Last edited Michael edwards 11:54, 4 January 2009 (EST)
NO INFORMATION IN THIS SCRIPT SHOULD BE USED WITHOUT THE APPROVAL OF A FULLY TRAINED PRACTISING SURGEON
- 1 LAY OUT OF OPERATION SECTIONS AND STEPS
- 2 STEP 26.01 INTRODUCTION
- 3 STEP 26.02 CLEAN AND DRAPE THE GROIN AREA
- 4 STEP 26.03 INCISE THE SKIN
- 5 STEP 26.04 DEEPEN THE INCISION
- 6 STEP 26.05 INSERT A SELF RETAINING RETRACTOR
- 7 STEP 26.06 PALPATE THE FEMORAL ARTERY
- 8 STEP 26.07 DEAL WITH OTHER STRUCTURES IF IN THE WAY
- 9 STEP 26.08 READJUST THE RETRACTORS
- 10 STEP 26.09 START TUNNELLING UNDER THE INGUINAL LIGAMENT
- 11 STEP 26.10 EXPOSE THE THREE FEMORAL ARTERIES
- 12 STEP 26.11 DISSECT OUT THE ARTERIES
- 13 STEP 26.12 CONTROL MINOR BRANCHES
- 14 STEP 26.13 PASS SLOOPS AROUND EACH FEMORAL ARTERY
- 15 STEP 26.14 CLAMPING AND ANTICOAGULATING EACH FEMORAL ARTERY
- 16 STEP 26.15 START BY CLAMPING THE SUPERFICIAL FEMORAL ARTERY
- 17 STEP 26.16 ANTICOAGULATE THE SUPERFICIAL FEMORAL ARTERY
- 18 STEP 26.17 CLAMP THE DEEP FEMORAL ARTERY
- 19 STEP 26.18 ANTICOAGULATE THE DEEP FEMORAL ARTERY
- 20 STEP 26.19 CLAMP THE COMMON FEMORAL ARTERY
- 21 STEP 26.20 ANTICOAGULATE THE COMMON FEMORAL ARTERY
- 22 STEP 26.21 CHECK THE CATHETER
- 23 STEP 26.22 MAKE THE ARTERIOTOMY
- 24 STEP 26.23 ASPIRATE BLOOD CLOT AND BLOOD
- 25 STEP 26.24 CHECK HAEMOSTASIS
- 26 STEP 26.25 PART OPEN THE CLAMP ON THE SUPERFICIAL FEMORAL ARTERY
- 27 STEP 26.26 PASSING THE FOGARTY CATHETER
- 28 STEP 26.27 PASS THE FOGARTY CATHETER DOWN THE SUPERFICIAL FEMORAL ARTERY
- 29 STEP 26.28 EMBOLECTOMISING THE DEEP FEMORAL ARTERY
- 30 STEP 26.29 EMBOLECTOMISING THE VESSELS PROXIMAL TO THE COMMON FEMORAL ARTERY
- 31 STEP 26.30 CLOSING THE FEMORAL ARTERIOTOMY
- 32 STEP 26.31 OPEN THE SUPERFICIAL FEMORAL ARTERY CLAMP
- 33 STEP 26.32 OPEN THE DEEP FEMORAL CLAMP
- 34 STEP 26.33 PART OPEN THE COMMON FEMORAL CLAMP
- 35 STEP 26.34 CHECK THE FEMORAL ARTERY IS PULSATING
- 36 STEP 26.35 CHECK HAEMOSTASIS IN THE REST OF THE FEMORAL WOUND'
- 37 STEP 26.36 INSERT A DRAIN
- 38 STEP 26.37 CLOSE THE SUBCUTANEOUS FAT
- 39 STEP 26.38 CLOSE THE SKIN
- 40 STEP 26.39 CHECK THE FEMORAL PULSE AGAIN
- 41 STEP 26.40 PERFORM A FEMORAL EMBOLECTOMY ON THE OTHER SIDE IF NEEDED
- 42 STEP 26.41 CHECK THE PULSES AND THE PERFUSION OF THE LOWER LIMBS
- 43 STEP 26.42 EQUIPMENT AND MATERIALS FOR FEMORAL EMBOLECTOMY
- 44 NEXT PART OF THE AORTIC ANEURYSM OPERATION
- 45 LAST PART OF THE AORTIC ANEURYSM OPERATION
- 46 BACK TO START OF THE AORTIC ANEURYSM OPERATION
- 47 CLICK HERE FOR THE PDF VERSION OF THE FEMORAL EMBOLECTOMY SCRIPT
- 48 WE WELCOME YOUR COMMENTS
LAY OUT OF OPERATION SECTIONS AND STEPS
The operation is divided into SECTIONS.
