SECTION 1.00 WORK UP
1.01 FOR AN ELECTIVE PATIENT
1.02 FOR AN URGENT PATIENT
1.03 FOR A RAPIDLY DETERIORATING PATIENT
SECTION 2.00 PRELIMINARIES
2.01 IN THE ANAESTHETIC ROOM
2.02 CHECK THE PERIPHERAL PULSES
2.03 CHECK THE RELATIVES HAVE BEEN WARNED
2.04 CHECK THAT BLOOD HAS BEEN ORDERED
2.05 CHECK THE PATIENT HAS BEEN SHAVED
2.06 CHECK THE PATIENT HAS A BLADDER CATHETER
2.07 CHECK THE GRAFTS
2.08 CHECK THE MATERIAL OF THE GRAFTS
2.09 CHECK THE SUTURE FOR THE ANASTOMOSIS
2.10 CHECK THE AORTIC CLAMP
2.11 CHECK THE HEPARIN SOLUTION
2.12 CHECK DIATHERMY PAD
2.13 ANAESTHESIA
2.14 CHECK THE SURGICAL TEAM
SECTION 3.00 OPENING THE ABDOMEN
3.01 POSITION - SUPINE
3 3.02 STANCE
3.03 CLEAN THE SKIN
3.04 TOWEL UP
3.05 APPLY ADHESIVE DRAPES
3.06 CHECK THE DIATHERMY IS WORKING
3.07 CHECK THE SUCKER IS WORKING
3.08 CHECK THERE IS A STERILE BOWL
3.09 CHECK THE ANAESTHETIST IS READY FOR YOU TO INCISE THE SKIN
3.10 CHOOSE THE INCISION SITE
3.11 INCISE THE SKIN
3.12 DEEPEN THE INCISION
3.13 OBTAIN HAEMOSTASIS
3.14 OPEN THE PERITONEUM
3.15 TELL THE ANAESTHETIST IF THERE IS FREE PERITONEAL BLOOD
3.16 OPEN THE WHOLE OF THE INCISION
3.17 CHECK THE WOUND EDGES ARE FREE FROM ADHESIONS
3.18 APPLY SKIN TOWELS
3.19 RETRACT THE WOUND EDGES
3.20 SCOOP OUT ANY INTRAPERITONEAL BLOOD
SECTION 4.00 EXPLORING THE ABDOMINAL CAVITY
4.01 EXAMINE THE INTRA-ABDOMINAL CONTENTS
4.02 LOOK FOR AN ANEURYSM
4.03 LOOK FOR A RETROPERITONEAL HAEMATOMA
4.04 LOOK FOR ISCHAEMIC DAMAGE TO THE BOWEL
4.05 LOOK FOR OTHER ANEURYSMS
4.06 LOOK FOR OTHER PATHOLOGY IN THE ABDOMEN AND PELVIS
4.07 FOR AN INFLAMMATORY ANEURYSM
4.08 FOR A DEFINITE QUIESCENT ANEURYSM
SECTION 5.00 CONTROLLING THE UPPER END OF THE ANEURYSM
5.01 FOR A LEAKING ANEURYSM
5.02 ASSESSING THE ANEURYSM
5.03 PALPATE THE AORTA ABOVE THE UPPER END OF THE ANEURYSM
5.04 PALPATE THE AORTA ABOVE THE TRANSVERSE COLON
5.05 OBTAIN ACCESS TO THE UPPER END OF THE ANEURYSM
5.06 RETRACT THE TRANSVERSE COLON UPWARDS
5.07 MOBILISE THE DUODENUM
5.08 RETRACT THE DUODENUM UPWARDS
5.09 MOBILISE THE LEFT RENAL VEIN
5.10 DIVIDE THE LEFT RENAL VEIN
5.11 DISSECT THE SUPRA ANEURYSMAL AORTA
5.12 LIGATE THE LEFT RENAL VEIN
5.13 DISSECT OUT THE SUPRA ANEURYSMAL AORTA
5.14 CLAMP THE AORTA
5.15 CHECK THE CLOTTING STATUS OF THE BLOOD
SECTION 6.00 CONTROLLING THE LOWER END OF THE ANEURYSM
6.01 INCISE THE PERITONEUM OVER THE ANEURYSM
6.02 DIVIDE THE INFERIOR MESENTERIC ARTERY
6.03 DISSECT OUT THE COMMON ILIAC ARTERIES
6.04 CLAMP THE LEFT COMMON ILIAC ARTERY
6.05 LOCALLY ANTI-COAGULATE THE DISTAL LEFT ILIAC ARTERY
