Supraceliac Aorta-to-SMA Bypass with Ileocecectomy for Acute-on-Chronic Mesenteric Ischemia Complicated by Bowel Necrosis and Perforation

CHAPTER 1

My name is Benjamin Pearce. I'm an associate professor of surgery at University of Alabama in the division of vascular surgery and endovascular therapy. Today we have a very interesting case for you. This is a patient that's 63 years old. She was transferred into our facility about a week ago. She's had the usual risk factors for peripheral vascular disease, including hypertension, hyperlipidemia, and she's been a chronic tobacco abuser via smoking. She has had approximately four to six months of abdominal pain. This really started after she had had an aortobifemoral bypass done elsewhere for aortoiliac occlusive disease. She began having trouble with intermittent constipation followed by bouts of diarrhea. She then began having unrelenting pain and was actually admitted to an outside facility approximately three months ago for over 23 days. During that time, she received TPN and had an extensive workup, looking for other reasons for abdominal complaints. EGD was performed, showing some gastropathy, as was colonoscopy. She also had a workup for autoimmune diseases. On transfer here, she is seen to have a complete occlusion of the superior mesenteric artery with a bulky plaque that is over three to four centimeters distal to the origin of the SMA. Her celiac artery is open, although it has the small J anatomy, consistent with some compression from the arcuate ligament, and her IMA appears to have been ligated during her aortobifemoral bypass. We've actually admitted her to the hospital. She was not septic on arrival, she did have a mild lactic acidosis and was very somnolent. She was found to have pretty profound electrolyte abnormalities and a prealbumin that was unrecordably low in our system. Rather than take her straight to surgery, we resuscitated her, as she did not appear to be hemodynamically unstable, and we actually have had her on TPN for the past week. We have now gotten her prealbumin up over 10. She is mentating much better and we plan to do her definitive aorta-to-SMA bypass today. The key steps to this case will be exposure of the superior mesenteric artery where it is open in the root of the mesentery below the pancreatic border. Once this is done, I like to do that part first so that we don't have to move our retractor. We then will expose the supraceliac aorta and take down the median arcuate ligament in case we need to come back and do some endovascular intervention on her celiac artery in the future. She'll have much better success if we release the ligament. We will discuss mobilizing the left lobe of the liver to increase visualization in this area, and we'll plan to do a side-biting clamp and removal of an elipse of tissue with an aortic punch. We'll then make a retropancreatic tunnel, and the plan, if there's no bowel compromise on our entering the abdomen, would be to use a prosthetic graft with other potential autologous conduit saw as backup, depending on what we find once we perform laparotomy. So let's go do the case.

CHAPTER 2

Looks promising-ish. You can Bovie that. Okay, I think we got it. So close. Metz. Beauty. So she's just getting in sharply because it's redo, and that's pretty. All right. Going up just to the xiphoid, left of the xiphoid. The xiphoid's right here. Very good. Definitely a hernia there, huh? Good. Get a little bit more of that. I need a couple Kochers in a second. Let's see what we got here. Scissors. Now the question is, is this all something that we can, forcep, that we can just divide? Does it feel free underneath there? Feels free. Good and Bovie under your finger. Just... Yeah. This line that's being created. Probably some of the falciform adhesions too. There we go. Get the scissors or a Bovie and take that off. The colon's definitely sickly. Still kind of dilated. All right, you wanna work getting this stuff off my side here first. She'll take Metz. She's gonna take these adhesions down a little sharply. The liver looks a little strange and kind of see where it decussates with the abdominal wall there. Yeah, it's good. Can I get this headlight turned on please. The green button. Weird sort of rind almost. But they were coming down like they're just, there you go. Thank you, very nice. And we may end up having to open the whole abdomen just to see. Okay. Your side, now. We definitely have to move this whole left lobe of her liver to get where we need to be. Okay, Bovie to me. So we may have to go down here just to get everything out of the pelvis so we can take a look at all of it. Just move one on either side again. Jake, hold that for me. Scissors. Okay, give her some scissors. Jake, hold hers. Hold this one, Jake. And some of her problem is just like bowel obstruction too. Need to get this omentum up out of the way here. It's a little hard to see in there. Give Jake a handheld Deaver. See if you can put a, let me move this one here and put a Deaver in the middle of that and see if we can't, yeah, we can see my finger. Yes. Weird rind. This is all just omentum, right? Leave a little bit down on her pelvis. Good. Long tip Bovie, can you get it on my finger there? Good. No, that's not good. No, she's got a hole in her colon. All right. That's probably what this has all been. Yep.

