Rutherford's 061: Open Surgical Technique скачать в хорошем качестве

Rutherford's 061: Open Surgical Technique

#VascularSurgery #OpenSurgery #Rutherfords #SurgicalTechnique #BypassSurgery #Endarterectomy #Thromboembolectomy #VascularGraft #SurgicalInstruments #ArterySurgery #VascularAnastomosis #LimbIschemia #CarotidSurgery #FemoralArtery #PTFE #VeinGraft #SurgicalSkill This video provides a deep dive into open surgical techniques in vascular surgery, drawing from Rutherford’s Vascular Surgery and Endovascular Therapy, Chapter 61. Open surgery remains crucial, often considered the gold standard for durability. Successful procedures rely on choosing the optimal procedure at the right time, ensuring necessary access and exposure, and executing the operation carefully and efficiently. Key considerations include assessing inflow, outflow, and selecting the appropriate bypass conduit. The toolkit is highly specialized, featuring vascular clamps with fine serrations designed to grip vessels gently to minimize damage, available in various shapes and sizes, including those for partial occlusion or artificial grafts. Needle holders, forceps (like DeBakey or Gerald), scissors (Metzenbaum, Stevens', Pot), and right-angle clamps are also specialized for delicate vascular work. Self-retaining retractors (OmniFlex, Bookwalter, White Laner) are essential for stable visibility and freeing hands. Non-absorbable monofilament sutures, typically polypropylene or polyester, are standard for lasting strength, often double-armed and sometimes moistened with saline. PTFE sutures minimize bleeding from needle holes in PTFE grafts. Grafts like polyester and PTFE are used for larger vessels (aorta, legs), while autogenous vein grafts are preferred for smaller artery reconstructions due to compatibility and lower infection risk. Basic techniques involve exposure and dissection, controlled blood flow, and the repair or reconstruction itself. Exposure requires finding the most direct route using anatomical landmarks and palpation, with gentle handling of tissues crucial. Reoperating in scarred areas demands sharp dissection and a known-to-unknown approach. Anticoagulation, usually unfractionated heparin given just before clamping, is standard practice to prevent clots. Vessel control methods include clamps placed ideally on disease-free segments, balloon occlusion (Fogarty catheter) for heavily diseased vessels or specific locations, gentle vessel loops for smaller branches, pneumatic tourniquets for extremity work, and specialized internal occluders. Key procedures discussed include thromboembolectomy, primarily using balloon catheters (Fogarty) inserted via an arteriotomy to remove clots and restore flow, with success confirmed by back bleeding, thrill, or intraoperative angiography/fluoroscopy. Endarterectomy involves carefully removing plaque from the inner artery wall, common in carotids and femorals, with various techniques like open, semi-closed, or eversion approaches, requiring tacking sutures for smooth endpoints. Arteriotomies are closed primarily or with a patch to prevent narrowing, using continuous or interrupted non-absorbable sutures, always passing the needle from inside to outside the vessel wall. Patching is often preferred, especially in smaller or diseased arteries, using materials like vein or PTFE. Anastomosis techniques to join vessels include end-to-end or end-to-side connections, crucial for bypasses and segment replacements, with specific approaches like anchor or parachute techniques used depending on location and vessel size. Side-to-side anastomosis is less common but used for AV fistulas. Adjunctive techniques like vein patches or distal AV fistulas can improve outcomes in challenging infranginal bypasses. Open surgery demands deep knowledge, precision, and meticulous technique.