Aortic Aneurysm Repair

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Aortic Aneurysm Repair par Mind Map: Aortic Aneurysm Repair

1. Profile

1.1. THI

1.2. ~60 yr old male [Caucasian]

1.3. September 1 (1:15 - 3:30)

1.4. AA Repair

1.5. TMC Biodesign Fellows Observing (x8)

2. People

2.1. Surgeon (Right side of table)

2.2. Assistant (left side of table

2.3. Scrub nurse (Right side of table): Delivering items to surgeon

2.4. Anesthesiologist x4: Responsible for BP, Temp.

2.5. Circ Nurse: Bringing new items to sterile field.

2.6. Perfusion Specialists

3. Product

3.1. Surgicel (used for hemostasis) - nurse cut these into smaller pieces)

3.2. Laparotomy pads (used to stuff abdominal cavity as a check for extent of bleeding pre-closure)

3.3. Chest tubes (2)

3.4. Sutures

3.5. Staplers (3)

3.6. Green leaf (guard used to protect organs during closure)

3.7. Vancomycin (?) - antibiotic powder sprinkled on organs

3.8. Bacitracin (?) - antibacterial topical agent

3.9. Ioban incise drapes (barrier to bacterial contamination)

3.10. Dacron graft

3.11. Cauterizing pen

3.12. Ultrasound machine

3.13. Forceps (both ends were used)

3.14. Clamps

3.15. Retractor (holds abdominal cavity open)

4. Place

4.1. OR @ THI, Very well-lit yet cluttered

4.2. picture goes here

5. Process

5.1. 1:15

5.1.1. Assistant unclamped aorta after completion of Dacron graft insertion

5.2. 1:27

5.2.1. Inserting lap pads in all areas

5.2.2. Removing lap pads and checking how much blood

5.2.3. Waiting while lap pads are in cavity

5.2.3.1. Why is this a problem?

5.2.3.1.1. OR Time

5.2.3.1.2. Patient cooling and drying out

5.2.3.1.3. Under additional anesthesia (uncertainty point)

5.2.3.1.4. Room for error / subjective decisions

5.2.3.2. Why does it happen?

5.2.3.2.1. Can't visualize where bleeding is coming from

5.2.3.2.2. Not a discrete source; not a "gusher"

5.2.3.2.3. Depending on pressure force to reduce bleeding

5.2.3.2.4. Coagulation

5.2.3.2.5. Don't check for bleeding until the very end.

5.2.3.3. What do they need?

5.2.3.3.1. Surgeons need a way to distinguish between surgical v. non-surgical bleeding in order to

5.2.3.3.2. Surgeons need a way to identify severity of non-surgical bleeding

5.2.3.3.3. Surgeons need a way to rule out surgical bleeding

5.2.3.3.4. Surgeons need a way to minimize the time to identify critical bleeds in order to reduce time to close.

5.2.3.3.5. Surgeons need a better way to control localized coagulation

5.2.3.3.6. Surgeons need a better way to minimize heat loss during open surgery.

5.2.3.3.7. Surgeons need a way to minimize desiccation of tissue during closure.

5.2.3.3.8. Surgeons need a way to identify surgical bleeds as they occur.

5.2.4. Remove lap pads and check amount of blood in pad and match it to where it came from in cavity

5.2.5. Tissue noted to be desiccated after lap pad removal

5.2.5.1. Long period of open abdomen allows insensible losses/dehydration/volume loss

5.3. 1:28

5.3.1. Assistant suturing ?something

5.3.2. Perfusionist signalled to circulating nurse

5.4. 1:30

5.4.1. Anesthesiologist typing in computer drugs administered

5.5. 1:32

5.5.1. Scrub nurse cutting Surgicel into smaller squares

5.5.1.1. Why does this happen?

5.5.1.1.1. Doesn't want to open another packet.

5.5.1.1.2. Wants to save money.

5.5.1.2. Why is this a problem?

5.5.1.2.1. Extra step for the scrub nurse

5.5.1.2.2. Could potentially cause delay in surgery.

5.5.1.3. Needs

5.5.1.3.1. Scrub nurses need a way to accurately size Surgicel to their requirements.

5.5.1.3.2. A way of stopping localized bleeding with an efficient use of resources.

5.5.1.3.3. A way of stopping localized bleeding w/o affecting post-op imaging (e.g. CT).

5.5.1.3.4. Surgeons need a way to control diffused bleeding while minimizing harm.

5.5.1.3.5. Surgeons need a way to accurately position Surgicel.

5.5.1.3.6. A shapeless coagulate (e.g. foam, liquid).

5.5.2. Surgeon adds Surgicel to field to assist in stopping local bleeding

5.6. 1:34

5.6.1. Surgeon cauterized pinpoint spot on bowel

5.6.1.1. Uses bovie with long tip

5.7. 1:35

5.7.1. Repositioned retractors

5.8. 1:49

5.8.1. Nurse crawled under drapes to doppler distal leg pulse

5.8.1.1. Why was this a problem?

5.8.1.1.1. Nurse had to disrupt sterile field

5.8.1.1.2. Time consuming

5.8.1.1.3. Poor visualization

5.8.1.1.4. Inaccessible

5.8.1.1.5. Higher chance of accidents/pulling leads/lines

5.8.1.1.6. Occupational hazard for nurse

5.8.1.1.7. Unreliable measurements

5.8.1.2. Why does nurse need to crawl on floor?

5.8.1.2.1. Distal pulse needs to be confirmed to rule out technical error of anastmasosis.

5.8.1.2.2. No easy access to distal pulses (fully draped)

5.8.1.3. Need

5.8.1.3.1. A surgeon needs non disruptive way of confirming distal leg pulses after an aortic operation that does not disrupt sterile field