The SECTIONS are displayed in sequence in the following paragraphs.
Each SECTION is divided into an unlimited number of very small STEPS.
Each STEP contains an unlimited amount of supporting information (PANTINOS)
STEP 26.01 INTRODUCTION
- A femoral embolectomy may be needed as a primary procedure or in various stages of an Aortic Aneurysm Graft operation.
- ie Section 12.00 Checking the iliac arteries
- Section 14.00 Dissecting out the femoral arteries.
- Section 26.00 Femoral embolectomy.
- Plus a proximal embolectomy of the aorta.
- The steps of the operation here are numbered to be consistent with the steps of the Aortic Aneurysm Graft script.
STEP 26.02 CLEAN AND DRAPE THE GROIN AREA
- For a femoral embolectomy on its own:
- Have access from the umbilicus to the mid thighs and from one anterior iliac spine to the other.
- Clean the skin of this area.
- Use 2 applications of eg Aqueous Povidone Iodine (Betadine).
- Dry off thoroughly with a third swab on a stick.
- Any residual liquid will prevent the adhesive drape sticking properly.
- Towel up:
- From suprapubic level to nearly mid thigh.
- From one anterior superior iliac spine to the other.
- Place a lower drape up to the mid thigh.
- Place an upper drape down to 5cm. above the symphysis pubis.
- Stick the left side drape from the lower drape to the upper drape, parallel to the anterior superior iliac spine.
- Stick the right drape from the upper drape to the lower drape, parallel to the anterior superior iliac spine
- Apply a transparent adhesive drape.
- Use an extra-large (60 x 60cm.) iodopohore impregnated drape,eg 3M Ioban.
- Hold the 2 left corners tightly yourself.
- Have your first assistant holding the 2 right hand corners tightly.
- Let the scrub nurse peel the backing off the underside of the drape.
- Keep tight hold - white knuckles.
- Lay the drape onto the square of skin which is exposed by the fabric drapes.
- Relax the tension so that drape will tuck neatly into the groin creases and over the genitalia.
- Squeeze air bubbles from under the drape by rubbing the drape with a gauze swab.
- As part of an aortic aneurysm operation::
- Clear a space 8cm. above the groin crease (more for a fat patient), 10cm. below the groin and 20cm. wide, centered on the mid inguinal point .
- ie the surface marking of the femoral artery.
- Make sure the handles of the retractors are not lie on this area.
- If the adhesive plastic drape has torn or become unstuck:
- Resterilise the skin with Povidone iodine,
STEP 26.03 INCISE THE SKIN
- Use a No 22 blade on a large scalpel handle to incise the cutis.
- Make a vertical incision in the midinguinal line, from 5cm. above the groin to 8cm. below it.
STEP 26.04 DEEPEN THE INCISION
- Use the firestick to incise into the subcutaneous fat down to the fascia lata.
STEP 26.05 INSERT A SELF RETAINING RETRACTOR
- Use a Cones self retaining retractor with the handle pointing towards the knee.
- Retract the subcutaneous fat by prising the jaws open.
