Exposure and surgery on the carotid and neck arteries

Topographic anatomy of the cervical neurovascular bundle

During surgery, the surgeon must have a clear understanding of the mutual arrangement of the elements of the main cervical neurovascular bundle. The common carotid artery is located strictly medially. The internal jugular vein runs laterally to it. Between these two large vessels, and somewhat posterior to them, lies the vagus nerve.

In the surgical wound, one can also find the superior root of the cervicalansa, which is the descending branch of the hypoglossal nerve (cranial nerve XII). Additionally, the superior thyroid artery and vein pass through this area.

The fascial apparatus in the surgical area is represented by the superficial (first) and investing (second) fasciae. Directly, the sheath of the neurovascular bundle is formed by the prevertebral/internal cervical fascia (fourth cervical fascia). In the access area, the sternothyroid muscle, superior belly of the omohyoid muscle, and sternocleidomastoid muscle (m. sternocleidomastoideus) are visualized.

Access between the heads of the sternocleidomastoid muscle

This option for exposing the common carotid artery is used in the lower third of the neck. The surgeon makes a skin incision approximately 6–7 cm long. The incision line runs strictly along the posterior/outer margin of the sternal head of the m. sternocleidomastoideus.

Sequentially, the skin, subcutaneous fat (SCF), and subcutaneous neck muscle (platysma) are incised. Next, the operator uses a grooved probe to carefully open the second fascia of the neck. During the manipulations, the horizontal branch of the external jugular vein appears in the wound — it must be bluntly retracted toward the clavicle to avoid accidental injury.

Then, the third cervical fascia is incised, which is anatomically tightly fused with the sheath of the neurovascular bundle. At the final stage of isolating the blood vessel, the sternal head of the sternocleidomastoid muscle is retracted medially, and the internal jugular vein is carefully displaced laterally.

Exposure in the omotracheal triangle

In the omotracheal triangle, located inferior to the omohyoid muscle, surgical access is performed as follows. An incision 5–6 cm long is made. It runs along the anterior margin of the sternocleidomastoid muscle, starting from the level of the lower margin of the thyroid cartilage and extending inferiorly.

As in other cases, the skin, subcutaneous tissue, and platysma are incised first. Then the surgeon opens the anterior wall of the sheath of the sternocleidomastoid muscle, after which the muscle belly itself is retracted laterally.

The next layer to be opened is the posterior wall of this muscle's sheath (it is fused with the third cervical fascia), as well as the wall of the vascular bundle's sheath itself. For safe isolation of the artery, the omohyoid muscle (m. omohyoideus) is retracted laterally, and the sternohyoid muscle (m. sternohyoideus) along with the lateral lobe of the thyroid gland is displaced medially.

Access in the carotid triangle

The carotid triangle is located superior to the omohyoid muscle. The skin incision here is also 5–6 cm and runs along the anterior margin of m. sternocleidomastoideus. However, the starting point of the incision is the level of the upper margin of the thyroid cartilage, from which the line goes down.

After passing the skin, subcutaneous adipose tissue, and platysma (platysma), the external jugular vein appears in the wound. This blood vessel must be transected after prior ligation between two placed surgical ligatures.

Next, surgical instruments are used to open the anterior wall of the fascial sheath of the sternocleidomastoid muscle. The muscle itself is bluntly retracted laterally. Direct approach to the bloodstream is carried out in the gap between the sternocleidomastoid and omohyoid muscles.

Exposure of the lingual artery

In addition to the carotid artery, surgical practice frequently requires working with the lingual artery. Its surgical exploration is performed within a specific anatomical formation—Pirogov's triangle.

For a successful operation, it is necessary to clearly know the boundaries of this triangle:

• Superiorly: bounded by the hypoglossal nerve (n. hypoglossus, cranial nerve XII).
• Inferiorly and posteriorly: the boundary is formed by the posterior belly of the digastric muscle (m. digastricus).
• Anteriorly: the landmark is the margin of the mylohyoid muscle (m. mylohyoideus).

To gain access to the contents of the triangle, the submandibular salivary gland is carefully retracted superiorly. Located within Pirogov's triangle are the target lingual artery (often requiring ligation) and its accompanying lingual vein.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topography of the superior root of the cervicalansa (descending branch of cranial nerve XII).
• Features of external jugular vein ligation in the carotid triangle.
• The relationship between the third and fourth cervical fascias in the area of the carotid sheath.
• The role of the omohyoid muscle as a landmark in surgical approach selection.
• Technique of displacing the submandibular salivary gland during the search for the lingual artery.

Other topics in the «Neck Surgery» section

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