CHAPTER 3

Okay. So this will be interesting. Let's get, we can't use a cell saver now. Gimme a waste tip. I'm gonna have to look for vein now too. Now that's what it looks like there. This was all a chronic thing. That's a big hole. Let's get this teased apart. Scissors. Here we go. I'm gonna have to straighten all this out so we can resect that piece. You know what I mean? See how it's like thinned out? You can put the Balfour in. It explains why she was so sick. All right. Balfour, thin blades. These are the shortest ones? Probably not. Thank you ma'am. So like to use this Balfour because it frees up some of our retractor spots on the automatic thing. Let's have that Deaver back. Can I open this up? Yeah, go ahead. Okay, hold that, Jake. Thank you. Good. Pull up. Yep, you have that waste sucker. Let's just go ahead and open her. Let's see. Okay, we may have to use femoral vein too. You wanna put the, dry lap, on in and go ahead and give ourselves two hands to work with. Yeah, put the big retractor in. Okay. This is our Omni retractor we like to use for these cases. Like I said, this case is getting harder now because she had a hole in her where we kind of expect this watershed ischemia that she has. Good. Do you have a blue towel? Thank you. Okay, thank you. Definitely wanna expose her aortic graft. Do you have the Mayo body wall for the machine there? Okay, lock it. Scissors. Can I have a pickup? See if you can get - Bovie, Bovie that. What a mess. Get scissors. Metz. Good. Let's see. All right, let's try and get all this controlled now. if we can, give us that handheld back. All right, where's the hole again? Almost there. Okay, good, suck all that out. Let's try to separate these. We need a GIA stapler in the room. Here's the problem. Look how ischemic this is too. Huh? It's almost like she had an anastomosis or something there, doesn't it? Let's try and free this loop up. Scissors. But see how ischemic that area? You can see it's like dead there. She has an ischemic hole in her small intestine there, Jennifer. Might have an anastomosis here too, I don't remember. It's almost like she had a resection and it fell apart, you know? Golly. It's okay, suck that, Jake. This whole segment's gonna have to come out. Try to - yep. Hold on one second on that one. There we go. Good. Wow, that is terrible. This piece too, right? Yeah this one. Question is, should we wash her out? And put her back together, like do the bypass another day sort of thing. Okay. All right, let me have an Allis clamp. Give her 3-0 Vicryl just stitch this closed so it doesn't keep spilling everywhere and we'll get everything straightened out and then we'll resect. I mean, do you think that like? This part is dead, like ischemic. That part is just dead. It's been, that hole was there when we started, you know what I mean? The reason she wasn't peritonitic was because it was trapped by all the adhesions, but we're gonna resect it all and then probably not put it back together until a couple days from now. You know what I mean? But before I start chunking the stapler across, I'd like to straighten this all out, at least see what it is, but no, I think we probably need to either, we either gotta get her vein or we gotta do like a cryo. Well we're gonna at least do the bypass today and then we'll bring her back and wash her out and, well I'm gonna, I need to look at her legs. Can we get the, get an ultrasound? I'll look at her leg vein and we'll make a decision. I kind of don't feel a lumen there, like there was an anastomosis, but you wonder if she perforated into her... Like I said we're gonna have to get her all straightened out at some point to see what's what. Good, see right there. See she's got her terminal ileum here. This is the fold of Treves, and this is her cecum. So I would be shocked if this was some sort of an anastomosis up here. Like I said, we're gonna have to get all this straightened out before we're done. Okay. I wonder if some of this is stuck here because she perforated a while ago, right? Okay. Better. Okay, I think that's pretty good. All right, let's see if we can make sense of where's what now. It's pretty ischemic even in here, but obviously not as bad as what all this stuff. Here we go. And that's your suture. Let's go ahead and take this out. Let's walk back to the front. We're gonna put some marking sutures on. The Prolene will be proximal. So this is ligament Treitz, we all agree? Okay. Do you have a like a 4-0? Here's a needle. You got a little long, Jake. There you go. Here's a needle back. All right, do you have a hemostat? Bovie. Stapler. Stapler. Uh Huh. So this is a - what do we call it, a GIA, right? I'm just gonna staple off the end of the part so we can stop contaminating and we'll know where to come back later and fix. We may end up having, this all may come as one thing later, but we might as well save it for now, right? Staple. Good. Let me have a Kelly please. Bovie. Another Kelly. Another Kelly. Scissors. 3-0 silk, please. Heavy scissors next Jake. Something's bleeding, let's see. Another one? What do I need to call that specimen? Small bowel. Okay. Another 3-0. Okay. Be nice to avoid getting in the colon, right? Metz. You have an Adson right angle? Oof. It's just all falling apart. It doesn't look like an anastomosis but it must be. Why would they have an anastomosis here though? Because like I said, the TI's here. She still has her cecum. Huh? She's inflamed, you said? Definitely a hole there. Looks weird, doesn't it? Let me just chunk all this stuff out. This is all gonna come out anyway, so... Nothing inside the colon, right? Doesn't look like it, looks good. Colon's over here. Hold that with your left hand, let's see. Definitely in something. I might need to take out part of her colon too. If she had a fistula colon, and it's just... That's probably what it is, huh? At this point we've already mucked it up enough, we gotta get it separated, you know. Holding her colon there. Let's come across, probably gonna take out part of her colon too, don't you think? Come through that. Go ahead and get it out. Let's take care of this. She must have a fistula to her colon, you know what I mean? Okay. Let me have the Allis, those Allis clamps back? Get the LigaSure too. Do we have a LigaSure, that's a good idea. Let me have the hemostat. I'll take the Bovie. Okay. Stapler. Amber, are there more GIA's in the room? What's on top of the stapler right there? Yeah, that. Good. I'm gonna wait for the LigaSure and just go across this. All right. I think I'm gonna go talk to her daughter. And explain what's going on. Colon over here looks okay. Why don't you wash a bunch of stuff out. I think we got all the bowel up and straightened out now, right? Hold that up. Let's just look down here. Irrigation. Thank you. Okay, I love it. I have the last one here. Okay, dry lap. There's another, we got that. -That's the same thing. We just need to take this piece. Take it with the LigaSure. Yeah, let's go. Can you call - Heather or Amber, will you call the operator and ask them to have whoever's on call for acute care surgery to come stop by here, please. I just want to get their opinion about the colon here. And then after that let's start thawing out some cryo femoral vein, I think. Actually, we can do cryo SFA, might size up better to the, here's another specimen. Is it colon? It's small bowel. And then I'm gonna go talk to this patient's family. Hey Parker. Hey, how are you? Good. I'm sorry, we have a bad, like a mesentery ischemia case where I took out the terminal ileum for the most part. But she also has a hole in her transverse colon and I agree she probably just needs to have a right colectomy, that she's gonna have to come back for many looks. I haven't revascularized her yet so I didn't know if it was easier to just chunk over the colon