STEP 26.06 PALPATE THE FEMORAL ARTERY
- This is easier to find when the artery is:
STEP 26.07 DEAL WITH OTHER STRUCTURES IF IN THE WAY
- Coagulate or ligate veins running into the sapheno-femoral junction.
- Elevate the inguinal ligament and the abdominal wall with a Langenbeck retractor in a fat patient.
- Make sure there is no femoral hernia in the fatty tissue in the femoral triangle
- Avoid damaging lymph nodes and lymphatic vessels to prevent lymphoceles postoperatively
- Excise inguinal lymph nodes only if they are obstructing the exposure of the blood vessels.
- Beware of lymphoceles postoperatively if nodes are removed.
- Avoid the femoral vein medially.
- The vein may be confused with a nonpulsating femoral artery.
- Avoid the femoral nerve laterally.
STEP 26.08 READJUST THE RETRACTORS
- This will give a better view of the arteries.
STEP 26.09 START TUNNELLING UNDER THE INGUINAL LIGAMENT
- This will give a good exposure of the common femoral artery as it emerges from under the inguinal ligament as a continuation of the external iliac artery.
- Use finger dissection for 2cm. on the lateral side of the external iliac artery.
- This will avoid damage to the femoral and external iliac veins which run medially.
STEP 26.10 EXPOSE THE THREE FEMORAL ARTERIES
- The 2 femoral arteries are:
- The common femoral artery coming from under the inguinal ligament as a continuation of the external iliac artery.
- It bifurcates into the superficial and deep femoral arteries at some point between the inguinal ligament and up to 10cm. more distally.
- The superficial femoral artery running down as a continuation of the common femoral artery at its bifurcation.
- The deep (profunda) femoral artery running initially medially and then behind the superficial artery to run into muscles laterally.
- Variations with early branchings are common.
- Use dissecting scissors.
- The arteries have charateristic transverse vasa vasorum on their surfaces.
- Dissect in a plane close to the artery, where the surface is shiny.
STEP 26.11 DISSECT OUT THE ARTERIES
- The aim is to clear all sides of the three vessels and every one of their branches so that they can be controlled with bulldog clamps and plastic threads (sloops).
- The site of the incision in the bifurcation of the common femoral artery should be central to this dissection.
- Clear 4cm. of each main artery and 2cm. of each branch.
- The profunda artery may be obscured by a tributary of a profunda vein, which should be double ligated and divided for access.
- Make sure you have found all the vessels.
- Look under and behind all the vessels to make absolutely certain.
- Use a small cholecyctectomy forceps.
- HINT FOR TRAINEES:
- Use a JAWS IN – JAWS OPEN – JAWS OUTJAWS SHUT technique to open the tissues behind the vessels.
- Avoid a JAWS IN – OPEN – SHUT – OPEN – SHUT method which can damage the vessels.
STEP 26.12 CONTROL MINOR BRANCHES
- Use sloops.
- Double loop a sloop around each vessel.
- Hold the end of each sloop with an artery forcep.
STEP 26.13 PASS SLOOPS AROUND EACH FEMORAL ARTERY
- Pass a small cholecystectomy forcep behind each vessel in turn.
- Grasp a sloop in the jaws and pull it half way through.
- Clip the two end of each sloop with an artery forcep.
STEP 26.14 CLAMPING AND ANTICOAGULATING EACH FEMORAL ARTERY
- READ ON
STEP 26.15 START BY CLAMPING THE SUPERFICIAL FEMORAL ARTERY
- Choose a bulldog clamp which is long enough and has a sufficiently strong spring to compress the artery.
- Open the jaws of the clamp as wide as they will go.
- Place the open clamp carefully across the artery at right angles.
- Have 2mm.of each jaw protruding beyond the artery.
- Let the jaws close on the artery.
STEP 26.16 ANTICOAGULATE THE SUPERFICIAL FEMORAL ARTERY
- Use 20ml. of heparin saline in a syringe with a green topped 21SWG needle.
- Push the needle through the anterior wall of the superficial femoral artery 10mm. distal to the clamp.
