The subclavian artery is ligated above and below the clavicle.
Ligation of an artery above the clavicle .
To make the vessel accessible here, the hand of the patient lying on the back, and therefore the clavicle, is strongly pulled downward and a transverse incision is made through the skin and subcutaneous muscle of the neck (Platysma) 1 cm above the clavicle. The incision should be of such size that the lateral edge of the sternocleidomastoideus muscle (m. Sternocleidomastoideus) is exposed in the anterior corner of the wound and extends outside to the acromial end of the clavicle. In the subcutaneous fat layer, ligate in two places and cut between the ligatures of the external jugular vein (v. Jugularis externa). Since the latter only in the area of the incision leaves through the cervical fascia from the subcutaneous fatty tissue into the depths, it is often found only under this fascia. After dissection, the fascia penetrates through the fatty tissue containing the lymph nodes into the supraclavicular fossa in a blunt way. Having opened the second fascia of the neck, the lower edge of the thin scapular-hyoid muscle (m. Omohyoideus) is exposed and the brachial plexus (plexus brachialis) is immediately found in depth.
On the sore tip of a deeply inserted finger, you can easily feel the pulsating artery and, under his control, circle the Deschamp needle around the artery. Due to the richness of this entire area with vessels, mainly easily tearing veins, you should very carefully move the adjoining muscles apart and carefully guide the needle around the artery. On the left side, the thoracic duct (ductus thoracicus) lying behind the artery is also at risk of damage.
Rice. 8. Exposure of the subclavian artery above the clavicle.
1 phrenic nerve; 2- anterior scalene muscle; 3- sternocleidomastoid muscle; 4- subclavian vein; 5- clavicle; 6- brachial plexus; 7- subclavian artery; 8- scapular-hyoid muscle
Ligation of the artery below the clavicle.
When ligating the subclavian artery below the clavicle, an incision is made 2 cm below and parallel to the latter. The skin, subcutaneous tissue and superficial fascia are dissected. The pectoralis major muscle (m.pectoralis major), together with the fascia covering it, is cut from the clavicle obliquely downward and outward. Then the sternoclavicular fascia (f.clavipectoralis) is carefully opened and the pectoralis minor muscle (m. Pectoralis minor) is exposed. Along the upper edge of the latter, the subclavian artery is found, medial to which lies the vein, and laterally to the brachial plexus (Fig. 9).
Fig 9. Exposure of the subclavian artery below the clavicle. 1 - skin with subcutaneous fat; 2 - pectoralis major muscle; 3 - pectoralis minor; 4 - subclavian vein; 5 - subclavian artery; 6 - trunks of the brachial plexus
Collateral circulation during ligation of the subclavian artery develops through anastomoses a. transversae colli and a. transversae scapulae, c aa. circumflexae humeri anterior et posterior and a. circumflexa scapulae, as well as branch anastomoses a. thoracica interna c a. thoracica lateralis and a. thoracica suprema.
Axillary artery ligation (a. Axillaris).
The axillary artery is ligated in two places: at the exit from under the collarbone and in the axillary fossa. The level of ligation of the artery depends on the purpose of the operation. If the ligation is performed for an artery injury, then in order to preserve the nutrition of the limb, one should strive to ligate it above the discharge of the subscapular artery (a. Subscapularis), since a collateral pathway is created through the anastomoses system to fill the brachial artery (a. Brachialis).
Access to large vessels of the forearm
Access to the brachial artery
B. Access to the III segment of the subclavian artery
Direct access:
Skin incision along the continuation of the inner groove of the shoulder from the lower edge of the pectoralis major muscle to the apex of the axillary fossa;
The subcutaneous tissue and superficial fascia are dissected. The dense intrinsic axillary fascia, under which the axillary vein lies, is dissected along a grooved probe. The axillary vein is bluntly exposed and retracted to the side, after which the axillary artery becomes visible.
