Part 72 (1/2)
[Ill.u.s.tration: FIG. 247. EXPOSURE OF THE INTERNAL JUGULAR VEIN HIGH UP.
A, Common facial vein; B, Sterno-hyoid muscle; C, Omo-hyoid muscle; D, Anterior border of the sterno-mastoid muscle retracted outwards. A ligature is placed around the jugular vein just above the common facial vein. When the jugular is ligatured at this spot it is not necessary to tie the facial vein. In actual practice the vein, of course, would be tied and cut between two ligatures, the upper portion of the vein being brought out into the neck.]
When the vein has been identified, a blunt dissector is pa.s.sed between its outer wall and the sheath, so as to separate the two. The sheath is incised upwards and downwards until the vein is freely exposed. If the vein be patent, it will be of a bluish colour, expanding and diminis.h.i.+ng in volume with each act of respiration. If it be thrombosed, there is usually accompanying periphlebitis which may make the separation of the sheath from the vein and the surrounding tissues difficult. If there be no periphlebitis, the thrombosed portion may be purplish, or, if the clot be of long standing and breaking down, more of a yellowish colour; the vein stands out as a cord and does not pulsate. If the thrombus be limited to the portion above the entrance of the common facial vein, the upper portion of the jugular may be small and collapsed, only becoming full and pulsating below the point at which the facial joins it.
The next step in the operation is to get well below the point at which the jugular is thrombosed. If the thrombus be practically limited to the jugular fossa the vein may be ligatured above the common facial; if not, as low down the neck as possible. In ligaturing the vein low down in the neck, the skin incision must be extended downwards, and as the lower portion of the neck is reached, the omo-hyoid will have to be pulled aside. The probe should be pa.s.sed all round the vein so as to make certain that it is freed from its sheath, and especially that it is separated from the vagus nerve which lies behind it.
An aneurysm needle threaded with silk is now pa.s.sed around the vein from within outwards. The loop of silk is cut so as to form two ligatures, and the aneurysm needle then withdrawn; the lower ligature is first tied, its ends being cut short. The upper ligature is then tied a short distance above it, but in this case the ends are left long. The vein is raised from its bed by slight traction on this ligature and is cut across between the two, the lower portion being allowed to sink back into the wound. The upper portion is then carefully separated for some distance upwards. Lying behind the vein may be seen the vagus nerve (Fig. 248). Any tributaries are clamped between two forceps, cut across, and ligatured, the upper end of the vein being brought out into the upper angle of the wound. Care must be taken that enough of the vein is dissected out to allow of this being done, especially if the ligature is applied above the level of the common facial; in this case the facial need not be tied.
If there be no periphlebitis, inflammation of the soft tissues, or thrombosis of the vein itself in the neck, the wound may be closed by means of silkworm-gut sutures, excepting at its upper angle through which the open end of the jugular vein projects. If, however, the vein be thrombosed, and especially if there be periphlebitis, the wound should be left open, except perhaps at its lower angle, and should be lightly packed with gauze, as in these cases cellulitis of the neck may afterwards occur.
After completion of the operation in the neck the surgeon turns to the mastoid process. If the ligature of the vein has been the primary step, the mastoid operation is now performed and the lateral sinus is freely exposed for a considerable distance behind the thrombus. If, however, the mastoid operation has been the first stage, and the jugular has been tied as soon as exposure of the sinus showed it to be thrombosed, the operation on the mastoid is now completed and the sinus opened as already described (see p. 444). The next step is to incise the sinus freely from above downwards towards the jugular fossa and curette out the thrombus.
If there be considerable haemorrhage, it means that the thrombus is probably parietal and situated within the jugular bulb, the bleeding presumably coming from the inferior petrosal sinus or other tributaries which enter the bulb or upper portion of the jugular vein. If the bleeding be excessive, the sinus is plugged after a moment or two, by inserting a piece of gauze into its lumen towards the jugular bulb.
[Ill.u.s.tration: FIG. 248. LIGATURE OF THE INTERNAL JUGULAR VEIN LOW DOWN IN THE NECK. The upper portion of the vein is dissected out and brought into the neck. A, A', Cut ends of the ligatured facial vein; E, Descendens noni nerve; F, Carotid sheath and internal carotid artery; G, Vagus nerve; H, Gland; J, Lower end of the internal jugular vein. The hook pulls aside the omo-hyoid muscle.]
In this case the portion of the vein brought into the neck is usually also filled with blood. After isolating it from the deeper tissues by packing strips of gauze round it, the vein is deliberately opened just above the ligature. The bleeding usually stops after a moment or two, but if it cannot be controlled, the lumen of the vein must again be closed by a ligature, the end of the vein being allowed to project on to the neck.
If there be no bleeding from the lower portion of the lateral sinus and jugular bulb, it means that the vessel is completely thrombosed at this point. The clot should now be removed by curetting through the sinus from above downwards towards the jugular bulb, and also from below upwards through the open end of the jugular vein.