- Make sure the needle does not go through the back wall.
- Withdraw on the piston to check that blood aspirates back into the syringe.
- If blood cannot be aspirated:
- Pull the needle out of the artery and try to aspirate again.
- Push the needle further in and reaspirate.
- Insert the needle through a different site.
- If you still cannot aspirate blood:
- The vessel may be thrombosed or blocked with an embolus.
- Continue anticoagulating the other vessels.
- If you aspirate blood:
- Inject the 20ml. of heparin saline into the vessel.
STEP 26.17 CLAMP THE DEEP FEMORAL ARTERY
- Apply a clamp as for the superficial femoral artery.
- The artery is often less accessible than the superficial artery.
STEP 26.18 ANTICOAGULATE THE DEEP FEMORAL ARTERY
- Inject 20ml. heparin saline distal to the clamp, as for the superficial femoral artery.
STEP 26.19 CLAMP THE COMMON FEMORAL ARTERY
- Apply a clamp as for the superficial femoral artery.
- Place it 4cm. proximal to the superficial femoral clamp to make enough space for the arteriotomy.
- Use a De Bakey clamp if a bulldog is not long or strong enough.
STEP 26.20 ANTICOAGULATE THE COMMON FEMORAL ARTERY
- Inject 20ml. heparin saline as for the superficial femoral artery.
- Hold a pledget on a sponge holder onto the injection site for 1 minute to control any bleeding.
STEP 26.21 CHECK THE CATHETER
- Check it is a No 4 French Gauge catheter. I.e 4mm. in circumference.
- Check you have a spare No 4 catheter available.
- Have the catheter brought to the operating table.
- Make sure it does not flip onto unsterile areas.
- Remove the central wire.
- Test the balloon at the tip of the catheter.
- Have 0.75ml of heparin saline inserted into a 2ml. syringe.
- Check that there is no air in the syringe, which will upset the feel of the procedure.
- Push the syringe onto the catheter until any creaking on the joint stops.
- Inflate the balloon with the 0.75ml. of liquid.
- Check that the balloon does not burst and the balloon is a regular sphere shape.
- Check the balloon deflates on release of the syringe.
- Replace the catheter if substandard.
STEP 26.22 MAKE THE ARTERIOTOMY
- Use a No 28 blade on a long handle.
- Choose a site:
- On the front of the distal common femoral artery.
- On a healthy piece of artery if possible, 20mm. long.
- Avoid dense calcified patches.
- Make a transverse 28mm. cut.
- This will be big enough for the inflated balloon to pass through.
- Make sure the ends are cut cleanly to give the maximum length.
- Avoid peeling the intima off the subintima, especially distally.
STEP 26.23 ASPIRATE BLOOD CLOT AND BLOOD
- Use a vascular sucker.
- Avoid suction on the inside wall to prevent damage to the endothelium.
STEP 26.24 CHECK HAEMOSTASIS
- Check the clamps are properly positioned and tightly closed.
- Check you have not missed any branches.
STEP 26.25 PART OPEN THE CLAMP ON THE SUPERFICIAL FEMORAL ARTERY
STEP 26.26 PASSING THE FOGARTY CATHETER
- Use the same technique as for the iliac artery.
- As a reminder:
- Follow these steps.
STEP 26.27 PASS THE FOGARTY CATHETER DOWN THE SUPERFICIAL FEMORAL ARTERY
- Use your fingers to hold the catheter.
- Use vascular forceps to hold the catheter in any awkward angle to pass down the artery.
- Open the clamp a little more to let the catheter pass through.
- Pass the catheter down ideally to beyond the popliteal trifurcation.
- The catheter will pass through thrombus and embolus material.
- If catheter meets an obstruction at about 20cm. i.e. at the adductor hiatus:
- This may be due to a kink in a tortuous vessel,
- Bend the distal 2cm.of the catheter.
- Repass the catheter and rotate it to negotiate any kink.
