Respiratory Flashcards
he cartilages and associated ligaments of the external nose viewed from the lateral aspect (A) and rostral aspect (B).
Midsagittal section of the nose of a dog showing the four conchae (dorsal, middle, ventral, and ethmoidal).
What are the 3 paranasal sinuses?
Maxillary recess
Sphenoidal sinus
Frontal (rostral, lateral, medial)
Catheter position with the dog in dorsal recumbency. A Foley catheter with the balloon inflated in the nasopharynx and pharyngeal gauze sponges (not shown) minimize leakage of infusate caudally. A cuffed endotracheal tube (et) further diminishes the risk of aspiration. Sixty-mL syringes are used to inject infusate into the dorsal nasal meatus via polypropylene infusion catheters. Infusion catheters are attached to water manometers via three-way stopcocks so that intranasal pressures can be monitored. Inflated Foley catheter balloons obstruct the nares to diminish leakage of infusate rostrally. Tubing clamps on Foley catheters are closed when fluid is observed within the catheter lumen. B, Sagittal section showing the position of the endotracheal tube (et), nasopharyngeal Foley catheter (npf), pharyngeal sponges (s), infusion catheter (ic), and rostral nasal Foley catheter (nf) in relation to the hard palate (hp), soft palate (sp), cribriform plate (cp), rostral frontal sinus (rfs), medial frontal sinus (mfs), and lateral frontal sinus (lfs).
Catheter position with the dog in dorsal recumbency. A Foley catheter with the balloon inflated in the nasopharynx and pharyngeal gauze sponges (not shown) minimize leakage of infusate caudally. A cuffed endotracheal tube (et) further diminishes the risk of aspiration. Sixty-mL syringes are used to inject infusate into the dorsal nasal meatus via polypropylene infusion catheters. Infusion catheters are attached to water manometers via three-way stopcocks so that intranasal pressures can be monitored. Inflated Foley catheter balloons obstruct the nares to diminish leakage of infusate rostrally. Tubing clamps on Foley catheters are closed when fluid is observed within the catheter lumen. B, Sagittal section showing the position of the endotracheal tube (et), nasopharyngeal Foley catheter (npf), pharyngeal sponges (s), infusion catheter (ic), and rostral nasal Foley catheter (nf) in relation to the hard palate (hp), soft palate (sp), cribriform plate (cp), rostral frontal sinus (rfs), medial frontal sinus (mfs), and lateral frontal sinus (lfs).
Nasal reconstruction after excision of nasal planum and premaxilla. A, Bilateral lip flaps remain after surgical excision. The exact size and shape of these flaps vary based on the amount of resection and the patient’s nasal conformation. An effort should be made to maximally preserve these flaps if reconstruction is anticipated. The alar fold remnants are debrided (asterisks). The rostral aspect of the nasal septum is debrided and is covered by surgical apposition of the associated mucosa. The lip flaps are then rotated dorsally, such that the tips of the flaps (arrows) will be positioned on the dorsal midline (arrowhead). B, The mucosa associated with the flap is apposed to the ipsilateral nasal mucosa around the circumference of the nasal orifice. C, The labial mucosa of the flap is incised from the sagittal midline of the nasal orifice to a point on the labial mucocutaneous (asterisk). This incision will be the division between the nasal and oral cavities and should terminate at a point where the new philtrum will be created. To maintain correct orientation for this incision, temporary sutures may be used to secure the flap to the sagittal midline on the nasal floor (arrow). The ideal location of the new philtrum should be identified before this incision and should allow for optimal opening of the new nasal orifice. Potential philtrum locations can be evaluated by securing the two flaps together with a towel clamp before committing to one location. At the location of the new philtrum, the mucocutaneous margin is excised on each flap (between the arrowheads). Rotation of the flap will cause dog ears to form bilaterally. These should be resected before closure; however, the flap itself should not be incised because the blood supply to the flap may be damaged. D–E, The tissues are then closed routinely in three layers, creating separate oral and nasal compartments and direct apposition of similar tissues.
