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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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346 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Sternocleidomastoid Muscle
and Great Auricular Nerve
Then, we approach the carotid sheath by dissecting the anterior margin of the sternocleidomastoid muscle
cleanly from the adjacent adipose tissue. The great auricular nerve can be identied on the sternocleidomastoid
muscle posterior to the parotid gland; care must be taken to avoid post-operative sensory decits in the mandible
and auricle if the great auricular nerve is injured.
CHAPTER 4B: SURGICAL TECHNIQUE 347
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Carotid Sheath and Internal
Jugular Vein
Progressing deeper along the anterior margin of the sternocleidomastoid muscle, the carotid sheath and internal
jugular vein can be reached.
348 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Opening of Carotid Sheath
The carotid sheath is opened using a microscope; ansa cervicalis can be preserved by proper dissection from the
surrounding tissue. Lymph nodes should be removed by dissecting the surrounding connective tissue, taking
care not to damage their vessels, which facilitates the deployment of the surgical eld.
CHAPTER 4B: SURGICAL TECHNIQUE 349
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Common Facial Vein
The common facial vein often enters the internal jugular vein in the vicinity of the posterior belly of the digastric
muscle, but care must be taken when dissecting it, as there is a great deal of variability among individuals.
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Hypoglossal Nerve
The hypoglossal nerve is found just behind the posterior belly of the digastric muscle. Hypoglossal nerve runs
straight caudal after exiting from the hypoglossal canal, where it branches out the ansa cervicalis. Then, the
hypoglossal nerve travels forward.
CHAPTER 4B: SURGICAL TECHNIQUE 351
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Part 1: Dissection of Common
Carotid Artery from Carotid
Sheath
The CCA, internal carotid artery, ECA, and superior thyroid artery are dissected from the surrounding tissues to
make space for the insertion of a tourniquet or clip. At this time, the underside of the carotid bifurcation where
the plaque is present should not be dissected from the carotid sheath. As mentioned in other sections, in recent
years there has been an increase in the number of patients with unstable plaques with a necrotic core, and inadvertent dissection of the plaque area increases the risk of intra-operative embolization.
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Part 2: Dissection of Common
Carotid Artery from Carotid
Sheath
Once all carotid artery dissections are completed, indocyanine green (ICG) videoangiography is performed. We
typically administer 5 mg of ICG intravenously in a single examination. Plaque localization can be predicted by
the reduced uorescence emitted from ICG in the area where the plaque is present. It should be noted, however,
that plaque present across the arterial lumen is masked by the uorescence emitted from the blood in the foreground, making it appear as if no plaque is present. In the delayed phase, the vasa vasorum in the carotid artery
can be clearly detected.
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Carotid Sinus Nerve Blockade
An incision line is drawn from the CCA to the ICA. We performed a carotid sinus nerve blockade with 1%
lidocaine prior to incision of the carotid artery. Whether this procedure prevents intra-operative and postoperative blood pressure uctuations remains controversial.
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Carotid Clamping
To clamp the carotid artery, the superior thyroid artery and the ECA are rst blocked with Sugita aneurysm clips.
Then, using bulldog forceps, the common carotid artery and nally the ICA are clamped.
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Incision along Common and
Internal Carotid Arteries
A small incision is made in the CCA using No. 10 scalpel to conrm that there is no blood ow in the carotid
artery, and then the CCA and ICA are incised using straight scissors.
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