LECTURE 9.
OPERATIVE SURGERY OF VESSELS
The surgery of the vessels is one of the contemporary medicine’s actual problems. This part of the medical science obtained the considerable development and the general recognizing only in the middle of the XX century. Its successes are interlinked with the working out of the renewing lood flow methods in the organs and extremities by the different pathology ipearances.
All vessels can be divided on three groups: the afferent or transport – the arterial group; the efferent ones – the vein link and the metabolic – the microcircular channel. It’s known that the arterial wall of three layers: the external one – the adventitia, the middle – muscular and internal – endothelial. Taking into account the prevalence or another structural elements in the wall of the afferent vessels all arteries are divided on three types: the elastic, muscular and mixed. The aorta, brachiocephalic trunk, carotic and subclavial arteries and other big vessels are belonged to the elastic type. The blood pressure is high in the systole of the left ventricle it is the same as the pressure in the le arterial wall bears the pressure to
Operating on the vessels the surgeon must remember not only the structure peculiarities of the veins and arteries but have the clear notion about correlation of the vessel-nervous bunch parts and their correlation with the surrounding tissues – that’s the topographic anatomy.
The vessel-nervous bundle topography is determined mainly by two factors: in the first place the correlation of the vessel-nervous bundles with the muscles and intermuscular spaces, in the second place their correlation with the fascias and the role of them in the creating the vascular vaginae. N.I. Pyrogov payed the attention just to this regulation and his merit is that he firstly formulated the basic rules of the vascular vaginae structure. In detail these rules were stated by N.I. Pyrogov in the book “The surgical anatomy of the arterial trunks and fascias” published in 1837.
As a conclusion N.I. Pyrogov proposed three rules of the vascular- nervous bundle topography:
1. Vascular-nervous bundle sheath is formed by solid & fibers connective tissue
2. Sheath of the vascular-nervous bundle is triangular in shape.
3. Apex of sheath directs to bone & closely attaches to periosteum.
The vascular-nervous bundle obligatory include the arteries, veins and nerv are not dependense of the body region. The anatomic unity of this bundle excites in it. But there is also the functional unity besides the an one. The artery brings the blood saturated of the oxygen and nutritive substances. It gives them the nerves, arteries and veins wall throught thinnest branches, it supplies them by the blood. At the same time vein takes away the blood from the nerve and artery and in that way supports the constant metabolism. The nerve through the smallest branches innervates the arteries and veins walls. The nutrition of the vessels is disturbed without nervous regulation. It’s neseccary always to account it in the extracting of the vessels.
Lesghaft’s rules of vascular-nervous bundle organization:
1. All main arterial trunks are situated on the concave or flexion surfaces of the body & limbs.
Just the concaved surfaces are the s ways of the blood passing.
2. Vascular ramification depends on limb skeleton structure & is connected by arterial archers on peripheral part of limb.
So there is one bone on the shoulder and thigh and accordingly there are by one big artery. There are by two bones on the forearm and shin and accordingly – by two big arterial vessels; there are five rays on the brush and foot and accordingly- by five big vessels. The second part of this rule testifies that the arterial trunks on the periphery united archwise. And really, for example, there are the complex anatomic arcus which are characterised by the big potential possibilities in the violated blood circulation compensation in the region of the ulnar, genus, talocrural and other joints.
3. All arterial trunks ramify on their way
The dimensions of each branch are correlated to the organ activity energy.
4. Moveable parts of body have dense arterial net & roundabout collaterals
The functional sense of this rule is very important. If the collateral ways will be absent, for example, in the region of the ulnar joint then slipping with the bent elbow you can to awake with the necrotic forearm, since all vessels would be pressed in those conditions. The presence of the collateral ways prevents these complications.
Taking into account the placing of the extremities’ vascular-nervous bundle in the operative approaches to them we must use the proectal lines as a refferernce point for the incision.
The proectal lines are conducted mostly in the intermuscular intervals direction in which the blood vessels pass. The outgoing points for this are most permanent anatomic formations which are not liable to the displacement. So the proectal line of the humeral artery passes from the middle of the inquinal hollow to the middle of the elbow dimple, the radial – from the middle of the elbow dimple to the internal edge of the ray awllike processus. On the lower extremity: the proectal line of the femoral artery passes from the middle of the inquinal ligament to the posterior edge of the thigh internal epicondyle (Ken’s line) etc.
All operations in the blood vessels diseases and damages are divided into four groups:
1. the operations conducing to the liquidation of the vessels hole (the ligation of the vessels);
2. the operations directed to the renewing of the vessels passaging (the vascular suture, shunting etc.);
3. the palliative operations;
4. the operations on the vegetative nerves which innervate the vessels.
