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PREOPERATIVE DIAGNOSIS: Aortoiliac occlusive disease.
POSTOPERATIVE DIAGNOSIS: Aortoiliac occlusive disease.
OPERATIVE PROCEDURE: Aorto-bi-common iliac bypass.
PROCEDURE: Under adequate prep and drape of the abdomen, a vertical midline incision was made and the
abdomen explored, finding no abnormalities with the exception of the known aortoiliac occlusive disease. The
table-fixed retractor was used throughout the procedure to facilitate exposure. The transverse colon was retracted
superiorly and held in place with retractors. The small bowel was retracted through the patient's right side and,
likewise, held in place with retractors. The retroperitoneum was mobilized over the palpable calcified aorta from the
aortic bifurcation to the approximate level of the left renal vein. In the process, the duodenum was swept towards
the patient's right side, taking down the back side of the ligament of Treitz. This part of the dissection was done
with maximal hemostasis using the harmonic scalpel. In the process of this dissection, it was discovered that the
patient had very large inferior mesenteric artery which merged with a large _____ which was directed in the
cephalad direction, all of which were preserved in the course of exposure of the aorta. Preoperative angiograms
documented a fairly large inferior mesenteric artery also, suggesting a collateral pathway for the GI tract. Palpation
of the aorta revealed dense fibrocalcific disease in the distant two-thirds, which extended well into the common iliac
arteries bilaterally on palpation. Therefore, any attempt at aortoiliac endarterectomy was abandoned and the
operator made a decision to perform aorto-bi-common iliac bypass. Vessel loops were placed around the origin of
the inferior mesenteric artery and, after careful dissection along the common iliac artery bilaterally, vessel loops
were placed at the origin of the external and internal iliac arteries bilaterally, preserving the sympathetic plexus over
the left common iliac and the entire course of the dissection. After all of the above was accomplished to my
satisfaction, the patient was systemically heparinized. Vessel loops were pulled taut initially, distally on the external
and internal iliac arteries bilaterally, followed by occlusion of the inferior mesenteric artery with its associated vessel
loops. The proximal aorta was then cross-clamped below the left renal vein in the soft part of the aorta, and the
aorta opened on its anterior surface along a distance of about an inch well above the take-off of the inferior
mesenteric artery. Endarterectomy was accomplished of the aorta in this location to my satisfaction. This was
followed an end-to-side anastomosis of a 12/7 bifurcated Dacron graft, which was cut to match the size of the
aortotomy. Then, 3-0 Prolene was run from both apices of the aortotomy to include the proximal graft in an end-toside
configuration. Minimal bleeding at the anastomosis was then controlled with subsequent placement of 5-0
Prolene sutures. Once absolute the hemostasis around the anastomosis was accomplished, the anastomosis was
wrapped with Surgicel and both limbs tunneled appropriately to the distal common iliac arteries. The left side was
anastomosed first, cross-clamping the proximal common iliac artery and opening the distal common iliac artery,
which was relatively uninvolved with vascular occlusive disease in comparison to the proximal two-thirds of the left
common iliac artery. The left limb of the graft was cut to an appropriate length in configuration for a direct end-toside
anastomosis which was accomplished using 4-0 Prolene suture. Flow was released first into the left internal
iliac artery, followed by retrograde flow into the left common iliac artery, followed finally by release of flow into the
left external iliac artery. Surgicel was likewise placed around this anastomosis with absolute hemostasis. The right
side was accomplished in an identical manner as the left. The graft was beneath the ureter on both sides of the
common iliac artery. Excellent pulses were palpated in the external and internal iliac arteries bilaterally distal to the
anastomosis previously described. At this point, _____ retractors were removed and the retroperitoneum was
closed over the aorta after hemostasis was assured with 2-0 Vicryl. The viscera were returned within the abdomen
and the abdomen was then closed using running #1 looped PDS on the fascia, 2-0 Vicryl in the subcutaneous and
skin staples on the skin. The patient returned to the recovery room in stable condition. Blood loss was about 1500
milliliters. Then, 750 milliliters of shed blood was retransfused to the patient in the course of the operative
procedure.
