Emergency Surgery Workshop Davos 2011: Presentation by Robert Seelos, MD, Head of Vascular Surgery, Cantonal Hospital Lucerne and Head of Vascular Surgery, Cantonal Hospital Zug, Switzerland

1. Surgery under critical environmental conditions
- Vascular Surgery -
Robert Seelos, MD, Lucerne
www.vascular-international.org

2. Vascular injuries … role of vascular surgery?
to prevent loss of life and limb due to
… bleeding → bleeding control
… ischemia → revascularisation
… reperfusion injury → fasciotomy

3. Amputation in natural disasters
Bam 2003, Pakistan 2005, Sichuan 2008
Amputation rate 0.4 –10.8 % in injured patients
Haiti 2010
Amputations „several thousands“

4. Vascular surgery in natural disasters
Dpt. of Orthopedics, West China Hospital Chengdu
1410 patients 332 lower leg fractures
Vascular injury 25/332 7.5 % (closed 5.9 %, open 8.9 %)
50 % popliteal injury
Time to treatment 1-64 hrs, mean 23.3 hrs
All treated surgically and patent, 75 % by direct suture
28/332 8.6 % compartment syndrome
Liu: Chin J Traumatol 2010;13(1):10

5. Vascular injuries … prognostic factors
Energy impact
-blunt
-high/low velocity penetrating
Additional venous injury
Time and severity of ischemia (6 hrs)
Contamination
Site of injury

6. Vascular injuries … site
Femoral/Popliteal artery
High rate of limb loss
Reconstruction
Crural arteries
Low rate of limb loss
Ligation
There is acute, non-complete, compensated ischemia !
Wounds will not heal !

7. Vascular injuries… detection
Hard signs Soft signs
Absent pulses Diminished pulses
Signs of ischemia Pattern of concomitant
injuries
Expanding hematoma Hematoma
Active hemorrhage Unexplained hypotension
Bruit/palpable thrill Neurologic abnormalty
Operative exploration

8. Vascular injuries … simple diagnostic tests
Doppler Signal present?
95 % arterial injuries detected by
Absent pulses + ABI < 0.9
limitation: mangled extremity

9. On table angiography …blunt injuries, multilevel

10. Vascular injury - ischemia severity
Category sensation paralysis arterial venous suggested
loss Doppler Doppler treatment
I none none audible audible not
immediately
threatened,
investigate
IIa minimal none often audible prompt
(toe) or audible treatment
none for salvage
IIb more than partial usually audible immediate
toes, rest inaudible treatment
pain for salvage
III profound, rigor absent absent irreversible,
anaesthetic primary
amputation
SVS/ISCV acute limb ischemia classification 1997

11. Decision … salvage vs. amputation
Functional limb ? (tibial nerve)
№ secondary procedures ?
Rehabilitation ?
Ethical issues ?
Limb salvage 87% ischemia < 6 hrs
61% ischemia > 6 hrs
Glass: J Plast Reconstr Aesthet Surg 2009 May;62(5):571

12. Vascular injuries … MESS 6

13. Vascular injuries … MESS 10
Primary bk amputation

14. Vascular injuries… surgical principles
Proximal control (tourniquet, compression, clamp)
Debridement vessel wall
Fogarty thrombectomy of appositional thrombus
Temporary shunting if anatomically possible, proximal arteries
External Fixation ?
Repair - suture
- end-end anastomosis
- patch
- graft
Fasciotomy

15. Course structure
2 days 10 % theory
15 hrs training -Principles vascular
24 trainees trauma
8 tutors -Vascular access
Pontresina
Simulators 90 % basic skills
-debridement
-shunting
-Fogarty technique
-anastomosis
-patch-plasty
-bypass

16. Instruction – „keep it simple“
Fogarty - simulation

17. Damage control – debridement, shunt
End-End anastomosis Shunt insertion

18. Revascularisation
Simple bypass Quality control
techniques

19. Assessment, debridement, thrombectomy

20. Revascularisation vein graft, nerve repair

21. Discussion
VS can provide simple tools to treat vascular lesions even under critical
environmental conditions!
BUT
How many vascular injuries do occur in different scenarios? Awareness?
How many limb losses could be avoided?
Is it efficient to provide VS in disaster scenarios?
Does simulator based training result in competency?
What is the half life of those skills?