[Ill.u.s.tration: FIG. 249. FREE EXPOSURE OF THE LATERAL SINUS, WHICH HAS BEEN INCISED, WITH LIGATURE OF THE INTERNAL JUGULAR VEIN. The lateral sinus is obliterated posteriorly by a plug of gauze pressed in between its outer wall and the underlying bone. The sinus is freely exposed almost down to the jugular fossa. The vein has been ligatured and its upper portion sutured to the skin wound in the neck. The arrow shows the direction along which the sinus and vein are syringed.]
The venous channel is afterwards syringed through from above downwards.
To do this, a piece of rubber tubing is inserted into the opening in the lateral sinus and some warm saline solution is injected through it with a syringe. If the clot be not firmly adherent it can usually be washed out through the opening in the vein. No force should be used. If gentle syringing be not sufficient to expel the clot, the attempt must be given up. The chief objection against syringing is the possibility of particles of the septic thrombus being forced into the veins communicating with the jugular bulb. A small drainage tube is inserted within the sinus.
In order to keep the lumen of the vein in the neck open, it should be st.i.tched to the edge of the wound surface by several catgut sutures (Fig. 250). If the bleeding necessitated plugging of the lower end of the sinus and retention of a ligature on the vein in the first instance, syringing should be postponed until the first dressing; the portion of the vein left protruding through the skin wound in the neck is then cut across, and the edge of the vein sutured to the margin of the wound under cocaine.
The mastoid cavity is lightly plugged with gauze and a dry dressing applied. The wound in the neck is similarly treated.
=After-treatment and progress of the case.= There is frequently considerable shock after the operation, especially if exposure of the jugular bulb has been undertaken, partly owing to the duration of the operation and to haemorrhage. If the patient be very collapsed, a continuous saline injection, to which some brandy may be added, may be given per r.e.c.t.u.m according to Moynihan's method. After the primary shock has pa.s.sed off, the immediate result is usually satisfactory.
_If the jugular vein has not been ligatured_, the first dressing should be performed within forty-eight hours, the gauze packing being removed, the wound syringed out, and afterwards repacked. The plugs of gauze, which were pressed in between the outer wall of the sinus and the overlying bone in order to obliterate the lumen of the latter, should not be interfered with for at least six days. If the case progresses favourably, the temperature becomes normal within a day or two, the patient feels well, and the wound a.s.sumes a healthy appearance. If, on removal of the gauze plugging, haemorrhage takes place, then the plugging must be renewed and not touched again for three or four days. After it is possible to remove these plugs, the wound is treated as has already been described in Schwartze's operation or in the complete operation in which the posterior wound was left open.
_If the jugular vein has been ligatured_, the sinus and vein should be syringed through daily, and this should only be stopped after all secretion has ceased, usually a matter of a week or ten days.
_When the sinus, jugular bulb, and vein have been exposed throughout their length_ the wound is treated as an ordinary surgical one, being packed until it granulates up from the bottom (_vide infra_).
[Ill.u.s.tration: FIG. 250. METHOD OF SUTURING THE OPEN END OF THE INTERNAL JUGULAR VEIN IN THE NECK.]
Apart from intracranial and pyaemic complications, the progress of the case may be delayed owing to the enfeebled and septic condition of the patient, and also from the occurrence of abscesses in the neck, or region of the mastoid itself. These abscesses are the result of septic thrombosis occurring in some tiny vessel. The first sign of their occurrence is an attack of pyrexia, shortly followed by a painful swelling at the affected spot. Any collection of pus should be drained at once. Although it is quite good practice to close the incision in the neck in a clean case, yet there must be no hesitation to open it up on the slightest sign of it becoming septic.
The case may appear to progress favourably for the first week or ten days, and then an intermittent and increasing pyrexia may occur for no obvious reason. This is usually due to extension of the infection along the petrosal sinuses, or perhaps along the transverse sinus.
Symptoms of involvement of the cavernous sinus may arise, perhaps even with formation of a peri-orbital abscess; or, on the other hand, the patient may gradually sink in consequence of septic toxaemia; or the end may come more suddenly with the onset of basal meningitis.
Unfortunately, these cases are almost hopeless from the first, as very little can be done from a surgical point of view owing to the fact that they are not seen soon enough.
_In thrombosis of the cavernous sinus_ the only hope of recovery lies in its exposure and incision of its wall. The sinus may be approached by tracking forwards the superior petrosal sinus--a matter of considerable difficulty, and seldom justifiable. Recently Charles Ballance has suggested the adoption of the Hartley-Krause route for extirpation of the Ga.s.serian ganglion, and says he has found the operation easy and effectual. If pus be evacuated from the sinus he considers it advisable to adopt the recommendation of Voss, who cuts away the zygoma and removes more bone from the basal aspect of the skull so as to get direct drainage (Allb.u.t.t and Rolleston's _System of Medicine_, 1908, vol. iv, Part ii, p. 495).
EXPOSURE OF THE JUGULAR BULB