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265
a
Fig. 30.8 Bimanual palpation to ascertain stability of the nasal bones
To identify maxillary fractures, stabilize the head with
your nondominant hand, hold the premaxilla with the index
and thumb ngers on the dominant hand, and try to mobilize
the midface. Do not hold the teeth as they may be mobile.
Mobility of the inferior maxilla separate from the upper midface indicates a Le Fort I fracture (Fig.30.9a and b). If the
nose and maxilla move as a unit, the injury may be a Le Fort
II fracture (Fig.30.10a and b). If the maxilla, the nose, and
the lateral orbital rims move as a unit, a Le Fort III fracture
is suspected (Fig.30.11a and b).
Le Fort fractures predispose patients to cerebrospinal
uid (CSF) leaks with rhinorrhea. Clear or yellow rhinorrhea
in patients with midface fractures suggest a CSF leak. The
uid should be accumulated and sent for beta-2 transferrin
test.
Use your index ngers and palpate the zygomatic arches
bilaterally. Compare the level of the index ngers on both
sides from a posterior view. Asymmetry due to depression of
the zygomatic arch may suggest an arch fracture.
Palpate the preauricular area and ask awake patients to
open fully their mouths while palpating the preauricular area
to assess temporomandibular joint function. Normal mandibular opening is 35–55 mm without deviation. Limited
range of mandibular motion or deviation with opening suggests injury to the temporomandibular joint, mandible, or
muscles of mastication. Palpate the inferior border of the
mandible to identify steps or painful areas suggestive of a
fracture. Findings from this examination in the intubated
patient are compromised.
The ocular examination is crucial because 15–20% of
patients with major facial trauma suffer from signicant ocular injuries. An initial ocular examination should be performed immediately to ascertain visual status, pupillary
appearance and function, and extraocular muscle function.
When feasible, the ocular examination should be comple-
b
Fig. 30.9 (a) Clinical examination and (b) three-dimensional CT of Le
Fort I fracture. Notice the correlation between the fracture line on CT
(arrows) and the area being palpated for mobility on the clinical
picture
mented by an ophthalmologist when the eye is at risk for
injury, e.g., direct globe injuries or midface injuries.
The ocular examination includes the following elements:
1. External examination:
(a) Gross inspection of the eye and ocular adnexa can
reveal lacerations and abrasions. Eyelid lacerations
may be full thickness with underlying globe injury.
Examine the conjunctiva and look for subconjunctival hemorrhage (Fig.30.12). Subconjunctival hemorrhage is associated with midface fractures. In the
awake patient, assess extraocular muscle function by
asking the patient to follow your moving index nger
with his eyes through the major visual elds to conrm that the globe moves freely in all directions,
while looking for limitation of motion or diplopia. In
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R. Nashef and T. B. Dodson
a
b
a
b
Fig. 30.10 (a) Clinical examination and (b) three-dimensional CT of
Le Fort II fracture. Notice the correlation between the fracture line
(arrows) on CT and the area being palpated for mobility on the clinical
picture
the intubated patient, evidence of extraocular muscle
entrapment can be assessed using the forced duction
technique. With forceps, grasp the insertion of the
inferior rectus muscle and rotate the globe. There
should be free, passive movement. Restricted movement suggests entrapment of the inferior rectus in an
orbital fracture.
2. Optic nerve function:
(a) Assess grossly whether the patient can perceive light
or movement. If light perception or movement is
absent, an urgent ophthalmology consultation is indicated. In the cooperative patient, one of the best tests
to evaluate the optic nerve function is the subjective
red color saturation. A red object is presented to one
Fig. 30.11 (a) Clinical examination and (b) three-dimensional CT of
Le Fort III fracture. Notice the correlation between the fracture line on
CT (arrows) and the area being palpated for mobility on the clinical
picture
eye at a time; in case of signicant optic nerve injury,
ipsilateral color perception will be altered.
3. Pupil evaluation:
(a) In the nonverbal or uncooperative patient, the pupil
examination may be the only measure of ocular function and can provide insights into neurologic function. Inspecting the pupils includes three parts:
• Size and shape:
– Changes in size might indicate injury in cranial
nerves (CNs) III and V, while changes in shape
might indicate a damage or trauma to the globe.
