Monitoring

SSEPs, EEG, no motors

Preop

Make sure you know the patient's pre-induction SBP. Make sure a preinduction a line is placed. Lang will want the SBP to remain higher throughout the case. 

Setup

One Layla bar on the side opposite the pathology but place on the head of the bed, on the top rail.

No Foley.

Positioning

Do not turn the bed. Leave it with the head towards anesthesia.

Move the patient north or south until the shoulders are at the break in the bed. 

Place an arterial line pressure bag longitudinally between the shoulder blades with the line and bulb pointing towards the patient's head. Make sure you remove any hard plastic clips or hooks from the bag before putting it under the patient. 

Place a thin purple foam between the arm and torso on both sides, then wrap the sheet around the patient and tape down with 3-inch tape. 

Pump the arterial line pressure bag until the neck is slightly extended and rotate about 10 degrees to the side contralateral to the pathology. Avoid excessive rotation as this will cause the carotid bifurcation to retract deeper into the neck. 

Approach

Lang makes a transverse neck incision following a neck fold using a #10 scalpel blade to the depth of the subcutaneous fat. 

The operator holds Metzenbaum scissors in their dominant hand, Adson forceps in the other. The assistant holds a Bovie in their dominant hand and Adson forceps in the other. Pick up the skin edges with Adson forceps. Use the Bovie to go through dermis, stopping at the fat. 

Poke the Metzenbaum scissors through the platysma at the medial corner of the incision then turn the tips up, angle laterally, and spread to develop the plane beneath platysma. Spread the scissors wide and pull them away from the patient to present tissue to your assistant, who will go through it with the Bovie. Develop the whole incision in this way. 

At this point, the assistant switches from the Bovie to the bipolar. Grasp the cut edge of the platysma with Adson forceps and spread with the Metz to develop the plane beneath the platysma. As you proceed with this dissection, your assistant should bipolar the bands that develop and you should cut them. 

Place the hinged Weitlaner retractors in the incision at right angles to each other. The first retractor retracts side-to-side and should spread the wispy connective tissue at the medial border of the sternocleidomastoid. Place the retractor such that the handles are pointed to the patient's feet. The second hinged retractor is placed to spread in the head-to-foot dimension and the handles are pointed medially. 

Switch to Debakey forceps. The operator has Metz and Debakeys and the assistant has the bipolar and Debakeys. The plane along the medial border of the SCM should take you directly to the carotid sheath. You may encounter the common facial vein going across your plane which can be preserved or ligated, coagulated, and divided. 

Vessel Ligation

Grasp the tip of the tie with the tip of the forceps.

Pull the tie taut with your other hand.

Pass a right-angle forceps behind the vessel and open the tips. 

Pass the tips of the forceps deep to the waiting tips of the right-angle forceps and maneuver the taut length of the tie between the waiting tips. 

Close the tips of the right-angle and release the tie from the forceps. 

Pull the tie behind the vessel with the right angle. 

Release the tie from the forceps and tie down. 

Dissect the adventitia around the common carotid, pass a red vessel loop around it twice, use the Rommel tourniquet to pass a short length of rubber tubing around the ends of the vessel loop, and use a hemostat to attach to the drape. Do the same with the internal and external carotids. Lang does not use umbilical tape. 

When dissecting around the carotid bifurcation, warn anesthesia that this may induce bradycardia. If it does, ask anesthesia to treat with glycopyrrolate. 

Develop the plane beneath the common, internal, and external carotids. Then, tightly roll a moistened half-by-three patty into a cylinder and tuck underneath the vessel. This serves to push the carotid up, out of the dissection bed, closer to the operator. 

Ask anesthesia to give 2000 units of IV heparin then wait 3 minutes before clamping the vessels. Vessels are clamped on the inside of the double-looped red vessel loops (i.e. nearer to the bifurcation). 

ICA is clamped first with a bulldog clamp.

This is followed by CCA with a Debakey clamp. 

Finally, ECA is clamped by pulling tight the double-wrapped red vessel loop and snapping to the drape. If the superior thyroid artery is proximal to the loop (i.e. not excluded from the bifurcation by the red vessel loop), you may place a temporary aneurysm clip across it. 

After clamping, tuck the handles of the Debakey and back end of the bulldog behind the red vessel loops and pull the vessel loops with enough tension to keep the handles out of the way and relatively low profile. 

Feel, between your fingertips, for the extent of the plaque within the carotid bifurcation. Mark the arteriotomy to surpass the plaque on the ICA side. 

Start the arteriotomy with a #11 scalpel blade. 

Carry it through with Potts scissors. Try to get the bottom blade into the vessel lumen but take care not to injure the back wall of the vessel. 

Switch to toothless Gerald forceps at this stage.

Use the dissector to develop the plane between the plaque and the vessel intima, starting at the CCA. 

Once you have dissected the plaque circumferentially from the CCA, hold it away from the back wall of the vessel and cut it with Metzenbaum scissors. This necessarily leaves a cuff of plaque by the CCA, which is okay. Just make sure to tack this cuff of plaque down with the suture when you are sewing later. 

Have your assistant grasp the plaque from the newly cut CCA end and gently retract it towards the head and away from the vessel. Work your way towards the ECA, dissecting the plaque away from the intima with the dissector. 

Closure

He usually uses a JP drain. 3-0 polys for the platysma and dermal stitches. Double-ended barbed running subcutaneous suture for the skin. If no barbed suture is available, then 4-0 Biosyn subcuticular is acceptable. No glue. Steri strips transverse across the incision. May cover with a Primapore dressing. 

Postop

Usually SBP 100-140 but this should be confirmed.

All patients go to the ICU.

All patients get started on or increased to ASA 325.

Don't forget to put in the carotid endarterectomy PowerPlan.

Most patients go home the next day.

For postop exam, in addition to eye opening and following commands, always also check for a facial droop (due to marginal mandibular branch palsy) and for tongue deviation (due to hypoglossal injury). 

Quiz questions

• Once below platysma, while dissecting along the medial border of the sternocleidomastoid, what landmark are we looking for? 
  • Common facial vein
• What are the afferent and efferent nerves mediating the carotid body reflex? 
  • Afferent is via the carotid sinus nerve, aka Hering's nerve, a branch of cranial nerve IX
  • Efferent is via cranial nerve X
• What landmark gives the approximate location of the hypoglossal nerve? 
  • Posterior belly of the digastric muscle
  • Also the common facial vein