Repair of stenotic nares by the vertical wedge technique. I, The broken lines indicate the vertical wedge incisions on the wing of the nostril. The vertical broken line indicates the plane of the cutaway view (see II). II, Cutaway diagram of the rostral nasal passage illustrating the incisions for removal of the vertical wedge from the wing of the nostril. The depth of the wedge is indicated by the broken lines going to the alar cartilage. III, Line drawing illustrating the placement of sutures for closure of the wedge defect. B, Repair of stenotic nares by the horizontal wedge technique. I, Broken lines on the mucosa of the wing of the nostril indicate the mucosal incision. The vertical broken line indicates the plane for the cutaway diagram (see II). II, A cutaway diagram of the external nares and proximal nasal passages. The depth of the horizontal wedge is indicated by broken lines going to the level of the alar cartilage. III, Closure of the incision with interrupted sutures.
Dorsal approach to the nasal passage. I, Location of the frontal sinuses and nasal passages (shaded areas) and the incisions in the skin and bones (broken lines). IIa, The skin incision is shown with the nasal and frontal bones elevated to expose the nasal passage bilaterally and the entrance into the frontal sinus. The bones are hinged on the cartilaginous junction (a) at the rostral end of the nasal bones. IIb, A similar approach to one nasal passage. III, The bone flaps are replaced and held in position with sutures. Suture holes are made with a bone drill or Steinmann pin
Ventral approach to the caudal nasal passage. The incision through the soft palate (A) and hard palate (B) is held open with stay sutures. The palate bone (C) is resected as necessary to gain exposure to the nasal passage (D). Inset, The head position needed for this approach
Ventral approach to the rostral nasal passages. I, The midline incision has been made in the hard palate mucoperiosteum, and the mucoperiosteum (a) is retracted with sutures. The central two thirds of the hard palate (b) has been removed, exposing the ventral aspect of the rostral nasal passages (c). II, The mucoperiosteum is closed in two layers without replacing the hard palate bone.
Location of frontal sinuses (shaded) and the incision (a) for a sinusotomy in a dog. II, Removal of the frontal bone (a) and caudal nasal bone, exposing the frontal sinuses, the nasofrontal openings (arrow), and the right and left caudal nasal cavity (b and c). In the left frontal sinus (d), the compartmental divisions have been removed.
Bones of the skull (ventral aspect).
Terminal branches of the maxillary artery.
Palatinus = palatine bone → caudal border soft palate (contracts palate)
Tensor veli palatine = bony process rostral to bula → hamular process pterygoid →palatine apobeurosis (stretches btwn pterygoid bone)
Levator veli palatine = same origine tensor → caudal soft palate (closes nasopharynx)
Overlapping flap for repair of a cleft of the hard palate. A, Incisions are made in the mucoperiosteum to the bone along the dental arch about 1 to 2 mm away from the teeth and to the rostral and caudal margins of the defect on one side and at the medial margin of the defect on the other side. B, A periosteal elevator is used to create an overlapped flap on one side and an envelope flap on the other side. The major palatine artery must not be transected during flap elevation. When the artery is identified at the connective tissue side of the overlapped flap, careful dissection close to it will release it from surrounding tissue to accommodate the rotation of this flap. C, The overlapped flap is inverted at its base, turned, and secured under the envelope flap with horizontal mattress sutures so that large connective tissue surfaces are in contact.
Medially positioned flaps for repair of a congenital cleft of the hard palate. A, Incisions are made in the mucoperiosteum to the bone at the defect margins and along the dental arch about 1 to 2 mm away from the teeth on either side. B, A periosteal elevator is used to carefully undermine the two flaps. C, The flaps are moved medially and sutured to each other.
Medially positioned flap for repair of a cleft of the soft palate (note that repair of a cleft of the hard palate is already completed). A, Incisions are made along the medial margins of the defect to the level of the caudal end of the tonsils, and the palatal tissues are separated with blunt-ended scissors to form a dorsal (nasopharyngeal) and ventral (oropharyngeal) flap on each side. B, The two dorsal and the two ventral flaps are sutured separately in a simple interrupted pattern to the midpoint or caudal end of the palatine tonsils (note that suturing of the dorsal flaps is already completed). C, Repair of the clefts of the hard and soft palates is completed.
ronasal fistula repair. A, Oronasal fistula in the region of a missing left maxillary canine tooth. B, Incisions for single flap repair. C, The flap has been dissected free, advanced over the defect, and sutured in place.
