In emergency surgery, the suture of a divided vessel is occasionally applicable, but ligation will usually suffice. To suture a vessel, the blood current must be temporarily controlled by means of a clamp protected with rubber to prevent injury to the tunica intima. The vessel wall is seized with fine forceps and silk sutures placed one-sixteenth of an inch apart in a longitudinal wound, only piercing the outer coats. If an end-to-end anastomosis is required, three sutures are made by Murphy and the proximal end is invaginated in the distal, the sutures being passed first through the proximal and finally through the distal end from within outward and tied.
The indications for arterial suture are as follows:
- Where ligation might bring about serious nutritional changes
- In all wounds of large vessels
- Operative wounds where a part of the vessel must be sacrificed
LIGATION OF ARTERIES. It is a rule almost without exception that a divided artery must be exposed and both ends tied. Occasionally, in the case of secondary hemorrhage, it will be necessary to ligate at the site of hemothage and ligation at some point in the course of the artery above the lesion.
General rules for all ligations may be formulated:
- Put the patient in a position best to expose the artery and landmarks.
- Outline the course of the vessel, using aniline if necessary.
- Tie the vessel, but avoid tying near the origin of a large branch, if possible.
- Let the middle of the skin incision correspond to the point of ligation and let its length depend upon the depth of the vessel.
- Each structure must be identified as exposed.
The common carotid (Fig. 475) - The line of the artery corresponds to the anterior border of the sternomastoid. The incision should be three inches long in this line, the middle of the incision corresponding to the cricoid cartilage. Divide the skin, fascia, platysma; catch the bleeding veins, and divide the deep fascia along the sterno-mastoid, exposing the sheath upon which lies the descendens hypoglossi and the omohyoid, Just above the omohyoid open the sheath from the inner side so as to avoid the internal jugular. Pass the needle from outside, also to avoid the internal carotid.
<Callout type="important" title="Critical Rule">Avoid tying near the origin of a large branch.</Callout>
External carotid (Fig. 475) - Line: Continuation of the common carotid. Incision: From the angle of the jaw to the thyroid cartilage, dividing the skin, fascia, and platysma. Ligate divided veins. Divide the deep fascia, exposing the sterno-mastoid, which is to be retracted. Locate the posterior belly of the digastric, the hypoglossal nerve, and the tip of the cornu of the hyoid. Expose the artery opposite the cornu; pass the ligature between the superior thyroid and the lingual arteries, avoiding the descendens hypoglossi and the superior laryngeal nerve behind.
<Callout type="risk" title="Risk of Injury">Be cautious when passing the needle near critical structures like the internal carotid.</Callout>
Ligature of the subclavian (Fig. 475) - Position: Place the patient on his back with shoulders raised, head turned to opposite side, and angle of shoulder depressed. Incision: From the posterior border of the sternomastoid, over the clavicle, to the anterior border of the trapezius, drawing the skin down first to prevent wounding the external jugular. Relax the skin, The incision now lies one-half inch above the clavicle. If more room is needed, partially divide the trapezius and sternomastoid. Divide the deep fascia and ligate veins.
<Callout type="gear" title="Specific Equipment Required">Use a needle with aneurysm to pass through the vessel carefully.</Callout>
Key Takeaways
- Ligation is preferred over suturing for arterial injuries in emergencies.
- Proper positioning and identification of landmarks are crucial before ligating an artery.
- Care must be taken to avoid tying near the origin of large branches.
Practical Tips
- Always use a clamp with rubber protection when suturing vessels to prevent injury to the inner lining.
- Practice identifying key anatomical structures in your training to ensure quick and accurate interventions during emergencies.
- Keep a supply of specialized surgical equipment, such as aneurysm needles, for handling arterial injuries.
Warnings & Risks
Risk of Complications
Incorrect ligation can lead to serious nutritional changes or tissue necrosis.
Potential Injury
Be cautious when passing the needle near critical structures like the internal carotid artery.
Modern Application
While many of these techniques are still applicable in modern survival scenarios, advancements in surgical equipment and techniques have improved outcomes. Understanding basic arterial ligation can be crucial for first responders or those in remote areas without immediate access to advanced medical facilities.
Frequently Asked Questions
Q: What is the primary method used for closing a divided artery in emergency surgery according to this chapter?
The primary method used for closing a divided artery in emergency surgery, as described in this chapter, is ligation. Suturing is only occasionally applicable and usually insufficient.
Q: What are the general rules for performing arterial ligations mentioned in the chapter?
General rules for all ligations include putting the patient in a position best to expose the artery and landmarks, outlining the course of the vessel using aniline if necessary, tying the vessel avoiding near the origin of large branches, ensuring the middle of the skin incision corresponds to the point of ligation, and identifying each structure as exposed.
Q: What are some indications for arterial suture according to this chapter?
Indications for arterial suture include situations where ligation might bring about serious nutritional changes, wounds involving large vessels, and operative wounds where a part of the vessel must be sacrificed.