The ligation of the vessels is the most spreading method of the bleeding
stop in the blood vessels wounds. The great destruction often have a place in such wounds that doesn’t be able to connect their edges for the vascular suture putting on.
The ligation of the vessels is possible to do by two methods: in the wound and on the extent.
The ligation of the vessels in the wound is done mainly in the process of the primary surgical wound working up or in the traumas that accompany with the gap of the artery or vein wall.
The ligation of the arteries on the extent means above the wound place is done in such cases when the search of the bleeding springs in the wound is difficult or there is the danger to contaminate the surrounding tissues in the manipulations, also in the higher amputations or exarticulations of the extremities. Such cases are the bleedings the splintered tissues, the contaminated wounds, the damaging of the vessels the ligation of those is connected with the searching of the bleeding springs in the big muscle mass .
The operative approach is realised by the layer incision of the t issues taking the proectal lines of the arterial trunks bearings. The straight approach to the vessels is shortest. But many vascular-nervous fascicules are built so that the arteiy is covered by the nervous trunks in the proectal line and it’s easy to damage them in the straight approach. That’s why the approach in such cases is realized not in the proectal line but step back from it to 1 -2 sm means it’s realized by the round way. The axiliar and humeral arteries on the upper extremity, the popliteal and posterior wall arteries in the middle third on the lower extremity are ligated in the round approach.
The soft tissues are incised on the own fascia in the round approaches. The nearing muscle is moving out after the incision of the own fascia which create the anterior wall of the muscle vagina and then the posterior wall of the vagina, which is at the same time the anterior wall of the vascular- nervous fascicule vagina according the first rule of N.I. Pyrogov, is incised.
It’s neccessary to enter the solution of the novocainum in the vagina incision.The novocainum on the one hand perforins the hydravlic preparing, on the other – supplies the blockade of the reflexogenic zones. The arterial vessel is ligated by the silk ligatures after its removing. We must to put on the central end two ligatures one of which is lace inserted. The last prevents the 1slipping down of the proximal ligature and possible bleeding. The peripheral end of the vessel is ligatured by the separate silk ligature. In the incomplete incision of the vessel the last one is cut without fail between the peripheric and lace inserted ligatures. It’s neccesary to remember that the nuding of the vessel on the long extent (more than 5 sm) can lead to the violation of its wall trophic and aneurism formation in the postoperative period.
The switching the big vascular main-ways off is accompanied the decreasing of the blood flow to the distal extremity partand so to the tissues’ hypoxia, the general contraction of the microciculatory channel most violation of the blood flow in the distal extremity part. That’s why the choice of the ligation ;place for each vessel on the extremity must always be anatomically based most optimal for the collaterals appearance in the postoperative period.
Collateral circulation after ligation of axillary artery
1. r. descendens a.transversa colli – a. subscapularis (a.circumflexa scapulae)
Collateral circulation after ligation of brachial artery in upper third
2. aa. collaterales ulnaris superior et inferior – a. recurrens ulnaris
Collateral circulation after ligation of brachial artery in cubital fossa
Rete articularis cubiti:
n a.collateralis radialis
n a.a.collateralis ulnaris superior et inferior
n a.a.recurrens radialis
n a.a.recurrens ulnaris
n a.a.recurrens interossea
Collateral circulation after ligation of a. ulnaris
n a. radialis
n a. interossea anterior,
n arcus palmaris profundus
Collateral circulation after ligation of a. radialis
n a. ulnaris
n a. interossea anterior,
n arcus palmaris superficialis
Collateral circulation after ligation of femoral artery under the inguinal ligament
Collateral circulation of femoral artery in the adductor canal
The effectiveness of the collateral blood circulation is in the straight dependense of the following factors:
1 ) the diameter of the intervascular anastomosis;
2) the presence of the preexisting collaterals, their degree of the functioning intensivitv;
3)the kind of the pathologic process. The gradual reorganization of the collateral net is done, the collateral blood circulation renews in the whole size in the chronic processes, assosiated with the blood circulation violation in the main-way; the development of the compensational blood circulation is done very difficult in the acute obturation of the main-way vessel;
4) the functional condition of the tissues, their needing in the oxygen”
5) the general condition of the haemodynamic (the minute volume, blood pressure).