6.06 CLAMP THE RIGHT COMMON ILIAC ARTERY
6.07 LOCALLY ANTI-COAGULATE THE DISTAL RIGHT ILIAC ARTERY
SECTION 7.00 OPENING THE ANEURYSM
7.01 DISPLAY THE ANTERIOR SURFACE OF THE ANEURYSM
7.02 LOOK FOR THE INFERIOR MESENTERIC ARTERY
7.03 LET THE ANAESTHETIST CATCH UP WITH BLOOD LOSS
7.04 CHECKS BEFORE OPENING THE ANEURYSM
7.05 OPEN THE ANEURYSM
7.06 REMOVE THE ANEURYSM CONTENTS
7.07 INSERT A RETRACTOR INTO THE ANEURYSM
7.08 ANTICOAGULATE THE ILIAC ARTERIES AGAIN
7.09 CONTROLLING THE LUMBAR ARTERIES
7.10 UNDERRUN THE LUMBAR ARTERIES
SECTION 8.00 CHECKING THE ILIAC ARTERIES
8.01 CHECK THE ILIAC ARTERIES ARE PATENT
8.02 PASSING A FOGARTY CATHETER
8.03 CHECK THE FOGARTY CATHETER
SECTION 9.00 CHOOSING A STRAIGHT OR TROUSER GRAFT
9.01 CONSIDER A STRAIGHT OR TROUSER GRAFT
SECTION 10.00 USING A STRAIGHT GRAFT
10.01 CHECK THE STRAIGHT GRAFT
10.02 CUT A LENGTH OF STRAIGHT GRAFT
SECTION 11.00 UPPER ANASTOMOSIS
11.01 START THE UPPER ANASTOMOSIS
11.02 CHECK THE HAEMOSTASIS
11.03 TRIM THE UPPER END OF THE OPENING IN THE ANEURYSM
11.04 CHECK THE INSIDE OF THE AORTA AT THE LEVEL OF THE ANASTOMOSIS
11.05 SELECTING A SUTURE
11.06 HINTS ABOUT SUTURING
11.07 HINTS ABOUT TYING KNOTS
11.08 HINTS ABOUT TIGHTENING THE SUTURE
11.09 HINTS ABOUT FOLLOWING
11.10 MAKING THE POSTERIOR HALF OF THE ANASTOMOSIS
11.11 HOLD THE GRAFT VERTICALLY
11.12 STARTING THE POSTERIOR HALF OF THE ANASTOMOSIS
11.13 INSERT THE RIGHT SIDE STITCH
11.14 TIE THE RIGHT SIDE STITCH
11.15 INSERT THE LEFT SIDE STITCH
11.16 TIE THE LEFT SIDE STITCH
11.17 RETURN TO THE RIGHT SIDE OF THE ANASTOMOSIS
11.18 INSERT THE NEXT STITCH
11.19 CONTINUE INSERTING THE STITCHES INTO THE POSTERIOR HALF OF THE ANASTOMOSIS
11.20 START THE ANTERIOR HALF OF THE ANASTOMOSIS
11.21 LAY THE GRAFT IN THE ANEURYSM
11.22 BEGIN ON THE RIGHT HAND SIDE OF THE ANASTOMOSIS
11.23 INSERT THE FIRST STITCH
11.24 CONTINUE THE ANTERIOR HALF OF THE ANASTOMOSIS
11.25 TIE OFF THE SUTURES
11.26 TEST THE UPPER ANASTOMOSIS
11.27 CLAMP THE GRAFT
11.28 PART- OPEN THE CLAMP ON THE AORTA
11.29 REAPPLY THE AORTIC CLAMP
11.30 REMOVE THE GRAFT CLAMP
11.31 SUCK OUT BLOOD CLOT AND DEBRIS FROM INSIDE THE AORTA
11.32 FLUSH THE GRAFT
SECTION 12.00 LOWER ANASTOMOSIS
12.01 STARTING THE LOWER ANASTOMOSIS
12.02 ADJUST THE TRAVERS SELF-RETAINING RETRACTOR
12.03 SUCK OUT ANY BLOOD FROM THE ANEURYSM
12.04 CHECK THE ILIAC ARTERY HAEMOSTASIS
12.05 CHECK THE LUMBAR ARTERY HAEMOSTASIS
12.06 CHECK THE INFERIOR MESENTERIC ARTERY HAEMOSTASIS
12.07 CHECK THE ILIAC ARTERIES AGAIN
12.08 CHECK THE AORTIC BIFURCATION
12.09 TRIM THE LOWER END OF THE OPENING INTO THE ANEURYSM
