OPERATIVE TECHNIC IN GENERAL SURGERY Edited by WARREN H. COLE, M.D., F.A.C.S. PROFFSSOR AND HEAD OF THE DEPARTALENT OF SURGERY, UNIVERSITY OF ILLINOIS COLLEGE OF MEIMCINE, DIRECTOR OF SURGICAL SERVICE, ELLINOES RESEARCH AND EDUCATIONAL HOSPITALS, CHICAGO Introduction by FRANK H. LAHEY, M.D., F.A.CS. } bisyie on tos rein Lo! LPL vee APPLE TON-CEN PURY-CROEF TVS, ING. NEW YORK 1949 ond J iD a) oa 21 THE BLOOD VESSELS Dante. Fnukin, MLD. AND Micuacn BE. DeBakey, MLD. ACUTE VASCULAR INJURIES Micnart. E, DeEBAKEY, M.D. Acute or fresh injuries of major arteries, because they literally threaten both fife and limb, have always constituted a serious problem in the surgical management of traumatic conditions, Despite the constant and tireless ef- forts of numerous investigators and the extensive experience provided by both World Wars, a completely satisfactory solution to this problem has yet to he evolved. Obviously, and this has long been recognized, ideal therapy has as its objective preservation or restitution of vascular function, Unfor- tunately, as pointed out in a previous consideration of this subject,’ this desideratum can be attained in only a limited number of cases, for certain definite reasons. Essentially, these reasons may be divided into two categories: (1) those in which the factors are of such vital significance that they seal the fate of the part regardless of any form of therapy; and (2) those which jeop- ardize the effects of ideal therapy or preclude its institution, These factors are; time-lag, practical technical considerations, the presence of associated injuries, the site of injury, the type of arterial lesion, and the possible occurrence of infection. The significance of the time-lag, ie., the time elapsing between wounding and institution of therapy, is obvious. Once this period exceeds the generally accepted limit of 6 to 8 hours, it is doubtful that reparative surgical therapy can influence the end result. The factor of associated injuries, whether they are local or remote, is also of considerable importance. Local wounds, de- pending upon their extent, may further impair or even completely destroy the regional circulation. More remote wounds may require attention far more urgently, as a lifesaving matter, than does the vascular wound, Perhaps the most important factors determining end results are the site and type of the arterial lesion. Wounds of certain vessels, such as the popliteal artery, are far more serious than wounds of other vessels, such as the brachial artery. Wounds above the profunda branch in both the femoral and brachial arteries are more likely to be followed by ischemic gangrene than wounds of these vessels below this branch. Accordingly, certain vessels have come to be regarded as critical and others as noncritical, and restora- Ry8 AGUTE. VASCULAR INJURIES 849 tive surgical procedures obviously assume greater importance in the former category of vessels than in the latter. The type of injury (laceration of the vessel, partial or complete severance, contusion and thrombosis, acute spasm, or false ancurysin) also influences the outcome. A small, cleanly incised longitudinal wound, or even an incised transverse wound, may be repaired with ercater chances of success than a lacerated wound in which there is much loss of substance. In vascular injurics, therefore, the circumstances and character of the in- jury often determine the therapeutic procedure and consequently predcter- mine the end result. Under certain conditions the only procedure applicable is ligation; it must be done for the basic purpose of controlling hemor- rhage. Under: other conditions some type of reparative procedure may be employed; since this constitutes ideal therapy, every effort should be made to apply it. ‘ . Supplemental Therapeutic Measures. All the established principles of good wound surgery, such as proper resuscitation of the patient and tho- rough débridement, are essential to the successful management of acute vascular injuries. These principles are discussed elsewhere and require no further claboration here. There are, however, certain supplemental thera- peutic measures that deserve consideration, including blood transfusion, sympathetic block or sympathectomy, anticoagulant therapy, and posture. The extent of blood loss in acute vascular injuries is often considerable. As a consequence of the reduction in the volume of the circulating blood, the amount of blood flow through the peripheral arteries is also reduced, and the circulation of the part distal to the vascular injury is even further im- paired. For these reasons, prompt restoration of the circulating blood vol- ume and of the hemoglobin concentration assumes particular importance. Vasospasm is a natural response to those forms of trauma which directly or indirectly affect vascular structures.