A Manual of the Operations of Surgery. Joseph Bell
out quite sufficiently in the description of each operation.
From its giving off no collateral branches, the common carotid artery may be tied at any part of its course.
It has been tied successfully at the distance of only three-quarters, or, in one case by Porter, hardly to be imitated, one-eighth of an inch from the innominate, and up to an equal distance from its bifurcation. In choosing the part of the vessel for operation, the operator must be guided by the position of the aneurism, if on the vessel itself, but if the aneurism be distant, as in scalp or orbit, he need have regard to position simply as facilitating the operation.
The easiest position in which to apply the ligature is just above the omohyoid muscle, the vessel being there superficial.
Ligature above Omohyoid.—Using the anterior border of the sterno-mastoid as a guide, but leaving it gradually above to a little nearer the mesial line, an incision (Plate IV. fig. 1), varying in length according to the depth of fat and cellular tissue in the neck, but with its central point opposite the upper border of the cricoid cartilage, must be made through skin, platysma, and superficial fascia. While making the incision the head should be held back, and the face slightly turned to the opposite side; the parts being now relaxed by position, the edges of the wound must be held apart by blunt hooks or copper spatulæ, and the deep fascia carefully divided over the vessel, which will be recognised by the pulsation. It may be noted here that even in thin subjects the sterno-mastoid edge invariably overlaps the vessel, though in many anatomical diagrams it would appear to be in part subcutaneous.
The descendens noni may possibly be seen, but this is by no means invariably the case, crossing the sheath of the vessel very gradually from without inwards in its progress down the neck. It must be carefully displaced outwards.
The sheath of the vessel is then to be cautiously opened to the extent of about half an inch. The internal jugular vein, possibly much distended, may overlap the artery on its outer side, and will require to be pressed, emptied, and held out of the way. A small portion of the artery being thoroughly separated from the sheath, the aneurism-needle must be passed from without inwards to avoid the vein, and keep as close to the artery as possible to avoid the vagus.
The tendon of the omohyoid muscle, or, in muscular subjects, a portion of its anterior fleshy belly, may be seen crossing the vessel from above downwards and outwards at the lower angle of the wound.
An enlarged lymphatic gland has occasionally given much trouble, by being mistaken for the vessel and cleaned, while the ligature has even been placed on a carefully isolated fasciculus of muscular fibres.
Ligature of Carotid below the Omohyoid.—An incision in precisely the same direction as the former, but at a slightly lower level, is required, but the dissection is rather more difficult. The edge of the sterno-mastoid when exposed must be drawn outwards; the sterno-hyoid and thyroid inwards; the omohyoid upwards; the sheath opened, and the descendens noni or its branches drawn to the tracheal side. The jugular vein and vagus are both at the outer side, and must be avoided, while the inferior thyroid artery and sympathetic nerve both lie behind the vessel, and may be included in the ligature if care be not taken.
Varieties.—Sedillot's Operation.—To secure the artery still lower in the neck: An incision two and a half inches long, from the inner end of the clavicle obliquely upwards and outwards in the interval between the sternal and clavicular attachments of the sterno-mastoid; this divides the superficial textures; the two portions of muscle must then be drawn apart. The internal jugular vein lies in the interval, and must be drawn to the outside before the artery can be seen at all, and it is this that makes this operation very difficult and dangerous, especially on the left side, where the vein is close to the artery, and probably even crossing it from left to right. The thoracic duct is behind.
Malgaigne's modification of the above is an improvement: to expose the external attachment of the muscle, to cut it through and turn it to the outside, as in the operation for ligature of the innominate, then to divide or pull inwards sterno-hyoid and sterno-thyroid, thus exposing the sheath. The needle must be passed from without inwards.
Results.—Pilz has collected 600 cases, of which 43.16 per cent. died. The united tables of Norris and Wood give 188 cases, with a mortality of sixty, or nearly one in three. These tables include cases in which the vessel was tied for wounds, and as a preparatory step in the operation of removal of tumours of the jaw, etc. Later statistics give a very much lessened mortality, due chiefly to the use of animal ligatures.
Of thirty-one cases in which it was tied for pulsating tumours of the orbit, only two died from the operation.15 Rivington's statistics to a later date give forty-six cases on forty-four patients with six deaths.
Both carotids have been tied in the same patient twenty-five times, at intervals of less than a year; and it is a very remarkable fact that only five of these fifty ligatures proved fatal,—two in which both were tied on the same day, and three in which the operation was performed to arrest hæmorrhage from malignant disease of the face and jaws—from gunshot wound,—and from syphilitic ulceration.
The external carotid, and also most of its principal branches, have been tied for aneurisms, wounds, goitres, enlargement of the tongue, vascular tumours on occiput and other lesions; also as a first stage in the operation of extirpation of the upper jaw, for the purpose of preventing hæmorrhage. However, such operations are rare, and will probably become rarer still, and it is hardly necessary to describe the operations on each seriatim.
Aneurism of the external carotid or branches are rare; if idiopathic, ligature of the common carotid will be found at once easier, not more dangerous, and more effectual than ligature of the branch; if traumatic, the aneurism itself should be attacked, and the bleeding point secured by a double ligature. Wounds are common enough, but if accessible at all, the injured vessel should be tied at the bleeding point; if inaccessible (and under this head we may include wounds of the internal carotid), the common carotid must be tied.
No one would think of trying the superior thyroids for goitre, unless they were so manifestly enlarged, tortuous, and pulsating, as to render the operation so simple (from their superficial position) as to require no special directions; besides this, the cases in which it has been already done have given very little encouragement to repeat it.
As cases may occur in which any diminution of the cerebral supply is contra-indicated, and thus the more difficult ligature of the external carotid may be preferred to the more simple operation on the common trunk, and as the lingual may require ligature near its root, in consequence of obstinate hæmorrhage from the tongue, short directions are given for the performance of both these operations.
1. Ligature of External Carotid.—Head in same position as for the common carotid. A straight incision parallel with the anterior edge of sterno-mastoid, but about half an inch in front of it, must begin almost at angle of jaw, and extend downwards nearly to the level of the thyroid cartilage. Cautiously divide skin, platysma, and fascia; the lower end of the parotid must be pulled upwards, and the veins, which are numerous, cautiously separated. The anterior border of the sterno-mastoid must be pulled backwards, and the digastric and stylo-hyoid forwards and inwards. The superior laryngeal nerve which lies behind the vessel must be avoided.
2. Ligature of Lingual.—To secure this vessel either before it becomes concealed by the hyo-glossus, or after it is under the muscle, a curved incision is necessary, following the line of the hyoid bone, and especially of its greater cornu, but a line or two above its upper border. After the skin and platysma are divided, the posterior belly of the digastric must be recognised, which again will guide to the posterior edge of the hyo-glossus. The edge of the sub-maxillary gland may very probably require to be raised out of the way. The artery can then be secured, either before it dips under the hyo-glossus muscle, or after it has done so, by the division of a few of its fibres on a director. Care is needed to avoid injury of the hypo-glossal nerve, which lies above the muscle.
The internal carotid artery occasionally, but very rarely, is the subject of aneurism. It may, like any other artery, be wounded, especially from the fauces. The treatment of either of these lesions is ligature of the common carotid itself, in