like it is right now so I can do the bypass and then when we can do the colectomy when we come back in like mature a mucus fistula or Hartmann's pouch like later date, you know what I'm saying? Yeah. Probably easiest just to yank it out now. And I would think just give her like an ileostomy and you know, I would re-anastomose her, but if you're ready for us, we can come there now. That'd be great. Pop out, yeah. Cool. Okay, thanks buddy, appreciate it. Bye-bye. It's probably better anyway, huh? It's all coming from here. Do you have that stapler? Just staple across that. Can we have an Allis, please? I think we got it. It's okay. Do you have a bucket of irrigation? Let's just wash all this out again. This is better, right? Just get this outta the way and then we are gonna have to get that piece of bowel off of that colon no matter what. So the fact that there's a hole in the colon doesn't... I just, like I said, I know it seemed like we were being kind of aggressive around there, but the thing was gonna have to come off no matter what. And this is all ischemic so it's almost like they mobilized the colon before. See there's like blood vessels in there. There we go. Try not to expose her aorta bifem while we do this, right? Yeah. The Allis clamp. Do you wanna load that stapler? Good, yep. See there, like I said, I don't wanna expose. Careful there. I'm just not quite sure where that plane is. We'll expose it. This is our proximal, yeah. So, we just need to chunk it out right about there, right? Nice to leave some of this omentum. Let's take this off so we can cover stuff with it, you know what I mean? And just come across it here and we'll flip it this way we can use this at least to cover our graft and stuff. Still coming out of it. Hey so yeah, sorry man. I appreciate you coming. So, the problem was her TI was dead. I chunked that out 'cause at a huge, when we opened and once we got the adhesions lysed, there was a huge hole in that. But then she had like a fistula to here and in getting it off we were clearly in the colon and I mean her whole watershed area is bad. So my hope was, like I said, I got this kind of up. Do you mind scrubbing for a second? Make sure I didn't do any, do - it's been a while since I took it out, I just, when you come across this, what do you use the green thing or do you use? I just use the green. Okay. But then I was thinking we can leave her in discontinuity today. Is that cool? Because I'm gonna bring her back and wash her out anyway. I'm gonna revascularize her now to try to get, the rest of this is like, it's not, this should come back. Yeah, that's what I would always suggest. But it's all boggy so you can just see she, but this part here you can kind of see, this was all this part that was basically dead and had the hole in it. Yeah, just take all that. So, okay cool. Thanks. We still get to do this part, right? Yeah. We're gonna have to mobilize that a fair bit too. It might be easier just to move it up, you know. Right here is where we're going to. See? She's got a good pulse in her hepatic. Here's her hepatic artery right there. Feel that Jake? You can feel a thrill almost. Yeah. Like I said, I stapled because it was a big tear so I knew it was all gonna come out. So... So she just came in with... She'd actually been here for about a week. I've been giving her TPN 'cause she was kind of like acute on chronic and she wasn't peritonitic or frankly perf because it was all contained by her... Done a pretty good job getting it up already. Yeah, well for the most part. But you guys are going to help me put her back together so I don't want to steal all the fun from you. I appreciate you coming down here, Parker. Yeah, you guys help us more than enough. Yeah, I know, but... Yeah, I always think it's a good idea to leave these people... In discontinuity. In discontinuity. Well I called, when Shannon came down, I was and that being honest with you, I just wasn't really thinking straight. I was like, should we just take out this part of the colon and leave it? But she's like, well you're not gonna put the two ends of the colon. I was like, you know what, that probably makes the most sense so let's just get rid of this. And then when she can actually get a, like I said, she can get a Hartmann's pouch or whatever and then way down the road if she's okay, she can, she could have something put back together again. Well colon is always so iffy. Yeah. That's, yeah. I don't worry about taking a small bowel out. I was, I had already done that. But the colon, I figured it better to get experts down here. Kinda like when we put popliteals back together for you guys now because it makes more sense. No, you know what I mean? No I agree. In the old days it wasn't, but it makes more sense to have... So you guys still have to bypass her today? Yeah. I just think if I don't bypass her now, I'm afraid more of this was gonna, it's gonna fall apart on us. So we're gonna use cadaver artery and then if I need to do something more definitive with like femoral vein or something later we can do that. I think her big issue is she's had this chronic SMA disease but somebody did an aortabifem on her at the other hospital and took out her IMA. Double burn or no? We're gonna give her a bunch of heparin in a minute. Probably a good idea. We should have this thing out in like five minutes. You're fine. No, no, no, you're fine. I appreciate, like I said, I've called you and asked for help. I'm not gonna rush you along afterwards. She just need volume or what do you think? Well no, I think she's.... Getting a little septic? Exactly. Okay. Okay. May take out more after they... Yeah, right. Well like I said, we're gonna bring her back and wash her out a bunch so we'll chunk this out and I think if we wash everything out really good and then we change gowns and gloves and we go do like a bypass like we meant to do and then we'll try and get her through all this. We'll use the cryo today and then if she gets better, better, better and we really feel compelled, we can always switch it out for her own femoral vein. But it probably just should be fine. Yeah. Do you want us look through everything else real quick or? Yeah, you're welcome to. I think we straightened everything else out. Specimen. Okay, thanks. So you know we... LT here. Like I said all this is okay. It was really that TI and so I just chunked it out. You can see where it's ischemic even where I took it out there. It looks fine how it is for now though. Yeah, my thought was we'll bring her back tomorrow and I'll take a look at it again. If we get outta your guys' way. No man, you, you're great. I really appreciate it. Yep. All right, cool. All right, thank you so much. Happy to come back anytime. Yeah, like I said, we'll bring her back and wash her out and I'll let you know when I think she's getting like towards the end of the week maybe if things are looking okay and you guys maybe could mature... Yeah, I think we would bring up... Bring this up like a Hartmann's and bring this up like as an ileostomy. Yeah. Okay, thanks man. You guys are great. Okay, I'll take a Poole sucker. More? I think we're okay at the moment. Dry lap. DeBakey, something on top of the bladder there. Can I have the regular tip on the sucker now? I think it's just scar. I'm gonna put a lap down the pelvis. Let's get some gowns and gloves, everybody change out and we'll go ahead and expose the SMA like we normally would right there. And then that way we don't have to move the retractor. Like I like to do the SMA, then we can, we can start our tunnel a little bit. There's probably the bottom of pancreas, right? And then, yeah, that's good. And then we can just move the retractor. So we're up here and we only have to do it once, you know what I mean? Yeah. All right, good. We're gonna change gowns and gloves.

