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 180 SECTION 6.00 - OPENING THE ABDOMEN (MIDLINE INCISION)
STEP 6.01 INCISE THE SKIN
- Have the first assistant hold the umbilicus to the right with a Littlewood forcep.
- Incise the skin with a scalpel with a No.22 Swann Morton blade.
- Cut the skin in the mid line and around the left of the umbilicus
- Start 20 cm. below the umbilicus and continue 5 cm. above and to the left of the xiphisternum.
- This will maximise access at the upper end of the wound.
- Clear access to the upper end of the abdominal aorta is absolutely essential.
STEP 6.02 INCISE THE SUBCUTANEOUS FAT
- Use eg a finger switch diathermy with blade (Firestick).
- Coagulate vessels in this layer as needed.
STEP 6.03 INCISE THE LINEA ALBA
- Use the firestick.
- Cut the linea alba up to the left lateral side of the xiphisternum.
STEP 6.04 OBTAIN HAEMOSTASIS
- The left superior epigastric artery lateral to the xiphisternum may need specific coagulation.
- If the patient is very shocked:
- There may be little bleeding from the abdominal wound until the blood pressure rises.
- This may not happen until the aorta is clamped or the operation is finished.
- Be prepared to diathermy bleeders in the wound edge at these later stages.
STEP 6.05 OPEN THE PERITONEUM
- Hold the peritoneum up between 2 artery forceps in the middle of the wound.
- Open the peritoneum with a scalpel ( blade held flat).
- Tell the anaesthetist if there is free peritoneal fluid
- This will alert him/ her to the correct diagnosis.
- Eg Blood from a ruptured aneurysm
- Faecal fluid from a faecal peritonitis
- Smelly bloody fluid from infarcted bowel.
- Prune juice fluid from pancreatitis.
STEP 6.06 OPEN THE PERITONEUM IN THE WHOLE LENGTH OF THE WOUND
- Use dissecting scissors.
- Extend the opening up to the left side of the xiphisternum and down to the lower end of the wound.
STEP 6.07 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 6.08 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 6.09 RETRACT THE WOUND EDGES
- 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.
- This will prevent the drapes tangling.
- Open the wound as much as it will go.
