55.6 Repairing blood vessels

Vascular surgery is normally considered to be strictly the work of a specialist. But the patient must reach the specialist within 4 hours of his injury; if this is impossible, you will have to do as best you can yourself. If you operate carefully, and handle the patient’s injured artery gently, you may succeed in repairing it. In doing so you may save his life, or his limb, so that you and he enjoy one of the most rewarding forms of fine surgical craftsmanship. The penalty for failure will certainly not be worse than that of not trying. You don’t need any special equipment, but it will take you a long time. Use the finest instruments you have; eye instruments are suitable if you treat them carefully, and so are eye sutures. But successful repairs have been done with quite coarse ones. You will also need good aseptic technique, a strong light, adequate anaesthesia, good eyesight, or magnifying spectacles, and a blood transfusion. Your repair may thrombose later, but it may stay open long enough to let an effective collateral circulation develop.

Figure 55.3: INJURIES TO ARTERIES. A, a lacerated artery. B, a piece of saphenous vein being sewn over the laceration. C, a bruised piece of artery being excised. D, and E, an oblique anastomosis. F, G, and H, you may be able to anastomose an artery by passing a stiff plastic catheter, such as that from a intravenous cannula, through an arteriotomy incision, and then using this as a stent over which to do the anastomosis. I, if you try to patch a vessel, start by fixing it with two sutures at either end like this. From the Field Surgery Pocket Book, with the kind permission of Guy Blackburn. F, G, and H, kindly contributed by Naim Janmohammed.

Arteries

have to be clamped or tied proximally before you can repair them, either in the wound itself, or at one of the sites of election using either a tape, or an arterial clamp.

Never clamp an artery with a haemostat. Even rubber tubes over the jaws of a haemostat will not prevent them from injuring it. Instead: (1) use the special arterial clamps, or (2) the Rummel tourniquet shown in Fig. 55-4. This is merely a length of stout linen or cotton tape passed round the artery and then threaded through a rubber or plastic tube. If you pull the tape and push the tube down on the artery you will occlude it. (3) Pass a fine rubber tube or catheter round the vessel, and hold it against your finger.

If the flow of blood in an artery stops, the blood in it is liable to clot, so stop it doing this by injecting dilute heparin into it proximal and distal to the clamp. Be careful never to inject more than one fifth of the anticoagulant dose of heparin for the whole patient (15,000 units in an adult).

Veins.

In the limbs you can tie most veins without causing any disability. Veins bigger than the femoral should ideally be sutured. This is more difficult than suturing an artery. Torn veins are difficult to see because blood wells up into the wound, instead of spurting like an artery.

• CLAMP, bulldog for arteries, Blalock cross action, assorted sizes, four only. If you want to clamp an artery temporarily, apply one of these, not a haemostat.

Figure 55.4: ANASTOMOSING AN ARTERY END TO END. A, shows how an artery can be closed temporarily with a Rummel tourniquet. This is a piece of tape passed round the artery and then through a rubber tube. B, an artery being anastomosed. Note that the arterial clamps have rubber over their jaws. Adapted from Hamilton Bailey by the kind permission of Hugh Dudley.