3) Close the skin with an absorbable subcuticular suture. The stab wounds are either left unclosed or closed with Steristrips, occlusive dressing applied and the leg ba ndaged with crepe bandages from ankle to groin. Saphenopopliteal ligation and/or stripping (Short saphenous disease) Preoperative preparati on The evident varicosities are marked with a skin pen as before, with the patient standing . A preoperative Duplex scan or the use of hand held Doppler will have allowed the accurate identification of the site of the saphenopopliteal junction. Position Prone. Incision Transverse skin crease incision placed 1cm distal to the site identified by Duplex scan or Doppler as the site of the saphenopopliteal junction. Procedure (cid:142)(cid:3) Insert a small self-retaining retractor to separate the skin edg es. Expose the deep fascia and open it transversely. (cid:142)(cid:3) Grasp the short saphenous vein with forceps and follow it to the junction, dividing the gastrocnemius veins and a vein coursing upwards to the posteromedial vein of the thigh. Achieve a transfixion ligation of the saphenopopliteal junction in a si milar manner to that described VARICOSE VEINS1 471 above for saphenofemoral ligation. Take care throughout the dissection to avoid damage to t he sural nerve. (cid:142)(cid:3) Stripping of the short saphenous vein is achieved as for the long saphenous vein by passing a stripping wire down the calf. The stripper wire is retrieved vi a an incision of sufficient size to clearly define the vein from the adjacent sural nerve a nd thus avoid inadvertent neural damage. Remove remaining marked varicose tributaries via s tab inci- sions as described above. (cid:142)(cid:3) Close the popliteal wound in layers, the deep fascia and subcutaneous fat with an absorbable suture and the skin with an absorbable subcu- ticular stitch after infil tration of the wound with 0.5% bupivacaine. Close the stab wounds with Steristrips and dres sings and a crepe ban- dage applied. Multiple stab phlebectomy This may be applied in isolation when there is evidence of distal varicosi- ties but no evidence of saphenofemoral or saphenopopliteal incompe- tence on Dup lex scanning. It is conducted as described above through multiple 3mm stab incisions placed at appropriate points along the marked vein in the long axis of the leg. Perforating veins can be dealed with similarly or ligated flush with the deep fascia when exposed through la rger incisions placed directly over the marked sites. Recurrent varicose veins When previous groin/popliteal exploration has been carried out and there is evidence of recurrence it is mandatory prior to any further re- exploration that Duplex assessment of the sites of incompetence is performed. Fibrosis around the previous s urgery makes re-exploration through a standard approach difficult and hazardous. Procedure Vascular clamps should be available in case there is injury to the femoral vein. (cid:142)(cid:3) The saphenofemoral junction is best approached through either a vertical incision, as to expose the femoral arterial vessels, or through the old transverse incision but exposing the femoral artery first. (cid:142)(cid:3) Expose and identify the f emoral artery and the adjacent common femoral vein. Follow the common femoral vein superior ly until the saphenofemoral junction is seen and expose the femoral vein for approximately 1cm above and below the site of the saphenofemoral junction. Carefully mobilize the junctio n. When you are sure you have completely mobilized the junction all round, pass Lahey force ps around the junction and apply a vascular clamp to the junction adjacent to the femoral v ein. Above this clamp apply an artery forceps leaving a rea- sonable length of vein between to allow safe division of the junction. Oversew the junction with a 5/0 Prolene suture wit hout compromise of the femoral vein and transfix and ligate the other end of the divided ve in with an absorbable suture. If there is a