• Reactivity to bright light:
– Each pupil should be viewed independently,
followed by swinging the light from one eye to
the other and back to determine whether there
is a relative afferent pupillary defect.
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Fig. 30.12 Subconjunctival hematoma, a possible sign for midface
fracture
267
Fig. 30.13 Ecchymosis in the oor of the mouth, a sign of a mandible
fracture, is due to disruption of the lingual cortex of the mandible with
bleeding into the adjacent soft tissues
• Pupillary accommodation:
– This examination assesses miosis during near
synkinesis. This test may be of little value when
evaluating eye trauma, especially if the remainder of the pupil examination is normal.
Determination of sight, extraocular muscle function, and
pupillary status should be completed by the trauma surgeon
for every patient with trauma to the periorbital region. More
specic and complicated inspection and tests, including
visual eld determination, penlight examination, and intraocular pressure measurement, should be done by the ophthalmologist when the patient can tolerate these exams or as
needed, in the ED.
30.9 Intraoral Examination
Rapidly identify lacerations or other soft tissue injuries, and
palpate the wounds for retained foreign bodies such as teeth,
parts of the teeth, or shrapnel. Sweep your gloved nger to
remove loose foreign bodies, e.g., removable dental prostheses and fractured teeth. If an avulsed tooth is intact, do not
discard it. Place it into saline and milk or reinsert it into the
socket. Note the presence or absence of teeth. Intraoral lacerations may involve the salivary ducts. This is not an emergency but should be noted and managed secondarily.
Ecchymosis in the oor of the mouth (Fig.30.13) or in the
Fig. 30.14 Bimanual palpation of the mandible to assess for stability
of the lower jaw
maxillary buccal vestibule suggests mandibular or midface
fractures.
Examine the dentition for evidence of fractured or avulsed
teeth. Patient complaint of an altered bite, steps or spacing
between the teeth, or an inability to interdigitate the teeth
suggests a fracture. Check the stability of the mandible by
holding it with both hands and try to mobilize it (Fig.30.14).
Sublingual ecchymosis suggests a mandibular symphysis
fracture. Other ndings include gingival lacerations or a
biplanar occlusion (Fig.30.15).
Use your index nger to palpate the zygomatic buttresses,
bilaterally; this region could be reached on the deepest point
between the buccal mucosa of the cheek and the maxilla.
Step-offs on this region indicate a zygomatic fracture.
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Fig. 30.15 Biplanar occlusion due to mandibular fracture. Notice the
laceration of the mandibular gingiva at the fracture
Most neurosensory injuries are managed as a secondary
procedure. Suspected facial nerve injuries should be evaluated immediately and managed as soon as the patient is stable enough for operative intervention. Facial nerve
exploration and repair are commonly done in conjunction
with repair of associated facial lacerations.
R. Nashef and T. B. Dodson
Fig. 30.16 3D CT demonstrating a complex, panfacial fracture
30.10 Imaging
Advances in imaging technique have made it a critical component of evaluating maxillofacial injuries. Maxillofacial
imaging is usually not an emergent procedure and may be
delayed until the patient is stable or completed in conjunction with imaging of the cervical spine or head.
Computed tomography (CT) with three-dimensional
reformatting is the current standard (Fig. 30.16). Imaging
orders should include axial cuts (1mm thick) with sagittal,
coronal, and three-dimensional reformatting. Contrast is
usually not needed unless the injury is old and there is concern about a secondary inammatory process. Absent CT
imaging and alternative imaging choices include panoramic
radiographic technique to demonstrate mandibular and dental injuries, mandibular series, Waters’ and Caldwell’s views,
and a submental vertex.
30.11 Initial Treatment
30.11.1 Indications forImmediate Treatment
intheED
Many soft or hard tissues in maxillofacial injuries can be
managed in the ED as long as treatment time is short, e.g.,
<60min, and the patient is conscious, stable, and can tolerate
procedures involving the use of local anesthesia. Lacerations
that do not involve vital structures such as the facial nerve or
parotid duct can be repaired in ED setting. Dentoalveolar,
nasal, and some mandibular or zygoma fractures can be
reduced and stabilized in the ED.If there is a delay in treating unstable mandibular fracture, these fractures can be temporarily reduced and stabilized by placing a 24-gauge
stainless steel wire around the teeth on either side of the
fractures.