Modified split palatal U-flap for repair of a caudal hard palate defect. A, Incisions are made into the hard palate rostral to the defect to create one flap of slightly shorter and another of slightly longer length. B, The shorter flap is rotated and sutured to the caudal aspect of the debrided palatal defect. C, The longer flap is rotated and sutured to the rostral edge of the already transposed shorter flap
Other flaps:
- bilateral overlaping flap
- 2 layer technique for labial based mucoperiosteal flap
Sesmoid and interartytenoid cartilages also exsist
Note vocal ligament and vocalis m. from thyroid cartilage to vocal process
Mucosal folds over ventricularis and vocalis m, separted by region of everted mucosa = ventricle of laryngeal saccule
Note ventricular lig (vestibular lig?) attached at cuneiform with ventricularis m.
Laryngeal muscles, lateral aspect. The thyroid cartilage is cut left of midline and reflected
Rostral (A), dorsolateral (B), and lateral (C) views of the larynx from a canine cadaver specimen. A, Articulation of the thyroid and cricoid; Co, corniculate process; Cr, cricoid cartilage; Cu, cuneiform process; E, epiglottis; M, muscular process; T, thyroid cartilage; Vo, vocal fold; Arrow, location of ventricle (saccule).
Figure 101-4 Distribution of the laryngeal nerves, lateral aspect
Segmental hemilaryngectomy. I, The thyroid is incised ventrally. II, The incision (dotted line) is made through mucosa and cartilages to the level of the thyroid cartilage. III, The lateral surface of the thyroid cartilage is incised (dotted line), leaving the rostral (a) and caudal (b) segments to be reapposed. IV, The excised portion of the larynx is removed, exposing the cranial (a) and caudal (b) portions of the thyroid cartilage, rostral portion of the saccule mucosa (c), cut surface of the vocal process (d), ventral portion to the cuneiform process (e), and cut edge of the laryngeal mucosa (f). V, Thyroid cartilage segments (a, b) are realigned and sutured. The middle sutures (c) appose the thyroid cartilage and soft tissue to close the unequal cartilage edges. Inset, Cross-section through the resection showing the suture lines of the thyroid cartilages (a, b). The caudal edge (d) of the saccule mucosa is sutured to the cricoid cartilage (f), and the remainder of the saccule mucosa (c) is apposed to the remnants of the ventricular fold (e)
Total laryngectomy with permanent tracheostomy. I, Incisions (dashed lines) for transection of the trachea (a), cricopharyngeus and thyropharyngeus muscles (b), hyopharyngeus muscle (c), thyrohyoid bone (d), and ventral soft tissue. II, Incision (dashed line) in the pharyngeal mucosa area, which is made from the caudal (submucosal) approach as the larynx is removed. III, The trachea is positioned for a permanent tracheostomy. Sutures are placed between the sternohyoid muscle (a) and the trachea to hold it in position. Additional sutures are placed between the trachea and subcutaneous tissue (b) and skin (c). IV, Accurate alignment of the skin and mucous membrane must be obtained. Fine nonabsorbable sutures are shown correctly aligning the tissues
Stage II laryngeal collapse with eversion of laryngeal saccules ventrally and medial collapse (arrow) of the cuneiform processes
Cadaver specimens illustrating the coverage of the rima glottidis after unilateral lateralization with severe (A) and moderate (B) abduction of the arytenoid cartilage. With severe abduction, a larger portion of the rima glottidis is left uncovered by the epiglottis, exposing more of the airway for potential aspiration pneumonia. co, Corniculate process of the arytenoid cartilage; cu, cuneiform process of the arytenoid cartilage; e, epiglottis; rm, rima glottidis
Partial laryngectomy. I, Oral view of the larynx. The corniculate (a) and cuneiform (b) processes of the arytenoid cartilage, vocal cord (c), and epiglottis (d) are shown in their normal position. II, After partial laryngectomy, the tissue that remains is the dorsal tip of the corniculate process (a), the body of the arytenoid cartilage (b), and the distal third of the cuneiform process (d). A small amount of the ventral commissure of the vocal fold (c) is left in place
Scar tissue (sc) obstruction of most of the rima glottidis (rm) in a dog after vocal cordectomy. cu, Cuneiform process of the arytenoid cartilage
Vocal cordectomy through a ventral laryngotomy. I, Medial view of the right side of the larynx showing the vocal apparatus removed. The vocal process of the arytenoid cartilage (dotted line) has been removed (a); the corniculate process (b) and cuneiform process (c) are intact. The ventricular fold (d), and vocal cord, and vocal muscle (h) are removed. The mucosa of the lateral wall of the caudal extension of the ventricle (f) is left intact. e, Mucosa of the larynx; g, cross-section of thyroid cartilage. II, The mucosal edges of the laryngeal lumen are sutured to those of the remaining edges of lateral ventricle (a and c), with particular care to cover the base of the vocal process (b)
Figure 102-2 The canine carina, principal, and lobar branches.
