Chapter 54 - Abdominal vascular exposure Flashcards
(70 cards)
1
Q
Where does the aorta enter the abdomen
A
Aortic hiatus
Level T12
Surrounded by right and left crura
2
Q
First 2 branches of the abdominal aorta
A
phrenic arteries come off anterior-lateral
3
Q
Celiac artery is surrounded by
A
Fibrous splanchnic ganglionic tissue
4
Q
Location where the celiac splits
A
1 cm after origin
5
Q
Most common anatomy of the celiac
A
75% into 3 branches:
1) splenic
2) common hepatic artery
3) left gastric artery
6
Q
Course of the common hepatic artery
A
Runs on posterior wall of lesser sac on lower boundary of foramen Winslow
follows the upper boarder of the pancreas
7
Q
Branches of the common hepatic artery
A
1) Gastroduodenal –> gives off superior pancreaticoduodenal artery
2) Proper hepatic artery
8
Q
Proper hepatic artery course and branches
A
Anterior to portal vein
1) right gastric artery
2) left hepatic artery
3) right hepatic artery
9
Q
Hepatic artery anomalous anatomy
A
Right hepatic from SMA 18%
Left hepatic from left gastric 12%
10
Q
SMA level
A
mid L1
11
Q
Course of the SMA
A
Inferior course behind pancreas
anterior to 3rd and 4th duodenum
12
Q
SMA branches
A
1) inferior pancreaticoduodenal artery
2) 1st jejunal branch (spared in emboli)
3) middle colic
4) ileocolic
13
Q
Collaterals in the mesenteric vessels
A
Celiac-SMA: superior to inferior pancreaticoduodenal artery
SMA-IMA: meandering mesenteric artery and marginal artery of drummond
14
Q
Meandering mesenteric artery course
A
Develops if SMA stenosis
Runs with IMV
15
Q
Renal artery level
A
L1
16
Q
Rate of having accessories renal arteries
A
30%
17
Q
Course of renal arteries with veins
A
Left renal behind Left vein
Right renal behind IVC
18
Q
Juxtarenal aorta definition
A
1cm above to 1 cm below renal arteries
19
Q
Aortic bifurcation level
A
L4-L5
20
Q
IMA level
A
2-3 cm above aortic bifurcation
21
Q
IMA branches
A
1) superior rectal
2) sigmoid
3) left colic
22
Q
Right CIA in relation to vein
A
Anterior to IVC and Left CIV
23
Q
Cisterna chyli location
A
Right of aorta under right crus
24
Q
Midline celiostomy pros and cons
A
1) most versatile
2) higher post-op pain
3) higher incisional hernia (20-35%)
4) worse for patients with pulmonary compromise
25
Midline celiostomy how to
1) position supine
2) incision xiphoid to pubis
3) linea alba entry
4) viscera packed to right of abdomen or eiscerated in bowel bag or towel
5) retract with omni or thompson retractors
26
Transverse abdominal incision how to
Anterior/mid axillary to anterior/mid axillary
Supraumbilical (frown) start midway between xiphoid and umbilicus: for infrarenal and distal renal exposure
Infraumbilical (smile) start 3-4 cm below umbilicus: for pelvic and iliac aneurysms
27
Subcostal incision how to
2 finger below and parallel to costal margin
Lateral edge of rectus sheath to anterior axillary line
For hepatic, splenic, renal and abdominal venous upper exposure
28
Oblique flank incision
Retroperitoneal: left flank for aorta, right flank for IVC
29
Limitation of left flank incision
1) right iliac
| 2) right renal
30
Benefit of left flank incision
1) redo operations
2) suprarenal exposure
3) horseshoe kidney
4) morbid obesity
5) inflammatory aneurysm
6) diastasis abdominal wall
7) respiratory compromise
31
Left flank incision how
1) position modified right lateral decubitus with left shoulder 30-70degrees to OR table with hips rotated posteriorly in corkscrew manner; left arm supported on arm board
2) break table at umbilicus between left costal margin and iliac crest
3) incision, oblique from lateral edge right rectus starting 1 cm above the midpoint of umbilicus and pubis extend few cm into 11th intercostal space
4) divide obliques and transversus to rectus sheath
5) divide intercostal muscle on superior of 12th rib
6) retroperitoneal entry at tip of rib
7) Peritoneum stripped from muscle
8) dorsally strip peritoneum off lumbodorsal fascia
9) spleen and tail of pancreas and left colon to right side
10) renal can be up or left down
32
Modification of left flank incision
More midline allow iliac exposure
| More proximal/posterior with 9th or 10th space instead with chest entry
33
How to avoid phrenic injury during abdominal exposure
Divide diaphragm 2-3 cm away from chest wall attachments
34
Benefit of not dividing diaphragm in abdominal exposure
Earlier ventilation wean
35
How to decrease post-op pain in flank retroperitoneal incisions?
