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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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166 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-18
Exposure of Carotid Artery
with Retractors
This gure indicates our old method for correct placement of the three retractors necessary for adequate exposure of the carotid tree. Two blunt Weitlaner retractors are used, one oriented longitudinally with the handle
directed caudally over the patient’s chest. The lateral edge of this retractor is situated underneath the jugular
vein and can be used directly on the vein as long as the teeth are blunt. The medial edge of this retractor is always
kept under the skin supercially to prevent injury to the nerves in the anterior portion of the neck.
The second straight blunt Weitlaner retractor is used vertically as shown here to separate the rostral and
caudal margins of the exposure. This is effective in retracting the supercial tissues for high exposure of the ICA.
However, to adequately expose the ICA high and well above the plaque, I nd it necessary to use a third hinged
Richards retractor placed deep to the jugular vein laterally and in the deep tissues under the parotid gland medially. If this retractor is used gently, no palsies of the lower facial nerve branches should result. As can be seen in
this gure, the hinged retractor holds apart the tissues over the distal ICA and gives a nice exposure, allowing
isolation of the ICA with a silk tie well above the region of the plaque. The hinged retractor is placed early in the
procedure and aids in the nal dissection of the ICA.
For the new method, please see Fig. 4-19.
CHAPTER 4A: SURGICAL TECHNIQUE 167
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168 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-19
Ring Clamp and Blunt FishHook Retraction for Total
Carotid Exposure
As we gained further experience with CEA surgery, I became concerned that retractor injury could be responsible for nerve injuries, whether to the recurrent laryngeal nerve or similar minor cervical nerves. No matter how
careful we were to understand the neck anatomy and place retractors carefully, we had some injured nerves. In
recent years we have switched our practice to use this rigid plastic jointed exible ring for exposure, and the ring
secures multiple individual LoneStar retractors, which are essentially a blunt sh-hook with a exible band that
attaches in the grooves of the ring. As shown in this illustration, this system affords excellent visualization and
exposure of the carotid system. In rare cases where a very high ICA exposure is needed, we occasionally do place
a single hinged Richards retractor to open up the high exposure.
CHAPTER 4A: SURGICAL TECHNIQUE 169
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170 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Four Sutures in the Carotid
Sheath
I nd it helpful to place four sutures of 4-0 silk or Neurolon in the carotid sheath, to hold open the tissue planes
and elevate the carotid from its vascular bed. It is impossible to use a retractor to do this as effectively as these
simple sutures. In this illustration, one can see how nicely this isolates the surgical planes and denes the workspace for carotid reconstruction. The sutures are marked with yellow arrows in the photograph and black arrows
in the drawing.
CHAPTER 4A: SURGICAL TECHNIQUE 171
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172 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Unexpected Internal Carotid
Artery Atresia
This patient with transient ischemic attacks was found at arteriography of the right carotid tree to have what we
felt was a string sign, a narrow appearing ICA that can often be opened at exploration. The operative ndings
were, however, surprising and puzzling, and I have never seen such a case before or since. The common, external, and superior thyroid arteries were normal in appearance. The internal carotid was atretic, and was only a
tiny string of a vessel as can be seen. I spent a fair amount of time conrming this, dissecting completely around
the carotid bulb to be certain that I had not made an unwarranted anatomical assumption, but there were no
other vessels. I could not design a surgical strategy to remedy this, so we simply closed the patient and recommended maximal medical therapy. He suffered no harm from the surgical exploration, fortunately.
Another curiosity of this case is that his arteriogram had shown bilateral surgical disease. Three months
after this operation I explored the left carotid, which was anatomically normal (although with 80% stenosis), and
a standard endarterectomy was performed on that side.
CHAPTER 4A: SURGICAL TECHNIQUE 173
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174 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Thyroid Mass Found at Time of
CEA—Right-Sided Exposure
In this case after the carotid system was completely exposed, we found an unexpected mass in the area of the thyroid gland (illustrated between the two vascular forceps, medial to the CCA and below the Rummel tourniquet).
We made a decision to send a frozen section biopsy before proceeding (the rough area where the biopsy was
taken is clearly shown), in case this was a malignancy, but fortunately the diagnosis was one of benign thyroid
hyperplasia. Once we had this diagnosis, we proceeded with an otherwise uneventful carotid reconstruction.
CHAPTER 4A: SURGICAL TECHNIQUE 175
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