Jim

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35637,36247 What Am I Missing
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We incised the inguinal ligament bilaterally and used blunt dissection with our finger to make a retroperitoneal tunnel for later passage of the limbs AFB graft. We then made a midline incision from the xiphoid process to the pubis symphysis. Dissection was carried down to the fascia. The fascia was incised at the linea alba via the preperitoneal space was entered and the peritoneum was entered using sharp dissection. We then placed a Bookwalter retractor and retracted the abdominal wall. We then elevated the transverse colon superiorly and eviscerated the small bowel to the right side of the body and superiorly. We then took down the ligament of Treitz and mobilized the fourth portion of the duodenum to get exposure to the bra infrarenal aorta. We then incised the peritoneum overlying the retroperitoneum overlying the aorta and dissected out the aorta from the renal vein all the way down to the iliac bifurcation. We were able to get circumferential control of the infrarenal aorta. The patient had plaque that was renal so we had to get supraceliac control the way that, we actually placed a French sheath in the right femoral artery, advanced a wire, and Q50 balloon and pull once we heparinized we inflated the Q50 balloon for proximal control. We then transected the aorta with a knife and Potts scissors. We then bluntly removed the soft plaque and thrombotic material that was in the aorta and cleaned it out. Once we did that, we placed a clamp in the infrarenal portion of the aorta deflated the balloon, removed the balloon and the sheath out of view and clamped the aorta infrarenally. We then continued to transect the aorta completely. We then oversewed the distal stump with a running 6-0 Prolene suture. We then took a 20 x 10 Dacron graft and we sewed it end-to-end with a running 6-0 Prolene suture. Once we completed anastomosis, we tunneled our limbs to the right and left groin retroperitoneally anterior to the iliac arteries. We then sewed the limbs end-to-side to the femoral arteries bilaterally with running 6-0 Prolene suture. Once we completed anastomosis bilaterally. There were good pulses in the feet. We reversed heparin with protamine. We made sure there was good hemostasis in the groin was washed copiously with normal saline and closed the wound in 2 layers and then used staples for skin closure. We then made sure the retroperitoneum was dry. We did place a thrombotic agents in the retroperitoneum to help control some oozing which was stopped. We sewed the retroperitoneum with a running 0-Vicryl suture. We then returned the bowel to its normal position in the body removed the Bookwalter retractor, used 2-0 PDS sutures to close the fascia of the abdominal wall and used staples to close the skin. The patient was extubated and transferred to the ICU in stable condition.
 

Jim Pawloski

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35637,36247 What Am I Missing
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We incised the inguinal ligament bilaterally and used blunt dissection with our finger to make a retroperitoneal tunnel for later passage of the limbs AFB graft. We then made a midline incision from the xiphoid process to the pubis symphysis. Dissection was carried down to the fascia. The fascia was incised at the linea alba via the preperitoneal space was entered and the peritoneum was entered using sharp dissection. We then placed a Bookwalter retractor and retracted the abdominal wall. We then elevated the transverse colon superiorly and eviscerated the small bowel to the right side of the body and superiorly. We then took down the ligament of Treitz and mobilized the fourth portion of the duodenum to get exposure to the bra infrarenal aorta. We then incised the peritoneum overlying the retroperitoneum overlying the aorta and dissected out the aorta from the renal vein all the way down to the iliac bifurcation. We were able to get circumferential control of the infrarenal aorta. The patient had plaque that was renal so we had to get supraceliac control the way that, we actually placed a French sheath in the right femoral artery, advanced a wire, and Q50 balloon and pull once we heparinized we inflated the Q50 balloon for proximal control. We then transected the aorta with a knife and Potts scissors. We then bluntly removed the soft plaque and thrombotic material that was in the aorta and cleaned it out. Once we did that, we placed a clamp in the infrarenal portion of the aorta deflated the balloon, removed the balloon and the sheath out of view and clamped the aorta infrarenally. We then continued to transect the aorta completely. We then oversewed the distal stump with a running 6-0 Prolene suture. We then took a 20 x 10 Dacron graft and we sewed it end-to-end with a running 6-0 Prolene suture. Once we completed anastomosis, we tunneled our limbs to the right and left groin retroperitoneally anterior to the iliac arteries. We then sewed the limbs end-to-side to the femoral arteries bilaterally with running 6-0 Prolene suture. Once we completed anastomosis bilaterally. There were good pulses in the feet. We reversed heparin with protamine. We made sure there was good hemostasis in the groin was washed copiously with normal saline and closed the wound in 2 layers and then used staples for skin closure. We then made sure the retroperitoneum was dry. We did place a thrombotic agents in the retroperitoneum to help control some oozing which was stopped. We sewed the retroperitoneum with a running 0-Vicryl suture. We then returned the bowel to its normal position in the body removed the Bookwalter retractor, used 2-0 PDS sutures to close the fascia of the abdominal wall and used staples to close the skin. The patient was extubated and transferred to the ICU in stable condition.
Sorry that I cannot help you with this one, but I don't code open aortic aneurysm procedures.
Thanks,
Jim Pawloski, CIRCC
 
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