Access to the proximal aortic aorta through the lesser sac/supracoeliac control of the aorta

Access to the proximal aortic aorta through the lesser sac/supracoeliac control of the aorta:

The Mattox maneuver of left-sided visceral rotation is used to expose the proximal abdominal aorta. Alternatively, the aorta may be approached through the lesser sac. The lesser omentum is widely opened and the left lobe of the liver retracted. This provides a window to gastro-esophageal junction. Again, the esophagus is

mobilized and the aorta can be clamped (Fig. 3.2 ).

โ€ขSome have advocated aortic compression be accomplished with compression devices, either a sponge stick or a more formal device known as an aortic compressor (Fig. 3.3 ). This allows aortic compression and presumed occlusion without requiring any other maneuvers. These devices are applied to the aorta anteriorly, hopefully occluding aortic flow. Unfortunately, these devices often migrate, slipping off the aorta. The task of holding these devices is often left to the junior member of the team, who may not be able to maintain true aortic occlusion.

โ€ขEach of these operative maneuvers has signifi cant disadvantages. They each require timehemorrhage. In addition, it would be diffcult to worsen the liver bleeding, manipulating the aorta in the chest. This has the downside, however, of requiring the surgeon to open an uninjured body cavity. The thoracotomy itself, when performed rapidly, can be a source of substantial blood loss, as it is usually not possible to obtain meticulous hemostasis of the chest wall musculature. In addition, the open chest serves as a source of heat loss, worsening the possibility of hypothermia.

๐—ฆ๐˜‚๐—ฝ๐—ฟ๐—ฎ๐—ฐ๐—ผ๐—ฒ๐—น๐—ถ๐—ฎ๐—ฐ ๐—ฐ๐—ผ๐—ป๐˜๐—ฟ๐—ผ๐—น ๐—ผ๐—ณ ๐—ฎ๐—ผ๐—ฟ๐˜๐—ฎ: this effectively gives total vascular in-flow control to the abdomen. The supracoeliac aorta is palpated by dissecting through the lesser omentum (gastro-hepatic ligament) & palpating it against the midline vertebrae. Initially, manual compression may be used, but for effective and safe cross-clamping,the intra-abdominal portion of the oesophagus will need to be swept away from the aorta (towards the patientโ€™s left hand side) and the right and left diaphragmatic crus (& other connective tissue) separated from the aorta itself, with a combination of sharp and blunt dissection.

๐Ÿ‘‰For patients in extremis from haemorrhage with a suspected intra-abdominal source, or potential for problematic intra-abdominal control (e.g. hostile abdomen), then a left antero-lateral thoracotomy with cross-clamping of the descending thoracic aorta is the most rapid and effective way to gain immediate abdominal in-flow control.