CHAPTER 4

Now we're gonna do the mesentric bypass. So we'll do the distal exposure first. Here we go. Jake, you can feel the plaque in her SMA right here and hard. Yeah. This is the tunnel retropancreatic tunnel that we're gonna use eventually, just getting it started. Just bluntly sort of finger dissect the pancreas up in the air just to the left of the aorta. Can I get the thin slotted thing? Forcep. Just think it's just scar, right? Let me have a Adson right angle. You feel it? So we open the mesentery up and down. In her the plaque kind of goes, she's got an anterior plaque that goes down almost to the main division into the ileocolics. So we'll just plan on exposing it all the way down there and even towing the anastomosis on it. There it is. Some lacteals. There we go. Vein, artery. Do we have a sterile doppler? Let's get it out and let's take a quick listen. Hey Jake Cross. Good. All right, it's open. Just as small as we expect. Probably all the more reason to use that SFA, right? Heather, can you plug my headlight in? Yes. There's that big division there. We'll probably just, yep. Nice. Probably good enough there, right? We just do it like right here, let's see what this feels like. Should be okay. Feel it, nice and soft. Okay. Let's just see if it's any bigger up here. There's a plaque at some point. Do you see the plaque of it? What's that? It's big. What's that? The SFA? Yeah. It's big? Yes. Oh, okay, still better than vein, right? The femoral vein though. I think there's no reason not to just do it right here, right? Yes. Okay. All right. okay. We gotta do the, we gotta get the proximal down anyway.

CHAPTER 5

All right, now for the fun parts. Can I lap please? Can you put the bed in a little bit of reverse Trendeleburg, please. That helps get the viscera down out of the way here, let's move this here. You can probably relax that Mayo body wall on your side too. Can we have the Mayo body wall now. Okay. Put a body wall on the ribs here, other way. Oh, did it? I'll tell you what, let's just get rid of it then. And let's use the, we have another mayo body wall? Oh, we have one down here. Sorry about that. You guys got an NG in, right Gary? My man. All right Jake, excuse me. No, no, no, I'm just, I'm gonna feel for it more than anything. All right. So we're gonna start mobilizing the left lobe of the liver here, take down the triangular ligament. This will let us fold it underneath. Can you gimme a handheld Deaver please? I like Dr. Oakland with the technique of using the sucker. No, I liked that. That was cool. Hold that for a second. Jacob, do you know what we gotta watch out for when you start mobilizing this ligament here? Do you get too far to the patient's right? I'm not ready for you. Can you run into the IVC real quick? No, the IVC's gonna be deeper. You can get into the coronary veins. Let's see, there's the NG. Here's aorta. We gotta go a little bit... You're good. Can I have a - and I'll take a big right angle. There's a vein probably right there. See? Okay, sorry Jake, you may have that big right angle back. Yeah hold that liver like that. Get your Bovie. Good. We've irrigated a bunch, more than we've bled. Like I said, you always have them put the NG in so you can feel, put your fingers right here. You can hear it. So that's where you know where it is, helps you find where the esophagus is, right? Gastrohepatic ligament. And I'm gonna free up your hands here in a second. Okay, there's the crus. All right, let's see now, I almost feel like we just leave her liver like this. It'll be out of your way. Let me have a moist lap folded in thirds. Thank you. So we're putting this long lipped retractor in. It's got a little lip, it's called a Kelly. Get that liver over. Okay. Let me have the thinner malleable now. And we'll start getting that crus off and then we'll be looking at our spot. Thank you. The only other thing somebody can look for would be the - aortic punch. A 3.6 or a 4 is fine.

