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Vascular and Intestinal Anastomotic Workshop. PGY 1. Name the Instruments. PGY 1. Name the Instruments. PGY 1. Name the Instruments. PGY 1. Commonly used Sutures. PGY 2. Lembert Sutures. Definition? Reason?. PGY 2. Connell Sutures. Describe Connell suturing technique. Staplers. - PowerPoint PPT Presentation
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Vascular and Intestinal Anastomotic Workshop
Name the InstrumentsPGY 1
Name the InstrumentsPGY 1
Name the InstrumentsPGY 1
Commonly used SuturesBraided? Absorbable? Timeline # of throws
Silk Braided no n/a 3-4
Vicryl Braided yes 55-70 days 4-5
Prolene Mono no n/a 6-8
Chromic Mono yes 90 days 4-5
PDS Mono yes 180-210 days 6-8
Nylon Mono no n/a ~5
Gore Mono no n/a ~8
Monocryl Mono yes 90-120 days 5
PGY 1
Lembert Sutures
• Definition?• Reason?
PGY 2
Connell Sutures
• Describe Connell suturing technique
PGY 2
Staplers
Name the StaplerPGY 2
Name the Stapler…PGY 2
Name the StaplerPGY 2
Side to side anastomosis
• How do you set up a side to side anastomosis?
CRITICAL CONCEPTS• Non-tension• GIA stapler• Align anti-mesenteric
sides of bowel together• Staggered staple lines
PGY 2
End-to-end Anastomosis
• How do you set up a stapled end-to-end anastomosis?
PGY 2
Functional End-to-end anastomosis
• Describe another way to perform a stapled end to end anastoamosis
PGY 2
Stapler Loads• What is the difference
between the different stapler loads?
• What color load do
you use for vascular tissue? Stomach? Small bowel? Colon? Rectum?
PGY 3
Hand Sewn Anastomosis
• Describe the different types of suture techniques used in hand sewn bowel anastomosis
PGY 3
Hand Sewn Anastomosis
• Describe the steps for a 2 layer anastomosis
PGY 3
Hand Sewn Anastomosis
• Describe how to sew a single layer anastamosis
PGY 3
Arm Vascular Anatomy
• Describe the arterial and venous blood flow to the arm
PGY 2
Types of Surgical Dialysis Access
• What is the difference between an AV Fistulae and an AV Graft
PGY 2
Sites for AV fistulae
Radiocephalic AV Fistula
Brachiocephalic AV graft
Basilic Vein Transposition
DRIL procedure
• DRIL = Distal Revascularization Interval Ligation
• RUDI = Revision Using Distal Inflow
Vascular Anastomosis
• Identify autogenous materials for vascular anastomosis: – Saphenous vein, iliac vein
• Identify exogenous materials for vascular anastomosis: – bovine pericardium, ePTFE, gore-tex, cadaveric
• What is the dosing/timing for heparinization during a vascular anastomosis? – 75-100 units/kg, given 5 minutes prior to vascular occlusion
• How do you measure heparinization to confirm appropriate levels have been achieved? – Activated clotting time (ACT) of greater than 250
PGY 3
Zones of Retroperitoneum• Describe the Zones of the retroperitoneum
and the major vasculature that could be injured in each zone
• Zone 1: Midline retroperitoneum– Supramesocolic region (suprarenal aorta,
celiac, SMA/SMV, proximal renal artery)– Inframesocolic region (infrarenal aorta,
infrarenal IVC)• Zone 2: Upper lateral retroperitoneum
(renal artery/vein)• Zone 3: Pelvic retroperitoneum (iliac
artery/vein)
PGY 3
Zone I Great Vessel Injury
• Describe the approach for supramesocolic Zone I injuries: – Left medial visceral
mobilization– May also need to
transect the left crus (at 2o’clock position) to allow for control of the descending thoracic aorta
PGY 3
Zone I Great Vessel Injury
• Describe the approach for inframesocolic Zone I injuries:– Lift up on transverse mesocolon,
eviscerate small bowel to right, open mid-line retroperitoneum and cross clamp the aorta inferior to the left renal vein
– For IVC injuries, perform a right medial visceral mobilization (right colon and duodenum), leaving the kidney in situ
PGY 3
Zone I Great Vessel Injury
• Describe the approach to an inframesocolic Zone I injury to the IVC at the common iliac vein confluence: – After right medial visceral mobilization, it may be
necessary to divide and ligate the right internal iliac artery or to temporarily divide the right common iliac artery
PGY 3
Zone I Great Vessel Injury
• Describe the approach to an inframesocolic Zone I injury to the IVC at the level of the renal veins:– After right medial visceral mobilization, you should
clamp/compress the IVC proximally and distally and loop/clamp both the left and right renal veins. It may be necessary to perform a medial mobilization of the right kidney (watch out for 1st lumbar vein!)
PGY 3