Conversion of Failed Right Leg Below-Knee Amputation to Above-Knee Amputation for Severe Peripheral Arterial Disease

CHAPTER 1

Hi, my name is Faisal Aziz, I'm a vascular surgeon at Penn State Health, and today, we are going to do an above-knee amputation. So this patient that we are going to do an operation today is an elderly gentleman with history of severe peripheral arterial disease. What it does is, that it stops the blood flow to the lower extremities. So this gentleman had multiple operations before to restore the blood flow to the leg. Unfortunately, all of them failed over the course of past few years. So a couple of months ago, he underwent a below-the-knee amputation. But, because of the poor blood flow, the amputation did not heal. So what we're going to do today is to do an above-knee amputation. Now when you will look at this video, there are multiple ways of doing the above-knee amputation. The key step, or one of the key steps, is to stop the blood flow. When orthopaedic surgeons perform this operation, or when this operation is performed on patients with normal blood vessels, normally we put a tourniquet above the level of the amputation, so that I can squeeze and stop the blood flow, so the surgery can be performed without much blood loss. In this individual, he already has naturally-blocked blood vessels, so we're deciding not to put a tourniquet on. And he al'so has some stents higher up as well, so we're deciding not to put a tourniquet on, and our goal would be to do it expeditiously. He also has a history of a prior knee replacement and prior hip replacement, which means there's a metal in the hip joint, and there's a metal in the knee joint. So what we are going to do today is to find a place in the femur, suitable, in between these metallic reconstructions before, that we can perform our operation and remove the leg. The key steps today would be, as I mentioned before, is to not use the tourniquet. And our goal would be to cut down to the healthy tissue and find the femoral artery and find the femoral vein, and make sure we tie them tightly so they don't bleed, and remove the distal part of the leg.

CHAPTER 2

[No Dialogue.]

CHAPTER 3

Start from here, okay. Incision. Making an incision. What time was this Argatroban drip held, was in the morning, right? About 6:30 AM. 6:00 AM, I believe. Okay, what time is it? Right now it is 10:30. For four hours, okay, go, that's fine. Do the muscles. Straight line through, straight line. That too. This blood vessel. You see some edema because of the infection... Do you have a Kelly clamp for me? Let me see if we can try it. Now we use a tip of the... Thank you. Ensure that there's no named blood vessels or branches. You have 3-0's and 2-0's? Do you have a silk stitches as well? Like 2-0's and 0? Anything? Everything is a palm. Got a lot of muscle. Yeah. There's so much edema. Lift it up like this. Do me a favor, make the next line further The bleeders, suction there for a second. Okay, I'll go to about here. It's a fishmouth incision. Knife back. Bovie. Thank you. Look at me for a second. Mop it up for a second. Do we have blood in the room available as well? Yeah, we have... He may need, I mean watch his pressure as well. He may need a unit or two. Have you seen the artery or vein yet? It's further below. Okay, do you have a Weitlaner for me? Another Weitlaner for me. A Metz and DeBakey. I'll take a DeBakey. Thank you.

CHAPTER 4

So we're trying to look for artery and vein to make sure they're surgically divided. Back to me. So trying to look for artery and vein, I think they're here. Metz and DeBakey. Are we there? Okay, so that's the artery and that's the vein. I normally would've tucked both arms. Do you have a retractor, Army-Navy or something? Lana, can you come on top there for a second? I'm gonna ask you to retract this, retract this. Metz and DeBakeys.

CHAPTER 5

So that lead pipe is the artery, That's the vein. Both are gonna be extremely bloody. You have a right angle for me? So we're gonna do them separately. Suction. Hemostat for me. Hemostat. Metz for me. Right angle for me. So isolating the femoral artery and femoral vein. Hemostat, curved. Metz. Okay, 2-0 silk stitches. Looks like it's trying to run somewhere. Trying to run away. Drew, hold the right angle towards you. Very gradually, relax there. Come off. Good. See the artery's coming with it. Can you remove the plaque with it? With a DeBakey. Can you remove the muscle away from me so I can know where I'm tying? No, below that, thank you. Cut. Do it, go ahead Drew, I don't think she can see. Take this. Yeah, do you have a 2-0 silk tie? Yep. Drew, go ahead, tie this. Did we find the knife or not? Can you ask Rachel if she can find it or? Yes. Retract, and dig in, you know what I'm saying? Retraction is this, go back, go back. Retraction is this versus retract and then dig in, okay? Can you do that? Thank you. Come off. Can you readjust the Army-Navy, Drew? I have to see, otherwise it's gonna attack the muscle to it, it's not gonna be good. I'm gonna ask you to hold that. I got it. 2-0 stick tie for Drew, needle down. Okay. So now that's about it, that's good.