CHAPTER 6

Forcep. Right angle. Go ahead. Good. Big right angle now. Yeah please. Jake get the sucker for us. Feel one more time. Forcep, let's go a little bit to your side of this crus here. Good. She's so malnourished, all of her tissue just kind of splits apart and it's her aorta right there. Okay. You got this. Make sure the esophagus is all the way over here. Now run that crus there. Divide that. Let me have a renal vein retractor. Okay, so we got the esophagus behind that. Take that right angle. This will be the stuff that makes the median arcuate ligament here at the bottom of this crus. Forcep. Can I have an Adson right angle now? This should be about the last of the median arcuate ligament. See that white stuff and then the celiac right behind it. Good. See the top of the celiac artery there. We're plaquing it but it's open, this way though, if we have to come back and angioplasty or celiac or something, we've got it released now, you know? Can you give me a metal tip sucker now? Get that last, this last layer. Good. I just work inside that. Good. Scissors. Do a little desuction there. A little Patterson desuction. Good. Nice. Right angle back. Some last vestiges of the crus there. Good. Just lift away from it. I got you, Jake. See there's just a little bit of that sort of perineural sort of, it's always thicker than you think. You can touch mine. Some scissors and... Just like that. Okay. Nice to get this whatever - 3-0 silks, let's tie this just in case there's a little phrenic branch in there. We may switch the retractor out on your side for something a little bit deeper and I think we'll be looking at it. Good, very nice. Good. Can I get the Adson right anlge? 3-0 silks. Probably the other end of that other thing there. Don't you think? Like I said, we'll get a little better retractor I think on your side to pull that last bit away. Scissors. Metz. Sorry. Good. That's the last of the arcuate ligament there. Okay, let's try and put this longer splenic in and see if we can show it to you better. Now we have a renal vein retractor the other one. We'll put something on the liver over there. That'll do it. Good. Suck in there Jake. Try locking that. Okay, let me have that Kelly back now. Right above that thing. Good. Dry lap. Pick up that edge of that stuff right there. Forcep. All right, let's see. Now maybe we can, I gotta make sure the esophagus is not in the way. All right, lock that. Let me see another Kelly now. So we're just trying to get all this sit up so we can put a side biting clamp on and sew it. Thank you. Lock that one. All right, forcep. This is Jake see, top of the celiac here we've released the median arcuate ligament. Here's the supraceliac aorta. There's no plaque here. It feels good. Lemme see a Satinsky clamp. We're gonna use a side biting clamp. Should work. Make sure we're not gonna hurt anything when we do that. Dry lap. Why don't you double load a pledge it on a 5-0 C1, should be correct on that plaque there. Okay.

CHAPTER 7

Just fixing a little adventitial tear on a plaque. Thank you. Can I have some more...? Is there a long Castro? We can go get some. Let see if the Castro you have, it may be long enough. That was your way right? Yeah. This'll work. Don't worry about it. Free pledget. There you go. Needle. Good, there we go. Let me have a big right angle. Scissors to Victoria. Let me borrow your sucker for a second.

CHAPTER 8

Do you have a fat umbo tape? Yep. Okay, I'll take that Satinsky clamp and then the fat umbo tape to her. Getting around the aorta here so that we can pull up and make sure that we get the whole aorta in case we have a problem with the aorta. It's nice to have this loop around it. So you can always put a side-to-side clamp down even though we're gonna try and do this with a side-biting clamp. All right. Lemme see if I can make a tunnel here. So behind the pancreas, right? Pancreas is up in the air here. Do you have that satinsky clamp back? And then a red rubber. Can you use an umbilical tape? We sure can. Thank you. Okay. Let's take a look at the conduit. It may be easier to tunnel it first and then sew it. You know what I mean? Let's take a look at the artery. You can go ahead and give her 5,000 heparin. Thanks team.

CHAPTER 9

It flows nicely. Okay, good. All right let's reinforce some of these big branches, don't you think? Yep, Let me have a fine right angle. I'll take the red cap back. So on these cryo tissue, the little things are sewn in by a very hardworking person that's probably up in the middle of the night and either trying to get into med school or as a PA or something. So it always helps to just reinforce 'em 'cause we don't want these to come loose. You can just stick tie it, yeah. Single stick tie is fine. Reinforce 'em and make sure they're not gonna bleed in that retropancreatic tunnel. Four? Yeah. Scissors. I'm not gonna need this whole thing, but there's a whole mess of branches down here so we probably sew these, right? Give her another 6-0 BV. So Jacob, we're gonna, it's gonna take about 20 minutes, 30 minutes. We're gonna sew this in and then we're gonna reperfuse her guts and she may be unhappy when we do that. We'll be ready. I appreciate it. You guys are doing great. Her pHs and everything are okay? Good. 7.43. Beautiful, wow. Last time we're gonna hear that for a while. Another 6-0. And get that one. I know this is tedious, but you know, if those little things pop off in the middle of the night, we're in the F zone. Good. Beautiful. Cut, nevermind. Dry lap. Thank you, awesome. You already got that one? No, I think didn't you already get that one? You get that one too? There's two knots on there. It must be that one, you're right. I'll probably get these two and these two and then I think we'll be below the pancreas. Get that. Did we get that one already? No. One more, God willing. All right. Potts scissors. Nice. Forcep. We'll just leave that little big branch you tied on top and we can... Looks good. All righty. Here's the vein back, or the artery back. Thank you. What I'm looking for. Oh, good eyes, thank you. I'll take that Satinsky clamp. We're gonna clamp partial. Okay.

CHAPTER 10

You got a hemostat? You can let that sort of fall to your side if you want. Just put it down there. 11 blade.

CHAPTER 11

Key is don't make this hole too big until you know that the clamp's got it. Hep saline on an olive tip. Yeah, just let it kind of fall outta your way there. I don't see a bunch of blood coming out of it. Punch.

CHAPTER 12

Punch. So I like taking an elipse of the aorta out with this punch. This is a four. Yeah. Just so the anastomosis stays open better. Especially when you do these side-biting clamps clean. I think we did a, did we do a cross-clavian together? We did the same thing? So I know it separated time until before and after for you. Pretty tasty there. Okay, let's go with the HS-6 suture and I'll take the artery back. And I can use that short Castro. She's not too deep.

