vessel ligation
TRANSCRIPT
LIGATION OF VESSELS IN
ORAL AND MAXILLO FACIAL
SURGERY Presented by – Sumit aman MDS- 1ST YearDept. Of Oral And Maxillofacial Surgery
Moderator :Dr. Neelima Gehlot
Definition Why ligate? Procedure
Individual artery ligation
-External Carotid Artery-Lingual-Sublingual-Facial-Maxillary-Sphenopalatine-Greater Palatine-Ant./Post. Ethamoidal-Internal Carotid Artery
LIGATION Means act of binding or tying of blood vessels with sutures or
wires is called Ligation… * First ligation was done by
AMBROSE PARE in amputation procedure.
• AMPUTATION : is the removal of limb
by trauma,medical illness or surgery .it is used to cntrl pain or a disease process in affected limb such in Malignancy or Gangrene…
WHY WE LIGATE VESSELS??? AFTER AMPUTATION TO ARREST
THE BLOOD FLOW IN WOUNDS OF ARTERIES
WHERE HAEMMORRHAGE CAN’T BE CONTROLLED
IN SECONDARY HAMMORAGHE WHERE THEY CAN’T BE CONTROLLED BY OTHER MEANS
IN LOCAL HYPERTROPHIES TO ARREST THE NUTRITIONAL SUPPLY TO THAT AREA
IN CASE OF ANEURYSMS IN CASE OF MALIGNANT TUMOUR
TO STOP THE BLOOD FLOW IN ACUTE INFLAMMATION WHERE
NEITHER RESECTION NOR AMPUTATION IS POSSIBLE
IN VARIOUS OPERATIVE PROCEDURES WHEN WE ENCOUTER VESSELS TO REDUCE BLOOD FLOW TO THAT REGION .
1. EXPOSE THE SHEATH OF VESSEL
2. ISOLATE THE VESSEL
3. PLACE THE LIGATURE
LIGATION OF EXTERNAL CAROTID
ARTERY
EXPOSED AT TWO SITES
1. IN THE CAROTID TRIANGLE -AT ITS ORIGIN FROM THE COMMON CAROTID ( ABOVE THE ORIGIN OF SUPERIOR THYROID ARTERY)
2. IN THE RETROMANIBULAR FOSSA HERE WE LIGATE IT BEHIND THE ANGLE OF LOWER JAW ( DEALS WITH THE HAEMORRHAGE FROM ONE OF THE BRANCHES OF MAXILLARY ARTERY)
INCISIONA SUBMANDIBULAR SKIN
CREASE INCISION IS MADE APPROXIMATELY TWO FINGER BREADTH BELOW THE ANGLE OF MANDIBLE EXTENDING FROM THE INFERIOR TO THE MASTOID PROCESS TO JUST SHORT OF MIDLINE (behind the anterior border of sternocledomastoid process)
CONTINUE DOWNWARDS / TO THE ANTERIOR BORDER UP TO THE LEVEL OF CRICOID CARTILAGE
AFTER PENETRATING SKIN, PLATYSMA SUPERFICIAL SHEATH OF STERNOCLEDIOMASTOID IS INCISED
EXPOSURE OF GREAT VESSEL
WITH BLUNT DISSECTION ANTERIOR BORDER IS EXPOSED, MUSCLE IS RETRACTED AND DEEP LAYER IS SEEN
IN THIS PART Internal Juglar Vein IS EXPOSED
THE JUGULAR VEIN IS MOBILIZED BY OPENING THE CAROTID SHEATH & FREE THE JUGULAR VEIN.
