Thoracoabdominal Aortic Aneurysm Repair - Part 2
Dr. Patel continues repairs on this thoracoabdominal aortic aneurysm in Part 2 of this two part series. Watch as he works against the clock during visceral ischemia time until blood flow from the graft is restored to all the dependent organs!
Main Text Coming Soon...
1. Distal Descending Aorta Anastomosis
- Atrio-Femoral Bypass Removal
- Check Anastomosis For Leaks
- Sequentially Open Distal Clamps
2. Atrio-Femoral Bypass Removal
- Decannulate L. Inf. Pulmonary
- Close Purse String Suture of L. Inf. Pulmonary Vein
- Decannulate L. Femoral Artery
3. Celiac Artery Reconstruction
- Create Side-Arm Exit Point in the Aortic Graft
- Anastomose Side-Arm Graft to Aortic Graft
- Check Anastomosis for Leaks
- End-to-end Anastomosis of Celiac Artery to Side-Arm Graft
- Check Anastomosis for Leaks
- Close Aneurysm Sac Over Aortic Graft
- Repair Left Hemi-Diaphragm
- Insert Thoracic Drains
- Repair Thoracotomy
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarentee their complete accuracy
Let’s have four white towels. Sorry. You can let go with this. I wanted a red rubber and a snap on it. Suck in there please. Thank you. Now it's your turn to not be able to see anything, Jahan. Another shod please. Shod please. Give me a little. Hold that please. I'm going to want some, I'm going to want some transition stitches with pledget uh, Bruce, okay. Squirt for the strands. We are not pulling there we are doing this very gently. Stop there. Keep bouncing. Stop there. Shod. Pull on it. Pull on it. Stop for second there. Don't pull on it when I when you see a loop like that. Pull. Hold it on tension now.Okay shod shod.
Let's have a transition stitch to me with a pledget. Leave it out of my way now. Put that through the pledget. Pull your. Let's put that other one through the pledget as well. Hold these two like this. Give me a driver. Nope just give me a driver. Pick up to me. Nevermind Jahan’s helping me out. Need a pickup. Hold that one on tension still Sean. Come on guys we have visceral ischemia time here. Hold this one that's going to be my next runner. Let go. Shod. That one to Jahan. We're going to do one of my side actually going to run up my side do the same.
How long is it been on the visceral ischemia? 15 minutes. Thanks. Yes cut it, don’t cut the other one though. Empty driver please. Suck in there. Put the pledget on that one. Give me the other stitch so we can put that pledget through this hole. The first runner. Give this one to me pull this one up on tension. Cut square please. Take this. Too many of course. Take this one. Give me that. Empty driver right hand. Take this shod, that one. Give me the other one. Pull it up nice and snug, please. Motors still good? Take the other one off the shod. Hold that one up on tension. Going to follow myself. Going to want a pledget, Bruce. Yeah go ahead and put it on that. We don't want to be on sometime today or tomorrow. What are you doing?
Okay visceral layer’s going to open up here in a second. Drop your pump flows down, but don't turn it off. I'm going to give a little backward flush here. Okay. Okay backup. Let’s have you uh you guys already have the pledget? Let go. Cut. Squirt, please. We’re going take the distal clamp off now. We're going to go turn the pump flow down to 500 in a second here okay and you might have if you need a squeeze on the graft because of the visceral and the legs are coming back. Let me know though the legs are been fine so it's just a viscera. Cut. Take this. Okay turn your pump down please to 500. The legs are open. Right renal is open and SMA just opened. So everything is open.
How long was the clamp time. 20 minutes? Yeah you had right renal SA and Celiac ischemia at the same time. How are we doing is far as distal perfusion? Good, let's run a motor please. Do you know what warm him up a little bit and then, cause I'm ready to take the cannulas out actually. Thank you so just so proficient. I want greater than 60 mil mean of 65 at all times but I want her blood pressure like systolic about 120 in post-op minimum. I am going to want some separafilm on the field guys. Let have another dry lap. Let’s have some thrombeanies if you don’t mind.
Let’s have another one. Let's get ready to decannulate. Do you need more volume here? Let's get the bovie and the cell saver up here without losing it this time. There you go. Rotate towards me. I'm just going to do should we take the Venus out and pump through or are you want on none of that blood should we dump it into the field and then give you a cell saver. Do that? Okay?
I'm just leave it going for 500 for now let me know what y'all let's not worry about that until I'm closing and I'm sorry but I know I did ask for it thanks for getting us so quick. Normally no one ever has it now let's get this loosened up here let's get the you can you can let that go it's not going anywhere. Let’s open up this and get this line out of here. Let’s have a duval lung clamp please. Now whoever told them to clamp, which is going to be you, you’re going to pull it on tension when we take it out but then when I start to tie it down you going to let it go so that I don't rip the vein okay. Okay Jahan instead of this… Yep please. Spread your hands. Okay. Take this. Don't do anything. Not yet. Not yet.
