This article is part of the operation script for grafting an abdominal aortic aneurysm. The article can be used on its own, or to go to the next part of the operation, click on NEXT PART OF THE OPERATION at the bottom of this page.
AORTIC ANEURYSM 150 SECTION 3.00 PRELIMINARIES
STEP 3.02 CHECK THAT SYSTEMIC HEPARIN WILL NOT BE GIVEN
STEP 3.03 CHECK THE PERIPHERAL PULSES
- This is to be aware of pre-operative distal arterial blockage.
- The blockages may be due to thrombosis or embolism.
- In a hypotensive patient, the distal pulses may not be palpable because of vasoconstriction or poor cardiac output.
- You will need this information when diagnosing possible thrombosis or embolism, during or after the operation.
STEP 3.04 CHECK THE RELATIVES HAVE BEEN WARNED
- With an emergency grafting, the patient may only have a 25% chance of coming off the table alive.
- Make sure that you have made this point very clear to the relatives.
STEP 3.05 CHECK THAT BLOOD HAS BEEN ORDERED
- Group and save serum an elective case and 4 units or more may be needed for an emergency case.
- Ideally, 2 units should be present in the anaesthetic room at the time of induction of the anaesthestia for an urgent or emergency case.
STEP 3.06 CHECK THE PATIENT HAS BEEN SHAVED OR CLIPPED
- From the nipples to the knees.
- This can be ignored if the operation is very urgent.
STEP 3.07 CHECK THE PATIENT HAS A BLADDER CATHETER
- Run the drainage tubing between the patient’s feet with the collecting bag visible below the level of drapes.
- Empty, measure and record the urine volume on catheterisation.
- Make sure there is a volume scale on the collecting bag for monitoring the urine output during the operation.
- Stick the tubing to the operating table with 15cm. adhesive tape eg Elastoplast.
- Make a mesentery of the tape to prevent the tape being pulled off.
- Make sure the catheter tubing is slack and is not dragging on the patient’s bladder neck.
- Attach the drainage bag to the side of the operating table using a frame.
- Make sure the bag will be visible for inspection by the anaesthetist during the operation.
STEP 3.08 CHECK THERE ARE NO TED - ANTI THROMBOSIS STOCKINGS
- These compression stockings can impair blood flow in the lower limbs.
- They make the limbs look falsely ischaemic at the end of the operation.
- In any case, the lower limbs will be anticoagulated with heparin during the operation.
STEP 3.09 CHECK THE GRAFTS
- Make sure there are the following grafts actually in the theatre:
- eg Unigraft KDV grafts (BBraun Aesculap)
- Straight grafts
- 18mm. X 15cm.
- 20mm. X 15cm.
- 22mm. X 15cm.
- 24mm. X 15cm.
- Trouser grafts
- 14mm. X 7mm. X 40cm.
- 16mm. X 8mm. X 40cm.
- 18mm X 9mm. X 40cm.
- 20mm. X 10mm. X 40cm.
- Check the grafts are within their shelf life.
STEP 3.10 CHECK THE MATERIAL OF THE GRAFTS
- Ideally use an impermeable non stretch knitted graft.
STEP 3.11 CHECK THE SUTURE FOR THE ANASTOMOSIS
- eg 2/0 and 4/0 Prolene with a needle at each end (Ethicon W8577).
STEP 3.12 CHECK THE AORTIC CLAMP
- Small, medium and large Satinsky clamps will be needed – 3 of each.
- One to clamp the aorta and one to clamp the graft when testing the upper anastomosis.
- Two 25cm. straight vascular clamps will be needed for a large aorta.
STEP 3.13 CHECK THE HEPARIN SOLUTION
- 5000 units Heparin in 500 mls. of 0.9% Saline for local anticoagulation.
STEP 3.14 CHECK THE PATIENT HAS BEEN GIVEN ANTIBIOTICS INTRAVENOUSLY:
- Flucloxacillin 1500mg.
- Metronidazole 150mg.
STEP 3.15 CHECK THE DIATHERMY PAD
- Under the buttocks.
STEP 3.16 ANAESTHESIA
- Spend a few minutes with the anaesthetist going over the operation plan.
- Systemic anticoagulation with heparin during an elective operation is not really necessary, but you need to agree about it.
- Check that blood is available in the anaesthetic room before the anaesthetic begins.
- For elective cases.
- Endo-trachal intubation in the Anaesthetic Room.
- Central venous line.
- Arterial line.
- E.C.G.
- Epidural line
- Warmer eg Bair Hugger Warmer unit Model 505
- For emergency cases:
- The major priority is to get a clamp on to the aorta above the aneurysm as soon as possible.
- One of the major risks is severe hypotension and bleeding on induction of anaesthesia.
- The surgical team should always be scrubbed up and ready at the time of induction.
- In severe cases, the patient can be cleaned and towelled up in the Operating Theatre before induction.
STEP 3.17 CHECK THE SURGICAL TEAM
- You will need a very experienced first assistant ( Ask for a consultant if necessary).
- A second and preferably a third assistant should be strong and have sufficient endurance for a possible 3-4 hour operation.
- Check that the scrub nurse and particularly the runner nurse have enough experience.
- Make sure all the team have eaten properly and have been to the toilet.
- Go through the steps of the your planned operation with them.
STEP 3.18 CHECK THERE IS NO OTHER PROCEDURE TO DO