Roundabout access:
a skin incision 6-8 cm long from the apex of the axillary fossa to the bulge formed by the medial head of the biceps brachii;
Dissection of the subcutaneous tissue, superficial fascia and fascial sheath of the biceps brachii. Moving outwards its inner head, dissect the posterior wall of the fascial sheath along the grooved probe and, focusing on the median nerve, isolate the axillary artery from the tissues.
a. On the shoulder:
In order to avoid compression of the median nerve with a postoperative scar, it is advisable to expose the brachial artery not with an incision along the projection line (internal groove of the shoulder), but departing 1 cm from it to the outside, i.e. through the fascial sheath of the biceps brachii.
An incision of the skin, subcutaneous tissue, superficial fascia 6 cm long;
The anterior wall of the fascial sheath of the biceps brachii is dissected. Then the muscle is retracted outward. Then, along the grooved probe, the posterior wall of the fascial sheath of the biceps brachii muscle is opened, through which the median nerve accompanying the brachial artery shines through.
The brachial artery is secreted from the surrounding tissue. Wherein
it should be borne in mind that the median nerve:
in the upper third of the shoulder - lies outside the brachial artery;
in the middle third of the shoulder - crosses it in front;
in the lower third of the shoulder - lies medially from the brachial artery.
b. In the cubital fossa:
Skin incision from the middle of the skin fold of the ulnar fossa up to a point 4 cm above the medial condyle of the humerus;
The saphenous veins are carefully isolated and taken to the sides or crossed between the ligatures;
Having found the lower edge of the aponeurosis of the biceps brachii muscle, they cross it along a grooved probe. The brachial artery is found between the median nerve (lies medially) and the tendon of the biceps brachii (located lateral).
The palmar surface of the forearm is divided by two vertical lines into 3 equal in width both in the upper and in the lower parts of the site. The inner line corresponds to the course of the ulnar artery, and the outer line corresponds to the radial artery.
a. To the ulnar artery in the upper half of the forearm.
Skin incision along the projection line or along a line drawn from the inner epicondyle to the pisiform bone (Pirogov's line);
Dissection and dilution to the sides of the subcutaneous tissue and superficial fascia. The intrinsic fascia of the forearm is dissected along a grooved probe between the flexor ulnar of the hand and the inner edge of the superficial flexor of the fingers;
The superficial finger flexor is retracted outward with a blunt hook;
On the deep flexor of the fingers that appeared in the depths of the wound, retreating 1-3 cm outward from the ulnar nerve, the ulnar artery is sought.
b) To the ulnar artery in the lower half of the forearm.
Incision of the skin, subcutaneous tissue and superficial fascia along
projection line;
The intrinsic fascia of the forearm is dissected along a grooved probe between the flexor ulnar tendon and the superficial flexor tendon of the fingers.
The tendons of these muscles are parted and in the depths of the wound they find a neurovascular bundle surrounded by the fascia, in which the ulnar artery is located laterally, and the ulnar nerve - medially.
v. To the radial artery in the upper half of the forearm.
Incision of the skin of the skin and superficial fascia along the projection line 7-8 cm long;
The intrinsic fascia of the forearm is dissected along a grooved probe;
The brachioradialis muscle, which lies at the outer edge of the surgical wound, is retracted with a blunt hook outward. In the freed external groove of the forearm, a radial artery is found lying inward from the superficial branch of the radial nerve.
d. To the radial artery in the lower half of the forearm.
An incision of the skin and superficial fascia along the projection line 7-8 cm long;
The intrinsic fascia of the forearm is dissected along a grooved probe between the tendons of the brachioradialis muscle and the radial flexor of the hand. The radial artery lies superficially immediately following its own fascia of the forearm.
One of the main conditions for operations on the subclavian artery (a. subclavia)- a wide-1 cue access, for which it is necessary to perform a partial resection of the clavicle or its Subsection.
Most often, an arcuate incision is used. Janelidze or a T-shaped cut along I Petrovsky(Figure 8-2).