Guys get ready to hold your breathing here in a second. Let’s have a line clamp. Put the line clamp here. I can clamp down here. Well we got it. Go ahead. Go ahead. Hold your pump. Clamp all the way across. Click click click. Let's go. Sean, pull the cannula when I say go ahead slide it out. Go ahead and breathe. Scissors.
So you don't want the volume? Yes correct. Okay. Or can you take it now? Cut. Okay rotate the table towards me drop to table height. Let’s have an angled gerbode and a pickups please. Let’s have an angled hydrogrip. Put the venous cannula in the warm bucket of salinee. Give me the arterial cannula here. Where is the arterial cannula? Okay let’s have the cell saver. Put that in there. Keep it on the bottom. Go ahead and yes take the clamp off. Take this please, Bruce. Cell saver right in here.
Right down there okay. I've got my clamp open here as well. Go ahead and pump slowly into the field. Yep, can you put the cell saver down here. Pick up. That’s good, keep going. No when we see you we see the stuff turning clear will give you your lines. Let’s have a line clamp back to both me and Jahan. We're almost at the bottom got about 400 cc. Let’s get a little bit more. Okay that looks good. Clamp. Clamp.
Okay everybody move that way so we can give him his line clamps back or his lines back. Okay, you guys want to close this this up? Jahan you close, and you know how to do it right?
Okay. Let's have the let's have our retractors back, and we're going to put a little sidebiter on here and put this celiac artery in. Thanks. Do you have that 8 millimeter dacron graft will do a right here slightly over to the right line and just. Can I have schnitz. Give him an 11 blade. Let’s have a side biting satinsky clamp. I hope not. Let’s have a vessel loop and a snap. How... can you run a motor? It’s filling back up. See how it’s filling. I squeeze it and it fills. Let’s keep it on tension. Give me an 11 blade. Forceps. Let’s see that cut Brett. I'm going to do a 4-0 please. Let’s have four white towels. Give up, give Sean a 5-0 to get started, just to open this up a little. Stays exactly. Two 5-0 first for stays and then we'll use the 4-0s for the anastomosis. I'll take that shod. Thank you. Little slightly longer driver. Even it out. Good. Right up the pike. A little less. Keep going to run a three. May I have a shod please? Move back for one second.
Did you flush well proximally and distally? First distally first then proximally. Good. I'll take a shod. Relax for a second on your side. Okay bounce. Shod this this one. Can I have another stitch to me lefty. Yes. Thank you.
Are we going to give more heparin? No, we're going to reverse once celiac’s opened up okay. Do 2-0 PDS and 3-0 PDS in the groin guys. No vicryl? No. Tie this up. Stop the hook. If you need to charge your battery now, it's a good time. Okay shod. Empty driver to Sean please. Take... Cut Squirt to me please. Get ready to sew with your other side.
How many do we have much in the way of a lactic acidosis after that clamp timer now? Probably 21 minutes. How are the coags and stuff? Okay. What? Thank you. Scissor. Yup that’s what I am saying. Snap please. Hydro grip clamp. Another stitch please, Bruce, lefty. Another 4-0. I need that satinsky back. Stitch to me please. Cut squirt.
I had to reclamp partially here. Can you make sure that distal perfusion stays up cause I've got like a 50% clamp on the aorta here. Cut this one. That’s... Take this. Scissor. Please stop pulling up on, it's going to keep ripping the graft. It’s got 5000 stitches in it now. Suck all that stuff out. Um. Can I have a frown forcep, please. Forcep. Can I, thank you, have another one of these? Can I have the renal forcep now? Can I have a pod scissor? Let’s have a white sponge. Got it. Marking pen. Let’s have Hydro grip please. Let’s have a scissor. Let’s have a 5-0 prolene stitch to me. Move up this corner and pull it grab this corner. Pull it that way. Yup. There we go. Let go. Suck on the surface here so I can see what's what. Gently. Shod to me please. Shod right here. Squirt really well. You're going to hold this graph down just let that go then sharp hook it back so that we don't tear this artery. You’re going to hold this down like so. I'll take that sharp hook. Let’s have a blue towel for the to put underneath the clamp. Let’s have another stitch to me please. We’re going to take three of these. Shod. Grab the black line with your forcep and push the graph down so that I can tie the toe down. Okay go ahead and follow Jahan. Don't pull hard now this is a very delicate vessel. Let go. We are going to want some more sutures here with pledgets. Round handle forcep to me.
