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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3660_Библиотеки_им_академика_М_И_Перельмана
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136 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Alternate Incisions
There are three basic incisions customarily proposed for CEA. As mentioned previously, the one I prefer is a vertical incision along the anterior border of the sternocleidomastoid muscle that tapers off behind the pinna of the
ear to head toward the mastoid process. I personally nd this satisfactory for high exposure in essentially every
case and have never seen the need to vary this standard technique.
Some surgeons have proposed a transverse incision that fells nicely into skin creases in the anterior triangle
of the neck. This is a reasonable approach; however, it entails a greater degree of difculty to gain a high exposure, usually necessitating the use of an assistant pulling up rather heavily with army-navy retractors to expose
the distal internal carotid artery (ICA) in a high case. It has been my experience that if the platysma is properly
closed, there is no cosmetic difference between the vertical incision that I prefer and the transverse incision
despite the fact that the latter more naturally follows the skin lines of the neck.
The third potential incision is one that has been proposed by Sundt for a very high exposure that goes
anterior to the ear, up along the side of the face. For cosmetic reasons I have not considered it necessary to resort
to this incision, but I do agree that it would have utility in gaining an extreme high exposure, as Sundt has so
elegantly demonstrated. Likewise, in my practice I have not seen the necessity of dislocating the jaw to obtain
distal ICA control.
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138 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Side-by-Side Positioning
The photograph and drawing in this gure illustrate the positioning for a side-by-side carotid exposure when
the ICA is hidden, tucked away underneath the external carotid artery (ECA). (An angiographic view of this is
shown in Fig. 3-3.) As previously discussed, the face and head must be turned radically to the contralateral side
in order to swing the ICA out into a more accessible position for this type of exposure. Even with this type of
positioning, it will be necessary to do an extensive dissection along the ICA and to most likely pull it out from its
adventitial bed into a more accessible position before performing endarterectomy.
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140 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Incision for High Bifurcation
When a high bifurcation is anticipated, I take great pains to place the incision as high as possible so that it is not
necessary to come back out and extend it during the procedure. Although Sundt has suggested that the incision
can be taken up in front of the ear, this leaves a scar on the face and puts the branches of the facial nerve in jeopardy. I prefer to tape the pinna of the ear back and carry the incision as high as possible beyond the angle of the
jaw as it tapers posteriorly back underneath the earlobe.
In this gure, the angle of the mandible is marked and the cross hatches indicate the extent of skin incision
that will be necessary to expose the carotid tree.
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142 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Ease of Dissection and Exposure
In this illustration we have divided the potential areas for carotid exposure into four zones. First, dissection
along the more proximal CCA and under the omohyoid (“low-go”) is infrequent for us, but it is not difcult
when done with care. Second, dissection along the distal CCA, carotid bifurcation, and proximal ICA (“E-Z go”)
is routine and represents what we conceive of as the standard endarterectomy. Third, dissection further up the
ICA, in and around the hypoglossal nerve and under the mandible (“slow-go”), must be done carefully and
methodically in a small space, with perfect anatomical knowledge. Finally, extreme distal dissections (“No-go”)
are basically not required for routine atheromatous disease, and if an aneurysm or other lesion needs treatment,
there we would recommend endovascular technique as our rst choice.
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Draped and Ready for Incision
Following the skin prep, which is povidone-iodine only allowed to dry for 5 minutes, I re-mark the incision with
a sterile marker and square off the eld with four sterile towels. We then carefully apply an adhesive barrier
drape, taking care not to pull the towels into the eld and potentially limit the exposure. This is especially important with the towel at the cephalad end where high exposure may be needed.
The prep is gently painted-on only because of my fears that a scrubbing-type prep could dislodge friable
materials from the carotid plaque and cause a stroke. Likewise I do not follow with alcohol because it smears
and erases the skin markings.
In this photograph, please note the “L”-shaped marking of the angle of the mandible.
CHAPTER 4A: SURGICAL TECHNIQUE 145
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