Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 87 • Fasciotomy—Forearm and Leg 941

2. DISSECTION

◆ The subcutaneous tissues are divided to expose the deep fascia, and individual muscles are

mobilized for examination (Figure 87-1, C).

◆ If the muscles of the dorsal compartment require release after the volar fasciotomy, a

straight longitudinal incision is made below the lateral epicondyle toward the midline of the

wrist.

◆ Other incisions described for the treatment of compartment syndrome criss-cross the fore-

arm or gently sweep across it in various directions.

◆ Incisions that cross the forearm will transect more of the venous and lymphatic return than

will a straight incision, and the resolution of forearm edema could be impaired. Such

incisions may also prevent the future design of a radial forearm ﬂ ap, because the vascular

supply and outﬂ ow of the skin pedicle would be compromised.

942 Section XII • Vascular

3. CLOSING

◆ Dressings

◆ Cover the wound with saline-soaked gauze and a nonconstricting bandage.

STEP 1: SURGICAL ANATOMY FOR LEG

◆ The lower leg has four muscular compartments with dense investing fascia that contribute

to the predisposition of this region to develop neurovascular compromise following injury

generally referred to as compartment syndrome.

◆ The treatment of compartment syndrome requires incision of the investing fascia of all four

compartments: anterior, lateral, superﬁ cial posterior, and deep posterior (Figure 87-2, A).

STEP 2: PREOPERATIVE CONSIDERATIONS FOR LEG

◆ Same as previously mentioned for the forearm procedure.

STEP 3: OPERATIVE STEPS FOR LEG

1. INCISION

◆ Medial and lateral skin incisions are carried from just proximal to the medial and lateral

malleoli and carried cephalad to the level of the tibial plateau medially and the ﬁ bula head

laterally, where care must be taken to avoid injury to the peroneal nerve (Figure 87-2, B).

2. DISSECTION

◆ Both the superﬁ cial and deep posterior compartments are released through the medial

incision, and the anterior and lateral compartments are released through the lateral incision

(Figure 87-2, C).

CHAPTER 87 • Fasciotomy—Forearm and Leg 943

Left Leg

Medial

Left Leg

Lateral

Tibialis

anterior muscle

Extensor hallucis

longus muscle

Extensor digitorum

longus muscle

Long

peroneal muscle

Short

peroneal muscle

Fibula

Interosseus membrane

Peroneal

artery, and vein

Flexor hallucis

longus muscle

Soleus muscle

Gastrocnemius muscle

lateral head

Gastrocnemius muscle

medial head

Plantaris

muscle tendon

Posterior

tibial artery,

vein, and nerve

Tibialis

posterior muscle

Flexor digitorum

longus muscle

Anterior tibial

artery, vein,

and nerve

Tibia

Lesser saphenous vein

Superficial

posterior compartment

Lateral

compartment

Deep

posterior

compartment

Anterior compartment

Lateral incision

Medial incision

FIGURE 87 –2

944 Section XII • Vascular

3. CLOSING

◆ Dressing of saline-soaked gauze and a nonconstricting bandage.

STEP 4: POSTOPERATIVE CARE

◆ Pain control is often a signiﬁ cant issue following fasciotomy and is best managed with a

patient-controlled analgesia device. Wound care requires attention to aseptic technique and

ensures adequate material: sterile gowns, gloves, and dressing supplies are at hand before

dressing changes are begun to avoid contamination and serious morbidity associated with

wound infection. Elevation of the extremity will help reduce edema and hasten the recovery

and closure of the wound. The use of biologic dressings, either homograft or xenograft, may

also help in wound care.

STEP 5: PEARLS AND PITFALLS

◆ Most cases of compartment syndrome are adequately treated by release of the superﬁ cial

volar compartment, regardless of which surgical approach is chosen. Those clinical situa-

tions that mandate exploration of the deep volar or dorsal compartments, however, require

a signiﬁ cant understanding of anatomy to follow a surgical approach that will minimize fur-

ther injury. Clinical examples include high-voltage electrical injury, severe crush injuries,

extended extrinsic forearm pressure (such as an unconscious patient lying on his or her

forearm), and ongoing evidence of myonecrosis or sepsis despite previous superﬁ cial fasci-

otomy. In some cases, even after compartment fasciotomy, the epimysium of individual

muscles must be incised to relieve persistently elevated tissue pressure. This can be

achieved only with adequate visualization of the deep space.

