Right transfemoral amputation in Fontaine stage IV peripheral arterial disease – Vascular Surgery - vascular surgery
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Incision and fashioning of the anterior skin-muscle flap (extensors) with swift piercing soft-tissue transection
Fishmouth incision down to the fascia at the transition from the middle to the distal third of the thigh. Divide the great saphenous vein between ligatures (not shown in video). Insert the long amputation knife laterally at the angle of the incision, down to the femur, sliding on the femur anterially, and exiting medially at the posterior border of the quadriceps. Fashion the anterior skin-muscle flap by swiftlytransecting the musculature anteriorly along the incision in one motion with the amputation knife. In doing so, manually pre-stretch the quadriceps.
1. The interface between the anterior and posterior flaps is formed by the medial and lateral margins of the quadriceps muscle.
2. Short incisions (hacking) compromise wound healing. Transection should be rapid and smooth, as a swift, targeted approach will result in low blood loss.
3. Possibly mark the incision on the skin; center the angle of the fishmouth on the femur.
Locating and identifying the femoral vessels
Locate and identify the femoral vessels medially.
In partly patent superficial femoral arteries, secure the femoral vessels with suture ligation prior to dividing the musculature. There is no need for suture ligation if the vessels are already obliterated because of the underlying disease, as in the video.
Fashioning the posterior skin-muscle flap (lfexors, adductors,) with swift piercing soft-tissue transection
Transecting the femur
Retract the soft tissues with a Percy amputation shield and transect the bone about 2 cm distal to the angle of the flap. Smooth the bone edges with a rasp, possibly a Luer.
1. Shortening the femur too much results in a voluminous soft tissue shell, and the stump will "float" later on. If the femur is too long, it will work its way out through the soft tissue shell ("internal ulcer"), and the residual limb cannot bear weight. In both cases, the stump is at risk and a prosthesis cannot be fitted!
2. Elevating the periosteum may result in exostosis and is therefore not recommended.
Resectioning the sciatic nerve
Suture ligating the vessels
Femoral myoplasty, wound closure