RETRACT POSTERIORLY VEIN TO VISUALIZE ARTERY
AS THE DISSECTION PROCEED POSTERIORLY THE CAROTID BULB IS IDENTIFIED AND BIFURCATION IS SEEN
MANIPULATION OF BULB AT THIS STAGE LEAD TO ARRYTHEMIA AND ANAESTHESIST SHOULD BE INFORMED
LIGATION EXTERNAL CAROTID ARTERY IS
IDENTIFIED & LIGATED ABOVE THE SUPERIOR THYROID ARTERY
CLOSURE OF WOUND A VACCUM DRAIN IS PLACED AND
WOUND IS SUTURED IN LAYERS
HAMEORRHAGE DUE TO IJV OR ECA( profuse bleeding)
DAMAGE TO VAGUS NERVE (posteriomedially) LIGATION OF ICA( contra lateral hemiplegia &
blindness on the same side) HEMATOMA FORMATION INFECTION
ADVANTAGES: SIMPLER LESS DANGROUS PROCEDURE
artery is ligated in the retromandibular fossa behind the angle of mandible & here artery crosses the stylomandibular ligament at lateral side so
LIGATION OF CAROTID ARTEY AT THE STYLOMANDIBULAR LIGAMENT
INCISION STARTS THE TIP OF
MASTOID PROCESS AND CIRCLING THE MANDIBULAR ANGLE, CONTINUING FORWARD BELOW THE MANDIBLE FOR ABOUT ONE INCH
INCISION SHOULD BE AT EQUAL DISTANCE FROM THE POSTERIOR AND INFERIOR BORDER OF MANDIBLE
EXPOSURE AFTER THE BLUNT
DISSECTION OF SKIN, SOME POST. FIBERS OF PLATYSMA, RETROMANDIBULAR VEIN OR EJV IS LOCATED, CUT & TIED
BRANCHES OF GREATER AURICULAR NERVE IS CUT & TIED TO PERMIT THE MOBILIZATION OF CERVICAL LOBE OF PAROTID GLAND
ATTACHMENT OF PAROTID WITH STERNOMASTOID AT ANTERIOR BORDER IS SEVERED & GLAND IS RETRACTED ANTERIORLY & UPWARDS
UNDERNEATH THE PAROTID GLAND & POST. BELLY OF DIGASTRIC, SMALL THIN PART OF STYLOHYOID MUSCLE IS VISIBLE
ABOVE THIS- STYLOID PROCESS & STYLOMANDIBULAR LIGAMENT IS PALPATED
NOW MOVING THE JAW FORWARD ENTRANCE TO RETROMANDIBULAR FOSSA IS WIDENED & PULSE OF ECA IS FELT, ISOLATE & LIGATE IT
LIGATION OF LINGUAL ARTERY
INCISION INCISION GIVEN
BELOW THE LOWER BORDER OF
MANDIBLE AFTER PALPATING THE SUBMANDIBULAR GLAND
THE POSTERIOR PART OF INCISION
SHOULD BE TOWARDS THE TIP OF
MASTOID PROCESS AND ANTERIOR
SHOULD POINT TOWARDS THE CHIN
AFTER BLUNT DISSECTION SUBMANDIBULAR GLAND IS EXPOSED
POST BELLY OF DIGASTRICS IDENTIFIED, MYLOHYOID MUSCLE REACHED, HYPOGLOSSAL NERVE AND ACCOMPANYING VEIN IDENTIFIED
DIGASTRICS TENDON PULLED DOWNWARD , HYOGLOSSUS MUSCLE DISSECTED AND LINGUAL ARTERY IS FOUND AND LIGATED
FIBERS OF HYOGLOSSUS MUSCLE SHOWS VERTICAL COURSE (THIN & FINE) WHILE THAT OF MYLOHYOID SHOWS OBLIQUE COURSE (THICK)
INDICATIONS
INJURY IS OBSERVED WHEN SHARP INSUMENTS OR ROTATING DISC ARE SKIPPED ON FLOOR OF THE MOUTH
IN VARIOUS SURICAL PROCEDURE LIKE RANULA AND TUMOURS OF SALIVARY GLANDS
DIFFICULT TO LIGATE
SUBLINGUAL ARTREY MAY BE A BRANCH OF
1. LINGUAL ARTERY 2. SUBMENTAL ARTERY
INCISION
IN THE SUBLINGUAL GROOVE
STRUCTURES IN CLOSE ASSOCIATION
SUBLINGUAL GLAND(MED. &INF.)
SUBMANDIBULAR DUCT LINGUAL NERVE(MED.&
INF.) HYPOGLOSSAL NERVE
AND SUBLINGUAL VEIN
LIGATION OF FACIAL ARTERY
INCISION½ INCH BELOW & PARALLEL TO THE LOWER
BORDER OF MANDIBLE EXPOSURETHE SKIN, PLATYSMA MUSCLE AND DEEP FACIA
ARE CUT, SOFT TISSUE IS BLUNTLY CUT AND RETRACTED
LIGATION PULSE OF FACIAL ARTERY IS FELT &
ARTERY IS ISOLATED AND LIGATED FACIAL ARTERY CROSSES THE
LEVEL OF INFERIOR VESTIBULAR FORNIX IN THE REGION OF 1ST MANDIBULAR MOLAR
DURING BUCCAL SPACE INFECTION THE ARTERY IS DISLOCATED
AVOID DEEP INCISION, INCISION SHOULD BE DOWNWARDS & INWARDS INSTEAD OF STRAIGHT UPWARDS
LIGATION OF MAXILLARY
ARTERY
LIGATION CAUSES DECREASE IN INTRA VASCULAR PRESSURE GRADIENT, RESULTING IN HOMEOSTASIS