persistent long saphenous vein, identify it and strip it as in a Trendelenberg procedure. Otherwise the residual varicosities are dealed w ith by multiple stab avulsions as above. CHAPTER 12 Peripheral vascular surgery 472 Perforator surgery Indications Chronic venous disease: (cid:142)(cid:3) Pre-ulcerative veno us disease and Duplex evidence of perforator incompetence (cid:142)(cid:3) Healed yet recurrent ulcers (cid:142)(cid:3) Active ulcer that does not re spond to compression therapy. These may be performed in conjunction with surgery for primar y varicose veins. Options (cid:142)(cid:3) Cocketts procedure (cid:142)(cid:3) Dodds procedure (cid:142)(cid: 3) Subfascial endoscopic perforator surgery (SEPS). Cocketts procedure Incision Parallel to the subcutaneous posterior border of the tibia and 1cm behind it. The incision is vertical and extended distally as required. Procedure (cid:142)(cid:3) Deepen the incision and divide the deep fascia in the same verti cal plane. Reflect the edges of the wound so formed until the perforating veins are seen. Ligat e and divide the perforators flush with the fascia. (cid:142)(cid:3) Close the wound in lay ers and apply a dressing and a crepe bandage. Dodds procedure Position of patient Prone with the leg prepared from mid-thigh to ankle and with the foot in a glove. Incision Stocking seam in the mid calf extending from 2cm below the popliteal skin crease t o the level of the malleoli. Procedure (cid:142)(cid:3) Deepen the incision and divide the deep fascia vertically the le ngth of the incision, taking care not to injure the sural nerve and the short saphenous vei n. (cid:142)(cid:3) Using finger dissection, sweep the flaps laterally below the deep fascia a s far as the attachment of the deep fascia to the borders of the tibia to expose the perfor ating veins. (cid:142)(cid:3) Divide and ligate the perforating veins below the fascia. (cid:142)(cid:3) Secure haemostasis and close the deep fascia with a series of spaced interrupted absorbabl e suture and close the skin with an absorbable subcuticular suture. Apply dressings and a c repe bandage. Subfascial endoscopic perforator surgery (SEPS) Instruments CO insufflator, rigid endoscope , 3 chip video camera, light source and monitor, balloon dissector, two 10mm laparoscopy po rts, reusable clip applicator. VARICOSE VEINS1 473 Position Under general anesthesia and in Trendelenberg position with knee slightly flexed. Procedure (cid:142)(cid:3) Make a 10mm incision in the skin 4cm medial to the tibia and 10 \200\22315cm below the popliteal crease. (cid:142)(cid:3) Dissect the subcutaneous tissue and make a small incision in the fascia. I ntroduce the balloon retractor into this space and direct it towards the medial malleolus. The balloon is inflated to 200 \200\223300cc to open up the space and then deflated and CO2 insufflated to a pressure of 15mmHg. The zero degree telescope is introduced and a separat e 5mm/10mm working port inserted in the mid calf under direct vision to allow passage of th e clip applicator and scissors. The working port should be placed as posteriorly as possibl e but not through the gastro- cnemius muscle. All accessible perforators are clipped and di vided if necessary. (cid:142)(cid:3) Close the skin incisions and apply compression bandages applied as above. Endovenous vein closure This technique is currently being evaluated for the treatment of lo ng saphenous disease in situ, in place of surgical stripping, using a Closure System (VNUS Medical Technologies). The system has been applied to LSV of 12mm diameter and uses electro des to apply locally confined temperature changes to the vein wall resulting in a small thr ombus plug in a contracted vessel with de-endothelialised wall and an obliterated vein lume n. This page intentionally left blank Chapter 13 475 Urology Q. King and C. Harding Surgical management of Principles of urodynamic and reconstructive urology acute urological emergencies Bladder augmentation: