PREOPERATIVE DIAGNOSIS:
5.5 cm abdominal aortic aneurysm.
POSTOPERATIVE DIAGNOSIS:
5.5 cm abdominal aortic aneurysm.
PROCEDURE PERFORMED:
Open abdominal aortic aneurysm repair with an 8 mm Dacron tube graft.
COMPLICATIONS:
There were no complications during the procedure.
ANESTHESIA:
The patient under general anesthesia with
SPECIMEN:
No specimen sent to pathology.
DRAINS:
No drains left in place.
BRIEF STATEMENT OF MEDICAL NECESSITY:
This is a 70-year-old male with an abdominal aortic aneurysm that has grown to approximately 5.5 cm. The patient has a very short infrarenal neck and is therefore not a candidate for an endograft. He was counseled on risks and benefits of undergoing open abdominal aortic aneurysm repair and agreed.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room after undergoing general anesthesia, appropriate lines and catheters and tubes were placed. Foley catheter was placed. The abdomen was prepped and draped in normal sterile manner. I began by making a midline incision and this was carried down through subcutaneous tissue, identified the fascia and carefully opened this in a longitudinal manner. Identified the peritoneum and then sharply opened this after elevating it with a hemostat clamp. I then extended the peritoneal incision proximally and distally. I then identified the small bowel and eviscerated this to the right and identified the duodenum, which was adherent to the aneurysm, and carefully mobilized the duodenum up to the level of the ligament of Treitz and mobilized this laterally to the right. Once this was done, I then carefully continued our dissection superiorly on top of the aneurysm down to the aorta, which was normal. We carefully mobilized the renal vein, so that we could retract this out of the way. We then placed an Omni_____ retractor and carefully placed and some self-retaining retractors in abdominal wall and to elevate the transverse colon superiorly. We were able to dissect out carefully using blunt dissection and Bovie electrocautery, dissected out the bilateral renal arteries. The patient had an accessory right renal artery that was feeding the inferior right pole of the kidney. This was actually ligated as it came off anteriorly and would be in the way of the clamp. We carefully obtained loop control around the aorta just inferior to the renal arteries and then obtained control just above the renal arteries as well and obtained on the renal arteries. Once this was done, I then carefully dissected out the inferior mesenteric artery as it came off the normal aorta just distal to the aneurysm, obtained loop control here and then carefully dissected around the distal aorta as this was normal and would tolerate a tube graft. At this point, gave 5000 units of heparin and then allowed this to circulate. We then clamped the distal aorta using a Crayford clamp; then placed a Satinsky clamp around the infrarenal aorta and pushed this clamp up to just below the renal arteries. After notifying anesthesia, we went ahead and clamped and then opened the aneurysm sac using Bovie electrocautery and eviscerated all the sac contents out. There were several brisk bleeding lumbar arteries, which were oversewn using #0 silk with figure-of-eight and figure-of-sixteen sutures. Once this was done, we obtained hemostasis, placed Weitlaner retractor into the aneurysm sac and carefully teed off the sacs to expose the proximal aortic ring. The ring was very close to our proximal clamp was located. Therefore, we went ahead and placed another Crayford clamp across the aorta just proximal to the renal arteries. This was then clamped and the distal clamp below the renal arteries was removed. At this point, I brought the 18 mm Dacron graft onto the field using 3-0 Prolene on an SH needle, performed a running anastomosis sewing the posterior wall first, then sewed the anterior wall. Prior to completing this, we then flushed with heparinized saline into the graft. There was no evidence of leak, very carefully came off of the proximal clamp restoring flow to the renal arteries and flushed out the graft and then replaced the clamp in the proximal graft. Flow was then restored to the renal arteries. Ischemic time was approximately 20 minutes here. At this point, then teed off the aortic aneurysm distally in order to identify the distal ring. The inferior mesenteric artery was coming off just inferior to this and we elected to go ahead and try to sew in the graft so as not to occlude this so that we would not have to reimplant the inferior mesenteric artery. The graft was beveled to the appropriate length and using 3-0 Prolene again and an SH needle, performed an anastomosis here sewing the back wall first and then sewing the anterior wall and came around on the left lateral anterior side. The IMA was identified and the orifice was carefully sutured in place so as not to impinge on the orifice and to keep the IMA patent. Once this was done, we then de-aired the graft, backbled the clamps, released the clamps and tied down the suture. We did hold pressure on the left groin and the right groin prior to releasing the clamps. The right common femoral artery is occluded, but we carefully released the pressure on the left common femoral artery after pressure was restored. At this point, we inspected for hemostasis and we did achieve hemostasis. We gave approximately 30 mg of protamine and then we closed the aortic sac using #0 Vicryl in a running fashion. There was not much retroperitoneum to close; therefore, we did not close the retroperitoneum. At this point all laps and instrument counts were correct. We then had the nurses check for Doppler signal in the feet. There was Doppler signal in both feet. We closed the abdomen using #1 looped PDS in a running fashion from both ends. Staples were used to close the skin. The patient tolerated the procedure well, was taken to ICU in stable condition where he will be extubated.