Cross-section of the canine trachea. Note the attachment of the trachealis muscle to the external surface of the tracheal rings.
Permanent tracheostomy. A, Mattress sutures are used to appose the sternohyoideus muscles dorsal to the trachea. A segment of cartilage is removed, and the mucosa is incised (dashed line). B, Interrupted sutures are used to attach the mucosa to the skin at the corners of the stoma. A simple continuous pattern is then used to meticulously attach the tracheal mucosa to the skin.
Tracheal resection and anastomosis. A, Stay sutures are placed cranial and caudal to the area of resection, and a #11 blade is used to transect the trachea. B, Anastomotic sutures are preplaced to reappose the trachealis muscle; these are tied, and the anastomosis is then continued circumferentially around the trachea. C, Tension sutures are placed around a cartilage ring proximal and distal to the anastomosis to protect the suture line.
Anatomy of the left (A) and right (B) lung lobes.
Dorsal view of the bronchi in a cat (A) and dog (B).
Oxygen–hemoglobin dissociation curve (solid line) under conditions with a pH of 7.4, PCO2 of 40 mm Hg, and temperature of 37° C. The total oxygen content is also shown. Whereas the P-50 of dog blood (as shown) is approximately 29 mm Hg, the P-50 of cat blood is about 36 mm Hg.
Affects of PCO2, pH, temperature (T°), and 2,3-diphosphoglycerate (2,3-DPG) concentrations on the oxygen–hemoglobin dissociation curve
Forms of carbon dioxide (CO2) transport in the blood. All reactions displayed in this diagram can be reversed when the blood reaches the lung and CO2 diffuses into the alveolus
Lung lobe laceration. A, Superficial laceration closed with an interrupted Lembert suture pattern. B, Deep laceration closed with a hemostatic mattress sutures (1) and a simple continuous suture (2) to appose tissue margins
Partial lung lobectomy. A, Crushing forceps are placed proximal to the lesion. B, One or two rows of a hemostatic continuous overlapping suture is placed 2 mm proximal to the forceps. C, Abnormal lung is excised distal to the overlapping suture, and the transection site is oversewn with a simple continuous pattern (D)
Lung lobectomy. A, The artery supplying the lung lobe is triple ligated, with the central ligature being a transfixation type. B, The vein is double or triple ligated and transected. The bronchus is isolated and clamped distal to the vessel ends. C, The clamped bronchus is collapsed with preplaced interrupted horizontal mattress sutures. D, The bronchus is transected, and its end is oversewn with a simple continuous suture pattern.
Musculature of the thorax, lateral view
Musculature of the cranial thorax, ventra
Orientation of intrathoracic structures. A, Left lateral view. B, Right lateral view
Multiple lacerations and ruptures of intercostal muscles over consecutive intercostal spaces. B, Basket-weave pattern for stabilizing ribs.
Some variations of the thoracic duct and its entrance into the cranial vena cava.
Canine thorax, right lateral view, lung removed.