APPROACHES: CAN BE DONE BY1. TRANSANTRAL APPROACH & 2. INTRAORAL APPROACH
TRANSANTRAL APPROACH
BY CALD WELL LUC APPROACH
PROCEDURE A LATERALLY BASED U SHAPE
MUCOSAL INCISION IS CREATED POSTERIOR WALL OF
MAXILLARY SINUS IS IDENTIFIEDPOSTERIOR MAXILLARY WALL IS
REMOVED
EXPOSURE & LIGATION AREA IS ENLARGED,ARTERY IS
IDENTIFIED &LIGATED SUCCESS RATE 87% SUCCESS RATE
INTRA ORAL APPROACH
THIS PROCEDURE IS GIVEN IN 1984 BY MACERI & MAKILSKI
LIGATE INFRATEMPORAL PORTION OF MAXILLARY ARTERY
INDICATION:
- IN CHILDREN AS AN ALTERNATE TO EMBOLIZATION & EXTERNAL ARTERY LIGATION FOR REMOVAL OF VASCULAR TUMOR
- TO CONTROL BLEEDING IN VARIOUS MAXILLECTOMY PROCEDURES WHERE CALD WELL LUC IS CONTRAINDICATED
PROCEDURE:
- BY EXPOSING THE POSTERIOR PORTION OF MAXILLA THROUGH A POST. GINGIVOBUCCAL INCISION
- A FINGER IS INSERTED INTO THE DEPTH OF WOUND TO PALPATE THE MAXILLARY ARTERY
- THE NERVE HOOK IS USED FOR LIGATION
LIGATION OF SPHENOPALANTINE
ARTERY
CAN BE DONE BY TWO METHODS1. TRANSANTRAL LIGATION
2. ENDOSCOPIC LIGATION
TRANSANTRAL APPROACH
DESCRIBED BY SIMPSON et al. IN 1982
APPROACH CALD WELL LUC AVOID ENTANCE TO
PTERYGOPALATINE FOSSA MEDIAL, POSTERIOR & INFERIOR
WALL IS REMOVED SPHENOPALATINE & VIDIAN
NERVE IS DISSECTED & LIGATION OF ARETRY IS DONE
DESCRIBED BY WHITE (MODIFICATION OF SIMPSONS TECH)
APPROACH THROUGH 1. MEATAL ANTROSTOMY & 2. CANINE FOSSA NOT USING WIDELY AS COSTLY ADVANTAGES1. REDUCE PATIENT DISCOMFORT AND 2. DURATION OF HOSPITALIZATION
LIGATION OF GREATER
PALANTINE ARTERY
ENDANGERED DURING MINOR SURGERY PROCEDURES AND DURING DENTAL TREATMENT
INCISION --FROM THE LINGUAL ROOT OF FIRST MOLAR
IN AN ANTERIO POSTERIOR LINE IT SHOULD BE AS NEAR TO THE FREE MARGINS OF THE GINGIVA AS POSSIBLE
--THE KNIFE EDGES SHOULD BE DIRECTED OUTWARDS AND UPWARDS , NOT STRAIGHT UPWARDS
ANTERIOR AND POSTERIOR ETHMOIDAL
ARTERY
INDICATION1. WHEN LOCAL HAMEORRHAGE
CAN’T BE CONTROLLD BY OTHER MEASURES
2. TO DECREASE BLOOD FLOW TO UPPER NASAL VAULT FROM THE INTERNAL CAROTID SYSTEM
GENERALLY PERFORMED IN CONJUGATION WITH MAXILLARY ARTERY OR ECA
FIRST DESCRIBED BY :
KIRCHNER et al. IN 1961
INCISION A CIRCUMLINEAR
INCISION IS NORMALLY MADE BETWEEEN THE INNER CANTHUS OF EYE AND MIDDLE OF NOSE(LYNCH INCISION)
PROCEDURE THE PERIOSTEUM IS
INCISED AND ELEVATED THE FRONTOETHMOIDAL
SUTURE LINE IS FOLLOWED IN A POSTERIOR DIRECTION ABOUT 14-22mm TO THE ANTERIOR ETHMOIDAL ARTERY AND ITS FORAMEN
THE POSTERIOR ARTERY IS LIES AT FURTHER AT VARIABLE DISTANCE
THE OPTIC NERVE LIES 4-7mm POSTERIOR TO POSTERIOR ETHMOIDAL FORAMEN
LIGATION OF INTERNAL
CAROTID ARTERY
GENERALLY IT IS NOT DONE AS THE CHANCES OF BRAIN DAMAGE (CONTRALATERAL SIDE HEMIPLEGIA) ARE THERE, BUT IN SOME SELECTIVE CASES WE HAVE TO LIGATE THE ICA AS IN CASES OF ICA ANEURYSMS AND HEAD INJURIES.
COLLATERAL CIRCULATION OF COMMON CAROTID OCCURS AS FOLLOWS:
1 OCCIPITAL ANASTOMOSIS--- B/W THE TRANSVERSE CERVICAL & DEEP
CERVICAL BRANCHES OF SUBCLAVIAN ARTERY AND OCCIPITAL ARTERY
2 ANASTOMOSIS IN & AROUND THYROID GLAND B/W SUPERIOR THYROID BRANCH & INFERIOR THYROID BRANCH
3 ANASTOMOSIS B/W MIDDLE LINE B/W THE BRANCHES OF EXTERNAL CAROTID ARTERIES OF BOTH SIDES
SICHER’S ORAL ANATOMY- 8TH EDITION
PRINCIPLES OF SURGERY BY EDWARD WARN
HEAD AND NECK SURGERY- OTOLARYNGOLOGY BY BYRON. J. BAILEY- 2ND EDITION
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