Chapter 7 Operative Exposure in Neck Trauma: Exposure of the Carotid Artery and Jugular Vein

This chapter will discuss exposure of actual or suspected injuries to the carotid artery and jugular vein in the neck. Though the major emphasis is operative exposure, general review of the principles of diagnosis and management will also be presented.

Learning Objectives

By the end of the ASSET course, participants should be able to do the following:

1. Identify the three zones of the neck using anatomical landmarks.
2. Describe the diagnostic modalities available for injuries of the neck.
3. Describe how to position and prep patients undergoing operative exploration of the neck.
4. Demonstrate surgical exposure of the internal jugular veins and carotid arteries.

Considerations

• Penetrating injuries to the neck require operative intervention more commonly than blunt force injuries.
• Physical examination is helpful in determining the likely injury and determining the surgical approach.
• Findings such as carotid bruit, hematoma, tracheal deviation, active bleeding, neurologic deficit, and associated facial or thoracic injuries will dictate the management sequence and choice of incision.
• The neck is classically divided into three zones (Figure 1). The zone of the neck involved will influence the subsequent evaluation, surgical exposure, and management.
• Initial care should be focused on securing the airway with rapid intubation or a surgical airway.
• Cricothyroidotomy or tracheostomy may be difficult with anterior triangle hematomas.
• Stable patients will benefit from CT angiogram (CTA) or formal angiogram to evaluate for vascular injuries.
• Unstable patients or patients with hard signs of vascular injury should have emergent surgical exploration once the airway has been secured.

Positioning and Prep

• The patient’s arms should be tucked at the sides.
• A roll should be placed behind the shoulders and the head rotated to the contralateral side (Figure 1). If cervical spine injury is suspected, the head should be maintained in a neutral position, which makes exposure more difficult.
• The entire neck, anterior torso, and groin should be prepped in the event that median sternotomy or saphenous vein harvest is needed.

Surgical Exposure

Zone 1

• Zone 1 of the neck extends from the inferior aspect of the cricoid cartilage to the thoracic outlet.
• Suspected vascular (and other) injuries to Zone 1 of the neck usually require entry into the chest via sternotomy or anterior thoracotomy, as described in chapters 10 and 12.
• Some injuries to Zone 1 can be managed with a supraclavicular approach, as described in chapter 14, or an infraclavicular approach, as described in chapter 2.

Zone 2

• Zone 2 of the neck extends from the cricoid to the angle of the mandible.
• Zone 2 is a target-rich environment. It contains the jugular veins, the distal common carotid arteries and their bifurcation, the proximal portions of the external and internal carotid arteries, the vertebral arteries, the thyroid gland, the larynx, the proximal esophagus, the spinal cord, and the vagus, phrenic, and recurrent laryngeal nerves.
• Zone 2 is the most surgically accessible region of the neck, and penetrating injuries to this region often require operative exploration.
• Historically, Zone 2 injuries required mandatory surgical intervention. The use of adjuncts (in a stable patient) such as arteriography (CT or formal), bronchoscopy, laryngoscopy, and esophagoscopy have allowed for a selective nonoperative approach.
• The classic incision for unilateral exploration of Zone 2 injuries is a longitudinal incision made along the anterior border of the sternocleidomastoid muscle, extending from the retromandibular area near the mastoid to the clavicular head (Figure 2).
• The sternocleidomastoid is then separated from the underlying vascular sheath by sharp dissection on its medial border.

• Exposure of the carotid artery requires division of the omohyoid muscle and division and ligation of the common facial vein (Figure 3). The common facial vein generally lies over the carotid bifurcation.
• The vascular sheath is opened inferiorly in the plane anterior to the omohyoid muscle, and the internal jugular vein is dissected free after division of the omohyoid muscle and common facial vein (Figure 4).
• The bifurcation of the carotid artery into the external and internal branches occurs at variable levels in the neck. A low bifurcation on the left side of a neck and a high bifurcation on the right side of a neck can be seen in the figure below (Figure 4).
• The external carotid artery is identified by the presence of branches, of which there are seven.
• If exposure of both sides of the neck is required in Zone 2, a collar incision carried across the base of the neck at the level of the trachea can be used (chapter 8). An alternative is to perform a second incision on the anterior border of the sternocleidomastoid muscle in the contralateral neck.

• Injuries with ongoing hemorrhage in Zone 2 of the neck can be difficult to visualize, and proximal control in the chest may be required.
• If the carotid artery is injured, it is preferable to repair it rather than ligate. If vascular repair expertise is not available, or in damage control situations, the carotid artery can also undergo temporary shunting.
• The artery may be ligated in situations of extremis from exsanguinating hemorrhage from a carotid artery injury.
• Ligation of the common carotid is usually well tolerated due to the presence of collateral flow across the face from the contralateral external carotid.
• Ligation of the internal carotid artery will likely result in stoke if the circle of Willis is not intact, which occurs in about 15 percent of the population.

Zone 3

• Zone 3 is the smallest region of the neck and is bound by the bony structures of the skull and mandible.
• The contents of Zone 3 include the pharynx, vertebral arteries, and distal internal carotid arteries.
• The mainstay for hemorrhage control in most Zone 3 injuries is endovascular control.
• If there is active bleeding from a penetrating Zone 3 injury, balloon tamponade (Foley or Fogarty) may provide temporary control of bleeding.
• Surgical exposure of Zone 3 is challenging and may require disarticulation of the temporomandibular joint, partial resection or division of the mandible, and/or craniotomy to expose injured structures. Such techniques are beyond the scope of this manual and are best relegated to specialists with the requisite expertise.