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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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176 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-23
Major Nerve Structures
Potentially Injured during
Carotid Endarterectomy
When a carotid artery is being exposed, there are a number of nerves that are potentially vulnerable to injury
through lack of anatomic knowledge. These include the hypoglossal nerve, which should be visualized in a
high exposure. As mentioned elsewhere in this text, it can be isolated with the vessel loop and retracted gently
from the eld. The vagus nerve, which lies deep to the CCA and carotid bulb, can be injured by placement of
the DeBakey cross-clamp on the proximal CCA if it is not identied. The spinal accessory nerve is very high and
customarily out of the eld. However, in an extremely high exposure, it is conceivable that the spinal accessory
nerve could be damaged and this large nerve should be readily identied. The marginal mandibular branch of
the facial nerve can be injured by retraction high in the submandibular region, and it may be impossible in a high
case to avoid some degree of traction injury to this nerve. However, in my experience this has been a problem
that resolved spontaneously. The recurrent laryngeal nerve can be injured by injudicious placement of retractors deep on the medial exposure, and for this reason, as stated elsewhere, I always use blunt retractors and
always place them just under the skin on the medial side of the exposure, whereas laterally they can be placed
deep under the sternocleidomastoid muscle and under the jugular vein if necessary. Most recently, as shown in
Fig. 4-19, we secure exposure with a ring clamp and sh-hooks.
CHAPTER 4A: SURGICAL TECHNIQUE 177
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178 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-24
Other Nerves at Risk during
Carotid Endarterectomy
The superior laryngeal and the accessory nerves are easily injured at CEA if their anatomy is unfamiliar to the
surgeon. The consequences of such nerve injury are real and can be debilitating to the patient. I have illustrated
several examples of nerves which we identied, isolated, and preserved during routine carotid procedures. In
(A), the superior laryngeal nerve is shown just behind the ICA in a high exposure of a left-sided CEA. This nerve
can be easily injured by cautery, dissection technique, or the internal carotid cross-clamp. It is also easily preserved once the surgeon is aware of its location, which is constant in my experience.
In (B), we have illustrated a vessel loop encircling the spinal accessory nerve at a right-sided CEA. This
was a case in which the dissection went a little bit far lateral and the nerve was isolated under the sternomastoid
muscle. Customarily, I do not dissect this far laterally.
In (C), I present a re-operative right-sided carotid case, which accounts for the scarring and the murkiness
of the usual crisp tissue planes. There are two nerves isolated with vessel loops. The uppermost is the commonly
seen hypoglossal nerve, which we have discussed at length. Below this, running deep to the sternomastoid
muscle, we again see the accessory nerve, which we usually do not encounter. In this particular case, because
of the re-operation, we dissected further lateral than usual to establish the planes and secure control, and we
encountered and isolated the accessory nerve as well. Transection or traction injury of this nerve will produce a
painful shoulder drop, and should be avoided, of course.
CHAPTER 4A: SURGICAL TECHNIQUE 179
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180 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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CHAPTER 4A: SURGICAL TECHNIQUE 181
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182 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-25
Low Bifurcation with
Omohyoid Muscle
Surgery for a relatively low bifurcation of the CCA may expose the omohyoid muscle. It is crucial to establish
adequate control well below the carotid bulb in case placement of a shunt is necessary. I place the DeBakey crossclamp at least 2 cm below the encircling vessel loop so that a shunt can be placed and the vessel loop snugged
down around it before the cross-clamp is removed, thereby preventing signicant bleeding. In order to do this,
it is often necessary to identify and either retract or transect the omohyoid muscle. The muscle can be retracted
from the overlying carotid artery with the vertically placed rostral-caudal retractor or it can be cauterized with
the bipolar coagulator and cut to expose an adequate length of CCA. I like to tag the two ends of the muscle
with suture ligatures and re-oppose them at the conclusion of the case. The CCA dives a little more deeply at the
caudal end of the wound, and a signicant surface dissection is necessary to expose it. In point of fact, exposure
of an extremely low carotid bifurcation can be as difcult as exposure of a high bifurcation.
CHAPTER 4A: SURGICAL TECHNIQUE 183
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184 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-26
Isolation of Omohyoid
As discussed in Fig. 4-25, the omohyoid needs to be dissected free for either caudal retraction or full division
(division shown in Fig. 4-28). In this illustration the Church scissors are used in standard fashion to isolate the
muscle belly.
CHAPTER 4A: SURGICAL TECHNIQUE 185
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