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General Surgery
Abdominal Vascular Emergencies
Built from Maingot's Abdominal Operations
What’s inside
9 sections · 187 slides
Overview
- Scope of this topic
- How the topic is organised
Recognising an abdominal vascular emergency
Two clinical patterns, and the tests that separate them
- Two patterns of acute vascular disease
- Presentation of the bleeding group
- Presentation of the thrombotic group
- Plain radiographs and computed tomography
- Retroperitoneal blood on non-contrast computed tomography
- Indirect CT clues and diagnosis at laparotomy
Exposure and control of the abdominal vessels
Proximal control first, in normal vessel, before anything is opened
- Principles of operative vascular control
- Antegrade and retrograde balloon control
- Balloon tamponade of collateral back bleeding
- Supraceliac aortic control
- Steps in exposing the supraceliac aorta
- Complete division of the left crus
- Encircling the aorta with the fingers
- Dividing the gastrohepatic ligament and the left crus
- Encircling the supraceliac aorta by finger dissection
- Exposure of the visceral aorta
- Mobilising the left colon along Toldt's line
- Aorta exposed after left medial visceral rotation
- Infrarenal aortic exposure
- The left renal vein and its tributaries
- Exposure of the infrarenal aorta and the iliac vessels
- Exposure of the iliac arteries
- Danger at the aortic bifurcation
- Exposure of the distal iliac vessels and the crossing ureter
- Exposure of the celiac artery and its branches
- Exposure of the hepatic and splenic arteries
- Exposure of the superior mesenteric artery
- Exposure of the superior mesenteric artery through the mesocolon
- Exposure of the renal arteries
- Exposure of the right renal artery
- Right medial visceral rotation exposing the vena cava
- Exposure and compression of the abdominal veins
- Digital and sponge stick control of the vena cava
Principles of arterial repair
What the defect, the collaterals and the contamination allow
- Factors that decide the repair
- Primary repair and ligation
- Conduit choice in a clean field
- Conduit choice with contamination
- Choosing the conduit by contamination
Acute mesenteric ischemia
Pain out of proportion, a delayed diagnosis, and a high mortality
- Presentation and laboratory findings
- Imaging in mesenteric ischemia
- Causes of acute mesenteric ischemia
- 30-40%
- Initial management common to all types
- Acute mesenteric embolisation
- Where mesenteric emboli lodge
- Angiographic cut-off of the superior mesenteric artery
- Superior mesenteric artery embolus on computed tomography
- Technique of mesenteric embolectomy
- Adjuncts during embolectomy
- Catheter-directed thrombolysis
- Acute mesenteric thrombosis
- Thrombosis at the origin of the superior mesenteric artery
- Embolus compared with thrombosis
- Operative approach to mesenteric thrombosis
- Geometry of the mesenteric bypass
- Retrograde bypass to the superior mesenteric artery
- Endovascular treatment of mesenteric thrombosis
- Laparotomy after stenting, and retrograde open stenting
- Nonocclusive ischemia of the colon
- Management of ischemic colon in low-flow states
- Nonocclusive mesenteric ischemia
- Diagnosis and treatment of nonocclusive ischemia
- Mesenteric venous thrombosis and prothrombotic states
- Thrombus in the superior mesenteric vein
- Treatment of mesenteric venous thrombosis
- Judging viability of the large bowel
- Judging viability of the small bowel
- Fluorescein testing of bowel perfusion
- Second-look laparotomy
- Rationale of the staged approach
Abdominal vascular trauma
Damage control first, definitive repair second
- Frequency and pattern of vascular injury
- Initial assessment and triage
- Sequence in the operating room
- Damage control for vascular injury
- Damage control combined with endovascular repair
- Deciding whether to explore a contained hematoma
- Rules before entering a hematoma
- Injuries to the suprarenal aorta and vena cava
- Open repair of the suprarenal aorta
- Buttressing and limits of aortic repair
