Operative management of aortic aneurysmal disease

The following are “Know” from the syllabus

• Exposure of aorta and Common iliac arteries

• Repair of AAA

• Clamp neck of AAA

• Surgical exposure

  • Midline laparotomy from xiphisternum to pubis
    • Enter peritoneum and pack away small bowel to the right
    • May need a Left medial visceral rotation for exposure
    • Open overlying peritoneum and identify the aneurysm
    • Skeletonise the infrarenal aorta by dividing the overlying peritoneum
    • Identify the left renal vein which is retracted up with a vein retractor (it can be divided if need if the gonadal and adrenal veins are patent)
    • Identify and ligate the IMA
      • Usually small and sclerotic
      • If large and no back bleeding means it may b sole supply to colon and will need to be reimplanted
    • Clear peritoneum overlying common iliac arteries
      • Do not need to clear posterior border as this ma damage the veins

• Proximal and distal control

  • Systemic heparinisation (typically 5000 units IV)
  • Apply vascular clamps:
    • Aortic infrarenal clamp
    • Distal control via clamping of both distal common iliac
    • Assess for adequate control and minimal back-bleeding

• Opening the aneurysm

  • Make a longitudinal incision in the anterior aneurysm wall
  • Evacuate thrombus and debris
  • Identify and ligate bleeding lumbar arteries from within the sac using transfixion sutures (non-absorbable)

• Anastomosis

  • Proximal anastomosis:
    • Trim aortic neck if needed to healthy wall
    • Suture graft to aortic wall using continuous 3-0 or 4-0 polypropylene double armed suture
    • Begin with intial stitch by passing both needles from outside to inside on the graft and from inside to outside on the aorta.
      • This stitch is the tied
    • Over and over suturing is then continue from the midline with outside to inside on the graft and inside to outside on the aorta
    • Check proximal anastamosis by clamping distal graft and briefly opening proximal clamp
  • Distal anastomoses:
    • To the common or external iliac arteries
    • Ensure limbs are of adequate length and orientation to avoid kinking
    • Same as above
    • Once the first iliac anastamosis is performed, remove the clamp and occlude with a finger and then slowly release to decrease risk of hypotension.
    • Then do the other side

• Closure of aneurysm sac and abdominal wall

  • Once haemostasis is confirmed and anastomoses are secure, close the aneurysm sac over the graft using absorbable sutures
    • This protects the graft from contact with bowel and reduces risk of aorto-enteric fistula
  • Place drain if there is any concern about bleeding
  • Close abdominal wall in layers; ensure hemostasis and warmed patient

• Postoperative care and monitoring

  • ICU or HDU monitoring for first 24–48 hours
  • Monitor for complications:
    • Bleeding, renal dysfunction (check urine output, creatinine)
    • Bowel ischaemia (lactate, abdominal pain, haematochezia)
    • Lower limb ischaemia (pulses, compartment pressures)
    • Graft thrombosis or infection
  • Continue prophylactic antibiotics and anticoagulation as indicated