Name:
13 Iliac Vessels Med
Description:
13 Iliac Vessels Med
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/c80423ba-9f03-408c-8776-37c785eb7100/thumbnails/c80423ba-9f03-408c-8776-37c785eb7100.jpg?sv=2019-02-02&sr=c&sig=ibPDXYhh94DAb47GOiQyp8tQ3rcLwEJ83gKHZSi0NBA%3D&st=2024-12-21T12%3A00%3A05Z&se=2024-12-21T16%3A05%3A05Z&sp=r
Duration:
T00H06M11S
Embed URL:
https://stream.cadmore.media/player/c80423ba-9f03-408c-8776-37c785eb7100
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/c80423ba-9f03-408c-8776-37c785eb7100/1320Iliac20Vessels20Med.mov?sv=2019-02-02&sr=c&sig=BmkgEIp2ihctJvPk2vI0Jw5%2B10Gl%2FtwjTQi8LCFAU3o%3D&st=2024-12-21T12%3A00%3A05Z&se=2024-12-21T14%3A05%3A05Z&sp=r
Upload Date:
2022-03-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
In this video, I will discuss the proper technique for exposure and repair of the iliac vessels. I'll begin by reviewing the anatomy, necessary instruments,
Segment:1 Objectives.
proper patient positioning, then demonstrate exposure of the iliac vessels through a midline incision, with possible extension across the inguinal ligament. Finally, I will discuss the tips and pitfalls of this exposure.
Segment:2 Anatomy.
The aorta bifurcates become the common iliac arteries at the level of the fourth to fifth lumbar vertebrae, with the surface landmark being the umbilicus.
The common iliac arteries then bifurcate into the external and internal iliac arteries at the level of the sacroiliac joint. The external iliac artery then runs along the medial border of the psoas muscle. It then courses under the inguinal ligament to become the common femoral artery. The ureter crosses over the bifurcation of the common iliac artery. The left external iliac vein runs medial to the artery throughout its course. The right external iliac vein lies medial to the artery, at the inguinal ligament.
It then courses to the right as it moves further proximally, shifting to a posterior position relative to the artery.
Segment:3 Instrumentation and Positioning.
The patient should be positioned supine with arms abducted out at 90 degrees. The patient should be prepped and draped from the abdomen to the lower extremities to allow for extension of the incision, as well as checking distal pulses. Instruments should include a laparotomy tray, vascular instruments, and vascular conduits. Ideally, the operation should be performed in an operating room with angiographic capabilities.
It's possible to expose the distal aorta and iliac vessels utilizing a direct peritoneal incision, where the bowels are retracted cephalad. However, a medial rotation of the cecum and ascending colon on the right, or the sigmoid and descending colon on the left, provides a better exposure of the vessels and ureters. The small bowel is rotated cephalad and held in place with warm, wet towels.
A PAROCOG: peritoneal reflection is incised, and the large intestine is mobilized medially This technique provides excellent and expeditious exposure of the underlying iliac artery and veins, which can then be dissected free from their surrounding fat. Ureters are encircled with a vessel loop and gently retracted out of harm's way. It is important to avoid complete dissection of the ureter as the blood supply runs along the ureter laterally and medially. Proximal and distal control of the iliac arteries is then obtained utilizing vascular clamps or vessel loops.
A PAROCOG: It is important to gain control of the internal iliac artery as well, as back bleeding can persist, even with proximal distal control, in the common and external iliac artery. When mobilizing the iliac arteries, take great care to avoid damaging the closely associated and underlying iliac veins, which can be difficult to control. Exposure of the iliac veins is more challenging, given their more posterior position, especially on the right side.
A PAROCOG: Venous exposure can be achieved with mobilization of the artery and retraction with vessel loops. If necessary, ligation and division of the internal iliac artery can provide additional mobilization and better exposure. Shown here, once again, the left external iliac artery lies lateral to the left external iliac vein throughout its course. The internal iliac artery crosses medially over the vein. As shown here, the ureter crosses over the bifurcation of the common iliac artery.
A PAROCOG: Small arterial injuries can usually be repaired with mobilization and primary repair. For larger deficits, a six to eight millimeter PTFE graft is necessary. Internal to external, the common iliac artery transposition is a reconstruction option in stable patients. The internal iliac and distal external iliac arteries are mobilized to create adequate length. The internal iliac artery can then be anastomosed to the ipsilateral or contralateral common or external iliac artery using a running 4-0: monofilament non-absorbable suture.
A PAROCOG: Patients with arterial injuries frequently arrive in extremis, and in damage control situations and Argyle shunt may be used temporarily to restore blood flow, followed by semi-elective definitive reconstruction. Ligation is not advisable as it results in very high rate of limb loss. Place a suture around the middle of the shunt to prevent migration. On the right side, medial retraction of the artery provides excellent exposure of the vein, which can be encircled in vessel loops.
A PAROCOG: In rare circumstances, extension of an incision across the inguinal ligament may be necessary if there's a destructive injury of the iliac artery or vein at the inguinal ligament. This provides incredible exposure of the entire iliac artery and vein. Again, the right external iliac vein starts posterior the artery and becomes medial to it as it becomes the femoral vein. The distal external iliac artery and vein are shown ENSNARED: in vessel loops here.
Segment:4 Tips and Pitfalls.
A PAROCOG: The tips and pitfalls of this exposure include retraction of the ureter out of the way to avoid iatrogenic injury. When mobilizing iliac arteries, take great care to avoid damaging the closely associated and underlying veins, which can be difficult to control. Exposure of the iliac vein is difficult and requires mobilization of the iliac arteries. Avoid ligation and division of the iliac arteries unless absolutely necessary.
A PAROCOG: If repair of an iliac vein results in stenosis, consider anticoagulation and IVC filter placement to prevent pulmonary embolism. Examine closely for extremity compartment syndrome, and if it develops, perform a decompressive fasciotomy without delay. Thank you.
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