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General principles of

vascular surgical technique


Vascular anastomoses
SSCR - Basic Surgical Skills, 2nd edition, Bucharest
History of vascular surgery
Trojan War 500 B.C.
History of vascular surgery
Artery Vein ... 300 B.C.
History of vascular surgery
Vascular ligation... 150 A.D.
Ambroise Par
Objectives:
1. Why vascular anastomoses?
2. Instruments
3. Basic principles
Exposure

Hemodynamic control

Arteriotomy and graft preparation

Anastomosis

Releasing of the vascular clamps and reperfusion

4. Types of anastomoses
Vascuar pathologies
- wall
- lumen
Principles of vascular anastomoses
1. ASEPTIC technique
2. Controlled HEMODYNAMIC conditions
3. Appropriate instruments ATRAUMATIC
4. Restore of intimal continuity EVERTING
5. Maintaining lumen permeability NONSTENOTIC
and NONTHROMBOTIC
6. Maintaining VIABILITY

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


Vascular surgery instruments

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


Prehension
forceps
Pense
de prehensiune
General forceps
Dieffenbach
(Bulldog) vascular
clip
Cooley forceps
Cooley-Satinsky
forceps
Castroviejo
needle holder
Cutting
instruments

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


Cutting instruments

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


Microsurgery
1. Straight scissors
2. Curved scissors
3. Castoviejo needle holder
4. Retractor
5. Scalpel
6. Adson forceps
7. Curved Gerald forceps
8. Straight Gerald forceps
9. DeBackey forceps
Types of suture

Double ended
Monofilament
Synthetic
Slowly absorbable
Round bodied needle
The thickness of the thread depends on the
thickness of wall (not the lumen diameter)
SSCR - Basic Surgical Skills, 2nd edition, Bucharest
Prostheses
Synthetic:
Polyester = Dacron
Polytetraflourethylene=
Gore-tex

Biological:
Homonymous vein
(Treated) cadaver artery
or vein
Bovine pericardium

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


Types of vascular anastomoses
1. End-to-end anastomosis
2. End-to-side anastomosis
3. Side-to-side anastomosis
4. Enlarging patch angioplasty

SSCR - Basic Surgical Skills, editia 56, Bucuresti


Exposure and Dissection

The periadventitial adipose


tissue is dissected on a
minimum area required, not
more than 1 cm.

To prevent periadventitial fibrosis,


procaine + saline solution is
administered.

SSCR - Basic Surgical Skills, editia 56, Bucuresti


Bleeding control

Clamping
Ligation
Dabbing

Clamping may be longitudinal or transverse:

Longitudinal - partially maintains blood flow in large vessels while controlling


the bleeding in the damaged area.

Transverse - completely stops blood flow and it is done both downstream and
upstream of the incision.

SSCR - Basic Surgical Skills, editia 56, Bucuresti


Bleeding control
Atherosclerotic plaques are usually located on the posterior
wall of the artery. The clamp should be placed horizontally to
avoid fissure and fragmentation of the plaque.

SSCR - Basic Surgical Skills, editia 56, Bucuresti


Arteriotomy

Longitudinal Transverse

SSCR - Basic Surgical Skills, editia 56, Bucuresti


End-to-end anastomosis

1. Stay sutures placement


2. Anterior wall suturing
3. Exposure of the back
wall
4. Posterior wall suturing

SSCR - Basic Surgical Skills, editia 56, Bucuresti


End-to-end anastomosis

SSCR - Basic Surgical Skills, editia 56, Bucuresti


End-to-end anastomosis

When an end-to-end anastomosis has to be performed


between two different caliber vessels, the smaller
vessel will be incised and its edges trimmed to match
the larger one, which must be cut in an oblique manner
to avoid kinking.

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


End-to-side anastomosis

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


End-to-side anastomosis

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


Side-to-side anastomosis

Uses:
Portacaval shunt in portal
hypertension
Radiocephalic arteriovenous fistula for
hemodialysis

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


Patch angioplasty

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


Preventing thrombsis
Heparinotherapy

The vessel will be maneuvered without touching the


endothelium with the forceps

The sutures will not be placed in a chaotic manner

The needle will pass through the vessel wall on the first
attempt

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


Technical mistakes
Tearing of the wall

Improper spacing

Narrowing of the lumen


(purse-stringing)

Back wall stitch


SSCR - Basic Surgical Skills, 2nd edition, Bucharest
Alternatives

Fogarty
embolectomy
catheter

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


Balloon
angioplasty
and stenting
Bibliography

Tehnici chirurgicale suport de curs Societatea Studenteasca de


Chirurgie din Romania, Editura Universitara Carol Davila, Bucuresti
2013

Basic Surgical Techniques by R. M. Kirk, 6th edition published by


Elsevier

Ball and Feliciano World Journal of Emergency Surgery 2009

http://www.ecu.edu/cs-dhs/surgery/upload/Skills-lab-Vascular-surgery-
one.pdf

http://www.ecu.edu/cs-dhs/surgery/upload/Skills-lab-Vascular-
surgery-two.pdf

SSCR - Basic Surgical Skills, 2nd edition, Bucharest


Thank you for your attention!

SSCR - Basic Surgical Skills, 2nd edition, Bucharest

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