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For most maxillofacial injuries, broad-spectrum antibiotics decrease the risk for secondary wound infection.
Penicillin, rst-generation cephalosporins, or clindamycin
are excellent choices for empiric therapy. For intraoral
wounds, adding an antibacterial mouth rinse such as 0.12%
chlorhexidine is useful.
30.12 Denitive Treatment
30.12.1 Early Versus Late Management
For maxillofacial injuries requiring more extensive treatment, there exists a debate between early (<24h) and late
(>24h) treatment. Proponents of early treatment claim superior esthetic and functional outcomes, whereas those of the
delayed approach claim fewer complications due to infection. In most cases, however, maxillofacial injuries do not
require immediate operative treatment. Delaying treatment
for a few days after injury allows completion of all diagnostic workups and development of an operative plan, and
decreased swelling aids in delineating the degree of deformity and facilitates operative treatment, especially with midface fractures (Fig. 30.5b). When a multidisciplinary
approach is indicated for a particularly challenging injury,
delayed treatment permits the opportunity to organize treatment resources and develop and implement a rational treatment plan.
For patients with high-energy penetrating injuries, the
treatment plan usually is divided into three stages:
1. Debridement, fracture stabilization, and primary clo-
sure—supercial wounds should be meticulously cleaned
and freed from debris and foreign bodies, primary closure
of the wound should be attempted, and most maxillofacial injuries can be closed primarily. If the wound cannot
be closed primarily, consider packing and dressing
changes. This component of the treatment plan may be
implemented early or late. At this time, a comprehensive
physical examination can also be completed in a wellilluminated controlled setting.
Fractures can be reduced in a closed manner and stabilized with maxilla mandibular xation (MMF) or treated
with open reduction with rigid internal xation (ORRIF). Preserve the soft tissue attachments to the bone segments as possible to prevent necrosis of free bony
segments. In patients without severe comminuted fractures or infection, using reconstruction plate may be indicated and performed concomitantly with debridement
and primary closure. Application of arch bars for penetrating injuries in the jaws has proved invaluable in reestablishing arch form, occlusion, and stabilizing of
dentoalveolar fragments.
Reconstruction of soft tissue defects could be done at
the same early intervention stage, and it prevents extensive scarring of facial tissues associated with healing by
secondary intention. In case of large soft tissue defects
and absent adequate local tissue, delayed treatment is preferred, and the wound edges should be approximated.
2. Reconstruction of the hard tissue defects—management
of bony defects is usually delayed weeks to months and
part of the second stage of reconstruction. The goal of
delaying bony reconstruction is to allow for soft tissue
healing to avoid inadvertent entry into the mouth at the
time of bone grafting. Generally, 3months is adequate if
nonvascularized grafting is indicated. If vascularized
grafts are being used, the treatment time can be
accelerated.
Delayed treatment is indicated for the following
reasons:
• Early intervention may increase the risk of necrosis
due to detachment of bony fragments from the soft tissue surrounding it.
• MMF may produce a superior functional and esthetic
outcome.
• Late intervention decreases the risk of postoperative
infection and increases the success frequency of bony
reconstruction or augmentation.
3. Rehabilitation of the oral cavity, including the oral vestibule, alveolar ridge, and secondary correction of residual
deformities—this nal reconstructive stage restores the
jaw and dental function and commonly requires multiplestaged procedures with care delivered months after the
initial injury.
30.13 Conclusion
Trauma surgeons involved in the early management of penetrating maxillofacial injuries play a key role in determining
the ultimate esthetic and functional outcome associated with
operative management of these injuries. Establishing an airway, obtaining initial control of bleeding, rapidly assessing
the injuries, and requesting efcient imaging of maxillofacial injuries are marks of a well-trained trauma surgeon.
Important Points
• Obtain cervical clearance or inspect your patient with a
collar until the c-spine injury is cleared.
• Secure the airway and assure homeostasis prior to initial
inspection and treatment of the facial injury.
• Be aware of inappropriate management of the maxillofa-
cial soft and hard tissues. Do not discard broken bones,
and avoid careless vessel clamping and ligation while trying to obtain homeostasis.
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R. Nashef and T. B. Dodson
• While there are a few exceptions, to manage most maxillofacial injuries involving the dentition, an oral endotracheal intubation needs to be converted to nasoendotracheal
intubation or a surgical airway.