- Try passing a narrower catheter.
- If the catheter will still not pass:
- The superficial femoral artery is probably blocked with atheroma.
- Accept this situation and continue the embolectomy.
- If the catheter passes to 30cm. or more:
- Push the heparin saline into the balloon until resistance is felt.
- The resistance is the wall of the artery.
- If you push too hard:
- You can rupture the arterial wall, especially when it is healthy.
- This will most likely be in the vessels below the trifurcation.
- The balloon will suddenly inflate easily.
- This sudden inflation can happen also if the balloon bursts.
- Withdraw the balloon.
- If the balloon has burst:
- Replace it.
- Be more gentle with the new balloon.
- If you think you have ruptured the vessel:
- Plan to examine the limb at the end of the operation.
- Explore and repair the vessel as needed.
- Pull the catheter steadily out of the artery with your left hand.
- At the same time, with your right hand, increase or decrease the amount of liquid in the balloon.
- The aim is to match the diameter of the balloon with that of vessel being swept clear of the thrombus or embolus.
- You will probably feel the narrowing of the superficial femoral artery at the adductor hiatus (about 30cm. from the arteriotomy).
- You will feel the roughness of atheromatous plaques on the arterial wall.
- As the balloon of the catheter approaches the arteritomy:
- Get the first assistant ready with a vascular sucker to remove thrombus or emboli.
- If you bring up thrombus or emboli:
- Repeat passing the catheter until no more material is obtained on two passes.
- You should have a steady stream of back bleeding if the blockage is relieved.
- Flush 60ml of heparin saline down the superficial femoral artery.
- Reclamp the superficial femoral artery.
- If there is no back bleeding and the catheter passes to 30cm. or more:
- The limb may not be viable below the knee.
- However, the patient may eventually lose part of the left limb from ischaemia.
- Flush 60ml of heparin saline down the superficial femoral artery anyway.
- Reclamp the superficial femoral artery.
- Consider angiography at the end of the operation.
STEP 26.28 EMBOLECTOMISING THE DEEP FEMORAL ARTERY
- This is the same technique as for the superficial femoral artery.
- The catheter needs careful fiddling round the turns in the deep artery.
- The deep femoral artery is rarely thrombosed or embolised and is usually healthier than the two other femoral arteries.
STEP 26.29 EMBOLECTOMISING THE VESSELS PROXIMAL TO THE COMMON FEMORAL ARTERY
- Use the same technique as above.
- There is likely to be more blood loss due to higher pressures proximally.
- The catheter should pass into the graft.
- Release of thrombus and emboli is likely to cause a whoosh of blood.
- Warn your assistants to keep out of the way of the blood.
- Be very quick to close the common femoral clamp to minimise blood loss and loss of heparin saline.
- If there is no vigorous flow of blood down from the iliac artery:
- Try passing the catheter higher up above the graft.
- Consider reexploring the graft and anastomoses.
STEP 26.30 CLOSING THE FEMORAL ARTERIOTOMY
- First, flush out the isolated section of common femoral artery with 20ml. of heparin saline.
- For the closure,use a 4/0 polypropylene vascular suture with one needle removed (eg Ethicon W8953).
- Start at the far side of the arteriotomy.
- Place a first stitch 1mm. from the distal end of the arteriotomy.
- Pass the needle though the upper edge of the artery 1mm. from one lateral end.
- Pass the needle from outside to inside.
- Pass the needle though the corresponding edge of the lower edge, from inside to outside.
- This should prevent intimal delamination.
- Tie the first stitch with 4 throws.
- Cut the end 10mm. long.
- Continue the closure with continuous stitches 1.5mm. apart to the middle of the arteriotmy.
- Maintain a 250gm. tension.
- Insert a second stitch 1mm from the proximal end of the arteriotomy
- Tie off the stitch as for the first stitch.
- Stitch towards the middle of the arteriotomy as for the first stitch.
- Tie the two stitches together when they are 1.5mm. apart
- Use 4 throws.