___________________________________________________
POSTOPERATIVE DIAGNOSIS: Aortoiliac occlusive disease.
OPERATIVE PROCEDURE: Aorto-bi-common iliac bypass.
PROCEDURE: Under adequate prep and drape of the abdomen, a vertical midline incision was made and the
abdomen explored, finding no abnormalities with the exception of the known aortoiliac occlusive disease. The
table-fixed retractor was used throughout the procedure to facilitate exposure. The transverse colon was retracted
superiorly and held in place with retractors. The small bowel was retracted through the patient's right side and,
likewise, held in place with retractors. The retroperitoneum was mobilized over the palpable calcified aorta from the
aortic bifurcation to the approximate level of the left renal vein. In the process, the duodenum was swept towards
the patient's right side, taking down the back side of the ligament of Treitz. This part of the dissection was done
with maximal hemostasis using the harmonic scalpel. In the process of this dissection, it was discovered that the
patient had very large inferior mesenteric artery which merged with a large _____ which was directed in the
cephalad direction, all of which were preserved in the course of exposure of the aorta. Preoperative angiograms
documented a fairly large inferior mesenteric artery also, suggesting a collateral pathway for the GI tract. Palpation
of the aorta revealed dense fibrocalcific disease in the distant two-thirds, which extended well into the common iliac
arteries bilaterally on palpation. Therefore, any attempt at aortoiliac endarterectomy was abandoned and the
operator made a decision to perform aorto-bi-common iliac bypass. Vessel loops were placed around the origin of
the inferior mesenteric artery and, after careful dissection along the common iliac artery bilaterally, vessel loops
were placed at the origin of the external and internal iliac arteries bilaterally, preserving the sympathetic plexus over
the left common iliac and the entire course of the dissection. After all of the above was accomplished to my
satisfaction, the patient was systemically heparinized. Vessel loops were pulled taut initially, distally on the external
and internal iliac arteries bilaterally, followed by occlusion of the inferior mesenteric artery with its associated vessel
loops. The proximal aorta was then cross-clamped below the left renal vein in the soft part of the aorta, and the
aorta opened on its anterior surface along a distance of about an inch well above the take-off of the inferior
mesenteric artery. Endarterectomy was accomplished of the aorta in this location to my satisfaction. This was
followed an end-to-side anastomosis of a 12/7 bifurcated Dacron graft, which was cut to match the size of the
aortotomy. Then, 3-0 Prolene was run from both apices of the aortotomy to include the proximal graft in an end-toside
configuration. Minimal bleeding at the anastomosis was then controlled with subsequent placement of 5-0
Prolene sutures. Once absolute the hemostasis around the anastomosis was accomplished, the anastomosis was
wrapped with Surgicel and both limbs tunneled appropriately to the distal common iliac arteries. The left side was
anastomosed first, cross-clamping the proximal common iliac artery and opening the distal common iliac artery,
which was relatively uninvolved with vascular occlusive disease in comparison to the proximal two-thirds of the left
common iliac artery. The left limb of the graft was cut to an appropriate length in configuration for a direct end-toside
anastomosis which was accomplished using 4-0 Prolene suture. Flow was released first into the left internal
iliac artery, followed by retrograde flow into the left common iliac artery, followed finally by release of flow into the
left external iliac artery. Surgicel was likewise placed around this anastomosis with absolute hemostasis. The right
side was accomplished in an identical manner as the left. The graft was beneath the ureter on both sides of the
common iliac artery. Excellent pulses were palpated in the external and internal iliac arteries bilaterally distal to the
anastomosis previously described. At this point, _____ retractors were removed and the retroperitoneum was
closed over the aorta after hemostasis was assured with 2-0 Vicryl. The viscera were returned within the abdomen
and the abdomen was then closed using running #1 looped PDS on the fascia, 2-0 Vicryl in the subcutaneous and
skin staples on the skin. The patient returned to the recovery room in stable condition. Blood loss was about 1500
milliliters. Then, 750 milliliters of shed blood was retransfused to the patient in the course of the operative
procedure.
___________________________________________________