• Indications for use of a surgical airway include complicated injuries such that the nasoendotracheal tube impedes
the operative approach, respiratory hygiene, or planned
prolonged intubation.
• Most maxillofacial bleeding can be controlled using
direct pressure and local hemostatic measures.
Occasionally, interventional radiology may need to be
consulted.
• Inspection of the maxillofacial injury starts from an external approach, and it includes the forehead, orbits, nose,
midface, joints, and lower face, based on the later order.
• Intraoral inspection includes soft and hard tissues. Be
aware of the following signs, which indicate jaw fracture,
ecchymosis in the oor of the mouth, step-offs, and biplanar occlusion on the same jaw.
• The 3D CT is used as the standard for facial trauma imaging. In case CT is not available, plain X-rays can be used
instead though with less accuracy.
• Immediate treatment in the ED is indicated for simple lacerations, dentoalveolar trauma, and some of the mandibular and zygomatic fractures.
• For more complicated fractures (high energy), the
sequence of treatment is debridement, reconstruction, and
rehabilitation.
Suggested Reading
Cunnigham L, Haug R, Ford J.Firearm injuries to the maxillofacial
region: an overview of current thoughts regarding demographics, pathophysiology, and management. J Oral Maxillofac Surg.
2003;61:932–42.
Glapa M, Kourie J, Doll D, etal. Early management of gunshot injuries
to the face in civilian practice. World J Surg. 2007;31:2104–10.
Hochberg J, Ardenghy M, Toledo S, etal. Soft tissue injuries to face and
neck: early assessment and repair. World J Surg. 2001;25:1023–7.
Motamedi M. Primary management of maxillofacial hard and soft
tissue gunshot and shrapnel injuries. J Oral Maxillofac Surg.
2003;61:1390–8.
Motamedi M.Primary treatment of penetrating injuries to the face. J
Oral Maxillofac Surg. 2007;65:1215–8.
Schütz P, Hamed HH. Submental intubation versus tracheos-
tomy in maxillofacial trauma patients. J Oral Maxillofac Surg.
2008;66:1404–9.
Soparkar CN, Patrinely JR.The eye examination in facial trauma for the
plastic surgeon. Plast Reconstr Surg. 2007;120(Suppl 2):49S–56S.
Ueeck B.Penetrating injuries to the face: delay versus primary treat-
ment– considerations for delay treatment. J Oral Maxillofac Surg.
2007;65:1209–14.
Ward Booth P.Maxillo facial trauma. In: Ward Booth P, Schendel S,
Hausamen JE, editors. Maxillofacial surgery. 2nd ed. Edinburgh:
Churchill Livingston; 2006. p.2–300.
Operative Strategies inPenetrating
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Trauma totheNeck
LibbySchroeder andMarcde Moya
31
The neck is a region dense with vital structures. As such,
careful assessment and timely treatment can signicantly
affect morbidity and mortality. Penetrating neck injuries,
dened as penetration of the platysma, account for approximately 5–10% of all penetrating injuries. How these injuries
are assessed and treated has dramatically changed over the
last four decades. This chapter will focus on some of the
“tricks of the trade” and damage control options for operating on the neck after penetrating injuries.
In 1969, Cook County investigators divided the neck into
three zones. In an effort to standardize therapy and research
efforts, Roon and Christensen recapitulated this classication in 1979. Zone I refers to the area from the clavicles to
the cricoid cartilage. Zone II refers to the area from the cricoid cartilage to the angle of the mandible, and zone III
refers to the area from the angle of the mandible to the base
of the skull. However, since the rst description of these
zones, much has changed in how we approach, image, and
treat patients with neck trauma. In fact, some have advocated
moving toward a “no zone approach,” relegating the zones to
research rather than practical clinical guidelines in stable
penetrating trauma patients. This approach focuses on signs
and symptoms rather than zones.
