Exposures Flashcards
What are the 4 main branches of the SMA?
- inferior pancreaticoduodenal - first jejunal branch (spared in embolic SMA occlusions) - Middle colic - Ileocolic
How do the celiac and SMA collateralize?
Superior and inferior pancreaticoduodenal arteries
How do the SMA and IMA collateralize?
Meandering mesenteric artery and marginal artery of Drummond
What are the 3 main branches of the IMA?
- superior rectal - sigmoid - left colic
What is the risk of incisional hernia with a midline laparotomy for AAA repair?
Up to 30%
What are 7 benefits of a retroperitoneal exposure/when is it beneficial?
- redo - suprarenal pathology - horseshoe kidney with multiple renals - morbid obesity - inflammatory aneurysms - diastasis of abdo wall - resp compromise (theoretically less pain)
What is a kommerell diverticulum?
Aneurysmal degeneration - usually of an abherrent right subclavian artery
What incision do you use to access the innominate artery?
Median sternotomy
What incision do you use to access the proximal left carotid artery?
Median sternotomy
What incision do you use to access the proximal right subclavian artery?
Median sternotomy
What incision do you use to access the proximal left subclavian artery?
Anterolateral 3rd interspace left thoracotomy
Can be accessed by median sternotomy but challenging
In a median sternotomy - which 2 nerves do you have to be careful to preserve during the superficial dissection? What are their courses?
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
Where does the left recurrent laryngeal course?
Around the ligamentum arteriosum and ascends anterior to the arteries
What is a trap door thoracotomy
Extension of third interspace anterolateral thoracotomy with a sternotomy - allows for emergent control of subclavian and access to proximal left sided great vessels
How do you access either innominate vein?
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.
How can you access the left atrium (e.g. for complex venous outflow)
Anterior 3rd interspace throacotomy - pericardium opened, appendage immediately accessible and clampable with Satinsky
What are the first 2 branches of the aorta?
2 Phrenic arteries
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?
1 - adrenal (superior)
2- gonadal (inferior)
3 - lumbar (posterinferiorly)
Where must you be careful to preserve parasympathetic nerve fibres?
When exposing the left common iliac artery
Why should you avoid circumferentially circling the aortic bifurcation and clamp the common iliacs instead?
Risk injuring the caval confluence