- Cut the ends 10mm. long.
STEP 26.31 OPEN THE SUPERFICIAL FEMORAL ARTERY CLAMP
STEP 26.32 OPEN THE DEEP FEMORAL CLAMP
STEP 26.33 PART OPEN THE COMMON FEMORAL CLAMP
- If there is spurting:
- Insert extra 4/0 vascular stitches.
- If there is minor bleeding:
- Cover the arteriotomy with a swab and wait 3 minutes.
- Continue until the arteriotomy is dry.
STEP 26.34 CHECK THE FEMORAL ARTERY IS PULSATING
- If the femoral artery is not pulsating:
- Consider a recatheterisation.
STEP 26.35 CHECK HAEMOSTASIS IN THE REST OF THE FEMORAL WOUND'
STEP 26.36 INSERT A DRAIN
- This is often omitted.
- Use eg a medium Portovac drain.
- Pass the spike introducer through the lateral wall of the wound from inside out.
- Check that the drain:
- Does not damage the arteries.
- Pull the drain through the wound edge until the black localising mark appears at skin level.
- Cut the drain to include 5cm. of perforations.
- Tuck the drain into the wound.
- Suture the drain in place in the skin.
- Use No 1 silk on a hand needle (eg Ethicon W2793).
- Make a bite into the nearby skin.
- Tie the suture with 4 throws.
- Wrap the silk 4 times round the drain.
- Tighten the suture to make a minor waist in the tubing.
- Tie the suture with 4 throws.
- Cut the ends 40mm. long.
STEP 26.37 CLOSE THE SUBCUTANEOUS FAT
- Use continuous 2/0 vicryl (eg Ethicon W9136)
STEP 26.38 CLOSE THE SKIN
- Use continuous 3/0 Vicryl (eg Ethicon W9890).
STEP 26.39 CHECK THE FEMORAL PULSE AGAIN
- If the pulse is absent:
- Consider repeating the embolectomy.
STEP 26.40 PERFORM A FEMORAL EMBOLECTOMY ON THE OTHER SIDE IF NEEDED
- Use the same technique as for the first side.
STEP 26.41 CHECK THE PULSES AND THE PERFUSION OF THE LOWER LIMBS
- If blood flow is poor and there is evidence of a distal occlusive disease:
- Consider further assessment with angiography.
STEP 26.42 EQUIPMENT AND MATERIALS FOR FEMORAL EMBOLECTOMY
- These instruments and materials are for a femoral embolectomy as a primary operation.
- If the embolectomy is part of an aortic aneurysm graft, the instruments and materials will already be available.
- INSTRUMENT PACK
- FEMORAL/ILIAC ARTERIAL INSTRUMENT TRAY
- UNIVERSAL DRAPE
- UTILITY DRAPE
- 3 X 20ML SYRINGES 2 X 2ML SYRINGS
- SUCTION TUBING
- YANKEUR SUCTION END
- 500ML IV N/SALINE
- 5ML HEPARIN(1000ML)
- FINE SUCTION ENDS
- ORANGE & GREEN NEEDLES
- 1PKT SLOOPS
- FOGARTY EMBOLECTOMY CATHETERS – 3,4,5,6,7
- DIATHERMY POUCH
- NO MATERIAL
- TIES W9025 2/0 VICRYL
- TIES W9026 0 VICRYL
- FASCIA W9125 1 VICRYL
- SKIN W9890 3/0 VICRYL
- DRAIN W2793 1 MERSILK
- OTHERS W8935 4/0 PROLENE
- 1 X 22a
- 1 X 10
- 1 X 15
- PATIENT POSITION
- TABLE FITTINGS
- ANAESTHETIC SCREEN
- FOR BRACHIAL EMBOLECTOMY - ARM BOARD REQUIRED
- WOUND SPRAY
- FOR LOCAL ANAESTHESIA ONLY
- 40MLS 1% PLAIN LIGNOCAINE
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