DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right foot rest pain and tissue loss.
POSTOPERATIVE DIAGNOSIS: Right foot rest pain and tissue loss.
OPERATION PERFORMED: Right femoral to posterior tibial artery bypass with translocated nonreversed greater saphenous vein.
SURGEON: John Doe, MD
DRAINS: None.
SPECIMEN: None.
DESCRIPTION OF OPERATION: The patient was placed supine. The abdomen, both groins, and the right lower extremity were prepped and draped in the usual aseptic fashion. An oblique incision was made in the right groin. Common femoral, profunda femoris and superficial femoral arteries were dissected free from the surrounding tissue and encircled with vessel loops. The greater saphenous vein was identified at the level of the proximal thigh. The vein was of good diameter and quality. The vein was traced retrograde to the saphenofemoral junction. The vein was then mobilized from the groin wound to the mid leg. The patient was systemically heparinized. The vein was then harvested. The saphenofemoral junction was treated with a 5-0 Prolene stitch in the standard fashion. The vein was then placed in vein solution. The vein was distended and examined for defects. Small branches were ligated. No sutures were required. The vein was opened proximally. The proximal valve was excised. The vein was marked with methylene blue to ensure proper orientation.
Attention was then turned to the proximal leg. The below-knee popliteal artery was dissected free from the surrounding tissue in the standard fashion. The vessel was soft. No pulse was detected. The longitudinal arteriotomy was made. An attempt was made to pass a #3 Fogarty balloon catheter distally. If the catheter went easily, the anastomosis would be performed at this level. Secondary to the fact that the catheter did not pass distally, the dissection was continued distally. The tibioperoneal trunk was identified. The proximal peroneal and posterior tibial arteries were dissected free from the surrounding tissue and encircled with vessel loops.
The vein was then returned to the field. The common femoral artery was clamped with an angled DeBakey clamp. Straight bulldogs were placed on the profunda branches, and the superficial femoral artery was controlled with an angled DeBakey clamp. A longitudinal arteriotomy was made. Traction sutures were placed medially and laterally. The profunda origin was widely patent. The graft was sewn end-to-side to the distal common femoral artery using 5-0 Prolene suture. The running open technique was utilized. A single stitch was placed at the toe of the anastomosis. Prior to completion of the anastomosis, the area was flushed antegrade and retrograde. The vein was clamped with atraumatic plastic disposable bulldog.
Prior to starting the anastomosis, the vein was tunneled from the groin to the distal incision. An incision was made in the medial aspect of the distal right thigh and the popliteal fossa was entered. Following completion of the proximal anastomosis, the vein graft was allowed to distend. The LeMaitre valvulotome was used to lyse the valves. Brisk pulsatile bleeding was evident at the distal aspect of the vein graft. The vein graft was then clamped proximally with two separate plastic disposable bulldogs. The distal section was complicated by overlying veins. Several vein repairs were required. Dense plaque was noted at the tibioperoneal trunk. The longitudinal arteriotomy was made in the tibioperoneal trunk, extending into the posterior tibial artery. The Pruitt balloon occlusion catheter was used to control retrograde hemorrhage from the posterior tibial artery and the peroneal artery. The previous arteriotomy in the below-knee popliteal artery was closed with running 6-0 Prolene sutures. One stitch was begun proximally and distally and run toward the midpoint. The graft was placed in the appropriate degree of tension with the knee extended and cut to length in a bevel.
An end-to-side anastomosis was completed to the distal tibioperoneal trunk with the toe of the anastomosis on the posterior tibial artery. The running open technique was utilized. A single stitch was placed at the toe of the anastomosis. Prior to completion of the anastomosis, the area was flushed antegrade and retrograde. Following completion of the anastomosis, an area of hemorrhage was noted in the proximal posterior tibial artery. This did require several stitches to control.
The area was irrigated and examined for hemostasis. Topical hemostatic agents were applied. Palpable pulse was evident distal to the anastomosis. PT Doppler signal was evident at the ankle. The wounds were irrigated and examined for hemostasis. The wounds were closed in layers using 2-0 and 3-0 Vicryl sutures. The skin was closed with a 3-0 nylon vertical mattress stitches in the proximal portion. The remainder of the skin was closed with staples. A dry sterile occlusive dressing was applied. The patient tolerated the procedure well. There were no apparent complications. The patient was transported awake, alert and extubated to the postanesthesia care unit without incident. Triphasic posterior tibial Doppler signal was evident at the ankle and a biphasic DP Doppler signal was evident upon arrival.
