WELCOMWELCOMEE

EXPOSURE OF MAJOR EXPOSURE OF MAJOR BLOOD VESSELSBLOOD VESSELS

ProfessorProfessor

Abdulsalam Y TahaAbdulsalam Y Taha

20142014School of Medicine

Faculty of Medical SciencesUniversity of Sulaimani

SulaimaniRegion of Kurdistan

Iraq

https://sulaimaniu.academia.edu/AbdulsalamTaha

INTRODUCTIONINTRODUCTION

The work of the peripheral vascular The work of the peripheral vascular surgeon ranges widely through the surgeon ranges widely through the anatomy of the whole body and he is anatomy of the whole body and he is required to command a wide range of required to command a wide range of anatomical knowledge.anatomical knowledge.

Both diseased and healthy arteries may Both diseased and healthy arteries may be surprisingly friable, and rough be surprisingly friable, and rough dissection may cause severe damage and dissection may cause severe damage and be sufficient to jeopardize the result of be sufficient to jeopardize the result of the vascular reconstruction.the vascular reconstruction.

Exposure of Carotid ArteryExposure of Carotid Artery

The incision is The incision is placed along the placed along the anterior part of anterior part of sternocleidomastoisternocleidomastoid muscle as far as d muscle as far as the angle of the the angle of the jaw and passes jaw and passes slightly backwards.slightly backwards.

Exposure of carotid arteryExposure of carotid artery..

After incising the After incising the skin and paltysma, skin and paltysma, the SCM muscle is the SCM muscle is displaced displaced posteriorly and the posteriorly and the IJV comes into IJV comes into view. The anterior view. The anterior facial vein can be facial vein can be seen passing seen passing forwards.forwards.

The anterior facial The anterior facial vein is divided and vein is divided and the IJV is retracted the IJV is retracted posteriorly posteriorly exposing the CCA exposing the CCA covered with a covered with a layer of areolar layer of areolar tissue.tissue.

By dissecting along the medial By dissecting along the medial border of the CCA the superior border of the CCA the superior thyroid art will be seen and can thyroid art will be seen and can be encircled with a sling. The be encircled with a sling. The ECA can also be controlled in the ECA can also be controlled in the same way, care being taken to same way, care being taken to locate the hypoglossal n as it locate the hypoglossal n as it crosses the vessels high up in crosses the vessels high up in the wound.the wound.

The IJV is retracted posteriorly The IJV is retracted posteriorly and the vagus n will be seen and the vagus n will be seen between these 2 vessels.between these 2 vessels.

The descending hypoglossal n The descending hypoglossal n runs down the front of the CCA.runs down the front of the CCA.

The slings around the superior The slings around the superior thyroid and ECA can be used for thyroid and ECA can be used for retraction to expose the ICA retraction to expose the ICA more fully.more fully.

If it proves necessary If it proves necessary for more of the ICA to for more of the ICA to be exposed then the be exposed then the stylohoid m should be stylohoid m should be divided.divided.

More of the ICA can More of the ICA can be exposed by be exposed by division of the division of the digastric tendon or digastric tendon or subluxation of the jaw subluxation of the jaw in a forward direction.in a forward direction.

Exposure of vertebral arteryExposure of vertebral artery

An incision is made obliquelyjust lateral to the SCM

The IJV is exposed afterdividing the lateral

part of this muscle.

The IJV is retracted laterally The IJV is retracted laterally to expose the vagus n which to expose the vagus n which is also retracted laterally.is also retracted laterally.

The carotid art will be seen The carotid art will be seen medially and this should be medially and this should be dissected sufficiently to dissected sufficiently to allow medial retraction.allow medial retraction.

Dissection in the angle Dissection in the angle between the artery and vein between the artery and vein reveals the vertebral vein reveals the vertebral vein and behind it the vertebral and behind it the vertebral art crisscrossedart crisscrossed

by branches of the cervical by branches of the cervical sympathetic chain. sympathetic chain.

The vertebral v and The vertebral v and some elements of the some elements of the sympathetic trunk are sympathetic trunk are divided with downward divided with downward extension of the incision extension of the incision to expose the lower part to expose the lower part of the vertebral art of the vertebral art before it passes towards before it passes towards the vertebral bodies and the vertebral bodies and also to expose the also to expose the subclavian artery from subclavian artery from which it arises.which it arises.

For exposure of the distal For exposure of the distal vertebral art , an incision vertebral art , an incision should also be made along the should also be made along the line of SCM, which after line of SCM, which after exposure is retracted medially.exposure is retracted medially.

The dissection should proceed The dissection should proceed posteriorly, the CA and vein posteriorly, the CA and vein being retracted medially if being retracted medially if necessary.necessary.