Access by Janelidze
The incision provides the best route to the subclavian artery as it passes into the axillary artery.
Technics. The skin incision begins 1-2 cm outward from the sternoclavicular joint and is carried out over the clavicle to the coracoid process of the scapula. From here, the incision line is turned downward along the deltoid-chest sulcus (sulcus deltoideopectoralis) over 5-6 cm.Layer cut through the skin, its own fascia (fascia colli propria) and partially pectoralis major muscle (i.e. pectoralis major). On the anterior surface of the clavicle, the periosteum is dissected and a small section of bone is isolated with a rasp, which is cut with a saw Gigli. Next, the posterior layer of the periosteum and the subclavian muscle are dissected (i.e. subclavius). In the depths of the wound, they first find
Rice. 8-2. Operational access to the subclavian artery. 1 - by Petrovsky, 2 - by Janelidze.(From: Ostroverhoe G.E., Lubotskiy D.N., Bomash Yu.M. Operative surgery and topographic anatomy. - M., 1996.)
The ligation of the vessels of the neck is performed for injuries of the arterial and venous trunks, with aneurysm, secondary bleeding against the background of phlegmon, or as a prophylactic dressing to prevent bleeding when removing various neck tumors.
Operations on the organs of the neck -F- 639
la subclavian vein (v. subclavia), located in front of the anterior scalene muscle [T. scalenus anterior). Pushing inward the anterior scalene muscle together with the phrenic nerve, they are found within the interscalene space (spatium interscalenum) subclavian artery; lateral it is the trunks of the brachial plexus. To isolate the distal subclavian artery during its transition to the axillary artery, the clavicular-thoracic fascia is dissected (fascia clavipectoralis), expose and cross the medial edge of the pectoralis minor (i.e. pectoralis minor) and thus approach the neurovascular bundle of the lateral triangle of the neck. After the end of the operation, the ends of the dissected subclavian muscle and periosteum are sutured. The clavicle sections are matched and secured with sutures or knitting needles.
T-shaped access by Petrovsky
The incision provides wider access to the subclavian artery when it comes out from behind the sternum, as well as in the interscalene space (spatium interscalenum).
Technics. A T-shaped layer-by-layer incision of soft tissues is made. The horizontal part of the incision, 10-14 cm long, runs along the anterior surface of the clavicle, and the vertical part descends 5 cm from the middle of the previous incision. The collarbone is sawed off with a saw Gigli in the middle. The subclavian muscle is dissected with a scalpel. Next, the artery is isolated as described above. When accessing the subclavian artery on the left,
As for special approaches to the first zone of the neck, there is a unified point of view, which is that there is no universal access for all types of damage to the first zone and the upper thoracic aperture. About a dozen sentences are known in the literature. In particular, due to the complex topography of the subclavian vessels (upper mediastinum, then the first zone of the neck, then the axillary fossa), the access to their various departments should be different.
By the way, it is believed, not without reason, that, if the condition of the victim allows, preoperative angiography makes it possible to choose an adequate access.
K. L. Mattox et al. in case of damage to the subclavian artery on the right, it is recommended to use a median sternotomy. In case of damage to the proximal parts of the artery on the left - anterolateral thoracotomy in the third intercostal space, and in case of injuries of the distal parts - a transverse approach along the upper edge of the clavicle. In some cases, it is enough to cross the clavicle in order to expose the subclavian vessels in their middle third for 4-5 cm.
Naturally, during the operation in this area, care must be taken not to injure the brachial plexus... Access with resection of a part of the clavicle or sternum creates comfortable conditions for surgical operation [Petrovsky BV, Richter GA], but lead to disability of patients. Therefore, some surgeons, trying to avoid the dangers associated with transection or resection of the clavicle, find a way out by using a combination of supra- and subclavian approaches.