Canine thorax, left lateral view, lung removed. 1, Vertebral artery and nerve; 2, Communicating rami from cervicothoracic ganglion to ventral branches of cervical and thoracic nerves; 3, Left cervicothoracic ganglion; 4, Ansa subclavia; 5, Left subclavian artery; 6, Left vagus nerve; 7, Left recurrent laryngeal nerve; 8, Left tracheobronchial lymph node; 9, Sympathetic trunk ganglion; 10, Sympathetic trunk; 11, Ramus communicans; 12, Aorta; 13, Dorsal branch of vagus nerve; 14, Esophagus; 15, Ventral trunk of vagus nerve; 16, Accessory lobe of lung (through caudal mediastinum); 17, Phrenic nerve to diaphragm; 18, Paraconal interventricular artery, vein, and groove; 19, Pulmonary trunk; 20, Internal thoracic artery and vein; 21, Brachiocephalic trunk; 22, Cardiac autonomic nerves; 23, Thymus; 24, Cranial vena cava; 25, Middle cervical ganglion; 26, Left subclavian vein; 27, Costocervical trunk; 28, External jugular vein; 29, Vagosympathetic trunk; 30, Common carotid artery; 31, Longus colli muscle. LV, Left ventricle; RV, right ventricle
Compliances of the lungs and chest wall. Pressures for the curve are obtained during relaxation at points of no airflow. From below the functional residual capacity (FRC) up to about 75% of the total lung capacity (TLC), compliance of the lung is linear and approximately parallel to compliance of the chest wall. As TLC approaches, the lungs become less compliant (stiffer) because of stretching of the noncompliant collagen fibers, and the chest wall muscles are maximally stretched and unable to generate further pressure. Over the tidal volume, the respiratory system has a lower compliance than lungs or chest wall. FRC is the point where the forces of the lung and chest wall are equal and opposite. PCW, Transchest wall pressure; PL, translung pressure; PRS, transrespiratory system pressure
Hydrostatic, colloid osmotic, and net Starling pressures influencing the movement of fluid into and out of the pleural space.
Classification Scheme for Pleural Effusions Based on Protein Concentration, Specific Gravity, and Nucleated Cell Count
Suction is controlled at the level of the atmospheric vent and is usually maintained at 5 to 10 cm H2O, although negative pressures up to 20 cm H2O are possible with most systems
A three-bottle system (top) allows continuous suction to be applied to a thoracostomy tube. The bottles function as a collection reservoir, water seal, and suction control. The amount of negative suction applied to the thoracostomy tube is determined by subtracting the centimeters of water from tube submersion in the water-seal bottle from that in the suction control bottle. Portable disposable systems (bottom) are based on the same principle
A three-bottle system (top) allows continuous suction to be applied to a thoracostomy tube. The bottles function as a collection reservoir, water seal, and suction control. The amount of negative suction applied to the thoracostomy tube is determined by subtracting the centimeters of water from tube submersion in the water-seal bottle from that in the suction control bottle. Portable disposable systems (bottom) are based on the same principle
Shanghai rectractor
Rib resection thoracotomy. A, The periosteum has been incised and elevated off the lateral and medial surfaces of the rib. The rib is transected proximally and distally with a bone cutter. The medial periosteum and pleura will be incised to expose the pleural cavity. B, The periosteum is reapposed with preplaced interrupted mattress sutures before routine muscle closure.
The thoracic duct can be occluded by en bloc ligation of all structures in the area (arrows) dorsal to the aorta and ventral to the sympathetic trunk.
Double-valve Denver peritoneal–venous catheter. B, Placement of Denver catheter as a pleural–peritoneal shunt
Right lateral aspect of the canine heart.
Left lateral aspect of the canine heart
Right ventricle of the canine heart
Left ventricle of the canine heart
Events from the cardiac cycle.
Cardiac ventricular pressure–volume loop
Effects of preload, afterload, and contractility on cardiac ventricular pressure-volume loop and stroke volume (arrows).