* Its extent and degree vary con- siderably. It may range from localized constriction, with consequent minimal ischemia, to a more extensive and generalized involvement, especially of the collateral circulation, with consequent ischemia of a degree sufficient to produce actual gangrene. Rational therapy in such cases is based upon an attempt to counteract vasospasm and to produce maximun vasodihitation in the involved extremity. Since the disturbance is apparently due to a vasomotor refiex initiated in the traumatized Ussues, and since yvasocon- strictor impulses are transmited by way of the sympatheuc nerve fibers, interruption of these impulses prevents Vasospasin and permits vasodilata- tion. Vasodilatation may be achieved by débridement of surrounding traumatized tissue, by periarterial stripping of the involved area, by procaine hydrochloride block of the regional sympathetic ganglia, or by sympathec- tomy. Sympathetic block or sympathectomy, which is probably the most effective method of producing maxim vasodilatation ino these cases, should be employed in all types of peripheral vascular injuries accompanied by amanifestations of vasospasm Toomay be necessary to repeat the block at least once or twice daily for several divs. Body warmth ts carefully main: 850 THE BLOOD VESSELS tained but heat should not be applied to the involved part. As elevation of the part may accentuate ischemia, the extremity should be maintained at heart level, or preferably in a slightly dependent position. On a theoretical basis, as well as on the basis of experimental and clinical investigations. the use of anticoagulants (heparin and dicoumarol) would appear to be a valuable adjunct in vascular surgery.?°?! By this means the extension of thrombosis in the peripheral collateral tributaries or the occur- rence of thrombosis after operation at the site of repair, which so often spells failure, can be better controlled. tt should be realized, however, that anti- coagulant therapy is not without danger, especially in the presence of ex- tensive injury. The method requires careful observation and adequate laboratory checks. Clinically, the exact field of usefulness of anticoagulant therapy in acute vascular injuries has not been defined and must await further experience. That it is not essential to successful repair in certain forms of vascular injury is well known. Perhaps it will be found most useful in cases which require bridging of the arterial gap. Surgical Therapy. Lication. In cases in which ligation is promptly indi- cated, as in wounds of the smaller noncritical vessels or because of the type and character of the injury, it should be done not by ligation in continuity but by placing nonabsorbable ligatures well above and below the site of injury, with excision of the intervening damaged segment in order to clim- inate the dangers of secondary hemorrhage, thrombosis, and vasoconstrictor influences. Although it may be theoretically desirable to ligate at such a level as to avoid the creation of a blind pouch,'®™ the deliberate effort to do so frequently involves extensive dissection and may still further jeopard- ize the circulation of the injured limb. IE the concomitant vein is also injured, it should be similarly ligated; however, if undamaged it should not be disturbed. Suture Repair. As has been indicated, the ideal objective in the therapy of vascular injuries is the restoration of the flow of blood through the origt- nal channel. This may be achieved, depending upon the character and extent of the injury, by suture repair, end-to-end anastomosis, or vein grafts and prosthetic tubes. The fundamental principles underlying all of these methods of vascular repair have long been well known. They have remained essentially unchanged, except possibly for certain refinements in suture material or in prosthetic devices, since the time of their establishment through the research efforts of numerous investigators, including, particu: larly, the work of Glick,’ Jassinowsky,"” Murphy.’ Jaboulay and Briau,"! Dor fler,® Payr,** Hoépfner,” Matas,'*77 Carrel and Guthrie,?