Access to the subclavian artery above the clavicle
At access to the subclavian artery above the collarbone, the wounded man's head is tilted in the opposite direction, a roller is placed under the shoulder blades, and the collarbone and shoulder are pulled downward, for which the hand is pulled down. A horizontal skin incision starts from the jugular notch to the anterior edge of the trapezius muscle, retreating 1.5-2 cm from the upper edge of the clavicle. After dissection, the platysma is exposed and the external jugular vein is transected between the two ligatures. Having passed through the deep fascia of the neck and pushed laterally and up the scapular-hyoid muscle (if necessary, it can be crossed), they bluntly go into deeper layers and palpate the Lisfranc tubercle - the place of attachment of the anterior scalene muscle to the first rib. Near, lateral to the tubercle, the subclavian artery is located.
Crossing the operating field and the obstructing transverse vein of the scapula can be transected after ligation.
Access to the subclavian artery above the clavicle:1 - subclavian artery; 2 - brachial plexus; 3 - sternocleidomastoid muscle; 4 - scalene anterior muscle (crossed)
Access to the subclavian artery below the clavicle
Access to the subclavian artery below the clavicle is more difficult, since the artery lies much deeper here. Unlike access to the proximal artery, the victim is placed so that the shoulder is displaced upward, for which the roller is placed directly under the shoulder joint.
The skin incision is made from middle of the clavicle to the coracoid process, departing 1.5-2 cm from its lower edge. When dissecting the skin and superficial fascia, it is necessary to maintain the laterally located v. cephalica. The skin incision can be extended downward along the lateral edge of the pectoralis major muscle, if necessary, incising it in the transverse direction. After dissection of the coracobrachial fascia in a blunt way, they penetrate between the deltoid, subclavian and pectoralis major muscles, exposing the neurovascular bundle. The subclavian artery is located here between the plexus and the subclavian vein (medial to the plexus).
In other cases surgeons instead of crossing the clavicle, it is used to isolate it in the sternoclavicular joint, with the intersection of the cartilage of the ribs to the level of the third intercostal space and the transition to the anterior thoracotomy at this level, as a result of which access to the pleural cavity, to the subclavian vessels from below and to the anterior mediastinum on the side of the access opens. However, examination of the medial sections of the subclavian vessels and the brachiocephalic trunk requires a sternotomy: either a complete longitudinal sternotomy, or a partial longitudinal sternotomy with a transition along the third intercostal space towards the wound.
Complete longitudinal sternotomy, which has become widespread as a universal access in elective cardiac surgery, nevertheless has a number of significant disadvantages. The frequency of complications with it, according to the literature, reaches 11-13%, and with the occurrence of osteomyelitis and purulent mediastinitis, mortality (according to sources relating to the last quarter of the XX century) ranges from 25 to 50%. The high incidence of complications, from our point of view, is primarily associated with insufficiently strong fixation of the edges of the sternotomy wound, which leads to their dehiscence (separation from each other and pathological mobility) with a sharp slowdown or impossibility of consolidation.
Pathological mobility in conditions impaired blood supply to the body of the sternum and the presence of many foreign bodies in the form of metal wires fastening the sternum, contribute to the development of the inflammatory process, and with the addition of microflora - purulent osteomyelitis of the sternum. With the spread of a purulent process beyond the inner plate of the sternum, purulent mediastinitis occurs. In the contingent of patients under consideration, the situation is aggravated by the fact that the processes listed above proceed against the background of massive blood loss and primary tissue infection as a result of injury.
Partial sternotomy to some extent, it is devoid of the above disadvantages of a complete longitudinal sternotomy and has found widespread use as a component of complex combined approaches to the structures of the upper mediastinum. In the English-language literature, they are called "Trap-door access", in the domestic literature - patchwork access.
However, these accesses are too traumatic for victims in serious condition and have a noticeable effect on impaired respiratory function in the postoperative period.
