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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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156 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-13
Secure Ligation of the Common
Facial Vein
In this illustration the common facial vein has been isolated, double-ligated, and the ligatures have been backed
up with medium Weck clips. The vein will now be cauterized with the bipolar before it is divided. I have often
seen the silk ties work down and break away from the cut facial vein ends, and without a Weck clip backup this
could cause pesky bleeding. Similarly, please note the double Weck clip strategy on each end; I have also seen
single Weck clips work loose.
CHAPTER 4A: SURGICAL TECHNIQUE 157
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158 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-14
Minor Branches of Facial Vein
Once the common facial vein has been ligated, clipped, and cauterized, dissection proceeds up and down the
medial border of the jugular vein to open the carotid sheath and identify the underlying common carotid artery
(CCA). It is particularly important at this stage to use a “no-touch” type of technique to avoid dislodging any
atheromatous material from the carotid artery by harsh manipulation. I administer 5,000 units of intravenous
heparin as soon as the CCA is rst visualized within the carotid sheath.
In this example, an accessory branch of the internal jugular vein identied at a somewhat more caudal location than the common facial vein is being doubly ligated. It is crucial to identify these branches so that they are
not inadvertently torn when the jugular vein is retracted, particularly after heparin has been administered. After
ligation of all of these branches, the jugular vein can be retracted if necessary with a blunt Weitlaner retractor to
further expose the underlying CCA and carotid bulb.
CHAPTER 4A: SURGICAL TECHNIQUE 159
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160 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-15
Dissection behind the Parotid
Gland
Once the platysma has been divided, it is useful to prepare the incision for a high exposure in nearly every case
so that a difcult ICA repair will not necessitate returning to the supercial tissues for exposure during a critical
time in the procedure. I prefer to come down the subcutaneous tissues with the electrocautery set on coagulating current; I nd that this dissects down the medial sternocleidomastoid edge to the jugular vein quite nicely
and hemostatically. As this is done in the cephalad end of the incision, the parotid gland will be encountered in
the soft gritty tissues. I prefer to scoop behind the gland with the cautery tip, freeing it to be held forward by the
hinged modied Richards retractor. This gives a nice exposure of the underlying high complex, including the
jugular vein, hypoglossal nerve, and ICA as well as the digastric muscle. If the gland is transected, too much of it
remains posteriorly, which obscures the view, and the risk of sialorrhea or facial nerve injury is increased.
Here the artwork demonstrates all of the anatomy in the region of the parotid gland while the photograph
illustrates the plane between the gland [labeled with a (G) and held at its posterior margin by the vascular forceps] and the sternomastoid muscle. (The tendinous insertion on the mastoid process is well demonstrated here.)
CHAPTER 4A: SURGICAL TECHNIQUE 161
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162 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-16
First Demonstration of
Common Carotid Artery
with Control
In this left CEA, the jugular vein is retracted and the carotid sheath is opened after administration of heparin
to give the rst exposure of the CCA. Before dissecting up into the carotid bulb and the internal and external
carotid arteries, I ascertain that an adequate segment of CCA has been isolated and prepared for cross-clamping.
I then establish control by passing a vessel loop around it with a right-angled mosquito clamp, and I secure this
with a Rummel tourniquet, which is necessary in the event a shunt must be placed. Gaining control of the CCA
at this stage ensures that any inadvertent misadventure into the carotid branches during further dissection can
be quickly controlled by securing the CCA with a cross-clamp. Fortunately, however, this complication is rare.
Dissection then proceeds up into the region of the carotid bulb and then up both the external and internal carotid
arteries by separate incisions along the carotid sheath.
When dissecting in and about the carotid bulb, I notify the anesthesiologists in case any changes occur in
blood pressure or heart rate. This is an extremely rare occurrence. I do not typically inltrate the carotid sinus
but will do so with 1% plain xylocaine if it appears that the patient’s physiologic parameters are unusually susceptible to dissection of the carotid bifurcation region.
CHAPTER 4A: SURGICAL TECHNIQUE 163
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164 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-17
First CCA Control with 0 Silk
Tie and Rummel Tourniquet
Here is a later illustration of the rst isolation of the CCA and control with a 0 silk tie and the Rummel tourniquet. Note that Fig. 4-16 shows the CCA isolated with a vessel loop, a practice that we have abandoned in recent
years. On occasion the vessel loop that we previously used was too elastic to snug tightly around the CCA, and
we had some bleeding. After switching to the 0 silk tie, we are able to pull it up tighter around the CCA, without
stretching, and this problem has been solved. This photo also is a good demonstration of our new technique for
exposure, using a exible ring and elastic LoneStar sh-hooks, rather than rigid retractors as we previously did.
This exposure is further discussed in Fig. 4-19.
CHAPTER 4A: SURGICAL TECHNIQUE 165
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