MRCS (UK) PART-A COURSE Lecture Note 11. Vascular Surgery
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defined. Topic 1 | Amputations 1 Topic 2 | Acute Limb Ischaemia 3 Topic 3 | Peripheral Vascular Disease 7 Topic 4 | Arterial Occlusions/Insufficiency 13 Topic 5 | Lower Leg Ulcers 18 Topic 6 | Peripheral Vascular Disease 22 Topic 7 | Cardiopulmonary Bypass 39 Topic 8 | Chronic Venous Insufficiency And Varicose Veins 42 Topic 9 | Takayasu's Arteritis 45 Topic 10 | Klippel-Trenaunay Syndrome 50 Topic 11 | Amputations 51 Topic 12 | Cardiopulmonary Bypass 54 Topic 13 | Vascular Investigations 55 Topic 14 | Subclavian Artery 58 Topic 15 | Ankle-Brachial Pressure Index 64 Topic 1 | Amputations Amputations are indicated when the affected limb is one of the following: • Dead non viable • Deadly where it is posing a major threat to life • Dead useless where it is viable but a prosthesis would be preferable Orthopedic surgery • Amputation is often undertaken as an option of last resort e.g. Limb salvage has failed and the limb is so non functional that mobility needs would be best met with prosthesis. • Chronic fracture non union or significant limb shortening following trauma would fit into this category. Occasionally following major trauma a primary amputation is preferable. This would be the case in an open fracture with major distal neurovascular compromise and other more life threatening injuries are present. Vascular surgery • The first two categories are the most prevalent. • Diabetic foot sepsis is often a major cause of sepsis which can spread rapidly in the presence of established peripheral vascular disease. • As a general rule the main issue in vascular surgery is to optimise vascular inflow prior to surgery. The more distal the planned amputation is to be, the more important this rule becomes. otherwiseit will bemajor threat to like
• In other situations there has been something such as an embolic event that has not been revascularised in time. In this case the limb shows fixed mottling and an amputation will be needed. Types of amputations As the vast majority of commonly performed amputations affect the lower limbs these will be covered here. The main categories of amputations are: • Pelvic disarticulation (hindquarter) • Above knee amputation • Gritti Stokes (through knee amputation) • Below knee amputation (using either Skew or Burgess flaps) • Syme's amputation (through ankle) • Amputations of mid foot and digits Choosing a level of amputation depends on: • The disease process being treated • Desired functional outcome • Co-morbidities of the patient Above knee amputations • Quick to perform • Heal reliably • Patients regain their general health quickly • For this benefit, a functional price has to be paid and many patients over the age of 70 will never walk on an above knee prosthesis. • Above knee amputations use equal anterior-posterior flaps Below knee amputations • Technically more challenging to perform • Heal less reliably than their above knee counterparts. • However, many more patients are able to walk using a below knee prosthesis. • In below knee amputations the two main flaps are Skew flaps or the Burgess Long posterior flap. Skew flaps result in a less bulky limb that is easier to attach a prosthesis to. It is worth remembering that whilst it may be technically feasible to offer a below knee amputation there may be circumstances where an above knee option is preferable. For example, in fixed flexion deformities of the lower limb, little functional benefit would be gained from below knee amputation surgery. Question 1-3 Theme: Amputations A. Transfemoral amputation B. Gritti - Stokes amputation C. Digital amputation D. Syme's amputation E. Hindquarter amputation transformoral serve patella ofconscryscretelines) areostcoplastic amputation. · Rayamputation (along thehead ofmxtuers415). (Not ideal for prosthesis). more beautiful I fish mouth Flap). vskful to prostosis. + (local for prosthesis). SACN - Both flaps arequal Burgess - post flap is larger than conterior flap. timputat From => 10-12 cm below the T tuberosity fixed flaxion I Reformity (b"ovckn44 computation 7/ Picture in slick
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