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 170 SECTION 5.00 OPENING THE ABDOMEN (TRANSVERSE INCISION)
STEP 5.01 INCISE THE SKIN
- Use a scalpel with a no. 22 Swann-Morton blade.
- Start at the left midclavicular line, 5cm. above the umbilicus.
- Continue transversely to the right midclavicular line.
STEP 5.02 INCISE THE SUBCUTANEOUS FAT
- Use eg a finger switch diathermy with blade (Firestick).
- Coagulate vessels in this layer as needed.
STEP 5.03 RETRACT THE SUBCUTANEOUS FAT
- Use large abdominal packs to expose the external oblique muscle and aponeurosis.
STEP 5.04 CUT THE EXTERNAL OBLIQUE MUSCLE ON EACH SIDE
- Use the firestick.
STEP 5.05 CUT ACROSS THE ANTERIOR RECTUS SHEATH ON EACH SIDE
- Use the firestick.
STEP 5.06 TUNNEL BEHIND THE LEFT RECTUS ABDOMINIS MUSCLE
- Use your left index finger.
STEP 5.07 CUT ACROSS THE LEFT RECTUS MUSCLE
- Use the firestick.
- Identify the superior epigastric artery as it runs in the back wall of the rectus muscle.
- Coagulate the artery.
STEP 5.08 CUT ACROSS THE RIGHT RECTUS MUSCLE
- As for the left rectus muscle and left superior epigastric artery.
STEP 5.09 ELEVATE THE POSTERIOR RECTUS SHEATH
- Use 2 pairs of artery forceps.
STEP 5.10 OPEN THE UMBILICUS
- Use a scalpel with the blade held flat.
STEP 5.11 OPEN THE WHOLE ANTERIOR ABDOMINAL WOUND
STEP 5.12 CHECK THE PERITONEUM AROUND THE WOUND EDGES IS FREE FROM ADHESIONS
- Free any adhesions to the inside of the peritoneum for 5cm. around the wound edge.
- This will ensure that retractors do not damage adherent bowel of omentum.
STEP 5.13 APPLY SKIN TOWELS
- Tucking skin towels under the each lateral edge of the wound keeps the wound neat and may help sterility.
- Omit this in extreme emergency cases.
- Clip the towels to the ends of the wounds with towel clips.
STEP 5.14 RETRACT THE WOUND EDGES
- Usually a Deaver retractor is all that is needed.
- For a very obese patient:
- Use 2 Finochietto abdominal retractors.
- Place the worm gears on the opposite side of the wound.
- Have your first assistant place his/her hand between the drapes and the worm drive to prevent the drapes tangling.
- Open the wound as much as it will go.
STEP 5.15 CHECK FOR BLEEDING FROM THE WOUND EDGE
- Coagulate minor vessels in the rectus muscle plus epigastric vessels.
- Go to SECTION 7.00 EXPLORING THE ABDOMINAL CAVITY