* and Moure." The reader will find an excellent historical résumé of this phase of the subject in Matas’ publications.'7 Suture repair of arterial injuries is particularly indicated in: relatively small longitudinal or oblique wounds or in incomplete rinsections, espe- cially of the larger arteries, such as the carotid, popliteal, common femoral, subclavian and axillary arteries. In complete or incomplete transections in which there is much loss of substance, end-to-end anastomosis should be ACUTE VASCULAR INJURIES 851 done unless the defect is so great as to preclude approximation and some means of bridging the defect must be employed. The essential principles of the suture method of vascular repair are: (4) provisional hemostasis; (2) the use of fine needles and silk: (3) accurate approximation of the intima: and (4) gentle handling of tissues. After the injured vessel is exposed and isolated, provisional hemostasis is obtained by applying small rubber-shod spring artery clamps or by clamping soft rubber tubes snugly against the vessel above and below the site of the wound. All traumatized tissue and blood clots are removed, and ragged tissue and overhanging adventitia are excised, to provide clean smooth wound edges. “Uhis should be done with considerable care and gentleness to mini- mize contusion or other injury to the endothelial edges of the wound. The cleansing of the wound and of the lumen of the vessel is facilitated by use of a stream of normal saline solution or of a 1:1,000 solution of heparin in normal saline solution. Periodic irrigation of the structures throughout the operation is also desirable, to prevent drying of the tissues. Traction or guy sutures are placed at each end of the wound, penetrating all layers of the vessels, to facilitate apposition of the endothelial surfaces and the per- formance of the suture repair (Fig. 4794). The suture material should be of fine silk (00000 or 000000) directly attached to a fine curved needle. This type of atraumatic arterial suture is available commercially in sealed tubes containing liquid petrolatum. Various methods of applying the suture to approximate the wound edges have been employed, including single interrupted sutures, interrupted mattress sutures, a continuous over-and-over suture (Fig. 479b), or a con- tinuous mattress suture (Fig. 47gc). The continuous over-and-over stitch is the simplest and, in general, gives as good results as any of the others. The sutures should be applied fairly close together (about 1 to 1.5 mm. apart), to prevent leakage between them. After the passage of each stitch gentle traction is applied to the thread, so as to approximate the wound edges snugly, care being taken to provide intima-to-intima contact, Following completion of the repair and removal of the hemostatic clamps above and below the artery, slight leakage at the suture line may be observed. Usually it will stop after the application of gentle pressure with moist gauze over the anastomosis. If this is not effective, it can be controlled with a reinfore- ing suture. Exp-to-exp ANASTOMOSIS. End-to-end anastomosis is indicated in wounds that incompletely or completely transect the vessel unless the loss of sub- stance is so ereat (more than 2 em.) that the resultant defect will not permit the ends of the vessel to be brought together without too much tension on the suture line. Under these circumstances, some means of bridging the gap, such as the use of vein grafts or prosthetic tubes, will be necessary. Several methods of end-to-end anastomosis have been employed, including the suture method er the nonsunne method with extravasal aids ar supe porting appliances. “Phe many other methods which have been devised are now only of historical mterest.'* 852 THE BLOOD VESSELS The principles of the suture method of end-to-end anastomosis, which is generally used today, are essentially those developed by Dorfler © and per- fected by Carrel? Following exposure and isolation of the injured vessel, provisional hemostasis is obtained by the application of artery clamps to the artery above and below the site of injury. AH taumatized tissue and blood clots are removed and the overhanging adventitia is excised and stripped ea Z Z Z a oa Zz Zz 2 4 ZY | NE She Ny F SV) 4 ZA | A) 242) / dy of , Z AN Z NZ IN SA \Z TN ZA IZ UK A NZ M zy \Z \ ANI ive, Fic. 479. “Pechnic of suture repair of arterial wounds showing: a, continuaus over- and-over type of suture, and b. continuous mattress suture, away from the edges and the severed ends of the vessel. Irrigation with saline solution or heparin and saline solution is employed, as previously described. The cut ends of the vessel are brought in apposition and three stay sutures are introduced through all layers of the vessel at equidistant points of the circumferences and are tied, care being iaken to evert the edges to provide intimal apposition (Fig. q8o0a). By the application of gentle traction upon these stay sutures the oval outlines of the arterial ends are converted into straight triangular surfaces (Fig. 480b). The new contour facilitates apposition of the surfaces as well as eversion of the edves of the vessel, thus greatly simplifying the performance of suture anastomosis. ACUTE VASCULAR INJURIES 35: