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Vascular and Intestinal Anastomotic Workshop
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PGY 1 Name the Instruments
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PGY 1 Name the Instruments
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PGY 1 Name the Instruments
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Commonly used Sutures PGY 1 Braided? Absorbable? Timeline # of throws
Silk Braided no n/a 3-4 Vicryl yes 55-70 days 4-5 Prolene Mono 6-8 Chromic 90 days PDS days Nylon ~5 Gore ~8 Monocryl days 5
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Discuss bowel layers and roll in suturing an anastomosis
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PGY 2 Lembert Sutures Definition? Reason? Seromuscular
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PGY 2 Connell Sutures Describe Connell suturing technique
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Staplers
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PGY 2 Name the Stapler
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PGY 2 Name the Stapler…
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PGY 2 Name the Stapler
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Side to side anastomosis
PGY 2 Side to side anastomosis How do you set up a side to side anastomosis? CRITICAL CONCEPTS Non-tension GIA stapler Align anti-mesenteric sides of bowel together Staggered staple lines
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End-to-end Anastomosis
PGY 2 End-to-end Anastomosis How do you set up a stapled end-to-end anastomosis?
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Functional End-to-end anastomosis
PGY 2 Functional End-to-end anastomosis Describe another way to perform a stapled end to end anastoamosis
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PGY 3 Stapler Loads What is the difference between the different stapler loads? What color load do you use for vascular tissue? Stomach? Small bowel? Colon? Rectum?
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PGY 3 Hand Sewn Anastomosis Describe the different types of suture techniques used in hand sewn bowel anastomosis
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Hand Sewn Anastomosis Describe the steps for a 2 layer anastomosis
PGY 3 Hand Sewn Anastomosis Describe the steps for a 2 layer anastomosis
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Hand Sewn Anastomosis Describe how to sew a single layer anastamosis
PGY 3 Hand Sewn Anastomosis Describe how to sew a single layer anastamosis
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PGY 2 Arm Vascular Anatomy Describe the arterial and venous blood flow to the arm
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Types of Surgical Dialysis Access
PGY 2 Types of Surgical Dialysis Access What is the difference between an AV Fistulae and an AV Graft
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Sites for AV fistulae
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Radiocephalic AV Fistula
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Brachiocephalic AV graft
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Basilic Vein Transposition
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DRIL procedure DRIL = Distal Revascularization Interval Ligation
RUDI = Revision Using Distal Inflow
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PGY 3 Vascular Anastomosis Identify autogenous materials for vascular anastomosis: Saphenous vein, iliac vein Identify exogenous materials for vascular anastomosis: bovine pericardium, ePTFE, gore-tex, cadaveric What is the dosing/timing for heparinization during a vascular anastomosis? units/kg, given 5 minutes prior to vascular occlusion How do you measure heparinization to confirm appropriate levels have been achieved? Activated clotting time (ACT) of greater than 250
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Zones of Retroperitoneum
PGY 3 Zones of Retroperitoneum Describe the Zones of the retroperitoneum and the major vasculature that could be injured in each zone Zone 1: Midline retroperitoneum Supramesocolic region (suprarenal aorta, celiac, SMA/SMV, proximal renal artery) Inframesocolic region (infrarenal aorta, infrarenal IVC) Zone 2: Upper lateral retroperitoneum (renal artery/vein) Zone 3: Pelvic retroperitoneum (iliac artery/vein)
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Zone I Great Vessel Injury
PGY 3 Zone I Great Vessel Injury Describe the approach for supramesocolic Zone I injuries: Left medial visceral mobilization May also need to transect the left crus (at 2o’clock position) to allow for control of the descending thoracic aorta
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Zone I Great Vessel Injury
PGY 3 Zone I Great Vessel Injury Describe the approach for inframesocolic Zone I injuries: Lift up on transverse mesocolon, eviscerate small bowel to right, open mid-line retroperitoneum and cross clamp the aorta inferior to the left renal vein For IVC injuries, perform a right medial visceral mobilization (right colon and duodenum), leaving the kidney in situ
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Zone I Great Vessel Injury
PGY 3 Zone I Great Vessel Injury Describe the approach to an inframesocolic Zone I injury to the IVC at the common iliac vein confluence: After right medial visceral mobilization, it may be necessary to divide and ligate the right internal iliac artery or to temporarily divide the right common iliac artery
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Zone I Great Vessel Injury
PGY 3 Zone I Great Vessel Injury Describe the approach to an inframesocolic Zone I injury to the IVC at the level of the renal veins: After right medial visceral mobilization, you should clamp/compress the IVC proximally and distally and loop/clamp both the left and right renal veins. It may be necessary to perform a medial mobilization of the right kidney (watch out for 1st lumbar vein!)
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