Mandatory exploration of the neck was the standard of
care soon after WWII. However, mandatory exploration
produced a negative exploratory rate of approximately
50–60%. In the 1960s, routine operative explorations were
challenged, not just in the abdomen, by Dr. Carter Nance
and I.Cohn Jr., but also in the neck by Drs. Shirkey, Beall,
and Debakey. This initial push for nonoperative management eventually led to a more careful selection of operative
candidates. Over the last decade, larger prospective observational trials have demonstrated success with a more
selective approach. Bif etal. demonstrated in a series of
128 asymptomatic patients by physical exam that only one
L. Schroeder · M. de Moya (*)
Division of Trauma and Acute Care Surgery, Froedtert Hospital,
Medical College of Wisconsin, Milwaukee, WI, USA
e-mail: mdemoya@mcw.edu
patient had a missed injury. This injury was from an ice
pick. He went on to describe that only 15% of the patients
required adjuvant tests. Sriussadaporn etal. used selective
management of 57 patients based on clinical presentation.
Seventeen patients were successfully observed without
complication. Only 2 of 40 patients who underwent exploration were deemed to have unnecessary operations. Nason
etal. found that 67% of those mandatorily explored based
on violation of the platysma had a negative exploration,
while all patients with signicant zone II injuries were
symptomatic. Velmahos et al. described, in a large retrospective series, 3% of explorations were unnecessary, and
in the monitored group, 9% had missed injuries; however,
interpretation of the high missed injury rate was difcult.
The only randomized clinical trial comparing mandatory
exploration to selective observation was by Golueke etal.
where there was no difference in hospital stay, morbidity,
or mortality in 160 patients.
Clinicians began to use the hard signs of injury, i.e., active
bleeding, expanding hematoma, a bruit or thrill over the
wound, pulse decit, and a central neurologic decit to detect
a signicant vascular injury. Bubbling from wound, massive
subcutaneous emphysema, or hemoptysis would be considered hard signs of an airway injury. Some consider crepitance/dysphagia/hematemesis as soft signs of digestive tract
injuries. There are no hard signs of digestive tract injuries
rather they usually manifest themselves as neck cellulitis/
sepsis over the following 24h. Atteberry etal. in 1994 studied 28 patients with penetrating zone II neck injuries. They
compared the physical exam to angiographic, operative, and
ultrasonic ndings. There were no missed injuries albeit a
short follow-up period. The same group performed a follow up study with a larger series in 2000 after having instituted
strict physical exam-driven protocols for neck trauma. This
follow-up study with 145 patients over an 8-year period conrmed their earlier study. Again, the false-negative rate was
approximately 0.3% which was quoted to be equivalent to
false-negative rates of angiograms. The false-positive rate
was 10%. In 1997, Demetriades et al. reviewed their
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_31
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experience of 223 patients and claim that the negative predictive value of physical exam was 100%.
The last two decades have seen signicant improvements
in radiographic techniques as well, allowing for nonoperative evaluation for patients that lack hard signs of injury but
do have platysmal violation. CT angiography has largely
replaced 4-vessel angiography as a screening tool as it is easily accessible in most trauma centers in the United States and
eliminates the risk associated with a femoral venous puncture. It offers a similar level of sensitivity and specicity in
diagnosis of vascular injury with the added benet of a thorough evaluation of trajectory to aid in decision-making
regarding the need for operative exploration for esophageal
and tracheal injuries.
Once the decision to operate is made in either an emergent or urgent manner, there are few guidelines to assist the
surgeon. As in other trauma scenarios, bold yet directed/
accurate moves are needed to minimize ongoing blood loss
and maximize patient outcomes. However, in the neck, the
density of vital structures should heighten the surgeon’s precision, making knowledge of the anatomy essential.
Laryngeal
cartilage
Alternate
incision
Manubrium
L. Schroeder and M. de Moya
Mastoid
process
Standard incision
ant. border
of SCM muscle
2cm
31.1 Positioning
In the setting of an operative penetrating neck injury, the
need for adequate exposure trumps any concern for exacerbation of a spine injury, so optimizing positioning is essential. As long as the patient is moving their lower extremities
one may move the neck as needed. A lift (either a roll, thyroid pillow, etc.) is placed posterior to the scapula. This
raises the shoulders off the bed causing the neck to passively
hyperextend. This hyperextended position is complemented
by rotating the head away from the side of interest. Keep in
mind that your prep and draping should allow you to rotate
the head in the middle of the case if it becomes necessary to
explore the opposite side. If the trajectory of the injury
crosses the midline, the surgeon must be ready to access both
sides of the neck. The right arm of the patient can be tucked
to allow easier access to the head/neck of the bed by the surgeons. The left arm should be left outstretched to allow for
access of the chest for proximal control of the left-sided vessels. Both arms should be left outstretched if the patient sustained multiple stab or gunshot wounds (GSWs) to maximize
options. The patient should be routinely prepped from the
base of the skull to the groin.