CPB
CBP
Patent ductus arteriosus ligation. Patent ductus arteriosus ligation is accomplished through a left thoracotomy (A). The vagus nerve courses over the ductus arteriosus and serves as an anatomic landmark for identification of the patent ductus arteriosus. The vagus nerve is isolated by sharp dissection at the level of the ductus and gently retracted with a suture (B). The patent ductus arteriosus is isolated by blunt dissection without opening the pericardium. Dissection of the caudal ductus is accomplished by passing right-angled forceps behind the ductus parallel to the transverse plane. Dissection of the cranial aspect of the ductus is accomplished by angling the forceps caudally approximately 45 degrees. Dissection is completed by passing the forceps medial to the ductus in a caudal to cranial direction (C). Ligatures are passed around the ductus by grasping the ligature with right-angled forceps. The ductus arteriosus is closed by slowly tightening and tying the ligature (D)
Transventricular pulmonic dilatation valvuloplasty. Transventricular dilatation of the pulmonic valve is accomplished through a left fourth thoracotomy (A). A buttressed mattress suture is placed in the right ventricular outflow tract and passed through a tourniquet. A stab incision is made in the ventricle, and a dilating instrument is passed into and across the pulmonic valve (B). The pulmonic valve is dilated several times. The ventricular incision is closed after valve dilatation by tying the mattress suture.
Types of ASD:
Sinus venous defect: artrial septum junct cranial VC, anomalous pulmonary venous return
Coronary sinus atrial septal defect: unroofed coronary sinus(incomplete separation sinus and left atrium)
Ostium secundum: atrial defect mid-dorsal portion atrial septum
Patent foramen ovale: secondary caused by increased RA pressure due to concurrent right heart defects
Atrial septal defect and atrioventricular septal defect repair. Patch repair of an atrial septal defect or atrioventricular septal defect is accomplished through a right atriotomy approach during cardiopulmonary bypass (A). Bicaval venous cannulation is necessary to isolate the right atrium during bypass. Partial atrial septal defects (ostium primum ASDs) invariably are associated with a cleft defect of the septal mitral valve leaflet. The mitral valve cleft is repaired with 5-0 mattress sutures (B). The septal defect is closed with an autogenous pericardial patch (C). The patch may be extended beyond the margin of the defect to the caudal aspect of the coronary sinus to reduce the risk of atrioventricular node injury. The atriotomy incision is closed with a continuous mattress suture pattern oversewn with a simple continuous pattern.
Modified Blalock-Taussig shunt. A modified Blalock-Taussig shunt is accomplished through a left fourth thoracotomy. An autogenous arterial graft is harvested by ligation and division of the proximal left subclavian artery (A). The pericardium is opened and sutured to the thoracotomy incision. Tangential vascular clamps are placed on the pulmonary artery and ascending aorta, and incisions are made in each vessel (B). End-to-side anastomoses are performed using simple continuous suture patterns (C–D).
Tetralogy of Fallot repair. Open repair of tetralogy of Fallot is accomplished via median sternotomy during cardiopulmonary bypass. After the pericardium is opened, a ventriculotomy is made in the right ventricular outflow tract (A). The ventricular septal defect is visualized below the crista supraventricularis. The septal defect and overriding aorta are corrected with a synthetic patch secured with interrupted buttressed mattress sutures (B). If the defect is in close proximity of the tricuspid annulus, some of the mattress sutures may have to be placed through the annulus from the atrial side. The right ventricular outflow tract is corrected by placement of an oval synthetic patch within the ventriculotomy (C). The patch may or may not need to be extended across the pulmonic valve annulus depending on the location of the obstruction. The patch-graft is reinforced with buttressed mattress sutures as necessary
Correction of cor triatriatum dexter in a dog. A right fifth thoracotomy is performed and tourniquets are placed around the cranial and caudal vena cavae and azygous vein for venous inflow occlusion (A). The pericardium is opened to expose the right atrium (RA). The location of the obstructing defect is apparent on the caudal portion of the atrium (arrow). A tangential vascular clamp is placed on the atrial wall across the defect (B). An incision is made in the atrial wall within the vascular clamp. Controlling stay sutures are placed in the incision edges. During venous inflow occlusion, the obstructing membrane is partially excised. The vascular clamp is reapplied on the atrial incision as venous inflow occlusion is discontinued (C). The atriotomy is closed with a continuous mattress suture pattern oversewn with a simple continuous suture pattern (
Mitral valve replacement. The septal mitral valve leaflet and chordal apparatus are excised, leaving a 3-mm curtain of leaflet at the annulus (A). The mural mitral leaflet and chordal apparatus is retained to support the ventricle after surgery. Buttressed mattress sutures are placed through the valve annulus using 2-0 or 3-0 double-armed polyester suture (B). The mural mitral leaflet is imbricated into the mattress suture to prevent interference with the action of the valve prosthesis. The mattress sutures are passed through the sewing ring of the prosthesis. The prosthesis is seated into the valve annulus, and the sutures are tied (C)
Mitral partial ring annuloplasty. The size of the annuloplasty ring is chosen or fashioned to match the circumference of the septal leaflet. Double-armed 3-0 sutures are preplaced in the annulus from the atrial side (A). Sutures are placed with wide bites so the portion of the annulus will be imbricated when the ring is seated. Both ends of the sutures are passed through the ring. The ring is seated and the sutures are tied (B).
