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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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146 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Platysma with Michel Clips
Shown are initial stages of wound opening for CEA. I inltrate the skin with 1% xylocaine with 1:200,000 parts
of epinephrine to reduce supercial bleeding. The skin is then opened sharply down to the level of the platysma,
which is left intact. Michel clips are applied to hold sponges all along the wound edge before the platysma is
opened. This technique allows the platysma to be closed at the end of the procedure without removing the clips
and thus prevents troublesome skin bleeding during platysmal closure. As the platysma is opened sharply, the
rst blunt Weitlaner retractor is placed in the eld to hold the skin edges apart; the handle is typically placed
caudally so it will not interfere with the surgeon’s right hand.
This gure of a left-sided CEA shows the platysma sharply divided in preparation for exposing the underlying sternocleidomastoid muscle.
CHAPTER 4A: SURGICAL TECHNIQUE 147
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148 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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External Jugular Vein
After dissecting through the platysma muscle and as the leading edge of the sternomastoid muscle is exposed,
often the external jugular vein will be encountered at the superior end of the incision. A robust example of this
vein is shown here (by the vascular forceps). It can be readily dispatched with circumferential dissection, followed by Weck clip application to each end and bipolar coagulation between the clips, after which it is sharply
divided.
CHAPTER 4A: SURGICAL TECHNIQUE 149
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150 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Sternocleidomastoid Muscle
Exposure of the sternocleidomastoid muscle is the key to successfully isolating both the jugular vein and carotid
artery in the neck. Once the platysma has been sharply divided, a fatty layer is customarily encountered overlying the sternocleidomastoid edge. Dissection proceeds straight down along this fat until the edge of the muscle is
clearly identied. There is no need to expose its entire belly, but rather the edge must be dissected out and pulled
laterally. Ultimately, this process exposes the jugular vein and leads to the carotid artery. At this point, a second
blunt Weitlaner retractor is introduced vertically in the eld to spread the incision in a caudal-cephalad direction
and it also serves as a fulcrum over which the silk sutures can later be hung when the vessels are isolated. It is
important to note that the rst blunt Weitlaner retractor (holding the skin edges apart) may be deeply placed
under both the sternocleidomastoid muscle and jugular vein on the lateral side but must be kept supercial on
the medial side to avoid injury to the nerves in this region. It should be particularly noted that only blunt retractors are used in this area to avoid inadvertent injury to the major vessels of the neck.
The reader should note that we now use a ring retractor and sh-hooks instead of xed Weitlaner retractors
(see Fig. 4-19).
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152 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Jugular Vein—Common
Facial Vein
The internal jugular vein lies beneath the sternocleidomastoid muscle. As dissection proceeds in the wound
and the sternocleidomastoid muscle is held back with retractor No. 1, the jugular vein comes into view. Dissection proceeds along the supercial surface of the vein until the common facial vein is identied. In every case,
the common facial vein will need to be doubly ligated with 2-0 silk sutures and then divided in order to gain
adequate exposure of the underlying carotid artery.
The common facial vein is rst isolated by dissecting along either side of its origin with a mosquito clamp.
This dissection should be done at the takeoff from the jugular vein, rather than distally. Enough facial vein must
be dissected to allow placement of the silk ties and transection between them (approximately 1 cm of facial
vein is needed). I prefer to ligate each end of the vein, back up these ties with medium Weck clips, and then cut
between the ties and cauterize the free vein ends with the bipolar coagulator. An open vein dumps signicant
amounts of blood into the eld and obscures the visual anatomy of the carotid tree. In this particular example,
a proximal accessory unnamed branch has been ligated prior to approaching the larger common facial branch.
This is a commonly seen variant.
CHAPTER 4A: SURGICAL TECHNIQUE 153
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154 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Ligation of the Common
FacialVein
This gure illustrates the passage of silk ties behind the common facial vein in preparation for ligation. The rightangled mosquito clamp should pass freely behind the vein if the dissection is done properly. Any attempt to force
the mosquito clamp could result in an undesirable blind tear in the back of the common facial vein.
In this gure of a left carotid exposure, three retractors are used: retractor No. 1, separating the wound
edges and the lateral blade, which holds back the sternocleidomastoid muscle; retractor No. 2, widening the
wound exposure in a vertical fashion; and retractor No. 3, which is a hinged Richards retractor used at the cephalad end of the wound to demonstrate the high ICA exposure, as will be seen later. Note that per Fig. 4-19, we have
modied our retraction technique.
CHAPTER 4A: SURGICAL TECHNIQUE 155
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