The many measures are used for the improvement of the by-pass blood circulation after the operation:
1. Before the operation:
1) the training of the collaterals;
2) the novocaine blockade of the vessels;
2. During the operation:
1) the cut the artery between two ligatures;
2) the extirpation of the sympathetic nodes, desympathisation, denervation of the vessels;
3) the ligation of the artery and same name vein for the slowing down the blood flow and to support the sufficient blood pressure above the ligation place;
3. After the operation:
1) the infusion of the oxygenic blood w ith small portions;
2) the warming of the extremities but not with the hot things because that leads to the local hyperemia and collecting of the blood in one place;
3) the entering of the spasmolythics;
4)the massages, physical procedures which promote to the widing of the small vessels.
Vascular suture
The second group of surgery on blood vessels – is the operation aimed at restoring vascular permeability. This group is the most difficult surgeries and attracts attention of surgeons. Operations aimed at eliminating the lumen of blood vessels, often ending limb gangrene or necrosis of the organ. Vascular suture has long attracted the attention of surgeons. First wound artery with good results sewed Hellouel in 1759.
Over time, the imposition of vascular suture were considered inviolable following principles:
1) end vessels sewn must touch each other a smooth inner surface. Suture ligatures should not injure the inner membrane of the vessels;
2) to prevent blood clots suture should not act in the lumen of blood vessels or, if unavoidable , the contact between the blood stream and ligature should be kept to a minimum ;
3) is to ensure the seam sealing vessels. Also it should not cause vasoconstriction of vascular anastomosis.
We know that today prompted a large number of modifications of vascular suture, based on the classical method of Carrel . Carrel suture technique here is the The ends of the vessels to be connection , brings together three seams – holders carried out completely through the entire thickness of the vessel wall at an equal distance from each other. So that in cross section rivnostornniy vessel formed a triangle. In place of osculation walls impose stitch, stitches in capturing all the layers . This method ensures a tight matching edges of the wound and warns the surgeon of the seizure of the vessel wall opposite the seam . However, this prevents the possibility of narrowing the anastomosis and its distortion. When the vascular suture important conclusion is correct stitches , spacing between them shall be no more than 1-
After sew one side triangle, the main thread called “bind with thread stitch – holder. In a similar way to impose two other faces. To check the tightness of the joints clamps removed first from the distal end of the vessel, and then to the proximal. If leaks in some places broken, it is necessary to impose an additional single U-shaped nodal joints.
Autoplasty of vessels
This type of surgery involves the use of plastic for the purposes of the tissues of the body. To replace circular defects arteries in 1912 Carrel suggested to apply veins of different diameters. Autovenous plastic widely used in medicine. Since the thickness of the walls of arteries and venous grafts varies , with a view to preventing the eruption of joints and ensure adequate seal should capture the seam twice the venous wall , and the line of anastomosis strengthen various couplings with both synthetic and autotissues . In carrying out such operations should consider the presence and direction of valves in the vein lumen – proximal end autovenous to be the ” united with the distal end of the artery is held reversion venous graft.
Alloplasty – an operation in which the substitution of circular defects of vessels engaged in transplants that were taken from organisms within the same species.
Ksenoplasty – a transfer of segments of arteries or veins within the different types of the body (the dog – a monkey, from the pig – people).
Explantation – then transplant inanimate substrate, such as synthetic vascular prosthesis for replacement of circular defects of the arteries and veins. The first successes of this section surgery connected with the achievements of chemistry of polymeric compounds, insofar as it is used for plastic materials such as Dacron, Teflon, orlon, polypropylene, etc. The best ones are those where water permeability is in the range of 0.94 –
Sometimes when applying shunt thrombosis of blood vessels. In vascular surgery during shunt understand a new temporary or permanent workaround circulation. The creation of the shunt enables to carry out the weld overlay on any vessel in any location . Bypass surgery is one way to prevent oxygen hanger brain and spinal cord during aortic resection and concomitant use of hypothermia makes it possible to achieve better results in the postoperative period . In addition, when such a large vessel clamping the aorta as always there is a sharp increase in pressure in the cavities of the heart, which can lead to acute expansion of its cavities , in particular – ventricular cavity . The use of hypothermia in conjunction with the creation of the shunt allows you to avoid such serious complications.
The acute arterial occlusion can be a result of the embolia or thrombosis of the vessel. So in such case the choice operation is the embolectomia. The sense of the operation significates the removal of the embolic particle of the valves after sclerosis which have torn from the vessel space. The success of the operation is directly dependent from the time of the implemention. Accordingly to data by G.L.Ratner the healing and later well results have place in 84 % of the patients who have the operation in the first 12 hours after the vessel damaging in time where the process which connected with the ischemia is reverseble. In the progressing of the ishcemia signs the embolectomia is the acute surgery obligatory invasions.
