Chapter 54 - Abdominal vascular exposure Flashcards
Where does the aorta enter the abdomen
Aortic hiatus
Level T12
Surrounded by right and left crura
First 2 branches of the abdominal aorta
phrenic arteries come off anterior-lateral
Celiac artery is surrounded by
Fibrous splanchnic ganglionic tissue
Location where the celiac splits
1 cm after origin
Most common anatomy of the celiac
75% into 3 branches:
1) splenic
2) common hepatic artery
3) left gastric artery
Course of the common hepatic artery
Runs on posterior wall of lesser sac on lower boundary of foramen Winslow
follows the upper boarder of the pancreas
Branches of the common hepatic artery
1) Gastroduodenal –> gives off superior pancreaticoduodenal artery
2) Proper hepatic artery
Proper hepatic artery course and branches
Anterior to portal vein
1) right gastric artery
2) left hepatic artery
3) right hepatic artery
Hepatic artery anomalous anatomy
Right hepatic from SMA 18%
Left hepatic from left gastric 12%
SMA level
mid L1
Course of the SMA
Inferior course behind pancreas
anterior to 3rd and 4th duodenum
SMA branches
1) inferior pancreaticoduodenal artery
2) 1st jejunal branch (spared in emboli)
3) middle colic
4) ileocolic
Collaterals in the mesenteric vessels
Celiac-SMA: superior to inferior pancreaticoduodenal artery
SMA-IMA: meandering mesenteric artery and marginal artery of drummond
Meandering mesenteric artery course
Develops if SMA stenosis
Runs with IMV
Renal artery level
L1
Rate of having accessories renal arteries
30%
Course of renal arteries with veins
Left renal behind Left vein
Right renal behind IVC
Juxtarenal aorta definition
1cm above to 1 cm below renal arteries
Aortic bifurcation level
L4-L5
IMA level
2-3 cm above aortic bifurcation
IMA branches
1) superior rectal
2) sigmoid
3) left colic
Right CIA in relation to vein
Anterior to IVC and Left CIV
Cisterna chyli location
Right of aorta under right crus
Midline celiostomy pros and cons
1) most versatile
2) higher post-op pain
3) higher incisional hernia (20-35%)
4) worse for patients with pulmonary compromise
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
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
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
Oblique flank incision
Retroperitoneal: left flank for aorta, right flank for IVC
Limitation of left flank incision
1) right iliac
2) right renal
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
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
Modification of left flank incision
More midline allow iliac exposure
More proximal/posterior with 9th or 10th space instead with chest entry
How to avoid phrenic injury during abdominal exposure
Divide diaphragm 2-3 cm away from chest wall attachments
Benefit of not dividing diaphragm in abdominal exposure
Earlier ventilation wean
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
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
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
Branches of left renal vein
1) Adrenal
2) lumbar
3) gonadal
Exposing renal arteries
1) divide left renal vein or divide branches
2) divide crural fibres from diaphragm posterior to renal arteries
Exposing right iliac
1) extend retroperitoneal incision
2) retract cecum and small bowel laterally and superiorly
3) retract ureter laterally
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
Avoid aortic bifurcation in dissection because
IVC and CIV often stuck
White line of toldt is
lateral reflection of posterior parietal peritoneum of abdomen over ascending and descending colon
Lumbosacral fascia
Anterior to psoas
Stay anterior to this to avoid bleeding
Retroperitoneal exposure: reasons to stay anterior to left kidney
1) retroaortic left renal vein
2) need to expose long segment of SMA
Vein to divide in retroperitoneal exposure
lumbar branch of left renal vein
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
Transplant incision with medial visceral rotation also called
Mattox maneuver
Transplant incision risk of splenic injury
20%
SMA exposure
1) transperitoneal via lesser sac (3-5 cm)
2) medial visceral rotation
3) left flank retroperitoneal approach (8-10cm)
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
SMV in relation to SMA
SMV lies to the right of SMA
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
Porta hepatis structures and relation to each other
Portal vein: posterior and lateral
Proper hepatic artery medial
Common bile duct: anterior
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
Distal splenic artery exposure
Partial medial visceral rotation
Renal artery exposure
1) inframesocolic approach
2) full medial visceral rotation
3) retroperitoneal approach
Right medial visceral rotation also known as
Cattell-Brasch maneuver
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
Where do EIV and IIV converge
Sacroiliac joint
IVC starts at this level
L5 right of midline
Renal vein entry at this level
L1-L2
Retrohepatic IVC receives this many hepatic veins
3
IVC enters at this level into atrium
T8
How to divide lumbar IVC branches
suture ligation
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
Suprahepatic IVC exposure
Divide round and falciform and coronary ligament to strip liver
SMV course
Along 3rd duodenum and uncinate pancreas and dives under pancreatic neck to join splenic vein at L2 to make portal vein
Pringle maneuver
Finger into foramen winslow and pinch hepatoduodenal ligament
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
