DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Infrarenal abdominal aortic aneurysm.
2. Mild common iliac artery aneurysms bilaterally.
POSTOPERATIVE DIAGNOSES:
1. Infrarenal abdominal aortic aneurysm.
2. Mild common iliac artery aneurysm bilaterally.
OPERATION PERFORMED: Aortobifemoral bypass with 18 x 9 mm Gore-Tex graft.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PA-C
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 550 mL cell saver, all of which was returned.
IV FLUIDS: 4.5 liters of crystalloid and 1 unit cell saver.
URINE OUTPUT: 125 mL.
DISPOSITION: The patient tolerated the procedure well and was stable to PACU with Doppler DP and PT signals bilaterally.
OPERATIVE FINDINGS:
1. Large amount of posterior plaque, left common femoral artery.
2. Bilateral common iliac artery aneurysms, left greater than right.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman with an infrarenal abdominal aortic aneurysm measuring approximately 4.5 cm. He also has iliac artery aneurysms. It was discussed with the patient operative intervention, open versus endovascular approach. It was discussed that we thought that he was a better candidate for open aneurysmorrhaphy due to iliac artery aneurysm as well as ulcerated plaque, particularly on the left side. Risks, indications, and technique of the operative intervention, aortobifemoral bypass, were discussed with the patient. The patient understood and was agreeable for the aortobifemoral bypass.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and was identified as the patient. He had an epidural catheter placed and was placed supine on the operating room table. General anesthesia was induced. Central venous access and arterial line were placed. He was prepped and draped in the normal sterile fashion. Bilateral inguinal incisions were made and dissection down to the level of the common, superficial, and deep femoral arteries was performed. There was thickened intima throughout the right femoral system. On the left, however, there was a large, thick plaque posteriorly in the common femoral artery. Wet Ray-Tec sponges were then laid into these wounds, and each of the vessels, common superficial and deep femoral, were controlled with Silastic vessel loops.
Standard midline incision was made and entry into the abdominal cavity was performed. NG tube was noted to be in appropriate position. Liver was palpated with no abnormalities. There were some adhesions to the gallbladder and these were allowed to remain in place. Bowel showed no focal areas of abnormality. The retroperitoneum was then exposed and the duodenum was reflected to the right side. The small bowel was all packed to the right side of the abdomen. A Bookwalter retractor was used to retract the tissue.
Retroperitoneum was dissected. The inferior neck was dissected for an appropriate length. This was dissected circumferentially. Umbilical tape was placed around it. The iliac arteries were then dissected down to the level of the aneurysmal changes. Vessel loops were then used to tunnel from retroperitoneum to the femoral regions and umbilical tapes were placed through these areas. The patient then received 5000 units of intravenous heparin and appropriate circulation time was allowed. The iliac arteries were ligated using #1 Prolene ties x2 on each side at the level of the aneurysms. The aortic neck was then clamped using a Subramanian clamp. Aneurysm was opened and all mural thrombus was removed. There was a single lumbar vessel, which was oversewn.
An 18 x 9 mm Gore-Tex graft had already been selected. The tube portion was cut to the appropriate length, and anastomosis was performed using a CV3 stitch beginning at the posterior aspect of the wall and run circumferentially. It was tied. The graft limbs were clamped and then the anastomotic area was inspected. The anastomosis was hemostatic. The graft limbs were then clamped proximally, and graft limbs were tunneled appropriately. The right side was then clamped in common, superficial, and deep femoral arteries. Femoral arteriotomy was made with an 11 blade followed by angled Potts scissors.
The anastomosis was performed after graftotomy was made using a CV5 Gore-Tex stitch. This was begun at the heel and run circumferentially. Upon completion, the areas were back-bled with nominal back-bleeding from superficial femoral artery, better back-bleeding from the profunda femoris and common femoral arteries. The anastomosis was completed. The graft was de-aired prior to completing the anastomosis. The pelvic clamp was released followed by release of the graft clamp, and hemostasis was adequately achieved. The profunda femoris and then the superficial femoral artery were all released. The bleeding was controlled with Surgicel.
Anastomosis on the left was performed in a similar fashion. There was markedly thickened plaque over the posterior wall. The superficial femoral and deep femoral arteries were of better overall quality, softer with less plaque. Again, prior to release of the clamp, there was nominal back-bleeding from the superficial femoral artery and reasonable back-bleeding from the profunda femoris as well as the common femoral artery. The graft was de-aired. The anastomosis was irrigated and then completed. As opposed to the right side where there was nearly a 30 mmHg drop after opening of the limb, there was only about approximately 10-15 mm pressure drop after opening the left limb.
The areas were inspected. Single repair suture was used for hemostasis. The wounds were irrigated. The patient had Doppler DP and PT signals bilaterally with the left stronger than that of the right. The wounds were irrigated. The abdominal cavity was again inspected. The retroperitoneum was closed in two layers using 2-0 Vicryl in a running fashion to reapproximate the aortic wall as well as the retroperitoneum. Then, the abdominal cavity was again irrigated and then a #1 looped PDS suture was used to repair the abdominal wall. The groins were repaired in layers using 2-0 Vicryl for deep, 3-0 Vicryl for superficial fascia, and then 4-0 Vicryl subcuticular stitch for skin closures. A 4-0 Vicryl stitch was also used for skin closure of the abdominal wound. Appropriate dressings were applied. The patient was extubated on the operating table and transferred to the PACU in stable condition with Doppler DP and PT signals at his feet.