Hey uh give her protamine and start reversing her please. Okay well let’s tanker her up cause that's not acceptable that pressure. Run a motor please. Okay. We got most of the bleeding stopped here. Lots of ffp and platelets now guys okay. Can we have some warm irrigation in the room? Let's take this guys. Rotate the table away from me. Some more warm irrigation. Rotate away from me some more. Okay lots of protamine coags and platelets now guys. Last time to look at the anastomosis.
We’re seeing clot in the field so thank you. Look at Bonnie's and a 2-0 silk. Let’s see if that’s going to narrow that graft. Try it. Don't close it completely then. Yeah that's good. That's fine. We're going to close it up here. Did she have a PET CT? Suck up here so it doesn't drip all over my legs. 68-69-70-71-72. Let’s have another long silk runner. Please shod this or snap it. Yeah small clip Lisa. Can I have a Bonnie's?
Where is all this blood coming from? I need slack on that guys. Some more irrigation here. And the coags are okay? Are you waiting on those? Can you get some more ffp as well please? Thank you. Far away, far enough away from Goose there. That’s good. I’ll take this. I'll take another one of those heavy vicryl runners for the aneurysm sack. Now should be dry as a chip up there and it is. Relax for one second please. It’s a lot of mediastinum opened up here. Can I have the Bonnie's back please? If anyone has to reexplore this later remember I put that stitch there. Grab this with the Bonnie and pull it over so that doesn't rip it out. Try to tie it down.
There’s still a lot of oozing up here. Cut. I keep on going. Are you working on the coag and platelets and stuff guys? There’s still lot of raw surface that's just oozing now. Uh thank you. Yeah. Especially near the neck. Run up this one. Let’s see can I have vicryl stitch? You can stop going. We're done. Thank you.
What's the blood pressure been? 120s. That's perfect. 120 is fine. Do 120 to 140, don't overshoot but uh.
Okay, let's do this. Let's just close this up a little bit to get a little tamponade. Do you have that vicryl stitch and another thrombeanie for me okay. I'll take that vicryl Stitch next. Cut that one. Follow with your other hand for me. Ease up with the pull on your right hand as you pull up. Ease up on the pull. Okay. Little will tamponade nicely if we can get it closed up. That’s going to be good enough tied up. Pull up on it. Here you go. Let’s take this off. Actually let’s take it off just to uh.
Let’s have heavy silk stitch to me. We'll look at this wing in the second. Let's have a Bonnie's. Give us a head up and Berg. That’s good. Too much. Cut this please. Cut.
Let’s uh check that pulse in the celiac artery. Do you have a doppler on? Yeah take it out of a less head down up and Bergen give me a little. Rotation towards me please. Set them or flat the other way. Okay let's have that heavy ethibond runner. Let's do a little bit head down and drop the table height all the way if you can. Let’s have that ethibond runner. Just hold the spleen and kidney over gently. I'll take that ethibond bonnies. Cut. Take that. Driver. Yup. Jahan can you cut these out.
Preserved the central but does that now and the phrenic nerve but does that really preserve function, who knows. Let me tie myself. Okay. Don't poke a skunk. Coker please. Suction. Feet down and berg. That's good right there. Get your fingers deeper down in there. Hold this for second. Pull yourself up. Let's have a Coker to me. A little messed up and when I… Okay Jahan you hold this. Pop through. Closer up. That's good. Don't stretch the tissues to get your needle in. Move your needle to get your tissues. This one is supposed to be down here so you've got to make more. That one’s headed it up to there. See how much travel this one's got to be made to hear it's a smaller travel there, bigger travel on that side. Scissor. You guys start taking a little break out of the table. We do that first and then close it. Watch your fingers. This fran has to go all the way to there. So much smaller bites much bigger travels. Okay. I'll take a… keep you’re following yourself I’m not following you anymore. Let’s have a coker to me. Let's have a knife position at 2. Okay. Knife. Easy for second now. You got the makeup of this all the way to there okay.
Can you give us a little head down and berg? Okay. Get another stitch please another via... just tie this. You know another ethibond on long-running ethibond. Good bite don't stick the heart. No we're not going to pull it up; we’re just going to sort of keep running. Ah I pulled it out sorry. Rotate towards me. Can we go anymore or no? Keep going all the way. Ralph can I get a forceps and the scissors and cut this this marker stitch out.
Just the edge now. Now let’s have that heavy vicryl runner please. Scissor. Bonnies. And then follow here. Here you go. Let’s have the rake back. Another one of these heavy vicryls. Close them up just as nicely as you open them up and everything works out just fine.
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