Repair of an infrarenal abdominal aortic aneurysm

PREOPERATIVE DIAGNOSES:

1.  A 10 cm symptomatic infrarenal abdominal aortic aneurysm.

2.  Acute renal failure.

POSTOPERATIVE DIAGNOSES:

1.  A 10 cm symptomatic infrarenal abdominal aortic aneurysm.

2.  Acute renal failure.

OPERATION PERFORMED:                    Repair of an infrarenal abdominal aortic aneurysm with bifurcated aorta by Dacron graft. Also, insertion of a right femoral Quinton catheter.

SURGEON:                                                  Mohammed Abdallah, DO

ANESTHESIA:                                             General with endotracheal Intubation.

FINDINGS:                                                    A very large infrarenal abdominal aortic aneurysm extending almost up to the xiphoid involving the bifurcation.  Excellent flow through the Quinton catheter.  There were no complications.  Blood loss was about 600 cc.

PROCEDURE IN DETAIL:                        The patient is an 80-year-old gentleman who came in with abdominal pain and back pain.  The patient has not seen a physician in 30 years.  He was found to have a 10 cm infrarenal abdominal aortic aneurysm and urinary retention with acute renal failure.  The patient was taken to the operating room for repair of the aneurysm.  Risks and benefits were discussed with the patient and the family.

The patient was placed on the OR table in supine position.  General anesthetic was administered.  He was endotracheally intubated.  An NG tube was placed.  An A-line was placed.  The abdomen was prepped and draped in the usual sterile manner.  A midline incision was performed from the xiphoid to the suprapubic area.  Electrocautery was utilized to control the hemostastis and to further dissect the subcutaneous tissue and decussation to the fascia entering the abdominal cavity.  At this point, the bowel was rotated laterally to the right, and the retroperitoneum was exposed.  Sharp and blunt dissection was carried out at the isolated neck of the aneurysm, which was up near the xiphoid.  A vascular clamp was placed around the aorta at this point proximally and distally. The iliacs were dissected out and vascular clamps were placed around them.  The patient was given 5000 units of heparin and then, the iliacs were occluded, followed by occluding the aorta proximally.  The aneurysm was entered.  It was found that there was continuous bleeding from the left iliac.  Therefore, I decided to place a 14-French Foley catheter into the lumen, and the balloon was insufflated and a clamp was placed over the Foley catheter therefore occluding the lumen.  There was effective hemostasis at this point.  A 20-mm bifurcated graft was used to repair the aneurysm in an aorta-biiliac fashion.  The proximal anastomotic site was freshened up on the aorta, and an end-to-end anastomosis was created with a running 3-0 Prolene suture.  Then, the left iliac limb was dissected out, transected, and tailored to the graft.  An end-to-end anastomosis was created with a running 4-0 Prolene suture.  At this point, I opened up the left iliac limb.  The right iliac limb was dissected out and likewise the edges were freshened up and then, the graft was tailored to the ostium, and an end-to-end anastomosis was created with a running 4-0 Prolene suture.  Prior to completing the anastomosis, backbleeding was performed.  Once the anastomosis was completed, all laps and clamps were removed.  There was excellent hemostasis at the anastomotic sites.  The retroperitoneum was irrigated with antibiotic saline solution.  The aortic wall was reapproximated over the graft, specifically covering the proximal anastomosis and distal anastomosis.  This was done with a running 0 Vicryl suture.  Once this was done, again the retroperitoneum was irrigated with antibiotic saline solution.  The abdomen was then irrigated.  The fascial edges were then brought together from either end of the incision with running #1 PDS double-looped suture.  The skin was closed with staples and this terminated this part of the procedure.  At this time, the right groin was exposed and prepped and draped in the usual sterile manner.  The femoral vein was cannulated with an 18-gauge needle, the guidewire was sent through the needle without any difficulty.  A dilator was passed over the guidewire and dilated the tract and then removed.  The catheter was then threaded over the guidewire, and the guidewire was removed.  The catheter was secured to the skin with interrupted 3-0 Nylon stitch.  Both ports were aspirated and flushed without any difficulty and then kept with 2000 units of heparin and 2 cc in each port.  Sterile dressings were applied.  This terminated the procedure.  No complication.