CHAPTER 13

Thank you madam. Let's see. We may need that bigger needle after all. Wet her hands. Beautiful doctor. Oh it's so nice. Driver. Thank you. So we'll do this end to side. We'll anchor it in the heel and anchor it in the toe. Most important stitches are these ones back here on the heel. This is where we'll narrow it. Little short. Just take it in two until it's a little short I think for the hole we're working in. Get under the edge of that plaque. Like I said, it's okay, decent bite up here, right? We got the big old aorta. Okay, shod, here's your driver. I may open that up just a little bit. Gimme the punch back. Open it up, just a fraction more. I think we may get one more bite out of this bad boy. Thank you. Put that to my side. Good. Make sure I get a good... I can let go if I, if my hands are in your way. Here, I'll be back here. There you go. Oh I love it, that's tasty fresh. Look at that, nice bite. It's okay. Suck right up. Get that. Shod. It's come from the top. Can I see your sucker? Okay, another stitch to her. May I have another 4-0 C1. Good bite. Good. Do you like this needle or do you want a bigger needle? I think my concern is a bigger needle, we won't have room to manipulate in there. Good, good. Just keep going with that one, shod. Just do a little toe parachute here. Just 'cause we're working in a tight spot. Gives us more visualization of the anastomosis. Good. Let me get over here outta your way. Good, that way. Push down. You can just go right across it. Oh yeah. That was awesome. It's good. You got all three layers. Oh yeah, you're good. Push down away from the edge. Down and then, oh yeah. Money, money, money in the bank. The base of where that folded over. Yeah, I like it. I can get my hand in there. Uh huh. Another forcep. You hear that one? One more, where that little hump is yeah. Driver, thank you. You're great. This is a hard thing to do. That's why they don't do it in the small hospitals. Get that good bite and anchor that in there. Pull snug. Yeah, I like that. And push down away from the edge a little bit and take it. We're just gonna flush out the end of the grafts. So we're gonna go ahead and finish this anastomosis. We're gonna test your proximal. It looks good. We're gonna give you back the half clamp. She shouldn't notice too much 'cause she looks like she's doing okay even with the clamp. Gently. And get ready to suck while you do that. Ready? Okay, looks pretty good. Lemme see a Jake. Okay, relax, Victoria, let's have something for her to flush into. Tell me when you're ready. Ready. Okay, pinch it. Here comes your aorta, okay? That's not good. Let's see what's bleeding. Another, let me have a 5-0 C1. And then we're gonna need another one of those 5-0s with the double-loaded pledget like we had earlier. You want that now or in a second? In a second. Let's do the regular first. Move your sucker for a second. The aorta is being, misbehaving a little bit. Give Jake a bulldog to put on this graft. Is the metal one okay or you want to...? Oh it's not good. Metal one's fine. Forcep to me. Let's see if we can... You have a nerve hook? Forcep. Where was that little? Driver. Here's a needle. The other place that's bleeding is where we, the other side of where we put that pledget earlier up where the plaque was. There's something on the, my side of this anastomosis too, we'll have to fix. Why don't you hold that one. It's not good. Get this out. So see if it, we can see it better. Okay, let me have the pledget, loaded one. Oh periaorta's not liking it. Okay, let me have, we're gonna need a cherry clamp in a second. Okay, let's get this unraveled. Take that one. Okay, let me have a cherry clamp? I am gonna clamp for her aorta again. Okay, this is the one that's the other side of the one arm. This is this one. That's, which one is the other one I've got? This one. Which one? The one I'm holding. Okay. This is the one I just tied. This is the other side of this thing. It's just not in a shod. Let's cut that. Yep. Scissors. Okay, good. Here's a needle. Free pledget next. Pickup. Cut this. Thank you. Scissors. You have another double-loaded pledget in a second? Okay, good. Cut that. You can cut off your one on the side there too. Let's go ahead and get rid of all these. Okay Jake, let me see your sucker. Lemme see the metal tip sucker. DeBakey forceps. Let me see the double-loaded one. Hold that metal tip sucker. Thank you. Just put the clamp on so we're not tying under pressure, you know? Because it looked like she was not tolerating it very well when we, sometimes you can get away with just using the pledget supported, and tie it when it's still clamped but it was not gonna happen. It's okay, I got you. Free pledget next. Extra suture there. Thank you. Here's a needle, pinch. I'll take one more of these. Cut that. I can't quite tell where, I think it was right in here, right? Free pledget. Here you go. Hold that one please. Thank you. Needle. Okay, let's try again. Come off your aorta again, okay? Come also, Ellie. Better, got it. Much better. Bulb irrigation. Good. All right, what do you think gang? Huh? Pretty fun, right? All right. Ooh, look at that. It works. It works. You can get the bulldog. Give her a dry lap and a mark. Hear that? Beautiful.

CHAPTER 14

Okay. Let's take this out. Give her a Satinsky clamp. It's this one. Should go pretty easy. Beautiful doctor, that was a beautiful move. Nice and smooth. Let me have scissors. Cut this, Jake. There's a red thing. Got it. Good, good. Tilt that handle. Good. Good. Okay I'm gonna take the clamp off and make sure that it distends. Okay. So we just brought the graft through the tunnel. Retropancreatic into the mesentery down here. I'm gonna clamp it there. It's tense so it's not gonna be kinked and it's got pulsatile flow. All right, let's have the new net. Maybe like a quarter sheet or so.