5.8.1.3.2. Surgeon needs a way to confirm that distal pulses are intact in real time throughout operation

5.8.2. Surgeon unscrubbed, stepped out of room

5.8.2.1. Why are the surgeon loops so expensive

5.8.2.2. Why do you need multiple lenses for multiple objectives

5.9. 1:53

5.9.1. Assistant cleans hands with wet lap pad

5.10. 1:56

5.10.1. Repacking with lap pads, using two suctions to pack lap pads

5.10.1.1. How do you make the call that it has stopped bleeding sufficiently

5.11. 2:04

5.11.1. Cauterizing diffusely in left upper quadrant

5.12. 2:06

5.13. 2:15

5.13.1. Surgeon steps back in room and scrubs in

5.13.2. Surgeon and assistant start looking at spleen

5.13.2.1. Why did they need to take the spleen out

5.13.2.2. Was it pre-planned?

5.14. 2:17

5.14.1. Start to clamp spleen

5.15. 2:18

5.15.1. Tying off splenic vessels

5.16. 2:20

5.16.1. Spleen removed (scissors), handed off to scrub nurse and placed on back table

5.16.1.1. Why was spleen removed?

5.16.1.1.1. Inability to control bleeding

5.16.1.2. Why was this a problem?

5.16.1.2.1. Immune complications postop

5.16.1.2.2. Longer surgery

5.16.1.2.3. Medical/legal liabilty

5.16.1.2.4. Cost

5.16.1.3. Needs

5.16.1.3.1. Surgeon needs a way to control splenic bleeding without removal of spleen

5.16.1.3.2. Surgeon needs a way to localize bleeding around splenic area

5.16.1.3.3. Surgeon needs way to differentiate splenic bleeding that stops vs those that wont stop

5.16.1.3.4. Surgeon needs a way of avoiding splenic injury during aortic replacement

5.16.2. Sutures tied around clamp after spleen removed

5.17. 2:21

5.17.1. Spleen sent off to pathology

5.18. 2:21-2:26

5.18.1. More packing and checking with lap pads

5.19. 2:26

5.19.1. Vancomycin? powder sprinkled over field

5.19.2. Waiting while lap pads in place

5.20. 2:29

5.20.1. 1-2cm skin incision

5.20.2. Suture placed twice around incision

5.20.3. Punched clamp through incision

5.20.4. Chest tube fed into tip of clamp

5.20.5. Clamp pulled out of body with chest tube (high force)

5.20.6. Cut end of chest tube

5.21. 2:32

5.21.1. Assistant retracts tissue and suture passed around top/bottom rib

5.21.2. Needle cut off of end and clamp placed on  two ends, laid off to side

5.22. 2:33

5.22.1. Soft chest tube coiled around and placed deep in abdomen

5.23. 2:34

5.23.1. Green leaf inserted/removed/inserted into abdomen

5.23.1.1. Why was green leaf inserted into abdomen?

5.23.1.1.1. To protect bowel during wound closure

5.23.1.2. Why was it removed intermittently?

5.23.1.2.1. At times was getting in the way or covering too much of field

5.23.1.3. Why is this a problem?

5.23.1.3.1. Green leaf isn't doing it's job completely to protect bowel

5.23.1.3.2. Risk of injury on insertion/removal

5.23.1.4. Needs

5.23.1.4.1. Surgeons need a way to protect bowel while closing fascia all the way until full closure

5.23.1.4.2. Surgeon need a way to manipulate needle/suture and protect bowel without placing hand in field

5.24. 2:37

5.24.1. New bag of blood hung by anesthesiologist  who rolled back to force in at higher rate

5.25. 2:40

5.25.1. Begin suturing diaphragm

5.26. 2:45

5.26.1. Begin taking off clamps from rib sutures and tying down

5.27. 2:49

5.27.1. Scrub nurse looking for something ?instrument?

5.28. 2:50

5.28.1. 1/2 fascial layer closure finished (green leaf removed), repositioned

5.29. 2:50

5.29.1. Long metal instrument inserted and begin suturing from other corner of wound

5.29.2. Surgeon using needle driver in right hand, picking up needle in left hand

5.29.3. Assistant following/holding suture while surgeon drove needle through

5.29.4. Bowel kept popping out of wound and getting in way of surgeons

5.29.5. When wound opening was too small to use the malleable, switched to using the back of forceps to press down bowel

5.30. 3:02

5.30.1. Started to close final layer of skin

5.30.2. Dog ear noted on wound 3/4 of way towards surgeon side

5.30.3. Half of working field was in shadow, half had good light

5.31. 3:22

5.31.1. Begin stapling from both sides, used 3 staplers, spaced very close together

5.32. 3:29

5.32.1. Bacitracin? opened by circulating nurse and squeezed it into basin on scrub nurse table

5.32.2. Scrub nurse filled syringe with bacitracin

5.32.3. Surgeon squirted bacitracin over entire length of wound and on chest tube sites

5.33. 3:30

5.33.1. Bandages applied by assistant. Wound and chest tube sites covered

5.34. 3:31

5.34.1. Ultrasound machine brought into room. Assistant grabs it and waits to side with it covered

5.35. 3:33

5.35.1. Difficulty removing Ioban drape

5.35.2. Large grenade squeezed attached to floppy chest tube and laid on patients abdomen

5.36. 3:34

5.36.1. Drapes came down, difficulty navigating around chest tubes and for nurse holding on to her phone

5.37. 3:39

5.37.1. Nurse waved us away