Iliacomesenteric venous bypass in superior mesenteric artery occlusion—Vascular Surgery

Perform median laparotomy from xiphoid down to symphysis, carrying the incision to the left of the umbilicus.

Open the retroperitoneum to the right of the palpable aorta and coagulate any small visible vessels prior to transection. Locate the inferior mesenteric vein.

Tip:

An incision midway over the aorta may result in more severe bleeding from small, anteroaortic vessels, and there is the risk of inadvertent injury to the inferior mesenteric artery. Incisions carried more to the right of the aorta avoid these risks.

Locate the superior mesenteric artery in the course of the mesenteric axis using a Doppler ultrasound probe.

Tip:

Sometimes it is difficult to palpate the stenosed/occluded vessel, especially if the mesentery is quite fatty. As demonstrate din the video clip, it is quite helpful in such cases to locate the artery with a Doppler ultrasound probe prior to incision of the mesentery.

Displace the small intestine outside the abdominal cavity to the right and enclose it in a plastic bag. Displace the transverse colon and the greater omentum into the upper abdomen, cover them with a moist abdominal towel and kepp them there with a blade of the retractor system. Cover th mesentery of the descending colon with a moist abdominal towel and displace it to the left with another blade of the retractor system.

Tip:

Placing the small bowel in a plastic bag or wrapping it in plastic sheeting ensures that the bowel remains moist and does not sustain serosal lesions. This can also help prevent postoperative adhesions.

Incise the mesenteric root inferior to the colon and expose the superior mesenteric artery, which is soft and suitable for anastomosis in the dissected area. Free the artery circumferentially with Overholt forceps and encircle the vessel proximad and distad with vessel loops.

Tips:

1. In obese patients, a small retractor can facilitate the dissection of the artery.

2. Note and spare the small delicate side branches of the superior mesenteric artery!

After completely mobilizing the duodenojejuna flexure, divide the inferior mesenteric vein between suture ligatures and expose the infrarenal aorta. Since in the video clip, the aorta is badly calcified and not well suited for proper anastomosis with a venous bypass, the bypass will have to originate from the right iliac artery.

Tip:

The inferior mesenteric vein is divided because it will otherwise interfere with further dissection and disrupt the subsequent bypass procedure.