Taking into account the above aspects, it is worthy of attention modification of transverse sternotomy with the intersection of the first ribs and collarbones, developed at the N.V. N.V. Sklifosovsky V.V. Iofik. Its essence is to create a lateral flap while maintaining blood supply due to the muscular branches of the superior intercostal arteries, as well as the internal thoracic and lateral thoracic arteries. It is carried out as follows. In the position of the victim on the back, a strictly horizontal skin incision is made in the transverse direction, starting from the border of the lateral and middle third of the left clavicle to the medial third of the right clavicle, then continuing it vertically down to the level of the second intercostal space, after which a skin incision is made across the sternum, tilting it to 2 ° -3 ° caudal, to the left midclavicular line.
Layer-by-layer dissect subcutaneous fatty tissue, pectoral fascia, bundles of the right pectoralis major muscle. The left clavicle is cut in the middle of its outer third, the right clavicle - in the middle of the medial third. It must be emphasized that care must be taken during this step to avoid damaging the subclavian veins. Then the right I rib is crossed with a wire saw at the place of its attachment to the handle of the sternum. Next, the sternum is sawn transversely so that the line of its intersection passes along the junction of the handle and the body of the sternum
Then in a blunt way sever tissue behind the sternum... The cartilaginous part of the left I rib is easily broken at the junction with the bone part when the handle of the sternum is removed with the palm held under it. In this case, a well-perfused flap is formed on a wide musculocutaneous pedicle. After preparation, which does not meet any difficulties in a wound measuring 25-15 cm, the entire upper mediastinum becomes accessible to surgical action.
From this access if necessary, without using additional preparation or additional incisions, it is possible to perform an intervention on the vessels from the aortic arch to the bifurcations of the common carotid arteries, to operate on the trachea, esophagus, and cervical vertebral bodies. You can additionally increase the area of intervention by retracting the upper edge of the wound with a hook.
Operating angle exceeds 90 ° for all major vessels and approaches 90 ° when working on the trachea and esophagus. The proximal parts of both vertebral arteries are easily accessible - a situation that is impossible with other types of surgical approaches. At the same time, nutrition of the sternum body is not disturbed, since it is provided by two intercostal arteries, and the internal thoracic artery, located at a depth of 0.6 to 1.5 cm from the posterior edge of the sternum handle, cannot be damaged during access. A prerequisite for good wound healing is complete alignment and secure immobilization of both crossed collarbones and the sternum handle. The simplest and most accessible for the surgeon in an emergency situation is the implementation of osteosynthesis with Kirschner wires, which ensures the retention of fragments without their angular displacements, as well as displacements in length and width.
Patient B., 29 years old... Delivered to the N.V. IV Sklifosovsky in an extremely serious condition, with a clinical picture of hemorrhagic shock. 1.5 hours before admission from an unknown person, he received a stab-cut wound in the neck. Above the medial head of the right clavicle, in the first zone of the neck, there is a 4x1.5 cm wound covered with a thrombus, which intersects the lower third of the right sternocleidomastoid muscle. Revealed intense venous bleeding from the depth of the mediastinum, suspected injury of the brachial trunk.
Under endotracheal anesthesia a flap transverse sternotomy was performed. The revision revealed the passage of the wound canal from the right supraclavicular region, obliquely from top to bottom, from the right to the left, from the front to the back, through the upper mediastinum with the transverse intersection of the left brachial vein by 2/3 of the diameter and with the penetration of the wound canal into the left pleural cavity. Left-sided hemothorax 2.5 L. Blood from the pleural cavity is collected for reinfusion. The wound of the left brachiocephalic vein was sutured with a lateral continuous suture (prolene 5/0) on an atraumatic needle. The operation was completed by draining the left pleural cavity according to Bulau, metal osteo-synthesis with the needles of the clavicles and the handle of the sternum. The pleural drain was removed on the 6th day. On the 7th day, when the regimen was violated, the patient experienced migration outward of the wire, which fixed the fragments of the right clavicle. The needle was removed, the right arm was immobilized with a Dezo bandage.
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