12.10 REMOVE ANY ATHEROMATOUS PLAQUES FROM THE BIFURCATION
12.11 LAY THE GRAFT IN THE ANEURYSM SAC
12.12 PULL THE GRAFT DISTALLY
12.13 CUT THE GRAFT
12.14 CHECK THE LENGTH OF THE GRAFT
12.15 INSERT THE FIRST STITCH OF THE LOWER ANASTOMOSIS
12.16 INSERT THE SECOND STITCH OF THE LOWER ANASTOMOSIS
12.17 START THE POSTERIOR HALF OF THE LOWER ANASTOMOSIS
12.18 CONTINUE THE POSTERIOR HALF OF THE LOWER ANASTOMOSIS
12.19 TIE THE POSTERIOR SUTURE
12.20 CLEAN OUT THE GRAFT
12.21 FLUSH THE GRAFT WITH HEPARIN SALINE
12.22 START THE ANTERIOR HALF OF THE LOWER ANASTOMOSIS
12.23 INSERT A LOCK STITCH
12.24 INSERT TWO MORE STITCHES
12.25 WARN THE ANAESTHETIST YOU WILL BE RELEASING THE ILIAC CLAMPS IN A MINUTE OR TWO
12.26 PREPARE TO CLEAR THE GRAFT OF DEBRIS
12.27 REMOVE ANY SLOOPS FROM ABNORMAL ILIAC ARTERIES
12.28 PART RELEASE THE LEFT ILIAC ARTERY CLAMP
12.29 FLUSH HEPARIN SALINE DOWN THE LEFT ILIAC ARTERY
12.30 CLAMP OFF THE LEFT ILIAC ARTERY
12.31. CLEAN OUT THE GRAFT
12.32 FLUSH OUT THE GRAFT WITH HEPARIN SALINE
12.33 PARTLY OPEN THE RIGHT ILIAC CLAMP
12.34 TIE OFF THE 2 SUTURES ON THE ANASTOMOTIC VENT
12.35 CHECK THE LOWER ANASTOMOSIS FOR BLEEDING
12.36 PART OPEN THE AORTIC CLAMP
12.37 ASSESS THE AMOUNT AND SITE(S) OF BLEEDING
12.38 DEAL WITH ANY SERIOUS BLEEDING FROM THE UPPER ANASTOMOSIS
12.39 OPEN THE AORTIC CLAMP FULLY
12.40 PART RELEASE THE GRAFT CLAMP
12.41 CONTROL LEAKAGE FROM THE LOWER ANASTOMOSIS
12.42 CHECK THE ILIAC ARTERY PULSES
12.43 CHECK THE FEMORAL PULSES AGAIN
SECTION 13.00 HAEMOSTASIS
13.01 CHECK HAEMOSTASIS
13.02 INSERT A DRAIN
SECTION 14.00 CLOSING THE ABDOMEN
14.01 REMOVE THE ANEURYSM RETRACTOR
14.02 CLOSE THE ANEURYSM SAC
14.03 REMOVE THE ABDOMINAL PACKS
14.04 CHECK FOR HAEMOSTASIS
14.05 SUCK OUT ANY INTRAPERITONEAL BLOOD
14.06 WASH OUT THE PERITONEAL CAVITY
14.07 CHECK FOR ISCHAEMIC DAMAGE TO THE BOWEL
14.08 CHECK THE SWAB, NEEDLE AND INSTRUMENT COUNT
14.09 PLACE FORCEPS ON THE EDGE OF THE LINEA ALBA
14.10 CLOSE THE PERITONEUM AND LINEA ALBA
14.11 CLOSE THE SUBCUTANEOUS FAT
14.12 CLOSE THE SKIN
14.13 CHECK THE FEMORAL PULSES AGAIN
14.14 CHECK THE FOOT COLOUR AND PULSES
SECTION 15.00 FEMORAL EMBOLECTOMY
15.01 CLEAR THE GROIN AREA
15.02 INCISE THE SKIN
15.03 DEEPEN THE INCISION
15.04 INSERT A SELF RETAINING RETRACTOR
15.05 PALPATE THE FEMORAL ARTERY
15.06 DEAL WITH OTHER STRUCTURES IF IN THE WAY
15.07 EXPOSE THE THREE FEMORAL ARTERIES
15.08 DISSECT OUT THE ARTERIES
15.09 CONTROL MINOR BRANCHES
15.10 PASS SLOOPS AROUND EACH FEMORAL ARTERY
15.11 CLAMPING AND ANTICOAGULATING EACH FEMORAL ARTERY