CHAPTER 6

We're ready for the big knife, you know? Knife down. All right, do you have retractors, the rake retractors? All right, Leanna again, I'm gonna retract this towards you. One more, yeah, one more. Got it? Okay, yeah, we got it. We're good. Bovie. Can we have bone wax as well? Drew can you retract? It's fine. On the bone, on the bone, thank you. This way, because as you know, the shorter the bone, the better it is. We have the periosteal elevator, the big one. How about try that, will that Cobb work? I can get another. No, it's okay, we'll suffer. Okay, do you have a Kelly clamp? Yep. Retract like this for a second. Light, if you can shine that light here. The light right there. John, still looking for the knife? Wow. Okay, get the saw ready to go. This is towards here. Just like that. Get the suction ready, it's gonna bleed. Artery and vein right there. Where were their ties? They're further away? Okay, we're ready for the saw. I'm gonna take it off. Saw is on. And do you have the irrigation? Yep. Liana, this is absolutely important. What are you doing Liana? You retract like this, that's it. Now you're gonna irrigation and saw, right? So let me go all the way here. Retract this. Suction.

CHAPTER 7

Hemostats for me. Can you hemostat? That's just the bone. Nothing else. I think you got it. Okay. Usually the knife would've been so easy, you know what I'm saying? Yeah. Okay. Skin knife for me. Go ahead. Skin knife for, hold on a second. You have the big bone hook? I do. Okay. No Drew, join the lines below. Make sure you connect the dots. Go as deep as you can because we don't have a big knife. Want table up? You can have table up. Yeah. Can we have table up, please? Table up, just a little bit. All right. Enough? Yeah, that'll work. Can you give him a unit of blood probably as well because a unit of blood... Yeah. Go deep. All oozy. Very oozy. I mean losing his blood in the remaining portion of the leg. Go deep. Yeah, I'm buried. Straight line, like don't curve. Okay. Enough. All right. We're connected. Okay, lift it up for a second. This is the part of the operation where it really helps to have... The big knife. Big knife here, but we don't, so... And the minute we're done they're gonna say we got it. Hold it like this. Okay, turn the Bovie up. Coag 60, please. Coag going to 60. Watch the hook. I need a third hand. It's okay, now you can relax just a little bit. Not that much, but... Hemostat. Hemostat. More hemostat. This is sciatic nerve. You have 1% lidocaine by any chance or not? We have it in the room. I can get it. Get it. And then do you have a right angle for me? The 1% Lidocaine, John. Hemostat. Thank you. Okay. Okay.

CHAPTER 8

And a specimen. Can we get a bump? Okay. 2-0 silk ties. You can damage the muscle if they're not in the right spot, you know? So what you're doing is you're not on - if the bone, you know, see the sharp. If you, just as, on the muscle, they crush the muscle. When the amputations don't heal, we wonder what happened. Everything okay up top guys? Yep. He's hypotensive. Well I know he is getting blood. He on a little norepinephrine as well. Can you give him blood? Some volume as well, 2-0 silk ties. Let's go. Can you give him some Norepi? Yes. Thank you. Give him some volume. Give him some unit of blood. I'm not opposed to giving two units of blood either, to be honest. Can you turn the coag up to 80, please? Finger. 2-0 stick tie for me. Okay. You have a bump as well. Like how about the plastic container, do you have that? I have this and I have the container, whatever you want. We'll use a combination of both. Okay. Needle down. Yeah, give us a bump. Here's this. Dry towel for me. Thank you. Alright. Pressure. It went down further. I know. Can you give some more volume more? He's getting volume. He has a bad heart, TAVR, all those things, you know. Yeah, I know, I'm aware. - I know you're aware but it's trending the wrong way. 2-0 silk stitch. Thank you. Thanks. Give some, free for volume as well. I know it's a... Just stop suction for a second, pull it up. So I would give some volume as well if you don't mind. Yes. I'm giving the volume right now. Perfect, thank you. Because I think presses will make it falsely elevated as you know. Right. That's a number. That's amazing, when he was hypotensive he was not bleeding anymore, you know what I'm saying? Suction please. That's the response is usually always bleeding. Drew, the skin you cut is irregular, what happened? Think it's our gap, probably, causing it? Do you have bone wax? Okay. Okay. Do you have irrigation? Lemme see. Gimme a basin at the bottom. Even the blue one is fine. Thank you. Slow, slow. We have Vicryls, right? You have 0, 2-0, and a 3-0 right now, all round. I'll take 2-0 Vicryl, is fine. Do you have a 2-0 Vicryl?

