Chaper 53 - Thoracic & thoracoabdominal vascular exposures Flashcards
Median sternotomy patient position
Supine with arms tucked
Steps of median sternotomy
1) incision below sternal notch to tip of xyphoid
2) Divide pectoral fascia
3) Score midline of periosteum
4) Divide interclavicular ligament at top of sternal notch
5) Divide sternum with sternal saw
6) Cautery and bone wax for hemostasis
7) Divide sternopericardial ligament to free pericardium from posterior sternum
8) Free up brachiocephalic vein
9) Oper superior portion of pericardium
How to gain more exposure to carotids or subclavian after median sternotomy
Carotid: along anterior border of SCM
Subclavian: supraclavicular incision
What to do before using sternal saw to divide stenum
Hold mechanical ventilation
What must be divided to free the pericardium from the posterior sternum
Sternopericardial ligament
Where is the vagus nerve in relation to the subclavian artery
Vagus anterior; recurrent laryngeal posterior
Who and when was ministernotomy developed
Holman and Willett 1949
What are the benefits of mini sternotomy
1) decrease sternal instability
2) Decrease ventricular injury and post-op adhesions
3) decrease pain
4) decrease blood loss
Types of mini sternotomy
1) Inverse T
2) Upper J
What can be used to aid in determining the level or extent of sternotomy needed
TEE
Trans-sternal bilateral thoracotomy (Clamshell) disadvantage over sternotomy
Increase need for ventilation support post-op with clamshell
Trans-sternal bilateral thoracotomy (Clamshell) Steps
1) Right 4th intercostal mid-clavicular to left anterior axillary line
2) Dissect intercostal muscles
2) ligate IMA’s on both
3) dissed pericardium and pleural away from posterior sternum
4) retract left lung
Trans-sternal bilateral thoracotomy (Clamshell) position
Supine with left shoulder and hip raised slightly
Left posteriolateral thoracotomy is used for
Thoracic aortic pathologies
Left posteriolateral thoracotomy patient needs to tolerate
Single lung ventilation
Position for Left posteriolateral thoracotomy
Right lateral decubitus
Left posteriolateral thoracotomy steps
1) incision midpoint between medial border sacpula and thoracic spine
2) curvilinear incision into 4th intercostal space
3) flaps created
4) anterior edge of latissimus dorsi incised vertically
5) plane between latissimus and serratus anterior developed
6) Retract latissimus dorsi posteriorly and serratus anteriorly
7) Open pleural sac
Thoracoabdominal exposure position
Modified right lateral decubitus with
1) legs flat
2) flex table
Thoracabdominal exposure steps
THORACIC
1) divide latissimus dorsi and serratus anterior and rectus
2) Access into pleural space
3) Divide inferior pulmonary ligament
4) retract left lung
5) identify vagus, subclavian, esophagus, phrenic
ABDOMINAL
1) dissect lateral to rectus abdominus
2) divide anterior and posterior sheaths
3) divide obliques laterally
4) plane between transversalis and peritoneum developed
5) retract peritoneum and abdominal cavity to right
6) plane between retroperitoneal fat and psoas developed
7) Gerotas fascia and kidney lifted anterior medially
8) Dissect parietal peritoneam from periaortic fat
9) Identify ureter on back of peritoneal sac
10) ligate reno-lumbar vein
11) divide diaphragmatic crus
12) Divide median arcuate ligament
Relationship of esophagus to aorta in the thoracic cavity
Esophagus anterior medial to aorta
Where is reno lumbar vein
Beside left renal artery
What to do with retro-aortic renal vein when doing retroperitoneal exposure
Ligate renal vein distal to adrenal and gonadal
Standard transperitoneal abdominal exposure of visceral aorta
1) Supine, midline xiphoid to pubis
2) Left medial visceral rotation
3) release splenic attachment and mobilize superior medially
4) dissect between spleen and left renal by ligating splenocolic and splenorenal ligaments
5) Mobilize spleen and pancreas away from retroperitoneum
6) Dissect retroperitoneum and periaortic fat and left crus and median arcuate ligament
Retroabdominal exposure of visceral aorta
Modified rigth lateral decubitus only need mild 20-30 degress hips if not getting thoracic
curvilinear midline between umbi to pubis lateral to 10th -11th intercostal space
Key in retroperitoneal curvilinear incision
Stay in one dermatome
What to divide in retroperitoneal exposure if left kidney is left down
Gonadal vein
What is injured if retroperitoneal dissection and went before the psoas muscle
1) Ilioinguinal nerve
2) Genitofemoral nerve