15.12 START BY CLAMPING THE SUPERFICIAL FEMORAL ARTERY
15.13 ANTICOAGULATE THE SUPERFICIAL FEMORAL ARTERY
15.14 CLAMP THE DEEP FEMORAL ARTERY 15.15 ANTICOAGULATE THE DEEP FEMORAL ARTERY
15.16 CLAMP THE COMMON FEMORAL ARTERY
15.17 ANTICOAGULATE THE COMMON FEMORAL ARTERY
15.18 CHECK THE FOGARTY CATHETER
15.19 MAKE THE ARTERIOTOMY
15.20 ASPIRATE BLOOD CLOT AND BLOOD
15.21 CHECK HAEMOSTASIS
15.22 PASSING THE FOGARTY CATHETER
15.23 PART OPEN THE CLAMP ON THE SUPERFICIAL FEMORAL ARTERY
15.24 PASS THE FOGARTY CATHETER DOWN THE SUPERFICIAL ARTERY
15.25 EMBOLECTOMISING THE DEEP FEMORAL ARTERY
15.26 EMBOLECTOMISING THE COMMON FEMORAL ARTERY
15.27 CLOSING THE FEMORAL ARTERIOTOMY
15.28 OPEN THE SUPERFICIAL FEMORAL ARTERY CLAMP
15.29 OPEN THE DEEP FEMORAL CLAMP
15.30 PART OPEN THE COMMON FEMORAL CLAMP
15.31 CHECK HAEMOSTASIS IN THE REST OF THE WOUND
15.32 INSERT A FEMORAL DRAIN
15.33 CLOSE THE SUBCUTANEOUS FAT
15.34 CLOSE THE SKIN
15.35 CHECK THE FEMORAL PULSE AGAIN
15.36 PERFORM THE FEMORAL EMBOLECTOMY ON THE OTHER SIDE
15.37 CHECK THE PULSES AND THE PERFUSION OF THE LOWER LIMBS
SECTION 16.00 TROUSER GRAFT
16.01 CHOOSING A TROUSER GRAFT
16.02 CHECK THE TROUSER GRAFT
16.03 CUT THE TOP OF THE TROUSER GRAFT
16.04 MAKE THE UPPER ANASTOMSIS
16.05 RELEASE THE GRAFT CLAMP
16.06 FLUSH THE GRAFT
16.07 CLOSE THE ILIAC VESSELS
16.08 CLAMP THE RIGHT LEG OF THE GRAFT
16.09 EXPOSE AND CONTROL THE FEMORAL VESSELS
16.10 MAKE LEFT VASCULAR TUNNEL
16.11 PASS A ROBERT'S FORCEP UP THE TUNNEL
16.12 GRASP THE LEFT LEG OF THE GRAFT
16.13 MAKE RIGHT VASCULAR TUNNEL
16.14 PASS A ROBERT'S FORCEP UP THE TUNNEL
16.15 GRASP THE RIGHT LEG OF THE GRAFT
16.16 MAKING LEFT FEMORAL ANASTOMOSIS
16.17 CHOOSE THE SITE TO CUT THE LEFT LEG OF THE GRAFT
16.18 START THE LEFT FEMORAL ANASTOMOSIS
16.19 STITCH THE MEDIAL SIDE OF THE LEFT FEMORAL ANASTOMOSIS
16.20 STITCH THE TOE OF THE LEFT FEMORAL ANASTOMOSIS
16.21 STITCH THE HEEL OF THE LEFT FEMORAL GRAFT
16.22 CUT OFF THE TWO NEEDLES
16.23 OPEN THE LEFT SUPERFICIAL FEMORAL ARTERY CLAMP
16.24 TIE THE ANASTOMOTIC SUTURE
16.25 OPEN THE DEEP FEMORAL CLAMP
16.26 OPEN THE COMMON FEMORAL CLAMP
16.27 OPEN THE AORTIC CLAMP
16.28 MAKE RIGHT FEMORAL ANASTOMOSIS
16.29 OPEN THE CLAMP ON THE RIGHT LEG OF THE GRAFT
16.30 CHECK FOR FLOW AND HAEMOSTASIS ON THE RIGHT
16.31 TIE OFF ONE ILIAC ARTERY
16.32 CHECK HAEMOSTASIS
16.33 CLOSE THE LEFT FEMORAL WOUND
16.34 CLOSE THE RIGHT FEMORAL WOUND
16.35 CLOSE THE ABDOMEN
16.36 CHECK PULSES AND PERFUSION OF THE LOWER LIMBS
16.37 END
SECTION 17.00 EQUIPMENT AND MATERIALS