CHAPTER 9

Can you put the light there for a second? Go ahead and tie. You got the facia picked up or not? Go ahead tie. Thank you. Scissors. Drew always do with a finger down. Please. How many knots? Four. Good. Always finger down, always finger down, right? Because it becomes a habit. Dropping again, huh? Just a little bit. Lemme show you something. So whenever you tie, just watch my fingers, right? It's just like, it becomes a habit for blood vessels especially, you know what I'm saying? It just secures it and you can sometimes if it's deep in the belly, you can just change the angle, change the route and it just gives you a more precise, you know, idea to not go down, do you know what I'm saying? Alright, so let's keep going. It's called technique of successive bisection, right? Dividing everything into half, half. Let go for a second, lemme see if this is the facia. Yeah. Yeah, that's good. Go ahead, tie. Okay. Finger down, finger. Pressure is 83. Thank you. Needle down, everything is a pop off, just have to put more pressure. 2-0. You have to fix the doggie ear, huh? Okay. Needle down, Adson with teeth times two and do a bump and a stapler, the kidney basin is fine. Two Adsons with teeth and a stapler. Drew, so push deep and squeeze. Do you have a skin knife for me for a second? Uh-huh. Hold it up at on your side. This is a fresh blade. Up so I don't cut the other side. Push deep, squeeze. Push deep and squeeze. Push deep. Put multiple. Here. Staple here. Right next to mine. Okay. Hemostat for me. Marking pen. Skin knife for me to make - because I think I have... All right. I don't wanna, I'm not sure if I drew one line. Multiple lines, right? Knife down. 2-0 Vicryl. Doggy-eared, but I think it looks better. May need some more cutting to this. Adson - DeBakey to me. Can you Bovie there? Yeah, can I have the Bovie? Pressure up. DeBakey. Needle down. Adson with teeth times two, stapler. Add the stapler. Yeah. Let's see. Out of staples? No, we're good. Excited. Thank you. Do again. Looks okay, yeah. Wet. And how about I'm gonna cut the drapes a little bit. Okay. Give me a wet dry first and then put dry towels. I think we stayed below the nerve stimulator. For dressings, fluffs, four by fours. Kerlix, big mama ACE wrap. Do you have more four by fours? Yep. You want these? More. Even more. Another pack of four by's. And two Kerlix. Two Kerlix. And one big mama ACE wrap. Lemme see the leads for the nerve stimulator are up. That's good. Okay, let go for a second. Let's see how it rolls. Okay, we're ready for the big mama. Probably Ioban is a good idea, it's gonna keep falling down. Make sure we stay out of the nerve stimulator baby. I think we're gonna use Ioban as the tape, you know what I'm saying? Okay. The tape that you had, a small piece of tape. Thank you. Can you gimme the Ioban? Do you wanna lift it up for a second? Come down. One more Ioban of same size as well. Go one from top to bottom. Huh? Hold on a second. So nerve stimulator. It's okay, I got it. Alrighty, well thank you for your help everybody. Thank you. Thanks everybody.

