On an open repair of a ruptured abdominal aortic aneurysm (AAA) the main issue is the proximal control. How will the surgeon clamp quickly and effectively the abdominal aorta inside the hematoma?
First things first. Where am I standing? Despite been a right-handed, I prefer being on the left side of the patient. This has many benefits. First, I am away from the bowels which are on the patient’s right side; thus, I do not have to keep my left hand on them. Second I can handle the aortic clamp with my right hand which is an advantage on the proximal aortic control. Finally, as I work in a teaching hospital, I give my assistant (who is almost always a junior) the chance to do a part of the procedure.
The first thing I almost always do is to try to get a proximal control on a supraceliac level. The first assistant pulls the stomach downwards while I cut sharply the lesser omentum with a pair of long scissors. Then I put my left-hand index finger inside the lesser sac until I feel the pulsating aorta. I try to dissect around it bluntly with my index finger and finally I pass my index and middle finger on each side of the aorta. If I cannot do this with my fingers, I use the scissors to cut all tissues anterior to the aorta; usually, the only important issue I encounter with is the crus of the diaphragm, which I have no hesitation to cut. Then, I grasp a long aortic clamp and clamp the aorta, without seeing anything; just by feeling the jaws of the clamps touching my two fingers. When the jaws feel the backbone, I slowly close them and check the patient blood pressure. If the pressure starts to rise that’s it: the aorta is clamped! If not, I try again.
With this maneuver, the bleeding may temporarily decrease with the drawback of splanchnic ischemia. That means that there is not much time available. If the aneurysm is a juxtarenal, the procedure must be continued and get finished with proximal control at this level the soonest possible. On the commonest scenario of infrarenal AAA the proximal clamp must be repositioned on an infrarenal level. How will I do that? I follow a simple maneuever. To find out, read a bit more.
As said before, I stand on the patient’s left-hand side. After I have clamped the aorta on a supraceliac level, I raise the mesocolon by grasping the transverse colon with a swab. I give the transverse colon to an assistant on my right side to hold it. Then, I push quickly the small intestine on the patient’s right side and let my assistant hold it (either with his hands or using one or two large swabs). Finally, I put a large swab to push the sigmoid colon on the patient’s left. Here I am. Me and the big retroperitoneal hematoma… What’s next?
I push my left-hand index finger into the sac, actually I make a hole in the aneurysm sac with my fingers. Then I put my index finger, or index and middle finger or sometimes my whole palm (if the aneurysm is big enough to accomodate it) inside the aneurysm, and try to find the proximal neck with my index finger. It normally takes less than one minute overall. When I find the proximal neck, it feels like a nice hole, I push the index finger in. Then, with my right hand, I try to locate the left-hand index finger from within the hematoma. I make some space around it, and then get an aortic clamp (usually a short one) and put it on the space I have created across my left-hand index finger (which is inside the aortic neck). In fact, this way I have my clamp across the proximal neck. Then, I slowly close the jaws of the clamp until I feel them squeezing my left-hand index finger. I gradually withdraw my finger, keeping closing the aortic clamp. When the index finger is totally out, the aortic clamp has clamped the aorta at an infrarenal level. At this stage, the supraceliac clamp is released, and the blood supply on the viscera is restored.
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Want to know how to clamp the iliacs in this setup? Check it out in this post.