ileocystoplasy 520 Bladder augmentation: Debridement of Fournier \200\231s necrotising fasciitis 476 Exploration of the \200\230acu te Mitroffanoff appendicovesicostomy 522 scrotum \200\231 478 Suprapubic catheter placement 480 Urinary tract reconstruction after cystectomy 524 Reduction of paraphimosis Surgery for vesicovaginal fistula 482 530 Shunt procedures for Ureteroneocystostomy 532 Pyeloplasty 534 Procedures for hypospadias and priapism 484 Common urological chordee 536 procedures Urethral surgery for stricture: Surgical approaches to the urethroplasty 538 kidney, upper ureter, and adrenal gland 486 Simple nephrectomy 490 Inguinal orchidopexy 492 Circumcision 494 Correction of hydrocele Procedures for stress urinary incontinence 542 Procedures for Peyronie \200\231s disease 546 Principles of upper urinary 496 tract endourology Vasectomy 498 Urological oncology Percutaneous surgery of the upper urinary tract 548 Extracorporeal shockwave lithotripsy (E SWL) 552 procedures Radical nephrectomy and Ureterorenoscopic procedures 554 nephroureterectomy 500 Partial nephrectomy 502 Radical cystectomy 504 Radical retropubic Principles of laparoscopic urology prostatectomy 508 Inguinal orchidectomy 510 Partial penectomy 512 Common transurethral Laparoscopic urology: introduction 556 Laparoscopic radical nephrectomy 558 Laparoscopic pyeloplasty procedures 560 Transurethral resection of Laparoscopic retropubic radical the prostate (TURP) 514 prostatectomy 562 Transurethral resection of Laparoscopy for bladder tumor (TURBT) 516 cryptorchidism 564 Complications of laparoscopic Transurethral litholapaxy urology 566 518 CHAPTER 13 Urology 476 Debridement of Fournier \200\231s necrotising fasciitis Indication Fulminating polymicrobia l fasciitis involving the Colles \200\231, Dartos and Scarpa \200\231s fascia often as a co nsequence of perianal or periurethral sepsis. Position Supine or in lithotomy or extended lithotomy position, or with legs in Lloyd Davie s supports. Preparation (cid:142)(cid:3) Resuscitation and supportive care (cid:142)(cid:3) Intravenous fluids, broad-spectrum antibiotics and analgesics (cid:142)(cid:3) May require intensive c are, invasive monitoring. Procedure (cid:142)(cid:3) Incise through the affected skin and subcutaneous tissue. Use a combi- nation of sharp and blunt dissection to identify the plane of separation between vit al and necrotic tissue. The fasciitis seldom involves deep structures of penis, spermatic c ords, testes and adnexae or investing fascia of the abdominal musculature. Corpus spongiosu m may be involved if the process began as a urethral condition. (cid:142)(cid:3) Excise tissue until a bleeding edge is encountered. Where there is extensi ve undermining of apparently healthy skin by necrotic fascia, undermined tissue is unlikely to survive, and it may be wise to excise some of it. (cid:142)(cid:3) Superiorly, necrosis may extend as high as the clavipectoral fascia and cl avi- cles. Inferiorly, it may surround the anus, but seldom involves the thighs. (cid:142)(cid:3) If possible, cover the testicles by placing them in thigh pouches superficial to fascia lata \200\224if not, bring them together inferior to the penile root. If this is not done, the testes will retract into the vicinity of the external ring, produ cing a most unsatisfactory cosmetic result. (cid:142)(cid:3) Insert urethral or suprapubic Foley \200\231s catheter. (cid:142)(cid:3) D efunctioning colostomy may be required. Complications Patients are often very ill, and may develop any of the complications of hemo rrhage, acute sepsis and multiple system organ failure. Follow-up (cid:142)(cid:3) Intensive medical, nursing and nutritional supportive treatment. (cid:142)(cid:3) In the majority of cases, one or more subsequent debridement will be required. (cid:142)(cid:3) Reconstruction methods will depend on the extensiveness of fascio-cutaneous defect, but in general, thick split skin grafting of the penis and meshed thin skin grafting of