I used 35091 was not sure if this is right
5.5 cm abdominal aortic aneurysm.
POSTOPERATIVE DIAGNOSIS:
5.5 cm abdominal aortic aneurysm.
PROCEDURE PERFORMED:
Open abdominal aortic aneurysm repair with an 8 mm Dacron tube graft.
COMPLICATIONS:
There were no complications during the procedure.
ANESTHESIA:
The patient under general anesthesia with
SPECIMEN:
No specimen sent to pathology.
DRAINS:
No drains left in place.
BRIEF STATEMENT OF MEDICAL NECESSITY:
This is a 70-year-old male with an abdominal aortic aneurysm that has grown to approximately 5.5 cm. The patient has a very short infrarenal neck and is therefore not a candidate for an endograft. He was counseled on risks and benefits of undergoing open abdominal aortic aneurysm repair and agreed.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room after undergoing general anesthesia, appropriate lines and catheters and tubes were placed. Foley catheter was placed. The abdomen was prepped and draped in normal sterile manner. I began by making a midline incision and this was carried down through subcutaneous tissue, identified the fascia and carefully opened this in a longitudinal manner. Identified the peritoneum and then sharply opened this after elevating it with a hemostat clamp. I then extended the peritoneal incision proximally and distally. I then identified the small bowel and eviscerated this to the right and identified the duodenum, which was adherent to the aneurysm, and carefully mobilized the duodenum up to the level of the ligament of Treitz and mobilized this laterally to the right. Once this was done, I then carefully continued our dissection superiorly on top of the aneurysm down to the aorta, which was normal. We carefully mobilized the renal vein, so that we could retract this out of the way. We then placed an Omni_____ retractor and carefully placed and some self-retaining retractors in abdominal wall and to elevate the transverse colon superiorly. We were able to dissect out carefully using blunt dissection and Bovie electrocautery, dissected out the bilateral renal arteries. The patient had an accessory right renal artery that was feeding the inferior right pole of the kidney. This was actually ligated as it came off anteriorly and would be in the way of the clamp. We carefully obtained loop control around the aorta just inferior to the renal arteries and then obtained control just above the renal arteries as well and obtained on the renal arteries. Once this was done, I then carefully dissected out the inferior mesenteric artery as it came off the normal aorta just distal to the aneurysm, obtained loop control here and then carefully dissected around the distal aorta as this was normal and would tolerate a tube graft. At this point, gave 5000 units of heparin and then allowed this to circulate. We then clamped the distal aorta using a Crayford clamp; then placed a Satinsky clamp around the infrarenal aorta and pushed this clamp up to just below the renal arteries. After notifying anesthesia, we went ahead and clamped and then opened the aneurysm sac using Bovie electrocautery and eviscerated all the sac contents out. There were several brisk bleeding lumbar arteries, which were oversewn using #0 silk with figure-of-eight and figure-of-sixteen sutures. Once this was done, we obtained hemostasis, placed Weitlaner retractor into the aneurysm sac and carefully teed off the sacs to expose the proximal aortic ring. The ring was very close to our proximal clamp was located. Therefore, we went ahead and placed another Crayford clamp across the aorta just proximal to the renal arteries. This was then clamped and the distal clamp below the renal arteries was removed. At this point, I brought the 18 mm Dacron graft onto the field using 3-0 Prolene on an SH needle, performed a running anastomosis sewing the posterior wall first, then sewed the anterior wall. Prior to completing this, we then flushed with heparinized saline into the graft. There was no evidence of leak, very carefully came off of the proximal clamp restoring flow to the renal arteries and flushed out the graft and then replaced the clamp in the proximal graft. Flow was then restored to the renal arteries. Ischemic time was approximately 20 minutes here. At this point, then teed off the aortic aneurysm distally in order to identify the distal ring. The inferior mesenteric artery was coming off just inferior to this and we elected to go ahead and try to sew in the graft so as not to occlude this so that we would not have to reimplant the inferior mesenteric artery. The graft was beveled to the appropriate length and using 3-0 Prolene again and an SH needle, performed an anastomosis here sewing the back wall first and then sewing the anterior wall and came around on the left lateral anterior side. The IMA was identified and the orifice was carefully sutured in place so as not to impinge on the orifice and to keep the IMA patent. Once this was done, we then de-aired the graft, backbled the clamps, released the clamps and tied down the suture. We did hold pressure on the left groin and the right groin prior to releasing the clamps. The right common femoral artery is occluded, but we carefully released the pressure on the left common femoral artery after pressure was restored. At this point, we inspected for hemostasis and we did achieve hemostasis. We gave approximately 30 mg of protamine and then we closed the aortic sac using #0 Vicryl in a running fashion. There was not much retroperitoneum to close; therefore, we did not close the retroperitoneum. At this point all laps and instrument counts were correct. We then had the nurses check for Doppler signal in the feet. There was Doppler signal in both feet. We closed the abdomen using #1 looped PDS in a running fashion from both ends. Staples were used to close the skin. The patient tolerated the procedure well, was taken to ICU in stable condition where he will be extubated.
I used 35091 was not sure if this is right