I’ve sort of lost my enthusiasm for Gerald and Sara after having the copyright farmer creep around here. A commenter said he would like to hear a hairy surgery story so here goes.
About 20 years ago, I got a call from the emergency room at San Clemente Hospital. They had just admitted a man who had had an aortic aneurysm repaired at Kaiser about six weeks before. He was now passing blood per rectum and was shocky and pale. This is a diagnosis you can make on the telephone. It is also an extreme emergency. A leaking native aneurysm is bad enough. I’ve seen patients survive for hours in that case, including a couple who refused surgery until it was almost too late. When the patient has had aortic aneurysm, or aortic bypass surgery, this story means that the suture line at the junction between the graft and the neck of the aorta above the graft has eroded into the small intestine, the duodenum usually, adjacent to the graft junction. The aortic flow is being blocked from the gut only by a clot. When that clot goes, the patient will exsanguinate into the gut, a matter of a couple of minutes.
I called the OR at the hospital and asked everybody to come in as fast as they could. It was about 9 o’clock at night as I recall and, fortunately, the elective surgery for the day had all been completed. That was a small hospital with two big operating rooms, whereas the trauma center that my partner and I ran had 14. There was no time to think about transferring him.
When I arrived, everybody, including the anesthesiologist on call, was there. There had been some problems with anesthesia in the past but that night we had a good sturdy gas passer. Faint heart has no place in a case like this.
An internist friend happened to be there and he liked to assist in surgery, unlike most internists. He was fun to have around, even in a big hairy case, so I asked him if he could stay. It was going to be an all-nighter, but he was enthusiastic. Fortunately, I had used self-retaining retractors for years and these are almost an assistant surgeon in themselves. The types I used fastened to the table and had multiple blades, including some that were malleable, so they could be positioned and left in place. They never got tired.
The anesthetist put the patient lightly to sleep and we got the blood bank to get some type-specific blood on hand, there was no time for cross match but it would be done as we went along. I made the incision about 30 minutes after he hit the ER door.
What we found was what I expected; a large hematoma around the aortic suture line where the duodenum crosses the aorta. In the days when I was still in training, we saw quite a few of these cases because the anastomosis had been done with silk sutures. Silk lasts for years but not forever and the pulsatile aorta never heals completely to the graft. To make things worse, many of the early grafts were made of Teflon, which just does not heal to tissue at all. The combination of silk sutures and Teflon grafts gave those of us of that generation plenty of experience with “false aneurysms” at the suture line of prior aneurysm repairs and bypasses. In that case, the suture line had come apart but the surrounding tissues were strong enough to prevent complete rupture. I can remember a couple of cases where, when I opened the false aneurysm (having clamped the aorta above), the graft was lying free in the center, not attached to anything.
In this case, the cause of the problem was either a suture line that had not been adequately separated from the duodenum by pulling tissue between them as a barrier, or an infection. No matter the cause, it was infected now as duodenal contents were bathing the graft. Once, in a previous case, a gastroenterologist had endoscoped a patient for mild GI bleeding. Far down in the duodenum, he saw what looked like a piece of celery. He asked if we wanted it biopsied. My partner laughed and said, “No, that’s the graft.” It was stained green and had eroded the duodenum but the suture line was intact. Her aortic surgery had been years before.
The trick in these cases is to get proximal control. In a native aortic aneurysm, there is almost always a “neck” below the renal arteries. The length of that neck may be only a centimeter or two but it is there. Even in rupturing aneurysms, the neck can almost always be found by the experienced surgeon with blind finger dissection in the hematoma that surrounds the aorta. There are rare aneurysms in which the renal arteries and the other visceral arteries, the superior mesenteric and the celiac, come off the aneurysm but they are fortunately rare. Clamping the aorta above the renals is rarely necessary and risks postop renal failure. In these false aneurysms, however, it is not uncommon to have to clamp above the renals to get control. That should be done for as short a time as possible.
Once the false aneurysm is opened, a neck can usually be found to oversew the aorta. The surgeon should never do another anastomosis as the area is almost always infected. That was the case with our patient that night. I can’t remember anymore if I was able to find a neck to clamp or had to clamp above the renal arteries. Once the aortic flow was controlled, I oversewed the stump of the aorta with a monofilimant heavy suture, like polypropylene. Polyethylene is too slippery and the knots may slip. Suture material that is woven has interstices that can become infected. Even Nylon is better than woven material.
The bowel loop, almost always the duodenum, is repaired, usually with some sort of external patch, sometimes another loop of bowel to keep the suture lines separated.
The distal (downstream) stump of aorta is also oversewn. The inferior mesenteric artery comes off the aneurysm and was almost certainly ligated at the first surgery. There is almost always adequate collateral circulation to the colon but I have seen a couple of cases where the colon died, usually a consequence of the shock and low blood pressure which makes collateral flow a problem. That is usually recognized too late and is usually in patients that do poorly postop.
Once that part of the operation is complete, the rest is a tedious procedure of running bypass grafts from the axillary arteries on each side down the sides of the trunk to the femoral arteries to bypass the aorta. The area of the false aneurysm, even if fairly clean looking, is considered infected and is thoroughly irrigated and some antibiotic solution is left.
We finished our case about 9 AM and my friend the internist sang opera almost all night. That is one of the reasons I always enjoyed having him there. He didn’t do too much assisting but he stayed out of my way and never lost his enthusiasm.
The patient did not have any renal problems and went home about 8 or 9 days later. I sent Kaiser the biggest bill I had ever sent anyone, about $9,000, and they paid it without a peep. The surgery took a little over 12 hours and I thought the hourly rate was not unreasonable.
Not every case of mine was this successful and I had a similar case that ended in disaster, but that is a story for another day.
Thanks, Doc. I was the guy who requested a story like this. Some of the jargon is somewhat difficult for me to understand but I get the general idea. One thing got me though: a retractor, ostensibly made of surgical stainless (guess) like the one in the link you supplied: $11,350. Wow. From a layman, that sounds rather expensive for parts cut into what appear to be rather simple shapes; then again, there’s probably some materials research required to acquire those “malleable” properties that are essential to the surgeon. Does clamping the aorta result in back pressure that can “shock” the left ventricle and adversely affect heart function? In any event, well done. chuck
Clamping the aorta does result in back pressure and another one of my stories. When I was an intern, we had a patient present to cardiac surgery clinic who had both an abdominal aortic aneurysm and a thoracic aorta aneurysm. He presented a serious dilemma, namely the back pressure from clamping his aorta for the abdominal procedure would risk rupturing the thoracic aneurysm. The clinic decided (typically) to do nothing and wait for developments.
A couple of weeks later, he appeared on surgery admitting with abdominal pain and a pulsatile mass in his abdomen. I hurriedly lined up 20 units of blood, did cutdowns in both arms, (large bore IVs) put in a Foley catheter and called a cardiac consult. My friend, Earl Harrison (about whom I have many stories), the cardiology fellow, came to see this guy on the surgery admitting ward. He walked into the room and the guy was lying there in no distress. Earl said, “What’s the problem?,” or something like that.
I looked and the patient looked comfortable and his pulsatile mass mass was gone ! The urine bag was full with about 1700 ccs and my face turned red. The mass had been a full bladder and the whole thing was a false alarm. The aneurysm was unchanged and the mass was a full bladder transmitting the pulsation from the aneurysm. Earl thought it was pretty funny. He stayed on as faculty at LA County and I used to see him there all the time. I wonder if he is still OK. That was 55 years ago.