1) excise costochondral cartilage: prevent costochondritis
| 2) excise 1.5-2 cm posterior segment of rib
36
Lower quadrant incision with transplant hockey stick how to
1) 1-2 finger above symphysis pubis lateral to midline
2) extend curve laterally to edge of rectus
3) extend superiorly along lateral rectus sheath
4) divide fascia along with the transversalis
5) divide inferior epigastric
6) preserve spermatic cord, retract medially
7) retract peritoneal sac medially
37
Exposure of aorta and iliac
1) transverse colon reflect superior out of abdomen
2) small bowel to right
3) divide 3rd and 4th duodenum attachment to peritoneum
4) incise retroperitoneum over aorta
5) IMV division
6) expose left renal vein
7) divide lymphatics
8) clear anterior surface of aorta
9) avoid injury to nerve plexus around IMA
38
Branches of left renal vein
1) Adrenal
2) lumbar
3) gonadal
39
Exposing renal arteries
1) divide left renal vein or divide branches
| 2) divide crural fibres from diaphragm posterior to renal arteries
40
Exposing right iliac
1) extend retroperitoneal incision
2) retract cecum and small bowel laterally and superiorly
3) retract ureter laterally
41
Exposing left iliac
1) few cm via usual midline exposure
2) avoid parasymphatic nerves (Nervi erigentes)
3) retract sigmoid medially, incise lateral peritoneal reflection
4) protect ureter
42
Avoid aortic bifurcation in dissection because
IVC and CIV often stuck
43
White line of toldt is
lateral reflection of posterior parietal peritoneum of abdomen over ascending and descending colon
44
Lumbosacral fascia
Anterior to psoas
| Stay anterior to this to avoid bleeding
45
Retroperitoneal exposure: reasons to stay anterior to left kidney
1) retroaortic left renal vein
| 2) need to expose long segment of SMA
46
Vein to divide in retroperitoneal exposure
lumbar branch of left renal vein
47
Transperitoneal exposure to lesser sac
1) divide triangular ligament of left lobe of liver (avoid injury to hepatic vein)
2) left lobe retract to right
3) longitudinal incision through gatsrohepatic ligament (avoid injury to left hepatic artery abberant origin from left gastric)
4) esophagus and stomach to left
5) right crus exposure and division
6) divide median arcuate ligament
48
Transplant incision with medial visceral rotation also called
Mattox maneuver
49
Transplant incision risk of splenic injury
20%
50
SMA exposure
1) transperitoneal via lesser sac (3-5 cm)
2) medial visceral rotation
3) left flank retroperitoneal approach (8-10cm)
51
Distal SMA exposure
1) transperitoneal incision
2) transverse colon reflect superiorly
3) small bowel retract right and inferiorly
4) dissect SMA to right of ligament of treitz as it emerges from under the pancreas
52
SMV in relation to SMA
SMV lies to the right of SMA
53
Hepatic artery exposure how to
1) Transperitoneal
2) elevate right flank
3) retract liver superiorly
4) right transverse colon and small bowel retract inferiorly
5) transverse incision in gastrohepatic ligament
6) palpate hepatic artery in hepatoduodenal ligament
7) dissect out common hepatic artery as it passes over the pancreatic head
54
Porta hepatis structures and relation to each other
Portal vein: posterior and lateral
Proper hepatic artery medial
Common bile duct: anterior
55
Splenc artery
1) Transperitoneal or left subcostal incision
2) roll under left flank
3) divide gastrohepatic omentum above lesser curvature of stomach or divide gastrocolic ligament (reflect greater omentum superiorly and transverse colon inferiorly)
4) separate posterior gastric wall from pancreas
5) locate splenic artery along superior pancreas
56
Distal splenic artery exposure
Partial medial visceral rotation
57
Renal artery exposure
1) inframesocolic approach
2) full medial visceral rotation
3) retroperitoneal approach
58
Right medial visceral rotation also known as
Cattell-Brasch maneuver
59
Right medial visceral rotation how to
1) midline or transverse incision
2) lateral peritoneal reflection entered
3) reflect colon medially and anteriorly
4) Kocher maneuver: mobilize 2nd duodenum and head of pancreas
5) mobilize right renal vein
6) mobilize IVC as needed
60
Where do EIV and IIV converge
Sacroiliac joint
61
IVC starts at this level
L5 right of midline
62
Renal vein entry at this level
L1-L2
63
Retrohepatic IVC receives this many hepatic veins
3
64
IVC enters at this level into atrium
T8
65
How to divide lumbar IVC branches
suture ligation
66
Retrohepatic IVC exposure
1) midline or chevron incision
2) right triangular ligament division and peritoneal attachment to right lobe of liver divided
3) Mobilize right lobe medially and anteriorly
4) Divide venous tributaries to caudate and posterior right lobe
This allows visualization of retrohepatic IVC and right hepatic vein, maybe not the other two
67
Suprahepatic IVC exposure
Divide round and falciform and coronary ligament to strip liver
68
SMV course
Along 3rd duodenum and uncinate pancreas and dives under pancreatic neck to join splenic vein at L2 to make portal vein
69
Pringle maneuver
Finger into foramen winslow and pinch hepatoduodenal ligament
70
Splenic vein exposure
1) lesser sace divide gastrocolic ligament
2) inferior boarder pancreas exposed; greater curve of stomach elevated
3) dissect out splenic vein
OR
Trace IMV to junction with splenic vein
Rotate pancreas to inferior boarder
