Left Femoral-to-Peroneal Bypass Operative Example
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the operating table in the supine position. After adequate induction of anesthesia, the left groin and leg were prepped and draped in a sterile fashion. The procedure was begun by making an oblique incision in the left groin crease through the previous incision. Subcutaneous tissue was divided using electrocautery and scalpel down to the palpable fluid of the thrombosed femoroperoneal bypass.
Using sharp dissection, the hood of the previous femoroperoneal bypass was exposed and dissected. It was controlled for a distance of approximately 2 cm out onto the graft. The graft had a stump that remained patent from the proximal anastomosis for approximately 1 cm distally, and the vessel was controlled at this point. The common femoral artery proximally was controlled to allow for clamping if necessary. The intent was to clamp across the old hood of the graft and use the remaining stump as a site for proximal anastomosis.
The wound was then packed with saline-soaked gauze and attention was directed to the calf. A longitudinal incision was made in the midcalf just medial and posterior to the tibial border. Subcutaneous tissue was divided down to the fascia of the calf, which was opened. The soleus muscle was then taken down from its origin of the tibia, exposing the posterior tibial vein and artery as well as tibial nerve.
Deep to this, the flexor digitorum muscle was mobilized. Beneath this, muscle was identified, the peroneal vein and artery. The peroneal vein was then carefully dissected away from the peroneal artery, which was found to be soft and minimally diseased. It was superficially dissected for a distance of 2 cm and appeared to measure approximately 2 mm in size. The wound was then packed with saline-soaked gauze.
A Kelly-Wick tunneler was then used to create a subcutaneous tract and tunneled between the calf incision in the groin. The tunneler was left in place. The patient was given 3000 units of heparin. While the inflow and outflow had been exposed, the CryoLife greater saphenous vein had been prepared according to normal technique. The vein was then brought onto the field after adequate circulation of 3000 units of heparin.
The hood of the old graft was clamped and the graft was divided. The vein was patent at this point. The old vein graft was patent at this point and was spatulated slightly. The CryoLife vein was then reversed and the proximal end was spatulated.
A standard end-to-end spatulated anastomosis was created using two separate running 6-0 Prolene. After completion of this anastomosis, there was noted to be excellent flow out the cadaveric vein graft. The vein graft was marked with double length and was sutured to the tunneler. It was then tunneled through the subcutaneous plane into the calf incision. The patient was given additional 1000 units of heparin, and the tourniquet was applied to the proximal thigh.
The patient’s leg was then exsanguinated using elevation and Esmarch, and the tourniquet was inflated to 350 mmHg. The peroneal artery was exposed deep in the calf wound, and a longitudinal arteriotomy was made measuring 1 cm in length. The vein graft was then cut to an appropriate length and shape, and a standard end-to-side spatulated anastomosis was created using a running 7-0 Prolene.
Prior to completion of the anastomosis, the artery and graft were forward and backbled and flushed with heparinized saline. The anastomosis was then completed and flow was restored. There was noted to be an excellent pulse in the graft. Doppler evaluation demonstrated good flow characteristics throughout the graft in the outflow vessels. Hemostasis was obtained in both groin and the calf incision.
The calf incision was then closed with 3-0 Vicryl for the fascia and the subcutaneous tissue with 3-0 Vicryl as well. The skin was closed with 4-0 subcuticular Monocryl. The groin was closed with three separate layers of 3-0 Vicryl and skin with 4-0 Monocryl. Clean sterile dry dressings were applied, and the patient was transferred to the recovery room in stable condition, having tolerated the procedure well.
