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Vascular and Intestinal Anastomotic Workshop

Vascular and Intestinal Anastomotic Workshop. PGY 1. Name the Instruments. PGY 1. Name the Instruments. PGY 1. Name the Instruments. PGY 1. Commonly used Sutures. PGY 2. Lembert Sutures. Definition? Reason?. PGY 2. Connell Sutures. Describe Connell suturing technique. Staplers.

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Vascular and Intestinal Anastomotic Workshop

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  1. Vascular and Intestinal Anastomotic Workshop

  2. PGY 1 Name the Instruments

  3. PGY 1 Name the Instruments

  4. PGY 1 Name the Instruments

  5. PGY 1 Commonly used Sutures

  6. PGY 2 Lembert Sutures • Definition? • Reason?

  7. PGY 2 Connell Sutures • Describe Connell suturing technique

  8. Staplers

  9. PGY 2 Name the Stapler

  10. PGY 2 Name the Stapler…

  11. PGY 2 Name the Stapler

  12. PGY 2 Side to side anastomosis • How do you set up a side to side anastomosis? • CRITICAL CONCEPTS • Non-tension • GIA stapler • Align anti-mesenteric sides of bowel together • Staggered staple lines

  13. PGY 2 End-to-end Anastomosis • How do you set up a stapled end-to-end anastomosis?

  14. PGY 2 Functional End-to-end anastomosis • Describe another way to perform a stapled end to end anastoamosis

  15. PGY 3 Stapler Loads • What is the difference between the different stapler loads? • What color load do you use for vascular tissue? Stomach? Small bowel? Colon? Rectum?

  16. PGY 3 Hand Sewn Anastomosis • Describe the different types of suture techniques used in hand sewn bowel anastomosis

  17. PGY 3 Hand Sewn Anastomosis • Describe the steps for a 2 layer anastomosis

  18. PGY 3 Hand Sewn Anastomosis • Describe how to sew a single layer anastamosis

  19. PGY 2 Arm Vascular Anatomy • Describe the arterial and venous blood flow to the arm

  20. PGY 2 Types of Surgical Dialysis Access • What is the difference between an AV Fistulae and an AV Graft

  21. Sites for AV fistulae

  22. Radiocephalic AV Fistula

  23. Brachiocephalic AV graft

  24. Basilic Vein Transposition

  25. DRIL procedure • DRIL = Distal Revascularization Interval Ligation • RUDI = Revision Using Distal Inflow

  26. PGY 3 Vascular Anastomosis • Identify autogenous materials for vascular anastomosis: • Saphenous vein, iliac vein • Identify exogenous materials for vascular anastomosis: • bovine pericardium, ePTFE, gore-tex, cadaveric • What is the dosing/timing for heparinization during a vascular anastomosis? • 75-100 units/kg, given 5 minutes prior to vascular occlusion • How do you measure heparinization to confirm appropriate levels have been achieved? • Activated clotting time (ACT) of greater than 250

  27. PGY 3 Zones of Retroperitoneum • Describe the Zones of the retroperitoneum and the major vasculature that could be injured in each zone • Zone 1: Midline retroperitoneum • Supramesocolic region (suprarenal aorta, celiac, SMA/SMV, proximal renal artery) • Inframesocolic region (infrarenal aorta, infrarenal IVC) • Zone 2: Upper lateral retroperitoneum (renal artery/vein) • Zone 3: Pelvic retroperitoneum (iliac artery/vein)

  28. PGY 3 Zone I Great Vessel Injury • Describe the approach for supramesocolic Zone I injuries: • Left medial visceral mobilization • May also need to transect the left crus (at 2o’clock position) to allow for control of the descending thoracic aorta

  29. PGY 3 Zone I Great Vessel Injury • Describe the approach for inframesocolic Zone I injuries: • Lift up on transverse mesocolon, eviscerate small bowel to right, open mid-line retroperitoneumand cross clamp the aorta inferior to the left renal vein • For IVC injuries, perform a right medial visceral mobilization (right colon and duodenum), leaving the kidney in situ

  30. PGY 3 Zone I Great Vessel Injury • Describe the approach to an inframesocolic Zone I injury to the IVC at the common iliac vein confluence: • After right medial visceral mobilization, it may be necessary to divide and ligate the right internal iliac artery or to temporarily divide the right common iliac artery

  31. PGY 3 Zone I Great Vessel Injury • Describe the approach to an inframesocolic Zone I injury to the IVC at the level of the renal veins: • After right medial visceral mobilization, you should clamp/compress the IVC proximally and distally and loop/clamp both the left and right renal veins. It may be necessary to perform a medial mobilization of the right kidney (watch out for 1st lumbar vein!)

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