Fig. 31.1 Neck incision through the platysmal layer; then retract the
SCM muscle laterally
the mandible to the sternal notch to gain easy and wide access
to the neck structures. Carry the incision through the platysmal layer and retract the SCM muscle laterally (Fig.31.1).
Even if the hematoma is centered lateral to the SCM, staying
medial provides easier access to the vital structures. While a
key concept in any vascular repair is proximal and distal control, this may not by possible in the neck due to the small
operative eld limited by the mandible and sternum. As a
result, one must be prepared to gain control initially with
manual pressure or with a Fogarty balloon if available.
Trick
Always approach a neck hematoma medial to the SCM.
31.2 Incision/Approach
The most commonly used approach is via an oblique incision
just anterior to the sternocleidomastoid (SCM) muscle.
Extend this incision from the level 1cm below the angle of
Once you divide the platysma and retract the SCM laterally, your next objective is to identify the internal jugular (IJ)
vein and retract it laterally with a self-retraining blunt retractor. The facial vein usually needs to be ligated and divided to
allow the IJ to retract laterally. The facial vein often serves as
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Fig. 31.2 Carotid injury
a landmark for the carotid bifurcation which can be used to
orient yourself. Often there is a pseudoaneurysm/hematoma
encountered at this point; however, if the hematoma remains
intact, it is helpful to dissect alongside the hematoma in order
to gain control of either the proximal or distal vessels.
Depending upon the position of the hematoma, you may only
be able to obtain control of one or the other prior to invading
the pseudoaneurysm. I prefer to gain control with vessel loops
vs. vascular clamps in the neck, as the vessel loops are less
traumatic to a soft, healthy carotid artery and take up less
space in an already limited surgical eld (Fig.31.2).
Trick
If the pseudoaneurysm is contained in the neck, dissect either
proximally or distally to gain vascular control in more virgin
territory.
Once the most proximal or distal control is obtained, then
continuing your dissection to the center of the injury is the
next step. You will need to apply digital pressure as the pseudoaneurysm is entered to allow you to evacuate clot and gain
better proximal and distal control using clamps, vessel loops,
or a Fogarty balloon. If you must clamp the internal carotid
artery for an extended period of time, be sure to communicate this to your anesthesia colleagues, and ensure that they
maintain a mean arterial pressure of at least 100mmHg to
maximize cerebral perfusion.
On occasion, a zone I injury will require more proximal
control via a median sternotomy. A median sternotomy will
facilitate control of both sides, although it is near impossible
to gain control of the left common carotid artery at its takeoff
given the posterior position on the arch of the aorta. However,
usually the neck injuries only require control a few centimeters below the level of the clavicle/sternum, which a sternotomy can afford you. Disarticulation of the sternoclavicular
273
junction can be helpful in this regard. The utility of the highly
morbid trapdoor is minimal and rarely, if ever, necessary.
There is no need to heparinize the patient, and carotid
shunts are only occasionally used if there is an internal
carotid artery injury. If you nd that the back bleeding from
the internal carotid artery is poor, a thrombectomy should be
performed to evaluate and treat for distal clot with subsequent placement of a shunt as deemed appropriate. Shunting
should not be a concern when operating on the common
carotid artery as the internal carotid artery has additional
inow from the external carotid artery.
Trick
If you enter a pseudoaneurysm in zone 1 and you are unable to
control it more proximally, try replacing your nger with a Foley
catheter and inate the balloon. This will often tamponade the
bleeding in a GSW tract while you perform your sternotomy.
31.3 Vascular Repair
There are four options for vascular injuries: (1) ligation, (2)
primary repair, (3) patch repair, and (4) replacement. All
internal or common carotid injuries should be repaired since
there is at least a 75% stroke rate with acute ligation. If ligation is unavoidable, be sure to maintain an elevated arterial
pressure to aid in perfusion. The external carotid artery, on
the other hand, can be ligated with impunity. The most common vascular injury in the neck is the IJ.A unilateral internal
jugular vein can be ligated, but repair is preferred when the
patient’s hemodynamics allow. Also note that bilateral IJ
ligation is associated with a high mortality.