CHAPTER 15

So which we can do, let me have a forcep please and an Adson right angle. Bovie to her. Just finish opening this up so that we can, the whole thing kind of lay in there and we can even close a little bit over it. Good. All righty, get the blunt Weity back. All right, let's take a short Yasar. You wanna pass the Fogarty proximally? You want to? Yeah, not far though. Can we get a two Fogarty? I'll take one more Yasargil, please. 11 blade. Somewhere there. How long since we gave the 5,000? It's been around, let's see... I'll take a barrel. 30 minutes exactly. Perfect, thank you. Are you gonna sew with HS-6 again? Probably just 6-0 BV, I think. You have the, do you have fine Potts scissors? It looks good. I like it, what do you think? Yasargil thing empty. We can go ahead and sew in all but the one half of it and just pass the Fogarty before we're done. You know what I'm saying? I like it to be a little bit redundant just so when she stands up and her bowel drops down, it has a rural room to give so we'll probably do it right here. Potts scissors. Because when you distend it, it always gets a little bit longer. What about that little mark, right? Perfect. Gets rid of those little branches. Ooh, these are nice scissors. Save that please. Hep saline. Flush that a little bit. Are we down where you fixed all these things? Close. Good. You don't have to kill it. Just sort of flush it out. Good. Can I have some Lewey forceps? I'm clearly not gonna do it with those big fat things. Thank you. Do you have a small syringe? Like a three or a one? I just dunno what else to do with my hand. Can you remove that a little, yeah. Thank you. Touch more. Okay. Okay. 6-0 BV to her. Okay, good. Moisture on the same side here. Right angle. And then I'll take two more 6-0 BV1s. I do. Shod. Let me have that two Fogarty. And the Yasargil thing, empty. Let me see the Fogarty? Four. Just passing a Fogarty over to make sure there's no acute component to this or thrombotic component to it. Nope, good. There was some spasm. Let me have the Yasar thing. Okay, hep saline. I just was real gentle. You know what I mean? I know you're gun shy 'cause you guys, you have your driver on that other one? Good, very nice. Okay. And then just make sure we keep that branch over on your side. We're just being above it. We should have plenty to be above it and we'll just go past it before we come from my side. Oh it's nice. Oh, I like it so much. Uh huh. Oh yeah, that's money in the bank. Shod to her. Thank you. Shod. New stitch, same thing. Shod. Good, that's good. I'm trying to ride that. Mm hmm. There you go. Suck it out real good now, Jake, let's call this, she's just kind of oozy. Okay, good. Good. Nice. Right above that branch, I love it. Can you have them get the hockey stick in here? Yes sir. Thank you. I think we - didn't we have the machine in here earlier, didn't we? Yeah, we still have it. Perfect. Mm hmm. All right, we're a couple minutes, Gary, from giving you back the bowel, okay? Yes, sir. Good. Oh sorry. It's okay. You on that anterior wall, that right there. Good. Flush, can I get the Yasargil thing? Just flush here too. We already passed the Fogarty and flushed from the other side. Good. Nice. Hep saline. Okay, just hold that little edge like so. Thank you. One more. Needle? Let's take off - Yasargil thing - yeah, take off those. Don't take off this one yet. I'm gonna take off mine. Here you go. Do you have a Jake? Just gimme a stick one, give me a 6-0 BV. Can I have another 6-0 BV1? Needle, pinch. Thank you. All right, I feel better about it now. You can use that. Give her an empty driver. I'll take scissors. This is the obvious one here. There's one here too, huh? I'll take that single arm. Okay. I'm not worried about those little things. I just want these two big branches here. Wet my hands. All right, you ready? Needle coming back.

CHAPTER 16

Come back to bowel, okay? Get the Yasar thing to Victoria. Good, she got good pressure. Oh yeah. Go ahead and take that off. Bulb syringe. Cut these, dry lap, plastic sucker tip now.

CHAPTER 17

All right, let's have the - that back. That mamba jamba there. We're gonna take an ultrasound. So this is the graft on top and then the native SMA below and then that's the anastomosis. That's where the heel of the graft meets it. And then it's a little hard to see 'cause it's bi- I just closed some of the mesentery over this, but let's see if I can show it to you this way. You can see the SMA distal there and that's the anastomosis there. Like I said, I closed a little tissue over it so it's not picking up exactly right. But a little bit of some platelet stuff in there. Okay, looks good. Let's have a regular doppler. She's oozy. Pinch, open, pinch. Sounds good. That sounds good. Really good. So that's out at the small bowel. See? Pretty nifty huh? I hope that picks up on the mic 'cause you can hear when I pinch the graft almost nothing, and then when we take it off the bowel sounds normal. All right.

CHAPTER 18

Looks okay. A lot of it's just gonna be her being raw, right? When I reverse her. Probably ought too, don't you think? Probably aught to, yeah. Can you give her a test dose of protamine please, Gary? If she tolerates it, give her, you can go ahead and give her 50, okay? And I don't know how, what her labs look like, or tag looks like, if she's coagulopathic, I don't mind you giving her some product.

