Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

C H A P T E R 104 • Neck Exploration for Trauma 1159

Zone III

Angle of mandible

FIGURE 104–1

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Omohyoid muscle

Inferior thyroid artery

Middle thyroid vein

Thyroid gland

Parotid gland

Cross-sectional view (Figure 104-2)

Investing layer of deep cervical fascia

Carotid sheath

Prevertebral fascia

Retropharyngeal space

Investing fascia

FIGURE 104–2

C H A P T E R 104 • Neck Exploration for Trauma 1161

STEP 2: PREOPERATIVE CONSIDERATIONS

The most common indication for neck exploration is penetrating trauma, although blunt trauma may also present with vascular and aerodigestive tract injury requiring treatment, identified by hard signs on examination (active hemorrhage, expanding hematoma) or by diagnostic study, computed tomography (CT), or ultrasound.

STEP 3: OPERATIVE STEPS

1.POSITIONING AND PREPARATION

The patient is placed supine with a 3-inch towel roll beneath the shoulder, and the head is rotated to the contralateral side.

The field is prepared from the base of the skull to include the entire chest, abdomen, and both groins (for possible vein graft).

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3. CLOSING

A closed-suction drain is placed in the deep space between the investing fascia

(Figure 104-5) and closed with absorbable suture (3-0 Vicryl), and the skin is closed with subcuticular 4-0 Monocryl.

Inferior thyroid artery

Ansa cervicalis (sternohyoid branch)

Recurrent laryngeal nerve

FIGURE 104–5

C H A P T E R 104 • Neck Exploration for Trauma 1165

STEP 4: POSTOPERATIVE CARE

Elevate head, and maintain close observation for hematoma formation.

STEP 5: PEARLS AND PITFALLS

Selective use of closed suction drainage may be indicated in aerodigestive injuries.

SELECTED REFERENCE

1. Thal ER, Weigelt JA, Carrico CJ: Operative Trauma Management: An Atlas, 2nd ed. New York, McGraw Hill, 2002, pp 75-90.

C H A P T E R 105 • Subclavian Artery Stab 1167

Recurrent laryngeal nerve

FIGURE 105–1

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STEP 2: PREOPERATIVE CONSIDERATIONS

Operative approach to stab wounds of the subclavian vessels is based on the patient’s clinical (i.e., hemodynamic) status. In patients who present with massive bleeding in extremis, initial attempts at digital compression through the wound or a limited second intercostal anterior thoracotomy with compression of the vessels by insertion of two fingers may allow temporary control, permitting resuscitation and surgical exposure.

In patients with near normal vital signs or who stabilize with initial resuscitation, imaging studies, either angiogram or computed tomography (CT) angiogram that provides anatomic definition, can guide decisions on surgical approach. Both the right and left subclavian vessels can be approached by medial clavicular resection. If it is suspected that proximal control at either the innominate or aortic junction will be needed, a median sternotomy may be required.

STEP 3: OPERATIVE STEPS

The incision is at the second interspace.

A curvilinear incision 5 to 7 cm in length is rapidly created, beginning at the lateral border of the sternum through the pectoralis into the pleura (Figure 105-2).

The right second and third fingers are inserted and used to apply pressure superiorly and medially to compress the subclavian artery and vein against the clavicle (Figure 105-3).

After the hemorrhage is controlled, the subclavian vessels can be exposed by resecting the medial clavicle.