Caution
Bilateral IJ ligation has a high mortality associated with it.
Stab wounds are more easily repaired primarily given the
lack of associated tissue loss or blast effect. All GSWs need
to be debrided prior to repair and are less likely to allow primary repair (as seen in Fig. 31.3) without tension. Patch
repair can be performed with a synthetic patch or a biologic
patch (e.g., bovine pericardium, saphenous vein graft). The
biologic or synthetic patches may be quicker than saphenous
vein graft with no major downside. Interposition synthetic
grafts (PTFE or Dacron 6mm) are also easy to use and have
excellent patency rates.
31.3.1 Damage Control
1. It is OK to ligate the external carotid artery and a unilat-
eral internal jugular vein without much consideration.
However, ligation of common and internal carotid arteries
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L. Schroeder and M. de Moya
31.4 Tracheal Injuries
Tracheal wounds can be approached via either a midline or
transverse neck incision. However, if other injuries to the
esophagus or vascular structures are suspected, the approach
described above for vascular injuries is appropriate. Primary
repairs of the trachea are performed using an absorbable
suture in a full-thickness fashion. One may resect up to three
rings and still be able to approximate the trachea primarily;
therefore primary repair is in most circumstances achievable.
If there is signicant laryngotracheal damage, an initial lifesaving tracheostomy may be necessary; however, tracheostomy in general is not necessary. Mathisen and Grillo
outlined a few key principles in tracheal repair.
Fig. 31.3 Gunshot wound to the common carotid injury repaired with
a bovine pericardial patch
Trachea
Esophagus
Common
carotid
artery
Internal
jugular
vein
Sternocleidomastoid
Fig. 31.4 Once the bleeding is controlled, the rest of the neck structures and the tract of the missile/knife can be inspected
is associated with >75% stroke rate, so all attempts should
be made to repair these injuries.
2. If necessary, place a shunt in the carotid artery to allow
perfusion, while you tackle other severe injuries requiring
immediate intervention.
Once the bleeding is controlled, the tract of the missile/
knife and the rest of the neck structures must be inspected
(Fig. 31.4). Following the tract of the wound may raise or
lower your index of suspicion for specic injuries. The trachea, esophagus, and vascular structures must be inspected,
and if a bilateral neck exploration is needed, the rst incision
is then carried in a U fashion from the sternal notch to the
angle of the mandible on the opposite side. Endoscopy and
bronchoscopy can be used as adjunctive studies based on
intraoperative ndings but are not mandatory if the surgeon is
comfortable with the ndings of their open neck exploration.
Tricks
(1) Evaluate associated injuries. (2) Avoid searching for the
recurrent laryngeal nerves. (3) Separate tracheal and esophageal suture lines utilizing a muscle ap. (4) Conserve viable
trachea to maximize opportunity for successful primary
repair. (5) Avoid tracheostomy through the repair. (6) Flex
the neck postoperatively to reduce tension.
31.4.1 Damage Control
1. If patient’s hemodynamics make repair ill-advised at the
initial operation, advance the endotracheal tube beyond
the defect, and plan a staged repair.
31.5 Esophageal Injuries
Esophageal injuries are approached via either a right or left
oblique incision as described for vascular injuries. It is often
easier to approach from the left given the left of the midline
tract of the cervical esophagus. If there is a large defect, the
associated hematoma will usually guide the surgeon to the
site of injury. The identication of a small hole in the esophagus can be challenging. Combining a exible esophagoscopy
with an open approach can help the surgeon rule out any
small esophageal injury by insufating the esophagus under
saline looking for bubbles in addition to intraluminal inspection. If an injury is identied one should assume there is a
second injury until proven otherwise.
If a hole is discovered, debriding nonviable and questionable tissue is essential. A single- or double-layer closure is
acceptable. The mucosa of the esophagus will retract, and
therefore the surgeon must ensure that the entire edge is
identied and repaired. In addition, mobilizing a tongue of
either strap muscle or SCM to reinforce the repair will provide additional blood supply to the area and separate the
esophageal suture line from other repairs. The most common
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