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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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326 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-93
Y-Shaped Suture Line—No
Patch Graft
This is a right CEA in which a separate ECA endarterectomy and repair were performed. The Y-shaped suture
line of 6-0 Prolene can be seen; note the convergence of the external and internal carotid repairs at the region of
the carotid bulb. When blood ow is re-established, it is common for the ICA repair to rotate with the re-opening
of the vessel. In this case, the ICA suture line was straight up the mid-portion of the vessel when the arteriotomy
was performed. Later, the repair rotated because dissection of the lateral attachments of the carotid bed is always
more extensive than that medial to the carotid bifurcation.
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328 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-94
FloSeal for Hemostasis in the
Carotid Bed
When the repair is complete, we have started to use a hemostatic matrix product to assure complete hemostasis
in the arterial bed. There are several products on the commercial market; in this case we have used FloSeal, which
is what we had available. We spray one syringe of material in and around the repair, wait a few minutes, then
irrigate it away, after which we apply Surgicel gauze to the suture line, as seen in Fig. 4-95. We do not close the
wound until hemostasis is perfect and the irrigation runback is perfectly clear of any blood.
CHAPTER 4A: SURGICAL TECHNIQUE 329
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330 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-95
Surgicel on Dry Repair
This gure demonstrates the placement of Surgicel along the suture line of a non-patch case (A), which I customarily do when the repair is assessed to be dry. When the Surgicel turns black, as seen in this gure, there is certain
to be no further active arterial bleeding and closure of the wound can begin after placement of the Hemovac.
In (B), we have applied Surgicel gauze over a Hemashield patch graft repair. There is essentially no bleeding here, so the gauze remains white in this illustration.
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Closure of Sheath
The carotid sheath is re-opposed by pulling up the sternocleidomastoid muscle to some medial fascia and closing
this layer with interrupted sutures of 3-0 Vicryl placed approximately 1 cm apart. This closure of the sheath is
an important layer, both to secure the Hemovac and to prevent infection. In one case, I encountered a supercial
wound infection that fortunately respected this layer of the closed carotid sheath and did not penetrate to deeper
structures.
It is important to remember that nerves can be damaged by deep bites on the medial side; deep bites on the
lateral side under the sternocleidomastoid muscle also could injure the jugular vein. The rule is to place supercial bites on both the sternocleidomastoid edge and along the medial fascia. Likewise, it is important to remember the area where the common facial vein was ligated so that a needle is not inadvertently placed through the
distal stump.
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Closure of Platysma
The next layer to be closed is the platysma muscle, which hopefully was well visualized during the opening process and has remained somewhat preserved under the retractors. Closure of the platysma yields a nice cosmetic
result on the neck; even in patients with a vertical incision, the surgical wound is nearly invisible after 6 months.
I attribute the improved cosmetic result to scrupulous repair of the platysma muscle, preventing tension along
skin lines.
Note that the Michel clips are left on the wound until after the platysma is closed. I nd that Michel clips
and wound edge sponges help prevent the troublesome wound edge bleeding that often occurs while the platysma is being closed. For this reason, care is taken at the beginning of the procedure to ensure that the platysma
is not included in the Michel clips.
CHAPTER 4A: SURGICAL TECHNIQUE 335
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