The accessory n will be found The accessory n will be found crossing the levator scapulae m crossing the levator scapulae m , the upper part of this muscle , the upper part of this muscle should be divided with a scalpel should be divided with a scalpel passing an appropriate passing an appropriate instrument behind it to protect instrument behind it to protect the structures lying there.the structures lying there.

When the levator When the levator scapulae m has been scapulae m has been divided the anterior divided the anterior primary ramus of C2 primary ramus of C2 will be seen crossing will be seen crossing the cervical part of the cervical part of the artery. the artery.

Further access to the Further access to the artery can be artery can be obtained by dividing obtained by dividing C2.C2.

Exposure of subclavian Exposure of subclavian arteryartery

An incision is made lateralto the insertion of SCM.

The platysma and faciaare dissected to revealthe omohyoid m, lymph

nodes and fat. The lymphnodes and fat should be

displaced upwards.

The phrenic nwill be seen beneaththe deep facia overlyingthe anterior SM whichcan be felt as a band passingdownward and medially.

The brachial plexus willbe seen or felt laterally .

A curved blunt instrument isPassed behind the ant SM.

The anterior SMis divided carefullyprotecting the phrenic nerve which is best

performed by passing a sling around it.

Division of the ant Division of the ant SM reveals the SM reveals the subclavian artery subclavian artery and its and its suprascapular suprascapular and internal and internal mammary mammary branches. The branches. The vertebral artery vertebral artery can also be seen can also be seen mediallymedially..

Exposure of the distal subclavian and Exposure of the distal subclavian and proximal axillary arteryproximal axillary artery

The subclavian artery should be exposed as aleardy

described, the incision being taken across the

clavicle. This can be dividedas shown.

After division of the clavicledownward retraction revealsthe distal part of the subclavianart as it crosses the 1st rib andthe upper part of the axillary abeyond this.

Exposure of axillary arteryExposure of axillary artery

The middle part of theaxillary artery is exposed by

making an incision below the middle third of the

clavicle .

The skin and deep facia areincised and branches of the

acromioclavicular a can be seen coming through the

clavipectoral facia. The pectoralismajor m lies above and below

these branches.

The muscle fibers of the PMM are divided after tying off the

branches of the acromioclavicularartery. The axillary a can be felt in the depth of the wound and exposed by sharp dissection.One or two branches need to

be tied to expose it fully.

For more distal exposurethe pectoralis minor min the lateral part of the

wound needs to be dividedcompletely. Retraction is required

to access the artery.

RELAX

Exposure of brachial arteryExposure of brachial artery

This can be exposedthrought the upper arm by an incision

placed along its medialborder just behind the

biceps muscle.

After incising the skin and deepfacia the biceps muscle is retacted

anteriorly and the triceps posteriorly.The median nerve can be seen lying

superiorly to the brachial artery.

Further dissection will revealthe brachial vein which can

be retracted posteriorly to expose the ulnar nerve.

For exposureof the

bifurcationof the

brachial arteryan S-shaped

incision shouldbe made in the

antecubitalfossa.

After division of theAfter division of the bicipital apponeurosisbicipital apponeurosisthe brachial artery and the brachial artery and

its bifurcation into the its bifurcation into the radial and ulnar arteries radial and ulnar arteries will be seen where they will be seen where they

pass between the pass between the brachioradialis and flexor brachioradialis and flexor muscles. The median n muscles. The median n

and basilic v can be seen and basilic v can be seen posteromedial to the posteromedial to the

arteryartery..

Exposure of ulnar and radial arteriesExposure of ulnar and radial arteries..

The incisions are made

onthe anterior surface of

the forearm.

By dissection between the

brachioradialis mmedially and the

flexor carpi radialism laterally the radial

artery will be exposed along with

its associatedveins.

By dissectionof thepronator teresand brachioradialis m laterallyand the flexordigitorumsublimis mmedially theulnar arterywill be seen.

For exposureof the ulnarand radial arteryat the wrist theincisions shouldbe made asindicated.

The radial

artery isvery

superficialand

can be palpated

andexposed

easily.

The ulnarartery is alittle deeperbut again isrelativelysuperficialand can beexposed before it entersthe deepaspect ofthehypothenarmuscle.

Exposure of the ascending Exposure of the ascending aorta and arch branchesaorta and arch branches

Various incisions are madeto expose the AA and its

branches in the neck. The mostcommonly used is a vertical incision.

@A vertical incisionfrom suprasternalnotch to

xiphisternum.

@an electrical saw can be used.

@or a longRobert's clampand a Gigli saware used to dividethe sternum.

@after the sternumhas been divided it is

held apart by self-retainingretracter.

@the brachiocephalic v willbe seen and should be retracteddownwards to expose the aorticarch and the roots of the major

vessels.

@In order to expose thebranches of the aortic arch

in the neck a transverse limbis added to the vertical incision.