SELECTED REFERENCES

1. Lagerstrom CF, Reed RL Jr, Rowlands BJ, Fischer RP: Early fasciotomy for acute clinically evident post-

traumatic compartment syndrome. Am J Surg 1989;158:36-39.

2. Dente CJ, Feliciano DV, Rozycki GS, et al: A review of upper extremity fasciotomies in a level I trauma

center. Am Surg 2004;70:1088-1093.

945

Approximately 5% to 10% of patients with hypertension have renal artery stenosis (RAS) as the

underlying cause. Atherosclerotic occlusive disease in individuals older than 65 years and ﬁ bro-

muscular dysplasia (FMD) in children and young adult females (20 to 40 years of age) are the

most common etiologies. Atherosclerosis of the renal arteries is usually conﬁ ned to the oriﬁ ce

and proximal third of the involved vessel (more commonly the left) and should be considered

as an extension of aortic atherosclerosis. In 20% of patients with RAS, there is severe associated

aortic aneurysmal or occlusive disease, which determines the extent and type of procedure to

be performed. RAS may occur in isolation (anatomic stenosis) or in association with hyperten-

sive ischemic nephropathy. FMD may be medial (85%), perimedial (10%), or intimal (5%) and

usually involves the mid-portion of the main renal arteries and their segmental branches.

STEP 1: SURGICAL ANATOMY

◆ The renal arteries branch laterally from the aorta below the origin of the superior mesen-

teric artery. There is usually a single renal artery to each kidney. The right renal artery arises

higher and is longer than the left renal artery. The right renal artery runs posterior to the

inferior vena cava, right renal vein, head of the pancreas, and descending part of the duode-

num to the renal hilum. The left renal artery passes posterior to the left renal vein, body of

the pancreas, and splenic vein. Multiple renal arteries are present in up to 35% of patients

and should be identiﬁ ed and evaluated before any surgical intervention.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Medical history, physical examination, and assessment of renal and cardiac function should

be performed in all patients. Features suggestive of RAS as the cause of hypertension

include hypertension of abrupt onset, hypertension refractory to medical therapy (more

than three drugs), unexplained azotemia or azotemia induced by angiotensin-converting

enzyme (ACE) inhibitors, and hypertension in children and young adults.

◆ Screening and diagnostic studies: Duplex ultrasound is useful as a screening test for RAS

and evaluation of kidney size. Interrogation of the renal arteries from their origin to the

hilum can be achieved in 95% of cases. A peak systolic velocity of greater than 180 cm/sec

and renal-to-aortic ratio ⱖ3.5 with distal turbulence is usually indicative of a hemodynami-

cally signiﬁ cant stenosis (⬎60%). Occlusion of the renal artery is usually identiﬁ ed by the

absence of a Doppler signal.

CHAPTER

Renal Revascularization

Glenn C. Hunter

946 Section XII • Vascular

◆ Computed tomography (CT) or digital angiography is used to delineate the stenosis before in-

tervening. There is a high risk of contrast-induced nephrotoxicity, and care should be taken in

performing these studies in patients with renal impairment. The administration of intravenous

(IV) ﬂ uids (1.5 mL/kg/hr), limiting the dose of or diluting the contrast agent, and the adminis-

tration of acetylcysteine 600 mg orally before and after the contrast procedure are among the

measures used to reduce the risk of nephrotoxicity. Magnetic resonance angiography is an alter-

native method of assessing RAS in patients with a glomerular ﬁ ltration rate ⱖ30 ml/min/1.73 m

◆ Functional studies: A captopril renal scan may be helpful if there is unilateral stenosis and

minimal parenchymal disease. The signiﬁ cance of unilateral RAS should be conﬁ rmed by

plasma renin determinations. This may require admission to the hospital, withholding med-

ications that interfere with renin release, and sodium restriction (ⱕ2 g Na

⫹

/day) for approx-

imately 2 weeks.