- Endovascular repair of the injured aorta
- Open repair of the suprarenal inferior vena cava
- Retrohepatic caval and hepatic vein injuries
- Endovascular options in the suprarenal cava
- Repair of the infrarenal aorta and iliac arteries
- Graft or ligation in the aortoiliac segment
- Specific iliac artery injuries
- Endovascular repair in the aortoiliac segment
- Infrarenal cava and iliac vein injuries
- Repair or ligation of large abdominal veins
- Conduit choice for venous reconstruction
- Traumatic arteriovenous fistula
- Repair of an arteriovenous fistula
- Closing the communication from within
- Endovascular treatment of arteriovenous fistula
- Trauma to the celiac axis and splenic vessels
- Hepatic artery injuries
- Injuries to the superior mesenteric artery
- Mesenteric branch and inferior mesenteric artery injuries
- Injuries to the splenic, mesenteric and portal veins
- Portal vein injuries
- Exposure of the retropancreatic portal vein
- Renal artery injuries
- When to revascularise the kidney
- Renal vein injuries
Ruptured aortic and iliac aneurysms
The commonest lethal vascular emergency in the abdomen
- Pathophysiology of abdominal aortic aneurysm
- Familial and sex-linked risk
- 15th
- Diameter as the main predictor of rupture
- Other independent risk factors for rupture
- Classic presentation and its traps
- Who should be suspected, and aortocaval fistula
- Diagnostic imaging in suspected rupture
- Computed tomography in ruptured aneurysm
- Ruptured aneurysm with retroperitoneal hematoma
- Preoperative management
- Preparation for open repair
- Deciding where to clamp
- Intravascular balloon control before laparotomy
- Approaching the aneurysm sac
- Elevating the aortic neck off the spine
- Controlling the iliac arteries
- Opening the sac and controlling back bleeding
- Suture control of lumbar vessels from inside the aneurysm
- Repair of an aortocaval fistula from within the sac
- Reimplantation of the inferior mesenteric artery
- Sewing the proximal anastomosis
- Completing the graft
- Completed aortic tube graft
- Restoring flow to the legs
- Checking the colon and closing
- Rationale for endovascular aneurysm repair
- Anatomic criteria for endovascular repair
- Other anatomical considerations
- Anesthesia and balloon use in endovascular repair
- Steps of endovascular repair
- Suprarenal occlusion balloon and sheathed stent graft
- Finishing the endovascular repair
- Endoleak types and what they demand
- Completed endograft excluding the aneurysm
- Alternative endovascular strategies
- Reported results of open and endovascular repair
Visceral artery aneurysms
Uncommon, often silent, and dangerous when they burst
- Frequency and significance
- Frequency, rupture risk and repair of visceral artery aneurysms
- Frequency, rupture risk and treatment by site
- Splenic artery aneurysms
- Causes and presentation of splenic aneurysms
- Operative treatment of ruptured splenic aneurysm
- Endovascular treatment of splenic aneurysms
- Hepatic artery aneurysms: causes and presentation
- Treatment of ruptured hepatic artery aneurysms
- Difficult hepatic aneurysms and the aortohepatic bypass
- Ligation and endovascular options in the liver
- Superior mesenteric artery aneurysms
- Treatment of ruptured mesenteric artery aneurysms
- Access and embolisation for mesenteric aneurysms
- Celiac artery aneurysms
- When to reconstruct the celiac artery
- Gastric and gastroepiploic aneurysms
- Gastroduodenal and pancreatic aneurysms
- Aneurysms of mesenteric branches
- Inferior mesenteric artery aneurysms
Complications after aneurysm rupture
Bleeding, pressure, dead colon, and failing organs
- Burden of complications and postoperative bleeding
- Abdominal compartment syndrome
- Recognising and treating raised abdominal pressure
- Colon ischemia after ruptured aneurysm repair
- Systemic complications after rupture
- Limb ischemia after aneurysm repair
- Key points on diagnosis and control
- Key points on the three emergencies
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- Maingot's Abdominal Operations, 12th Edition