@By division of the SCMand anterior SM, the subclavianart can be seen and the phrenicN protected. This allows various

types of graft to be inserted between the AA & its branches

in the neck.

Exposure of the descending Exposure of the descending thoracic aortathoracic aorta

This is exposed throughan incision in the 5th or 8th inter-costal space ,

depending upon whichlevel is to be exposed .

The thoracic cavity is enteredby removing the rib and the lung

displaced forwards. The descendingaorta will be seen posteriorly.

Exposure of the lower thoracic and upper Exposure of the lower thoracic and upper abdominal aortaabdominal aorta

A midline incision is made in the abdomen with an extension throughthe costal margin along the 7th rib

for exposure of lower thoracic aortaand the 5th for exposure of the

upper thoracic aorta.

The rectus muscle and costalmargin are divided to allow exposure of the pleura which is then opened.

The diaphragm can be dividedeither transversely close to the

costal margin which avoids damageto the phrenic n, or vertically whichdamages the phrenic n but gives

much better exposure.

After division of the diaphragmthe thoracic aorta, liver, abdominal

contents and spleen can be seen.

An incision is made inthe peritoneum along

the lateral border of thespleen and colon.

The colon, spleen and pancreas aremobilized to the right which exposes

the AA and its main branches; the coeliacaxis, the SMA and the renal vessels.

The left renal vein can be seen crossing the AA.

Exposure of AA and its Exposure of AA and its branchesbranches

A: transverse incisionsB: vertical incisionsC: oblique incisions.

SMA

The peritoneum on the left side of theDJ flexure is incised carefully and the

bowel pushed to the right. This will expose the aorta.

Exposure of SMA Exposure of Exposure of SMA Exposure of AAAA

Alternatively a transverseabdominal incision can be used

with the same incision in theperitoneum close to the DJ flexure

in order to expose the aorta.

For retroperitoneal exposure theabdominal muscles are divided

and the peritoneum displaced toright. This will expose the aorta

and the Kidney.

Exposure of coeliac axisExposure of coeliac axis

The coeliac axisis exposed after

opening the abdomenthrough

a transverseor vertical

incision and openingthe lesser omentum.

After openingthe lesser sac,

the aorta is feltwhere the crura

cross it.

The crura aredivided to

expose the aortaand just above

the stomach, theorigin of thecoeliac axiswill be seen.

Exposure of splenic arteryExposure of splenic artery

The splenic artery is exposedby dividing the greater omentum

along the lower border of thestomach and displacing the

organ medially.

The artery will be seen runningalong the upper part of the

pancreas.

Exposure of SMA originExposure of SMA origin

An incision in theperitoneum lateral

to the colon and spleen.

The spleen, pancreas and stomachare mobilized to the right exposingthe kidney, the aorta and its major

branches and the renal veins. The originsof the coeliac axis and SMA and other branches

can be accessed in this way.

Exposure of SMAExposure of SMA

For exposure of the For exposure of the SMA lower down SMA lower down the intestine is the intestine is mobilized to the mobilized to the right and the right and the artery, along with artery, along with the SMV palpated in the SMV palpated in the free edge of the the free edge of the mesentery above mesentery above the jujenum. the jujenum. Incising the Incising the peritoneum will peritoneum will expose the artery expose the artery herehere..

Exposure of Exposure of hepatic arteryhepatic artery

Division of the Division of the lesser omentum lesser omentum allows exposure allows exposure of the hepatic of the hepatic artery as it artery as it crosses from the crosses from the coeliac arterycoeliac artery..

Exposure of Exposure of renal arteriesrenal arteries

The renal arteries The renal arteries are exposed using are exposed using a transverse or a transverse or vertical incision vertical incision after passing a after passing a sling around the sling around the left renal vein left renal vein which is pulled which is pulled downwardsdownwards..

The right renal a is exposed by incising the The right renal a is exposed by incising the peritoneum lateral to the duodenal loop and peritoneum lateral to the duodenal loop and

displacing it mediallydisplacing it medially..

Exposure of the Exposure of the iliac arteryiliac artery

An obliqueAn oblique

incision isincision is

made inmade in

the iliac fossathe iliac fossa..

To expose the iliac artery and vein the muscles are divided

and the peritoneum mobilizedmedially, taking care to avoid the ureter which crosses theBifurcation of the common

Iliac artery.

INTERNALILIAC

ARTERY

In order to expose this vessel, the common and external iliac arteriesare encircled with slings and pulled

laterally. This allows exposure of theorigin of the internal iliac artery which

can be dissected free with scissors.

Exposure of the IVCExposure of the IVC

The IVC is exposed by opening the patient's abdomen through a transverseor vertical incision, incising the peritoneum lateral to the duodenal loop

and ascending colondisplacing these structures medially to expose the entire vena

cava retroperitoneally.