the testes will produce a surprisingly acceptable appearance. (cid:142)(cid:3) More elaborate cosmetic or urodynamic surgery may be indicated, and will be tailored to the individual case. This page intentionally left blank CHAPTER 13 Urology 478 Exploration of the \200\230acute scrotum \200\231 Indications Acute orchalgia where torsio n of the spermatic cord cannot be emphati- cally excluded from the differential diagnosis. Position (cid:142)(cid:3) Supine, Lloyd-Davies, or lithotomy. Preparation (cid:142)(cid:3) Attempt manual detorsion. (cid:142)(cid:3) Obtain consent for orchidectomy if necessary. Counsel appropriately. (cid:142)(cid:3) Pre- or intra-operative ultrasound scan may be helpful but avoid delaying exploration in order to obtain one. (cid:142)(cid:3) Prep the genitalia and groins with antiseptic solution and shave appropriately. Procedure (cid:142)(cid:3) Examine properly under anesthesia. (cid:142)(cid:3) If there is no suspicion of testicular neoplasm, make a median scrotal incision or a transverse one crossing the midline. If neoplasm is suspected, approach as de scribed under \200\230Inguinal orchidectomy. \200\231 (cid:142)(cid:3) Incise through Dartos and the scrotal septum, and explore the affected testis first. (cid:142)(cid:3) Develop the avascular plane around tunica vaginalis and incise it. (cid:14 2)(cid:3) Deliver testis and adnexae (Fig. 13.1A). Intravaginal torsion of the spermatic cord is obvious unless detorsion has occurred. Ecchymosis, congestion, and oedema , together with a generous, or narrow pedicle, provide sufficient justification to fix the testis. (cid:142)(cid:3) Torsion of a testicular appendage should be managed by removal of the appendage, but there is no need to explore the contralateral testis. (cid:142)(cid:3) If spermatic cord torsion is diagnosed, reduce the torsion, and wrap the t estis within a warm moist swab while the contralateral testis is explored and fixed. (cid:142)(cid:3) Fix the testis by everting the tunica vaginalis in the manner of Jaboulay, and place three nonabsorbable sutures between the tunica albuginea of the testis (the medi al side of the upper pole is safest) or paratesticular tissue and Dartos (Fig. 13.1B). (cid:142)(cid:3) If the torted testis becomes pink, it is treated similarly. If it is obviously necrotic, ligate cord structures and remove it. If its viability is uncertain, we leave it in situ, and obtain a Doppler ultrasound scan after 24 to 48 hours. (cid:142)(cid:3) Close Dartos and skin in layers using absorbable sutures. (cid:142)(cid:3) Where an unsuspected testicular neoplasm is discovered, management will depend on the pati ent \200\231s age. In the prepubertal child, testicular conservation may be appropriate and frozen section should be obtained. This situation is fraught with medico-legal hazard, and informed consent is worthwhile taking some time over. EXPLORATION OF THE \200\230ACUTE SCROTUM \200\2311 479 Complications (cid:142)(cid:3) Infection (cid:142)(cid:3) Haematoma (cid:142)(cid:3) Testic ular atrophy, anti-sperm antibody production (cid:142)(cid:3) Recurrent torsion. Follow-up (cid:142)(cid:3) At least one outpatient appointment is arranged for counseling a nd examination (cid:142)(cid:3) Laboratory investigations only where clinically indicated. (A) (B) Fig. 13.1 (A) Exposure and (B) fixation of testis. CHAPTER 13 Urology 480 Suprapubic catheter placement Trocar and cannula technique for Foley \200\231s catheter ins ertion. Indications Bladder drainage where the urethral route is unavailable or undesirable (e.g. s tricture). Position Supine. Preparation (cid:142)(cid:3) The bladder should be palpably full or sonographic guidance sh ould be obtained. (cid:142)(cid:3) Abdominal and pelvic examinations should precede placement of the cannula unless contraindicated or impossible (e.g. compound fractured pelvis). (cid:142)(cid:3) Prep the lower abdomen and suprapubic area with antiseptic solution. Procedure (cid:142)(cid:3) Identify and