Artificial chordae tendineae repair. Artificial chordae repair is used to correct leaflet prolapse secondary to rupture or elongation or the chordae tendineae. A pledget-buttressed double-armed polytetrafluoroethylene (GoreTex) suture is passed through the appropriate papillary muscle and then twice through the margin of the leaflet. The length of the suture is determined by matching the leaflet margin with the margin of the opposing leaflet. The suture is tied
Edge-to-edge repair for leaflet prolapse. A buttressed mattress suture is placed in the free edges of the septal and mural valve leaflets at the point of greatest leaflet prolapse. The mattress suture is tied, resulting in a double orifice valve.
Heterotopic aortic valve implantation. Just before surgery, a valved conduit is constructed using a porcine bioprosthesis and appropriate size synthetic vascular conduit (A). The descending aorta distal to the origin of the left subclavian artery is approached from a left thoracotomy (B). The aorta is divided between two vascular clamps and a valved conduit is inserted into the descending aorta using simple continuous patterns (C). The vascular clamps are removed (D).
xAngiogram of a dog with pericardial rupture. The caudal vena cava is kinked (black arrow) between the diaphragm and the right atrium. The pericardium is compressing the caudal vena cava (white arrow)
A variety of atraumatic vascular clamps in differing configurations and sizes. From left to right: a DeBakey atraumatic angled vascular clamp, DeBakey atraumatic tangential clamps, a DeBakey-Satinsky atraumatic tangential clamp, a Cooley atraumatic clamp, a DeBakey atraumatic multipurpose curved clamp, and a Castaneda atraumatic neonatal clamp.
Arteriotomy clamp. The open tip allows for accurate assessment of the depth of the arteriotomy (inset).
An oblique end-to-end anastomosis commences by incising the vessel ends 180 degrees out of phase (A). The resultant corners and adjacent lateral edges are trimmed as needed (B). The anastomosis is begun with double-armed suture in one corner (C) and run to and around the opposite end (D) toward the starting point. The other suture is run up to meet the first suture laterally, trimming any remaining angles
The advantages of a heel-first, toe-last suturing sequence. The surgeon may make a final length adjustment by either trimming the toe (A) or extending the vascular incision (B
In side-to-side anastomosis, a single partially occluding vascular clamp is applied to both vessels simultaneously with the help of preplaced stay sutures (A–C). Briefly releasing the clamp after placing each corner suture of the ventral line (D) allows the dorsal suture line to fall away, which facilitates completion of the anastomosis (E).
Placement of a “patch” of autologous vascular or prosthetic graft. A thin, elliptical patch is fashioned, and mattress sutures are placed in both tips using double-armed suture (A). One mattress suture is continued through the corner of the vascular incision and is tied. Closure is aided by traction on the other suture (B) and is continued from each end, along the sides of the incision, and toward the middle, where the sutures are tied to each other (C and D).
A comparison of balloon-expandable and self-expanding stents. From top to bottom are the balloon-expanded Palmaz stent (A), the self-expanding nitinol Symphony stent (B), and the self-expanding stainless steel Wallstent (C).