Each side of the triangle is sutured consecutively, either by a continuous over-and-over stitch (Fig. y80b and c) or by a continuous mattress suture (Fig. 480d) as described above for lateral arteriorrhaphy, care being taken to provide apposition of the intima. As cach segment of the angle is com- pleted, it may be desirable to tic the running suture to the guy stitch. ut \ ‘ \ Hauler ah SG Nt, “NAW { / OW By ad) } LSE Ws eer Te x Niyp)yype wcll oN Fic. 480. Technic of end-to-end anastomosis of arteries by suture method showing: a. placement of three stay or guy sutures at equidistant points of the circuniference, b. traction upon guy sutures after they have been Ged converts oval outline edges of vessels into straight wiangular surfaces facilitating suture, c. cach side of triangle is sutured con- secutively by continuous over-and-over stitch, or d. by continuous mattress suture, End-to-end anastomosis may also be performed by the nonsuture methad, by means of a supporting appliance used to provide intima-to-intima appo- sition. Of the various types of appliances and technics devised for this purpose the only one that has survived is the method originally developed by Payr in 1goo. This method is exactly the same in principle as that re- cently advocated by Blakemore, Lord, and Stetho,' the only difference being that they used vitallium tubes instead of the magnesium alloy tubes en ployed by Payr. More recently, fibrin tubes have heen suggested for this purpose by Swenson and Gross?“ the advantage claimed by these observers being that the tube is gradually absorbed, in a matter of six or seven weeks, and the limen at the site of the anastomosis is thus able to increase in size with the subsequent growth of the paucnt, Obviously, this advantage ap- plies particularly to children, $54 ; THE BLOOD VESSELS In this method of anastomosis one end of the vessel is threaded through the tube, cuffed back, and fastened with a silk ligature over a eroove or a projecting ridge in the tube. The other end of the vessel is then drawn or invaginated over the cuff and secured in position with another ligature. The anastomosis is thus completed and a continuous intimal lining is established (Pig. 481). Be evememes ete ; Vatallitim bkube Y¥Auen Fic. 481. Technic of end-to-end anastomosis by nonsuture method using vitallium tubes of Blakemore, Lord and Stefko.! This drawing shows application of this method of anastomosis for performing vein graft using two tubcs but same method may be used for end-to-end anastomosis of arteries using one tube. a. Vein is threaded through tube, b. cuffed back and secured in place with a ligature, c. artery is drawn or invaginated over the cuff, and d. secured in position with two ligatures. The anastomosis thus provides a continuous intimal lining (inset). The obvious advantages of this method of anastomosis lic in its apparent simplicity and ease of performance. On the other hand, it has certain dis- advantages. 1. Tt utilizes an excess of vessel wall in the performance of the anastomosis and consequently would be impractical in cases in which some. loss of substance has already occurred from the original injury. 2. It re- duces the caliber of the lumen by the two thicknesses of the vein wall within the tube. Ina recent experimental study designed to determine the relative merits of this method of anastomosis and the suture method, the conclusion was reached that in cases in which there is no tension on the suture line and no defect to be bridged, the latter method is superior to the former.’ Per- REFERENCES 855 haps the nonsuture method of anastomosis will find its greatest field of use- fulness in cases in which it is necessary to bridg¢ the defect in the artery by a vein graft. In cases in which the injury is associated with such extensive loss of substance as to preclude end-to-end anastomosis and in which arterial liga- tion does not seem promptly indicated, some method of bridging the gap is desirable in order to restore continuity of the artery. This is particularly true of injuries of critical arteries such as the popliteal, common or internal carotid, common femoral, axillary, and brachial arteries. The various methods sugeested and practiced for this purpose include the use of vein grafts and prosthetic tubes? In the vein graft method a suitable segment of vein obtained from an accessible site is anastomosed to the proximal and distal ends of the artery by means of either the suture method or the non- suuure method (Fig. 481). In using vein grafts it is desirable to employ a segment without valves, or, if valves are present, to place the vein between the ends of the artery with the valves facing distally. Another technical con- sideration is that