Exposure of the Exposure of the portal veinportal vein

This is exposed in This is exposed in the free edge of the free edge of

thethe

Porta hepatis. The Porta hepatis. The hepatic artery is hepatic artery is

mobilized mobilized medially and the medially and the bile duct likewise. bile duct likewise.

The portal vein The portal vein lies behind these lies behind these

vesselsvessels..

Exposure of the Splenic veinExposure of the Splenic vein

As this structure lies behindthe pancreas it is best exposed

by incising the peritoneumlateral to the spleen.

The spleen is then mobilizedmedially and the vein will be seen

running along the back of the pancreaswhere it can be isolated if necessary.

Exposure of the superficial and deep femoral Exposure of the superficial and deep femoral arteriesarteries

A verticalor oblique

incision is made

in the groin.

The facia

overlyingthe vessels

is cutwith

a pair of scissors.

A pair of Laheyforceps is passedbehind the arteryand a sling passed

behind it.

Slings are similarlypassed around the

common and SFA and theupper branches of the deep

femoral arteries.

Exposure of Exposure of deep FAdeep FA

for extensive for extensive exposure of the exposure of the deep femoral deep femoral

artery the small artery the small veins which often veins which often

cross its origin cross its origin and lower down and lower down the circumflex the circumflex

femoral vein are femoral vein are divided and the divided and the

vessel fully vessel fully exposedexposed..

Exposure of the SFAExposure of the SFA

A verticalincisionis made in the

mid thigh

The vastusmedalis

and adductor longus

muscles areseparated and

the arteryexposed.

Exposure of the Popliteal arteryExposure of the Popliteal artery

A posterior S-shapedincision.

When the facia and fat have been dividedthe short saphenous vein will be seen. This

has to be divided to gain access to the poplitealfossa.

The medial The medial poplitealpopliteal

nerve and nerve and vessels willvessels will

be seen passingbe seen passing

between the between the two headstwo heads

of of gastrocnemiusgastrocnemius

muscle and aremuscle and are

surprisingly surprisingly superficialsuperficial..

For exposure of the aboveknee popliteal artery an

incision is made in the lowermedial part of the thigh along

the anterior border of thesartorius muscle.

The incision is deepened until the long saphenous vein can be seen

and should be protected. An incision ismade in the deep facia behind the vein

and the sartorius muscle retracted posteriorly.

Above knee popliteal arteryAbove knee popliteal artery

Using finger dissection the popliteal artery is felt in the

popliteal fossa lying anteriorlymedial to the vein.

Appropriate retractionallows a sling to be passedaround it to provide access.

The below knee popliteal arteryThe below knee popliteal artery

The below knee poplitealartery is exposed by usingan incision just behind thetibia, passing backwardsand slightly near to the

knee joint.

An incision is madein the deep faciaanterior to the

gastrocnemius muscle.

The gastrocnemius muscleis retracted posteriorly andthe soleus muscle can be

seen attached to the tibia. Thevessels passing behind it can be

felt above the popliteal fossa .

By dividing the tendon of thesoleus muscle where it is attachedto the tibia, the artery and vein can

be followed downwards. The artery in particular is crossed by

many small venous brancheswhich require careful ligation.

Exposure of Exposure of long long

saphenous saphenous veinvein

In order to In order to remove the long remove the long saphenous vein saphenous vein

multiple incisions multiple incisions are made along are made along the vein exposedthe vein exposed..

It is then removed byundermining the skin

bridges. The upper endof the vein can be found

first where it joins thesapheno-femoral junction from

where it can be traced by duplex ultrasonography and

marked before surgery.

The vein is then removedthrough a continuous

incision. This is probablybetter as it does less damage to the vein.

Exposure of the Exposure of the crural vesselscrural vessels

The posterior tibial The posterior tibial and peroneal and peroneal arteries are arteries are

exposed by further exposed by further detachment of the detachment of the soleus muscle from soleus muscle from the tibia until the the tibia until the peroneal artery peroneal artery

disappears through disappears through the interosseous the interosseous membrane half membrane half

way down the legway down the leg..

Exposure of the Peroneal arteryExposure of the Peroneal artery

1.The peroneal arteryis exposed the lowerhalf of the leg by an

incision on the lateralside.

2 .The fibula is exposedand a segment removed.

3 .Once the fibula is removed the artery can be seen behind it.

The anterior tibial artery

The anterior tibial arteryis exposed by an incision

over the anterior tibialmuscles.

By dissecting between themuscles the artery is founddeep on the interosseous

membrane. It can usually belocated quite easily by finding

a branch and following thisbackwards.

Anterior and Anterior and posterior posterior

tibial arteries tibial arteries at the ankleat the ankle

The incisions are placed over the dorsum of the

foot and over the posterior tibial

artery behind the medial malleolus.

THANK

YOU