Exposures

Question 1

What are the 4 main branches of the SMA?

Answer 1

• inferior pancreaticoduodenal - first jejunal branch (spared in embolic SMA occlusions) - Middle colic - Ileocolic

Question 2

How do the celiac and SMA collateralize?

Answer 2

Superior and inferior pancreaticoduodenal arteries

Question 3

How do the SMA and IMA collateralize?

Answer 3

Meandering mesenteric artery and marginal artery of Drummond

Question 4

What are the 3 main branches of the IMA?

Answer 4

• superior rectal - sigmoid - left colic

Question 5

What is the risk of incisional hernia with a midline laparotomy for AAA repair?

Answer 5

Up to 30%

Question 6

What are 7 benefits of a retroperitoneal exposure/when is it beneficial?

Answer 6

• redo - suprarenal pathology - horseshoe kidney with multiple renals - morbid obesity - inflammatory aneurysms - diastasis of abdo wall - resp compromise (theoretically less pain)

Question 7

What is a kommerell diverticulum?

Answer 7

Aneurysmal degeneration - usually of an abherrent right subclavian artery

Question 8

What incision do you use to access the innominate artery?

Answer 8

Median sternotomy

Question 9

What incision do you use to access the proximal left carotid artery?

Answer 9

Median sternotomy

Question 10

What incision do you use to access the proximal right subclavian artery?

Answer 10

Median sternotomy

Question 11

What incision do you use to access the proximal left subclavian artery?

Answer 11

Anterolateral 3rd interspace left thoracotomy

Can be accessed by median sternotomy but challenging

Question 12

In a median sternotomy - which 2 nerves do you have to be careful to preserve during the superficial dissection? What are their courses?

Answer 12

1 - Right recurrent laryngeal - around right subclavian artery

2 - Right phrenic nerve, anterior to right subclavian artery and anterior lateral to innominate artery, behind jugular/innominate vein

Question 13

Where does the left recurrent laryngeal course?

Answer 13

Around the ligamentum arteriosum and ascends anterior to the arteries

Question 14

What is a trap door thoracotomy

Answer 14

Extension of third interspace anterolateral thoracotomy with a sternotomy - allows for emergent control of subclavian and access to proximal left sided great vessels

Question 15

How do you access either innominate vein?

Answer 15

Molina et al described - supraclavicular approach, 1st rib resection, median sternotomy of 1st interpsace leaving sternoclavicular joint intact, close at end with 2 sternal wires at 90 degrees.

Question 16

How can you access the left atrium (e.g. for complex venous outflow)

Answer 16

Anterior 3rd interspace throacotomy - pericardium opened, appendage immediately accessible and clampable with Satinsky

Question 17

What are the first 2 branches of the aorta?

Answer 17

2 Phrenic arteries

Question 18

When exposing the pararenal artery and fully mobilizing the left renal vein, what are the major branches of the LRV that you may need to divide?

Answer 18

1 - adrenal (superior)

2- gonadal (inferior)

3 - lumbar (posterinferiorly)

Question 19

Where must you be careful to preserve parasympathetic nerve fibres?

Answer 19

When exposing the left common iliac artery

Question 20

Why should you avoid circumferentially circling the aortic bifurcation and clamp the common iliacs instead?

Answer 20

Risk injuring the caval confluence