Joseph Bell - A Manual of the Operations of Surgery стр 8.

Table illustrating anastomotic circulation after ligature of arteries of lower limb.

1. Aorta.Epigastric and mammary of both sides. Hæmorrhoidal and spermatic, with branches of pudic both deep and superficial.

2. Common Iliac.Internal iliac and branches, with those of the other side, along with the following:

3. External Iliac.Internal mammary and deep epigastric.

Iliolumbar and lumbar branches of aorta, with deep circumflex ilii.

Pudic from internal iliac, with superficial pudic of common femoral.

Gluteal, sciatic, and obturator, with the circumflex and perforating branches or deep femoral.

4. Femoral.External circumflex, with external articular of popliteal.

Perforating, with branches of gluteal and sciatic.

Profunda branches with anastomotica and articular branches.

Obturator and internal circumflex with anastomotica and superior internal articular.

Note.The importance of the articular branches of the popliteal explain the danger of gangrene after a sudden rupture or increase in size of a popliteal aneurism.

Ligature of the Innominate.The performance of this extremely dangerous, in fact almost hopeless operation, is by no means so difficult as might be expected.

The patient lying down with the shoulders raised and head thrown well back, the sternal attachment of the right sterno-mastoid must be very freely exposed. This may be done by an incision (Plate I. fig. 7) along its anterior edge from the upper edge of the sternum, as far as may be necessary; another about the same length along the upper edge of the clavicle, will meet the former at an acute angle, and will include a triangular flap of skin, which must be carefully dissected up. The sternal, and probably a portion of the clavicular attachment of the right sterno-mastoid, must then be cautiously divided. This being done, the sterno-hyoid and sterno-thyroid muscles require division immediately above their sternal attachments.

A dense process of cervical fascia (just becoming thoracic) now covers the vessel, binding it on the right side to the right innominate vein, and on the left maintaining the relation of the innominate artery to the trachea. The inferior thyroid veins lie on this fascia, and must be drawn aside, not cut. The fascia is then to be scraped through very cautiously, exposing the root of the right carotid, which, being traced downwards, will lead to the innominate. The following parts lie in close relation to the vessel at the point of ligature, and must be avoided:1. The left innominate vein crosses the artery in front from left to right, and must be drawn down. 2. The right innominate vein and right pneumogastric are in close contact with the artery on the right side; to avoid them the aneurism-needle must be entered on the outside (right of the vessel). 3. The apex of the right pleura and the trachea are in close contact behind, requiring the point of the needle to be kept close to the artery in bringing the thread round.

It might have been expected that the sudden arrest of so large a proportion of the vascular supply of the body, so very near the heart, would cause serious, or even fatal symptoms; this, however, is not the case, no serious inconvenience of this sort being experienced; yet hitherto every case has proved fatal, either from secondary hæmorrhage or inflammation of lungs and pleura.

In fifteen well-authenticated, and in three more doubtful cases, the ligature has been applied; all of these died at periods varying from twelve hours (as in Hutin's case), to forty-two days as in Thomson's, and sixty-seven days (Graefe's).11

A successful case of ligature of the innominate along with the right carotid and (after secondary hæmorrhage) the right vertebral, in a mulatto aged thirty-two, for a subclavian aneurism, has been put on record by Dr. Smyth of New Orleans, in the American Journal of Medical Science for July 1866.

And here we may also note that Mr. Heath has lately treated a case of innominate aneurism by simultaneous ligature of the third part of the subclavian and the carotid. Both ligatures separated on the eighteenth day, and the tumour was much smaller some months afterwards.12

Mr. R. Barwell has reported several most interesting cases in which simultaneous ligature of carotid and subclavian have proved of marked benefit in aortic as well as in innominate aneurisms.13

In four cases the operation was attempted, but the operators had to desist before the application of the ligature, in consequence of the diseased state of the arterial coats. Of these, three died, and one (Professor Porter's of Dublin) case recovered, the patient leaving the hospital with the aneurism nearly consolidated.

Dr. Peixotto of Portugal applied a precautionary ligature to the innominate in a case where secondary hæmorrhage occurred from the carotid. The ligature was not tightened beyond what was necessary merely to cause flattening of the vessel. The patient made a good recovery.

Professor George Porter of Dublin records an interesting case of subclavian aneurism, in which, after failing to close the axillary artery by acupressure, he applied L'Estrange's compressor to the innominate itself for three days, with temporary benefit. The patient eventually died of hæmorrhage.14

For a very full and interesting account of ligatures of vessels in root of neck we may refer to vol. iii. of the 1883 edition of Holmes' Surgery, pp. 119-122.

Ligature of Common Carotid.Though the anatomical relations of the right and left carotid are different at their origin, they so precisely resemble each other in the whole of that part of their course which is at all amenable to surgical treatment, that one description will suffice for both, and the necessary anatomy will be brought out quite sufficiently in the description of each operation.

From its giving off no collateral branches, the common carotid artery may be tied at any part of its course.

It has been tied successfully at the distance of only three-quarters, or, in one case by Porter, hardly to be imitated, one-eighth of an inch from the innominate, and up to an equal distance from its bifurcation. In choosing the part of the vessel for operation, the operator must be guided by the position of the aneurism, if on the vessel itself, but if the aneurism be distant, as in scalp or orbit, he need have regard to position simply as facilitating the operation.

The easiest position in which to apply the ligature is just above the omohyoid muscle, the vessel being there superficial.

Ligature above Omohyoid.Using the anterior border of the sterno-mastoid as a guide, but leaving it gradually above to a little nearer the mesial line, an incision (Plate IV. fig. 1), varying in length according to the depth of fat and cellular tissue in the neck, but with its central point opposite the upper border of the cricoid cartilage, must be made through skin, platysma, and superficial fascia. While making the incision the head should be held back, and the face slightly turned to the opposite side; the parts being now relaxed by position, the edges of the wound must be held apart by blunt hooks or copper spatulæ, and the deep fascia carefully divided over the vessel, which will be recognised by the pulsation. It may be noted here that even in thin subjects the sterno-mastoid edge invariably overlaps the vessel, though in many anatomical diagrams it would appear to be in part subcutaneous.

The descendens noni may possibly be seen, but this is by no means invariably the case, crossing the sheath of the vessel very gradually from without inwards in its progress down the neck. It must be carefully displaced outwards.