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Basic Surgical Technique Vein patch скачать в хорошем качестве

Basic Surgical Technique Vein patch 12 лет назад

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Basic Surgical Technique Vein patch

In this demonstration, a graft will be sutured on to an elliptical opening in a section of porcine aorta. A primary closure of this ellipse would result in significant narrowing of the diameter of the vessel. A synthetic patch will therefore be used to close the opening. In this example we are assuming the blood would be flowing from right to left. In order to avoid damaging the intima of the vessel, there are a number of ways to handle the tissues with the forceps. The first technique involves grasping the adventitia of the vessel to stabilise the tissues for suturing. Next, the forceps are inserted into the vessel and use the spring in the instrument to hold the tissues apart. Finally, one limb of the forceps may be gently inserted to retract one edge of the vessel. However, the full thickness of the vessel wall must not be grasped with the forceps as this will fracture the intima, particularly in vessels that are calcified. Double ended 4/0 prolene, a monofilament suture, will be used to fix the graft into the opening. One needle is held in a reverse grip in the needle holder and is first inserted into the shaped end of the graft. The suture is pulled through the graft as shown and then the other needle is passed through the graft at a point a few mm away from the first bite. The first needle is then driven through the apex of the opening, from inside to out. It is important to pass sutures in this direction to fix the intima to the graft and vessel wall and avoid turbulent flow once the graft is in place. The second needle is then passed through the vessel wall, from inside to out, at a point just lateral to the first bite. As the sutures are tightened, the graft can be placed at the apex of the opening where it will start bedding in to the wound. The long ends of the suture are tied with a two handed knot at a distance from the tissues and then slid down onto the vessel. One long thread is then held in a rubber shod haemostat as a regular instrument could damage the suture material. With the assistant taking up the slack in the other thread, and the needle held in a reverse fashion, further bites are placed through the graft and vessel wall. The needle is again passed from inside to out and the distance between bites is roughly 3mm. Once a few sutures are in place, a small ridge will form between graft and vessel wall. It is then possible to place sutures through and through, pulling the thread down along the line of the vessel to bring up the tension and then handing it to the assistant. As the distal end of the opening is approached, the size of the graft should be checked and adjusted as shown. This should always be done as the graft is sutured in place and not at the start of the procedure. At the apex of the opening, the needle grip should change from a back hand to a forehand hold. Once the distal end of the opening has been sutured, the thread is held in the rubber shod haemostat. The second needle is then used to fix the remainder of the graft in place. with the grip in a forehand position. Before the final bite is placed, the small opening is inspected for back bleeding from the distal end of the vessel. Any thrombus that has formed is expelled from the proximal end and heparinised saline is flushed through the distal end. The vessel is then re-clamped as the final bite is placed through graft and vessel wall. A hand tied knot is created with the two ends of suture, using 6 or 7 throws for monofilament

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