Vascular and Intestinal Anastomotic Workshop
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Transcript of Vascular and Intestinal Anastomotic Workshop
Vascular and Intestinal Anastomotic Workshop
Name the InstrumentsPGY 1
Name the InstrumentsPGY 1
Name the InstrumentsPGY 1
Commonly used SuturesBraided? Absorbable? Timeline # of throws
Silk Braided no n/a 3-4
Vicryl Braided yes 55-70 days 4-5
Prolene Mono no n/a 6-8
Chromic Mono yes 90 days 4-5
PDS Mono yes 180-210 days 6-8
Nylon Mono no n/a ~5
Gore Mono no n/a ~8
Monocryl Mono yes 90-120 days 5
PGY 1
Lembert Sutures
• Definition?• Reason?
PGY 2
Connell Sutures
• Describe Connell suturing technique
PGY 2
Staplers
Name the StaplerPGY 2
Name the Stapler…PGY 2
Name the StaplerPGY 2
Side to side anastomosis
• How do you set up a side to side anastomosis?
CRITICAL CONCEPTS• Non-tension• GIA stapler• Align anti-mesenteric
sides of bowel together• Staggered staple lines
PGY 2
End-to-end Anastomosis
• How do you set up a stapled end-to-end anastomosis?
PGY 2
Functional End-to-end anastomosis
• Describe another way to perform a stapled end to end anastoamosis
PGY 2
Stapler Loads• What is the difference
between the different stapler loads?
• What color load do
you use for vascular tissue? Stomach? Small bowel? Colon? Rectum?
PGY 3
Hand Sewn Anastomosis
• Describe the different types of suture techniques used in hand sewn bowel anastomosis
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Hand Sewn Anastomosis
• Describe the steps for a 2 layer anastomosis
PGY 3
Hand Sewn Anastomosis
• Describe how to sew a single layer anastamosis
PGY 3
Arm Vascular Anatomy
• Describe the arterial and venous blood flow to the arm
PGY 2
Types of Surgical Dialysis Access
• What is the difference between an AV Fistulae and an AV Graft
PGY 2
Sites for AV fistulae
Radiocephalic AV Fistula
Brachiocephalic AV graft
Basilic Vein Transposition
DRIL procedure
• DRIL = Distal Revascularization Interval Ligation
• RUDI = Revision Using Distal Inflow
Vascular Anastomosis
• Identify autogenous materials for vascular anastomosis: – Saphenous vein, iliac vein
• Identify exogenous materials for vascular anastomosis: – bovine pericardium, ePTFE, gore-tex, cadaveric
• What is the dosing/timing for heparinization during a vascular anastomosis? – 75-100 units/kg, given 5 minutes prior to vascular occlusion
• How do you measure heparinization to confirm appropriate levels have been achieved? – Activated clotting time (ACT) of greater than 250
PGY 3
Zones of Retroperitoneum• Describe the Zones of the retroperitoneum
and the major vasculature that could be injured in each zone
• Zone 1: Midline retroperitoneum– Supramesocolic region (suprarenal aorta,
celiac, SMA/SMV, proximal renal artery)– Inframesocolic region (infrarenal aorta,
infrarenal IVC)• Zone 2: Upper lateral retroperitoneum
(renal artery/vein)• Zone 3: Pelvic retroperitoneum (iliac
artery/vein)
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Zone I Great Vessel Injury
• Describe the approach for supramesocolic Zone I injuries: – Left medial visceral
mobilization– May also need to
transect the left crus (at 2o’clock position) to allow for control of the descending thoracic aorta
PGY 3
Zone I Great Vessel Injury
• Describe the approach for inframesocolic Zone I injuries:– Lift up on transverse mesocolon,
eviscerate small bowel to right, open mid-line retroperitoneum and cross clamp the aorta inferior to the left renal vein
– For IVC injuries, perform a right medial visceral mobilization (right colon and duodenum), leaving the kidney in situ
PGY 3
Zone I Great Vessel Injury
• Describe the approach to an inframesocolic Zone I injury to the IVC at the common iliac vein confluence: – After right medial visceral mobilization, it may be
necessary to divide and ligate the right internal iliac artery or to temporarily divide the right common iliac artery
PGY 3
Zone I Great Vessel Injury
• Describe the approach to an inframesocolic Zone I injury to the IVC at the level of the renal veins:– After right medial visceral mobilization, you should
clamp/compress the IVC proximally and distally and loop/clamp both the left and right renal veins. It may be necessary to perform a medial mobilization of the right kidney (watch out for 1st lumbar vein!)
PGY 3