Monitoring

SSEPs, EEG, no motors

Preop

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

Positioning

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. 

Approach

15 blade to go through the dermis.

Use Metzenbaum scissors in a spreading motion to go through the platysma at one point, then find the plane beneath the platysma. Spread the scissors under the platysma and hold up the muscle. The assistant uses the Bovie to incise the platysma in a transverse direction. 

Undermine the platysma by spreading with the Metz then bipolar and cut adhesions. 

Find the carotid. Strip adventitia. Use a right angle to develop the plane beneath the carotid. Pass a red rubber tie beneath the vessel to the right angle clamp. Use a Debakey forcep and pass point to deliver the tie to the right angle. Loop twice around the artery. 

Closure

He always uses a JP drain. 3-0 polys for the platysma and dermal stitches. Double-ended barbed running subcu suture for the skin. No glue. Steri strips transverse across the incision. May cover with a Primapore dressing. 

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 is gives the approximate location of the hypoglossal nerve? 
  • Posterior belly of the digastric muscle