Operative Strategies in Penetrating Trauma to the Neck

Fig. 29.1

Neck incision through the platysmal layer; then retract the SCM muscle laterally

Trick

Always approach a neck hematoma medial to the SCM.

Once you divide the platysma and retract the SCM laterally, your next objective is to identify the internal jugular (IJ) vein and retract it laterally with a self-retraining blunt retractor. The facial vein usually needs to be ligated and divided to allow the IJ to retract laterally. Often there is a pseudoaneurysm/hematoma encountered at this point; however, if the hematoma remains intact, it is helpful to dissect alongside the hematoma in order to gain control of either proximal or distal vessels. Depending upon the position of the hematoma, you may only be able to obtain control of one or the other prior to invading the pseudoaneurysm. It is unlikely that you will be able to do both prior to opening the hematoma, but if possible certainly gaining both proximal and distal control is ideal. I prefer to gain control with vessel loops vs. vascular clamps in the neck, as the vessel loops are less traumatic to a soft, healthy carotid artery (Fig. 29.2).

Fig. 29.2

Carotid injury

Trick

If the pseudoaneurysm is contained in the neck, dissect either proximally or distally to gain vascular control in more virgin territory.

Once the most proximal or distal control is obtained, then continuing your dissection to the center of the problem is the next step. You will need to apply digital pressure as the pseudoaneurysm is entered to allow you to evacuate clot and gain better proximal and distal control.

There is no need to heparinize the patient, and carotid shunts are only occasionally used if there is an internal carotid artery injury. If you find that the back bleeding from the internal carotid artery is poor, then nothing is lost by placing a shunt. The wound edges then need to be debrided and a decision is made about how to repair the defect. This should not be a concern when operating on the common carotid artery as the internal carotid artery has additional inflow from the external carotid artery.

On occasion, a zone I injury will require more proximal control via a median sternotomy. A median sternotomy will facilitate control of both sides, although it is near impossible to gain control of the left common carotid artery at its takeoff given the posterior position on the arch of the aorta. However, usually the neck injuries only require control a few centimeters below the level of the clavicle/sternum, which a sternotomy can afford you. Disarticulation of the sternoclavicular junction can be helpful in this regard. The utility of the highly morbid trapdoor is minimal and rarely, if ever, necessary.

Trick

If you enter a pseudoaneurysm and you are unable to control it more proximally, try replacing your finger with a Foley catheter and inflate the balloon. This will often tampanode the bleeding in a GSW tract while you perform your sternotomy.

29.3 Vascular Repair

There are four options for vascular injuries: (1) ligation, (2) primary repair, (3) patch repair, and (4) replacement. All internal or common carotid injuries should be repaired since there is at least a 75 % stroke rate with acute ligation. The external carotid artery can be ligated with impunity. The most common vascular injury in the neck is the IJ. A unilateral internal jugular vein can be ligated but repair if feasible is preferred.

Caution

Bilateral IJ ligation has a high mortality associated with it.

Stab wounds are more likely repaired primarily given the lack of associated tissue loss or blast effect. All GSW need to be debrided prior to repair and are unlikely to allow primary repair (as seen in Fig. 29.3) without tension. Patch repair can be performed with a synthetic patch or a biologic patch (e.g., bovine pericardium, saphenous vein graft). The biologic or synthetic patches may be quicker than saphenous vein graft with no major downside. Interposition synthetic grafts (PTFE or Dacron 6 mm) are also easy to use and have excellent patency rates.

Fig. 29.3

Gunshot wound to the common carotid injury repaired with a bovine pericardial patch

29.3.1 Damage Control

1.

It is OK to ligate common carotid artery, external carotid artery, and unilateral IJ, but remember ligation of internal carotid artery is associated with >75 % stroke rate.
2.

If necessary, place a shunt in the carotid artery to allow perfusion while you tackle other severe injuries requiring control.

Once the bleeding is controlled, then the rest of the neck structures and the tract of the missile/knife must be inspected (Fig. 29.4). Following the tract of the wound may raise or lower your index of suspicion for specific injuries. The trachea/esophagus/vascular structures must be inspected, and if a bilateral neck exploration is needed, the first incision is then carried in a U fashion from the sternal notch to the angle of the mandible on the opposite side.

Fig. 29.4

Once the bleeding is controlled, the rest of the neck structures and the tract of the missile/knife can be inspected

29.4 Tracheal Injuries

Tracheal wounds can be approached via either a midline or transverse neck incision. However, if other injuries to the esophagus or vascular structures are suspected, the approach described above for vascular injuries is appropriate. Primary repairs of the trachea are performed using an absorbable suture in a full thickness fashion. If there is significant laryngotracheal damage, an initial lifesaving tracheostomy may be necessary. Mathisen and Grillo outlined a few key principles in tracheal repair.

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