For the patients with the acute thrombosis of the arteries the surgery treating indicated only in cases with the segmentary process. In the segmentary thrombosis of the large arterial trunks indicated the thrombectomia – the removal of the thromb from the inner coat of the vessel wall.
The operations on the veins
Venous upper and lower extremities formed superficial and deep veins, which combined together numerous anastomoses. The inner membrane forms of valves that provide the centripetal movement of blood. Superficial ( subcutaneous ) veins developed more than deep. Peripheral veins of the upper extremities begin with subcutaneous venous network – rete venosum dorsale manus. This vein, including the radial part of the extremities are the origins for lateral saphenous vein main veins (v.cepnalica), and from the elbow – for medial saphenous vein v.basilica ( imperial
The operations on the veins are one of the most actual problems of the vessel surgery. The difficultness of this department of the surgery caused first from the especialities of the anatomical structure and circulation in the venous system. As early mentioned wall of the vein is thin, have the valves, collapsing easy. Slowly blood circulation promote the stasis and increasing of the hydrostatic pressure in the veins it can cause the permanent boarening of the veins and valve insufficiency. The increasing of the venous pressure can promote throwing of the arterial blood in the veins through the numerous arterio-venous anastomosis. It’s known tough connection between the superficial and deep venous systems. The circulation changes in the one system cause the pathological changes in the other one. Thus, dure long time increasing of the pressure in the system of the deep veins accompanies with the functional insufficiency of the valve apparatus of the communicant and small superficial veins, later in the pathology enlist the superficial venous mains too.
It’s important to note the varicosis of the low limbs veins more frequentle occurs in the wemen. This phenomenon can be explained as the especialities of the anatom-functional conditions of the women organism namely:
· more wide pelvis than in men it causes the increasing of the angle of the confluence veins of the low limbs in the pelvis vein and slowly blood flowing in the superficial venous system
· overflowinf of the pelvis vein from the blood due menorhea;
· also the pregnancy mainly assist veins’ bordering
· more soft resistance to the vessels from the near laying tissues;
· the female’s wall of the vessels are more thin and accordingly easy boarden.
The phenomenon of the stagnation of the vein leads to the trophical violations in the soft tissues of the low limbs. Thus the aim of the surgery treatment of the vein varicosis is the elimination of the blood stagnation in the superficial veins. Such aim we can achieve by the way of the removal the superficial venous net and creating the optimal condition for the circulation through the deep veins. There are the next methods:
· .the Madelung’s method – the general removing of the boardened veins of the thigh and ankle along all extent from the longitudinal incision;
· .the Narhat’s method – the removal of the veins parts from the separate cutting of the skin and soft tissues;
· .the Bebcock’s method – the subcutaneous dragging out of the veins by means of the special medica l probe.
For the elimination of the blood throwing from the deep venous net in the superficialis one spreads the method of Kocket-Linton when simultaneously with cutting out of the superficial veins provide the ligature of the over- and subaponevrotically situated the perforant veins. It’s understandly that all surgery invasions able just of the deep veins. In the case of the violations of the deep venous net functioning early indicated operations are unreasonable.
Sometimes the surgeons use more delicate correction of the venous stagnation such provide the reposition of the superficial ways under the wide fascia (the Ratner’s method) or even in the muscles bodies (the Check- Katsenstein’s method). Last years appear the new method of the creating of the venous valves through the invagination of the own vein’s wall (the method by Giano) or ligaturing of the channels of the large subcutaneous veins of the thigh. Sometimes the correction of the valves implements by the extravasal constriction of the subcutaneous vein of the thigh by means of the spiral (the A.M.Vedenskiy’ method).
Touch to the venous pathology of the upper extremity it is coonected with the violations of the circulation. For example Pedget-Shretter syndrome is a result of the acute thrombosis of the subclavial vein. Featurly here is the swelling of the upper extremity, acute pain. The removal of the thromb or thrombosis by means of the pharmacological measures assist the whole restoring of the extremity function. For the disorders of the circulation in the upper extremity we can add – the overextension of the anterior interscalenus muscle (the Nefcyger’s syndrome) or the pressing of the subclavial vessel by the trapezoid muscle, by remain of the neck’s ribs (neck’s ribs syndrome), by small chest muscle (the muscular pelvis minor syndrome) and others. But with the elimination of the causes of the circulation’s disorders the function of the extremity restore rapid.
Thus marking the conclusion of the surgery invasion on the vessels we have all reasons to note that the modern stage of the development of the vessel surgery assist us to the providing of the restoring blood system for the prevent of the acute complications and save the patient’s life.
