AAA - Open AAA Repair Operation
Your surgeon will advise you on the basis of the CT scan whether it is possible to perform ‘keyhole’ (endovascular) surgery, or not. In some cases this is not possible and, if fit enough, you will be offered a more traditional ‘open’ operation.
The following information will help explain the process of the Open AAA Repair.
Before going into hospital
Before aneurysm surgery, there are a number of tests that need to be done. These are of two types: those to assess your general fitness and those to assess your suitability for different types of aneurysm surgery.
Tests of fitness and suitability are normally done before a decision to operate is made. They normally include:
- Blood tests
- An ECG (electronic heart monitoring)
- Echocardiogram (an ultrasound test of the heart)
- Breathing test
- A CT scan of the aneurysm
Some hospitals will also require a chest x-ray prior to surgery.
Immediately before the operation a further blood test will be taken. You will be asked to sign a form confirming that you understand the why the procedure needs to be performed, the risks of the procedure and that you agree to the surgery. These may be completed at a pre-admission visit to the hospital a few days before your operation, or when you are admitted for the operation.
Your stay in hospital
You should bring with you all the medications that you are currently taking. You will be admitted to your bed by one of the nurses who will also complete your nursing record.
You will be visited by the Surgeon who will be performing your operation, and also by the doctor who will give you the anaesthetic. Physiotherapists and Intensive Care staff may also visit, to give you information about your postoperative care. If you have any remaining questions about the operation please ask the doctors.
The Operation
The Anaesthetic
The first part of the operation involves giving you an anaesthetic so that you will be asleep during the operation. A tiny needle will be placed in the back of your hand. The anaesthetic is injected through the needle and you will be asleep within a few seconds. Next, you may have a small tube placed in your back (epidural) to help with pain relief after surgery.
A tube (catheter) will be inserted into your bladder to drain your urine. Additional drips will be placed into a vein in your neck and your wrist for blood pressure measurements and to give you some fluids during and following surgery.
Sometimes, there will be a tube into your stomach (via your nose) to stop you feeling sick.
The Open Operation
You will have a cut, either down or across your tummy and occasionally a smaller cut may be needed in one or both groins.
The enlarged segment of aorta will be replaced by an artificial blood vessel (graft) made of Dacron. Sometimes this will be a simple tube, and sometimes, as in the illustration, a branching graft to each leg artery is used.
The redundant aneurysm sac is closed over the graft at the end of the procedure to separate it from the overlying structures.
The wounds are closed with either a stitch under the skin that dissolves or by clips that will need to be removed about 10 days after the surgery.
Recovery and Aftercare
You will usually spend 1-2 days in the Intensive Care or High Dependency Unit after your operation so that your progress can be closely monitored.
It is usually necessary for you to remain on a breathing machine for a short period after the operation but you will be taken off this as soon as possible.
Following this sort of surgery the bowel stops working for a while and you will be given all the fluids you require in a drip until your bowel can cope with fluids by mouth.
It may be necessary for you to have a blood transfusion. Some hospitals recycle your own blood lost during the operation and give it back to you.
The nurses and doctors will try and keep you free of pain by giving painkillers by injection, via the epidural tube in your back, or by a machine that you are able to control yourself by pressing a button.
Over the next few days as you start to recover, the various tubes will be removed and you will return to the normal ward until you are fit enough to go home (usually 8-10 days after the operation).
You will be given a small injection every day to lower your chance of getting a deep vein thrombosis (DVT) or pulmonary embolus (PE) after the operation. These will continue until you are fully mobile and discharged from hospital.
Going home and aftercare
If your stitches or clips are the type that need removing this is usually done whilst you are still in hospital. If not we will arrange for your GP’s practice or district nurse to remove them and check your wound.
You will feel tired for many weeks after the operation but this will improve as time goes by.
Exercise: Regular exercise such as a short walk combined with rest is recommended for the first few weeks followed by a gradual return to normal activity.
Driving: You will be able to drive when you are can perform an emergency stop safely. This will normally be 3-4 weeks after surgery, but if in doubt check with your own doctor. You should inform your insurers that you have undergone major surgery.
Bathing: Once your wound is dry you may bathe or shower as normal. This will normally be before you leave hospital.
Work: If this applies to you, you should be able to return to work within 6-12 weeks of surgery. Your GP will advise you of this when you see him/her for your sick-note.
Lifting: You should avoid heavy lifting or straining for 6 weeks after the operation.
Medicines: You will usually be sent home on a small dose of aspirin and a statin if you were not already taking them. This makes the blood less sticky and reduces your cholesterol levels. If you are allergic to aspirin, or if it upsets your tummy, an alternative drug may be prescribed.
Complications
As with any major operation there is a small risk of you having a medical complication such as:
- Heart attack
- Stroke
- Kidney failure
- Chest problem
- Loss of circulation in the legs or bowel
- Infection in the artificial artery
Each of these are rare, but overall it does mean that some patients may not survive their operation or the immediate post-operative period.
For most patients this risk is about 7% from an open aneurysm repair - in other words 93 in every 100 patients will make a full recovery from the operation.
The doctors and nurses will try to prevent these complications and to deal with them rapidly if they occur. Surgeons at your hospital will be able to tell you the local death rate for this operation.
If your risk of a major complication is higher than this, usually because you already have a serious medical problem, your surgeon will discuss this with you. It is important to remember that your surgeon will only recommend treatment for your aneurysm if he or she believes that the risk of the aneurysm bursting is much higher than the threat posed by the operation.
DVT/PE: after any large operation there is a risk of DVT or PE. You will be on medication to reduce the risk, but this cannot be completely negated. If you do get a DVT or PE you will require a period of tablets (warfarin) to thin the blood for 3 to 6 months.
Chest infections: These can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy.
Wound infection: Wounds sometimes become infected and this may need treatment with antibiotics. Bad infections are rare. Occasionally, the incision may need to be cleaned out under anaesthetic.
Graft infection: Very rarely (about 1 in 500), the Dacron graft may become infected. This is a serious complication, and usually treatment involves removal of the graft.
Fluid leak from wound: Occasionally the wound in your groin can fill with a fluid called lymph that may leak between the stitches. This usually settles down with time.
Bowel problems: Occasionally the bowel is slow to start working again after the operation. This requires patience and fluids will be provided in a drip until your bowels get back to normal.
Sexual activity (Impotence): This may occur in men due to nerves in your tummy being unavoidably cut during the operation. This occurs in about 10% of patients.
What can I do to help myself?
If you are a smoker you should make a determined effort to stop completely. Continued smoking will cause further damage to your arteries and increases the risks of heart attacks, strokes, and problems with the circulation in your legs.
General health measures such as reducing weight, a low fat diet and regular exercise are also important.