CHAPTER 10

What we did today was, we chose a fishmouth incision. What essentially it means is, is that, as you saw in the video, there are two curves. One in the anterior aspect, one in the posterior aspect, we called it a fishmouth incision. And I think overall it went pretty smooth. We were able to cut the skin first and the subcutaneous tissue. The muscles in the medial and anterior compartment of the leg, we divided with Bovie cautery. Then we were able to find the femoral artery and femoral vein. We tie them off separately. The key step is to make sure that we tie them separately because if we tie them together, that can lead to an arteriovenous fistula, which can lead to other complications down the road, including congestive heart failure. So as you saw, we identified them separately. We tied them off separately and cut them off. The next key step was to find the suitable portion of the femur bone and to divide it. And as you saw, that we kept the edge of the femur bone actually way higher than where the incision was, so we can have a nice flap to close over the femur bone. We divided the femur bone and after dividing the femur bone, we then divided the posterior compartment muscles. Usually we use it with a bluntly, with a sharp knife. Today we did not have the knife available, so we end up using Bovie cautery to divide the posterior compartment muscles. And then we also find the sciatic nerve. We injected lidocaine in the nerve so that made sure that the postoperative pain control is a better strategy with that. And then we sharply divided the sciatic nerve. We cut the leg and sent the distal leg as a specimen. And then as you saw that we saw multiple bleeding points in the muscles, which we each either controlled with stitches or with Bovie cautery. And after adequate hemostasis was achieved, we were able to close the posterior and anterior muscles by approximating the fascia of the muscles together. The skin we closed with staples. And as you saw that in some patients, like this individual who hasn't walked in a long period of time, that the medial edge of the amputation site was not symmetrical. So we had to extend the incision a little bit and shave off the extra edge to make it symmetrical. We close it off with staples and then put the dressings on. First and foremost is the indication of the operation, making sure that we have ensured enough blood flow to heal the level of amputation. So before this case, we had a long discussion with our team a few days ago as to what is the level of amputation. And during the operation as as you saw, first of all, we have to make sure the blood pressure is okay and the heart rate is okay because when we are removing the leg, we are also removing all the blood, which is inside the leg as well, which can be quite a lot of blood, which can lead to acute blood loss, anemia, and low blood pressure. So first and foremost that's more important. Secondly, as you saw, when we are cutting the muscles and the subcutaneous tissue, we just have to be careful to make sure that we are not burning the skin, for example, in the anterior edge. When we divide the muscles with Bovie cautery, we have to make sure that all bleeding points are adequately controlled. And make sure there's no hemorrhage. When we are dividing the main artery and main vein, we just have to be very careful that we don't tie them up together. We have to make sure we find the artery and the vein separately, cut them separately and put stitches on them separately. Because if that stitch becomes loose or it's not tied appropriately, that can lead to hemorrhagic shock. So that's the second point. And then we have to divide the femur bone very carefully. Many times we have seen that if the electric bone saw is deeper, then the bone, it can actually cut the posterior compartment muscles, which leads to different other problems including non-healing. So we have to be very careful when we're cutting the bone, we're just cutting the bone and not anything else. We also raise the periosteum on the bone as well to reduce the risk of periosteum formation down the road. And then after the amputation is complete, we just have to make sure that we all control all the bleeding points very, very accurately. Another thing, interesting thing for vascular patients is that they're needing an amputation because of a lack of blood flow to begin with. So we cannot put super tight stitches all across. So what you saw today was, we loosely approximated the fascia of the muscle so we're not choking on the blood flow to the muscle. So we use interrupted layers. And then for skin, we just use staples. So basically it's a two-layer, very relaxed in a way that it does not reduce the blood flow that would be required for healing. Whenever an amputation happens, it's a life changing event for a patient because the person has to relearn the whole act of walking once again. And it's the kind of operation which no surgeon wants to do. It's my least favorite operation to do an amputation. But postoperatively, our first goal is to make sure the pain is adequately controlled. So for this specific individual, as you saw, we injected the sciatic nerve with lidocaine. We also had nerve stimulator placed before the operation, so the nerve stimulators are present already. Postoperatively he'll be hooked up with a stimulator so that that controls the pain. So that's first and foremost. For the first 24 to 48 hours, we will watch him very closely for any signs of bleeding. And then subsequent to that, my plan is to keep him in bedrest tomorrow and then day after tomorrow, postoperative day two, we'll get physical therapy on board to assess him as to how strong his shoulders and his arms are to be able to use with a walker. And every human individual is different. Some people need more support, some people need less support. So we will see how the assessment is and how soon can he be safely discharged from the hospital. Majority of the times after leg amputation, people will end up in a rehab place for a few weeks to make sure that they strengthen up their upper body so that they can support the act of walking. And normally we take the staples out at about four-weeks time period as well. And that point in time we start using the shrinkers for the stump, which essentially shrink the stump. And eventually, very soon, a few weeks later, we will refer him to a prosthetic company, which we use here, which will fit him for the prosthetic. Initially temporarily, and then once he starts using the prosthetic in a routine basis, then they mold it and make a special prosthetic just for him so he can walk around. Amputation is a major operation, as I said before, it changes the patient's life forever. But important thing to remember for the audience is that amputations are associated with significant lifestyle changes. Also significant immobility down the road. And mortality. The literature shows that patients who go above-knee amputation as compared to those go undergo below-knee amputation, have a much higher risk of dying within 30 days and within 90 days. It's not because of the operation itself, it's because of the fact that, anybody who needs an amputation of the leg at such a high level, has such a profound underlying disease that put them at a high risk of cardiovascular morbidity and mortality.