mark the site of cannula insertion at a point a sho rt dis- tance above the symphysis pubis or equidistant between the fundus of the bladder and the pu bis. (cid:142)(cid:3) Remember that the bladder strips the anterior peritoneum from the abdominal wall as it fills, but that perivesical surgery, trauma or pathol- ogy may result in fixity and the interposition of bowel between bladder and abdominal wall. If in doubt us e sonographic guidance. (cid:142)(cid:3) Infiltrate the skin and subcutaneous tissue with 1 % lignocaine. (cid:142)(cid:3) Confirm site by aspirating via a small-gauge needle. (cid:14 2)(cid:3) Make a stab incision with an 11 blade, as deep as linea alba. (cid:142)(cid:3) Pl ace trocar and cannula in the incision, and firmly, but with fine control and accuracy, insert it into the bladder \200\224keep in mind the anatomical relati ons of the bladder. (cid:142)(cid:3) Remove the trocar and guide the Foley \200\231s catheter into the bladder, inflate the balloon and remove the guide. Complications (cid:142)(cid:3) Bleeding (cid:142)(cid:3) From the bladder (cid:142)(cid:3) From an enlarged intrusive prostate (cid :142)(cid:3) From perivesical venous plexus (cid:142)(cid:3) From the iliac vessels (cid:142)(cid:3) Rectal or enteric injury \200\224peritonitis or retroperitonitis (cid:142) (cid:3) Extravasation of urine (cid:142)(cid:3) Displacement or blockage of catheter (cid:1 42)(cid:3) Infection (cid:142)(cid:3) UTI (cid:142)(cid:3) Systemic sepsis (cid:142)(cid:3) Symphysitis pubis (now fortunately rare). SUPRAPUBIC CATHETER PLACEMENT1 481 Follow-up (cid:142)(cid:3) If the suprapubic catheter is regarded as definitive management, then simple replacement after an interval is possible without anesthetic or special equipm ent. (cid:142)(cid:3) Silicone catheters may be left in situ for three months and latex cathe- ters for one month. (cid:142)(cid:3) Special dressings are not necessary. Patients wear a cotton singlet, changed daily. (cid:142)(cid:3) If the placement of a suprapubic catheter was a temporizing measure, then, it may be removed when the primary condition has been satisfactorily treated. CHAPTER 13 Urology 482 Reduction of paraphimosis Position Supine. Preparation (cid:142)(cid:3) Analgesia, penile block, or general anesthesia (cid:142)(cid:3 ) If the condition has been neglected and become brawny, ulcerated, or inflamed give antibiotics (cid:142)(cid:3) Prep the skin with antiseptic solution, and drape. Procedure (cid:142)(cid:3) Gradual manual compression may be brought to bear on the oedema- tous foreskin as illustrated in Figs. 13.2A, B. (cid:142)(cid:3) When the volume of the foreskin has been reduced, simultanous traction may effect reduction. (cid:142)(cid:3) If this is not possible, make a dorsal slit: (cid:142)(cid:3) Identify the constriction ring in the midline dorsally and incise it through skin and Colles \200\231 fascia (Fig. 13.2C). (cid:142)(cid:3) Extend the incision proximal and distal to the constriction ring until all tension is removed. (cid:142)(cid:3) Obtain haemostasis and suture the longitudinal incision transversely (Fig. 13.2D). Complications (cid:142)(cid:3) Failure to relieve the constriction may result in ischaemia of the glans and necrosis (cid:142)(cid:3) Infection bleeding and haematoma formation. Follow-up Most patients are offered a definitive procedure such as circumcision, electively . REDUCTION OF PARAPHIMOSIS1 483 (A) (B) (C) (D) Fig. 13.2 Management of paraphimosis CHAPTER 13 Urology 484 Shunt procedures for priapism Indications Low-flow priapism that has not responded to medic al interventions and less invasive procedures such as cavernosal aspiration, irrigation, or intra- cavernosal vasoconstrictor injection. Position Supine. Preparation (cid:142)(cid:3) Prep from umbilicus to mid-thigh including groins and genitali a with antiseptic solution, and drape. (cid:142)(cid:3) A suprapubic or urethral catheter may be inserted for convenience and comfort postoperatively.