◆ Indications for the operative treatment of RAS include stenosis greater than 70% with

poorly controlled hypertension, renal insufﬁ ciency, or recurrent bouts of congestive heart

failure (CHF) with no attributable myocardial ischemia. Patients with branch vessel disease

and FMD and selected patients with restenosis after angioplasty and stenting may be

candidates for surgery.

STEP 3: OPERATIVE STEPS—AORTORENAL BYPASS

◆ The patient is admitted the day before the procedure for IV hydration, control of blood

pressure, and a mechanical bowel preparation. Antihypertensive medications should be

reduced to the minimum necessary to control the blood pressure. If the diastolic blood

pressure is higher than 120 mm Hg, the patient should be admitted to the intensive care

unit (ICU) and the blood pressure controlled with IV sodium nitroprusside or nicardipine.

1. INCISION

◆ A midline or transverse incision allows both access to the renal arteries and reconstruction

of associated aortic disease if required. The abdomen is explored, the transverse colon

and small bowel are lifted out of the abdomen, and a self-retaining retractor such as the

Omni-Tract system is placed (Figure 88-1, A).

2. DISSECTION

◆ The peritoneum over the aorta is incised in the midline, and the dissection is carried down

to the left renal vein superiorly and the aortic bifurcation inferiorly (Figure 88-1, B). The

left renal vein is then mobilized and retracted cephalad or caudally depending on the loca-

tion of the origin of the renal vessels. Retraction of the left renal vein is facilitated by liga-

tion and division of the gonadal, adrenal, and lumbar veins.

◆ Both renal arteries are then dissected out 2 cm beyond the oriﬁ cial stenotic lesion. An aor-

torenal bypass is the most common revascularization procedure performed but requires

clamping of the aorta. This technique is applicable only to patients with large paired renal

arteries with minimal aortic atherosclerosis or aneurysmal dilation.

CHAPTER 88 • Renal Revascularization 947

Midline incision

Transverse incision

Incision over

femoral vessels

and saphenous vein

Ligament

of Treitz

Inferior

mesenteric

artery

Marginal

artery

Peritoneal

incision

FIGURE 88 –1

948 Section XII • Vascular

◆ The proximal right renal artery is exposed by retracting the left renal vein superiorly

and the vena cava to the right. The distal portion of the renal artery is exposed by mobiliz-

ing the duodenum and hepatic ﬂ exure medially. If both renal arteries need to be exposed,

the entire small bowel is mobilized from the ligament of Treitz to the mesentery of the

cecum and along the right paracolic gutter to the foramen of Winslow. The peritoneal

incision is extended along the inferior border of the pancreas, exposing the aorta above the

origin of the superior mesenteric artery.

◆ Once the renal arteries have been isolated, a segment of the infrarenal aorta below the renal

arteries is mobilized. After systemic heparinization (100 U/kg) and the administration of

mannitol (12.5 to 25 g), the aorta is occluded below the renal arteries and above the bifur-

cation, and an ellipse approximately three times the diameter of the renal artery is excised

from the anterior lateral aortic wall. Saphenous vein or a prosthetic Dacron or polytetra-

ﬂ uoroethylene (PTFE) graft 6 or 7 mm in diameter is beveled, and the aortic anastomosis is

completed with 4-0 polypropylene suture (Figure 88-2, A-C).

Abdominal

aorta

Right

renal artery

Left

renal vein

Inferior

vena cava

Left

renal artery

FIGURE 88 –2

CHAPTER 88 • Renal Revascularization 949

Harvested

saphenous vein

Abdominal

aorta

Right

renal artery

Left

renal vein

Left

renal artery

Prosthetic

graft

Inferior

vena cava

FIGURE 88 –2, cont’d

950 Section XII • Vascular

◆ The renal artery is divided between clamps, and the proximal end of the artery is oversewn

with 5-0 polypropylene suture. The saphenous vein or prosthetic graft is spatulated, and

the distal anastomosis is constructed end-to-end with running (posterior wall) and inter-

rupted 6-0 polypropylene suture (Figure 88-2, D-E).

Inferior

vena cava

Abdominal

aorta

Right

renal artery

Left

renal vein

Left

renal artery

Completing

distal anastomosis

Left

renal vein

Right

renal artery

Prosthetic

graft

FIGURE 88 –2, cont’d