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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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186 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Retracted Omohyoid
Since we have started using the xed ring and retractor system, it is clearly not always necessary to divide the
omohyoid for low exposure. This illustration shows how well the sh-hook retractors can be placed to sling the
omohyoid down and out of the eld to facilitate proper CCA exposure and control.
CHAPTER 4A: SURGICAL TECHNIQUE 187
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188 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Division of Omohyoid Muscle
to Secure Adequate Low Carotid
Exposure
In this case, the bifurcation of the carotid artery is abnormally low. To obtain adequate proximal control of the
carotid artery for cross-clamping, it was necessary to divide the omohyoid muscle. This is accomplished by cutting the muscle after bipolar coagulation and then placing a stitch in each end of the cut muscle. At the end of
the procedure when the repair has been completed, the omohyoid muscle can be re-opposed by tying these two
stitches together and then introducing several more to pull the muscle together. No cosmetic or functional deformity should result from this maneuver.
CHAPTER 4A: SURGICAL TECHNIQUE 189
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190 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Hypoglossal Nerve
During the exposure of the ICA well above the plaque, the hypoglossal nerve is often visualized and must be
dealt with. In a low bifurcation, the hypoglossal nerve may not enter the eld. However, most average or high
bifurcations will necessitate exposure and control of this nerve. I dissect the nerve out carefully and isolate it with
a vessel loop once it is identied. When this is accomplished, even if bleeding ensues at a later point, there is no
question as to the location of the nerve and inadvertent transection or cauterization of the nerve can be avoided.
Only gentle retraction, if any, is applied to this nerve.
This gure shows the position of a rather straightforward hypoglossal nerve dissection. The nerve is identied as it comes down in the plane between the internal jugular vein and ICA and then loops medially over the
internal and external carotid arteries, exiting to supply the tongue.
CHAPTER 4A: SURGICAL TECHNIQUE 191
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192 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Sternomastoid Artery—An
External Carotid Artery Branch
This is a right CEA in which there is an artery, a branch of the external carotid, intimately intertwined with the
hypoglossal nerve, which has been isolated with the blue vessel loop. The digastric muscle has been cut for high
exposure. This artery is called the “sternomastoid artery” by some surgeons. To achieve proper high exposure,
it needs to be ligated and divided, so that the hypoglossal nerve can be further mobilized and adequate distal exposure achieved on the ICA. At the stage of the operation illustrated here, I consider the exposure to be
inadequate for correct ICA control. There is, to my mind, no functional consequence to sacrice this minor ECA
branch.
CHAPTER 4A: SURGICAL TECHNIQUE 193
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194 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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High Bifurcation with Digastric
Muscle and Hypoglossal
Nerve—Left Carotid Exposure
Once the jugular vein has been retracted and the CCA has been isolated, the carotid sheath is opened along the
mid-portion of the vessel to expose all branches of the carotid tree. Exposure of a high bifurcation and a high
plaque in the ICA is particularly difcult and may necessitate some rather extensive dissection. I dissect along
the medial border of the jugular vein while coming up the ICA. In this case, the hypoglossal nerve and ansa
hypoglossi complex have been isolated with several vessel loops and it was necessary to cut the digastric muscle
to obtain a high exposure of the ICA. I have found that the digastric muscle can be coagulated with bipolar cautery and transected sharply with no ill effects, and in combination with a hinged Richards retractor, this maneuver yields a very nice exposure of the distal ICA. In the photograph, a blue line has been drawn along the carotid
artery in preparation for surgical incision. It should also be noted that several 4-0 silk tacking sutures were used
to hold the carotid sheath open, thereby lifting the carotid bulb somewhat out of its bed and facilitating the surgical approach to the vessel.
CHAPTER 4A: SURGICAL TECHNIQUE 195
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