the vein segment he of the exact length required to bridge the gap, to avoid cither tension or kinking. Bridging of the arterial gap by intubation is another method Which has been used to provide for temporary maintenance of the blood flow. Its objective is the maintenance of the circulation of the injured limb until more suitable conditions or facilities permit a permanent type of repair or until the collateral circulation has become established. If this objective can be achieved, an emergency procedure, which may be difficult under the happiest circumstances, is converted into an elective one, or the sub- sequent gradual obliterative thrombosis in the tube, with occlusion of the main vascular channel, will have a much less deleterious effect than if the process had oceurred abruptly. In World War I silver tubes were used for this purpose. In World War II glass tubes as well as plastic tubes were employed.*.??, Unless circumstances or conditions contraindicate the use of heparin, its administration is particularly desirable with this method of provisional restoration of the vascular continuity, since thrombosis, which will invariably occur, should be delaved as long as possible. REFERENCES 1. Bianemore, H. H.. Lorn, J. Wa. Jao and Sierko. PLL. The Severed Primary Artery in the War Wounded: A Non-suture Method of bridging Arterial Defects, Surgery. 12:488-508, [Sept.}. 1gge: also JALAL. 127:085-Gg1, 548-753. 1945- , g. CARREL, AbENts. La technique operatoire des anastomoses vasculaires et de la trans plantation des visceres. Lyon Meéd., g3:859. 1002. g. Carrer, Avexis and Guineim, C. C. Uniterminal-and Biterminal Venous Trans- plantations, Surg., Gynec. & Obst., 2:266-286. [Mar.], 1906. 4. DeBary, Micharr. Traumatic Vasospasm. Bull. U.S. Army Med. Dept., No. 73 24-28, [Feb.]. 1944. 5. DeBaney, Micuace E. and Sivtont. Fiokinpo 4, Battle Injuries of the Arteries in World War fh An Analysis of 2.71 Cases. dan. Store. resgigageaza. PApr.y. 196. G. Doxeryvr, Juris. Ueber artericnnaht. Betty, zua. kin, Chir. a5:78i-S24, 18a9. . a7 i og 856 7. 8. 9. 10. 11, 17. 18, 19. 20, THE BLOOD VESSELS Gitck, Tu. Ueber Zwei Faille von Aorteninenrysmen nebst RBemerkungen tiber dic Nahe der Blutechisse, ctreh. fo klin, Chir,, 28:5.48-561, 1885, Gurate, CC. Blood-vessel Surgery and its Applications (International Mono. graphs), Arnold, London, 112. Hoprner, Epstenn, Ueber Geflissnaht. Gefisstransplantationen und Reptantation von amputirten Extremititen, elrch. f. Alin Chir., FOLNG-ATI, 1904. FHouman, Fauve. Further Observations on Surgery of the Large Arteries, Surg., Gynec. & Obst, 78:275-287. [Mar.], 104-4. JAnouray and Brau, E. Recherches expérimentales sur fa suture et la egreffe artériclle, Lyon Meéd., 81:97, 1896. JAsstnowsky, ALEXANDER, Em Beitrag zur Lehre von der Gefiissnaht, Arch. f. klin, Chir, 42:816-841, Sgr, Jouns, Thomas N. A Comparison of Suture and Nonsuture Methods for the Anastoniosis of Veins, Surg., Gynec. & Obst., 84:930-942, [May], 1947. Lericue, R. and Poricarp, A. ‘Ligation of Brachial Artery, Lyon Chir., 172250, 1920; JAMA, 75:639, 1920. Matas, Repowen. The Suture in the Surgery of the Vascular System, The Brown Printing Company, Montgomery, Ala., 1906, Matas, Rupotru. Surgery of the Vascular System, in Kren, W. W. Surgery: Its Principles and Practice, hy Various Authors, 5:17-350, W. B. Saunders Company, Philadelphia and London. 1921, Maras, Runowpn, Military Surgery of the Vascular System, in Keen, W. W. Surgery: Its Principles ana Practice, by Various Authors, 7:713-819, W. B. Saunders Com. pany, Philadelphia and London, 1921. . Movure, Pau. Les Greffes Vasculaires et particuliérement leurs applications chirur- gicales au rétablissement de la continuité des vaisseaux et des conduits musculo- membraneaux, Octave Doin et Fils, Paris, 1914. Merpny, J. B. Resection of Arteries and Veins Injured in Continuity—End-to-cnd Suture—Experimental and Clinical Research, Med. Rec., 51:73-88, [Jan. 16], 1897. Murray, Goxvon and Janes, J. M. Prevention of Acute Failure of Circulation Following Injuries to Large Arteries. Experiments with Glass Cannulae Kept Patent by Administration of Heparin, Brit, M. J., 2:6-7, 1940. Mecrray, Gornon, Heparin in Surgical Vreatment of Blood Vessels, Arch. Surg., 49°307-325, 1H40. Musrarp, W. TT. The Technic of Ihumediate Restoration of Vascular Continuity after Arterial Wounds. Indications and Results, lan. Surg., 134546-59, [July], 1946. Payr, Erwin. Beitriige zur Technik der Blutyefiiss und Nervennaht nebst Mittheilun- gen liber die Verwendung eines resorbirharen Metalles in der Chirurgie, Arch, f Alin. Chir., 62:67-y3, 1go0. SWENSON, OrvaR and Gross, Rosrrr E. Absorbable Fibrin Tubes for Vein Anas- tomoses, Surgery, 22:137-14, [July], 1947.