CHAPTER 19

3-0 Vicryl, if you got it, it can be interrupted. We'll go look at everything. What's that? Needle down. Another of Vicryl? So now we're just closing the mesentery back over the graft just to give it some protection. We may drop some omentum on there too, although it won't do much good when they come to take her Hartmann's up. It'll have to get pulled up with it, right? Best to probably leave that alone then. Can you give her another Vicryl? See if you can just sort of tack. Good. Nice. Yep, good. Jake, get ready to cut. That looks better. Yeah, it's peristalsing better too. Get another Vicryl, one right in the middle there. We're almost done. We're gonna do a temporary closure so we can bring her back and wash her out. That's - yeah, one more right there. Just, I would just do this. 'Cause the rest of it, I think when they take out her colon, if we try to tether anything else down, it might rip it. You know what I mean? I just wanna look, run everything and see where this oozing is coming from. Good, thank you guys. All right, let's have some, a bucket of warm irrigation. We're gonna put a bunch of irrigation in guys and she probably, we probably lost five or 600. Great. You guys are the best. See if can see abdominal walls. All right, let's get the lights down here and see. It's just raw, I think. Let me just pack all this - dry lap. Another dry lap and we're gonna take 'em out before we leave, but I'm just packing for now so I can make sure there's nothing actually bleeding. Let's look at the bowel. Dry lap. DeBakey forceps. You have a 3-0 Vicryl? Okay, I got it. Good. Look how pink it is now. Bovie. Look at this even where we cut it earlier. It's like 50 times better already. Look how pink that is now. Put a Vicryl here? Serosal tear? It looks okay. Another Vicryl, 3-0 Vicryl, there's something... All this raw stuff is just oozing now, you know? Because it was hyperemic from not being perfused before. Let's go look up here. Look at that, huh? Cut this. This, umbo tape's coming back in two. Worse if it's just all the raw surface from where we did all the adhesions and that stupid LigaSure thing. Do you have the LigaSure? Let me have it. Lap, lap. How's the left colon? Looks good. Do you have a sheet of new net, you know where we had all that bleeding in the wall of the pelvis? You have a bulb? Sheet of new net. Is it okay if it's cut in half or you wanna? I'll take the whole thing. I think it's like right in here, isn't it? Kind of right around top of the bladder there. Big, big one will be good. The one that looks like a skirt, Yes, that's what I'm talking about. Let's get it up in that right lower quadrant too, huh? Okay, we're gonna put a wound vac in, right? Hold on. Give her a 3-0 Vicryl, put a stitch in that. I'm glad we figured that out now. Yep that's good. That's it. Give her a 3-0 silk next, do a little Lembert on that. Cut that. Cut it. Down there. Yep. Okay, good. Yeah, very nice. No, you just do one like that? No, no that's it. And then you tie it. Then you do another one next to it. Scissors, we'll come back and look at this tomorrow. Good. Good. All right. Scissors. Put a bucket of irrigation in here. And that sucker again. Good, another one, another bucket. So let's take a look. Sigmoid. It is just stuck over to that side. You have the scissors? See if we can free it up. Suction. Sorry kid. Almost like there's a fistula there too, you know? There should be nothing else over here. Another silk. Needle. All right, dry lap. Thank you. Another dry lap. We're gonna leave these two in. See all this looks normal now. Pulse is booming. I'll take one more lap. Let's look up here. She doing okay up there Jacob? She's good. Good, you guys are awesome. Want to pack it since we're packing anyway, one more lap please. Three wraps total, won't hurt. In? We're gonna leave three in, yep.

CHAPTER 20

Well that wasn't exactly what we planned when we were in the operating room. Immediately upon entering the abdomen, there was diffuse adhesions as one would expect after a prior laparotomy. It was pretty evident once we got into the right lower quadrant and we're starting to mobilize down there that there was an evidence of likely a contained perforation due to the dense adhesions, I think the perforation in the ischemic terminal ileum had been walled off and that's why she wasn't more peritonitic when she presented. As you saw in the video, once we had completely mobilized the entire terminal ileum was essentially dusky and infarcted leading to that major hole. We also secondarily found what looks to be an ileal-to-transverse colon fistula in the area of the ischemic ileum. While the colon in this area wasn't frankly ischemic, in taking down this fistula, it was clear we were gonna have to resect the colon and since the watershed area of ischemia was in the entire right colon, we went ahead and performed an ileocecectomy, got out all non-viable tissue. We've left her in discontinuity intentionally so that once the revascularization is complete, we can bring her back and do what's called a second look or even potentially a third-look laparotomy. The remainder of the case went well. Obviously once you shift gears and have contamination of the abdomen with enteric contents, you don't wanna use a prosthetic conduit. In this case, I elected to use a cryo-preserved superficial femoral artery as our conduit. This provides us autologous conduit but saves her the longer operation. As this was already taking more than I thought and I was worried about her getting septic and having a higher complication rate. We can always come back and replace that with her own femoral vein if there's any concern in the future. But this conduit appears robust, it's autologous and in the retropancreatic tunnel, I think it'll provide her a good patency. Once we had control of the bowel contamination and we had done the ileocecectomy, the rest of the case actually moved along as expected. We were able to identify the superior mesenteric artery where it was patent in the root of the mesentery. We palpated there was no plaque in this area and confirmed with a doppler that it was patent. Once we had good exposure here, we began our retropancreatic tunnel. We then moved our retractors, mobilized the left lobe of the liver, taking down the triangular ligament and making sure we stayed away from the phrenic veins. We then were able to open the gastrohepatic omentum, divide the left crus as well as some of the right crus fibers, and then take down the entire median arcuate ligament until we could visualize the anterior surface of the celiac artery. As there is sometimes along the bulky plaque around the celiac, we had a little bit of friability of the aortic adventitia, but was easily controlled with pledgeted sutures. We then did a side-biting clamp after appropriate heparinization. Did an autologous conduit as discussed after using the aortic punch, removing an ellipse of tissue. It went very nicely in the tunnel. We had pulsatile flow. We were able to do our distal anastomosis end-to-side. We then did a completion duplex on the table showing excellent patency of the anastomosis and interrogated with doppler at the edge of the small bowel, at the conclusion of the case, we now have triphasic doppler signals, which completely abate with clamping of the graft. All in all, an unfortunate for the patient finding of this necrotic and ischemic bowel that had already perforated, but it shows you how to deal with these problems intraoperatively and be ready to pivot to do the right thing. One might argue that you should do the washout and then bring her back for the revascularization at another time period. But my major concern is failure of the staple lines at the ends that were stapled off without revascularization. And that's ultimately why we went ahead and did that. We'll plan on bringing her back and wash her out multiple times until we appear to have control of the abdominal contents and any concern for microbacterial infection, and we will do our definitive closure of the abdominal wall as well as maturing over her Hartmann's pouch and her ileostomy once we feel like we've completely controlled all the contamination and once we confirm the revascularization is gonna be intact and she'll be able to heal her bowel. It is a great case, something to learn from. We're going to do our best to get this patient through this very difficult episode.