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. Wolters Kluwer lippincott
WHliams & Wilkins tahir99 - UnitedVRG
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Anatomic Exposures
in Vascular Surgery
R G
d V
THIRD EDITION
i t e
U n . i r
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9 9 a n
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Anatomic Exposures
G
in Vascular Surgery
R
V d
it e
Gary G. Wind,nM.D., F.A.C.S. r
- U
Professor of Surgery s . i
99
Department of Surgery & ns
i r i a
Uniformed Services University of the Health Sciences
s
h r
Director of Art and Education, Vesalius.com
ta .
Bethesda, Maryland
pe
vi p
R. James Valentine, M.D., F.A.c.s.
Professor and Chairman
Division ofVascular and Endovascular Surgery
Executive Vice Chairman, Department of Surgery
Alvin Baldwin, Jr. Chair in Surgery
University ofTexas Southwestern Medical Center
Dallas, Texas
I
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Wmd,GaryG.
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Anatomic exposures in vascular surgery I Gary G. Wmd, R. James Valentine; illustrated by Gary G.
Wmd.- 3rd ed.
p.;cm.
i t e
Includes bibliographical references and index.
U
ISBN 978-1-4511-8472-3 (alk. paper) -ISBN 1-4511-8472-7 (alk. paper) n
Rev. ed. of: Anatomic exposures in vascular surgery I R. James Valentine, Gary G. Wmd.
. i r
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I. Valentine, R. James, 1954- II. Valentine, R. James, 1954- Anatomic exposures in vascular surgery.
m. Title.
& ns s
99
[DNLM: 1. Blood Vessels-anatomy & histology-Atlases. 2. Vascular Surgical Procedures-Atlases.
WG17]
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Care has been taken to confirm the accuracy ofthe information presented and to describe generally accepted
practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any
.
consequences from application of the information in this book and make no warranty, expressed or implied,
vi p
with respect to the currency, completeness, or accmacy of the contents of the publication Application of
the information in a particular situation J:eiiUUns the professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and
dosage set forth in this text are in accordance with current recommendations and practice at the time of
publication. However, in view of ongoing research, changes in government regulations, and the constant
flow of information relating to drug therapy and drug reactions, the reader is urged to check the package
insert for each drug for any change in indications and dosage and for added warnings and precautions. This
is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in the publication have Food and Drug Administration
(FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care
provider to ascertain the FDA status of each drug or device planned for use in their clinical practice.
This book was written by Drs. Gary G. Wind and R. James Valentine in their private capacity.
The authors are solely responsible for its content. No official support or endorsement by the Uniformed
Services University ofthe Health Sciences or the Department of Defense is intended or should be infi:Ired.
The opinions or assertions contained herein are the private views of the authors and should not be construed
as official or as necessarily reflecting the view ofthe Uniformed Services University ofthe Health Sciences
or the Department of Defense.
To purchase additional copies ofthis book, call our customer service department at (800) 638-3030 or fax
orders to (301) 223-2320. International customeill should call (301) 223-2300.
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10 9 8 7 6 5 4 3 2 1 tahir99 - UnitedVRG
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To our wives
Marilyn Gail Wind and Tracy Williams Valentine
for their patience and support
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Forearm Fasciotomy:
Jeffrey A. Marebessault, MD
Adjunct Faculty, Lincoln Memorial Unive~ity-DeBusk College
of Osteopathic Medicine, Harrogate 1N
Associated Orthopaedics of Kingsport, 1N
LeoDaab,MD
Fellow, Vascular Surgery
Walter Reed National Military Medical Center
Bethesda, MD
til
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Contributor:5 vii
Foreword from the First Edition xi
Preface to the Rr:5t Edition xiii
Preface to the Third Edition xv
CHAPTER3 111ondcAorta 79
CHAPTER9 Upp Abdamlnal Ao~ lndu.ng the Vlsanl and Supraa!llac Segments 217
VASCULARVARIATION 539
I I CONTENTS
The illustrations are the strong point ofthis excellent book. These have been drawn
from the perspective of a surgeon who clearly knows what is seen during a surgi-
cal operation. An anatomist illustrates the anatomy as seen in the dissecting room.
Drs. Gary Wind and R. James Valentine have given us outstanding drawings of
what a surgeon will see in the operating room.
Dr. Wind is experienced in the use of a microcomputer to create three-
dimensional reconstructions of anatomy. These unusual visual images and models
provide different concepts of conventional anatomic views. The knowledge gained
from this study of many regions ofthe body has been used to provide the unusual and
very informative illustrations that fill this book. In a standard illustration, it appears
that the vertebral artery travels only a short distance before it enters the foramen in
the transverse process of the sixth cervical vertebra. A sw-geon who has operated on
this artery at this point knows that there is a length of several centimeters before it
enters the bony foramen. This book is filled with similar useful information, which
has been uncovered by Dr. Wmd's special anatomical reconstructions. The text is
clear and concise and there is a good bibliography after each chapter. This text has
obviously been written by those who know what is of importance to a clinician.
Of special interest are two sections, the introduction on embzyology and the last
section on vascular variation. Such variations have always been a challenge for sur-
geons. Embryology demonstrates the possible explanations for these variations, and
the final chapter on anatomic variations will help the surgeon to expect and identify
the unexpected should he or she encounter them.
This is an anatomic book written by surgeons, but the objective has not been
to describe surgical procedures. It has been to describe and illustrate the anatomic
relationships ofblood vessels. The result is a book of great value, not only to vascular
surgeons but also to anatomists, because it throws new light on an old subject-gross
anatomy.
Charles G. Rob, M.D., F.R.C.S., F.A.C.St
Professor of Surgery
Uniformed Services UniveDity of
the Health Sciences
Bethesda, Ma.J:Yland
tDr. Charles RDb passed away in 2001. He wu a preemin.ezrt picm.cc:r ofVIlSCI11ar surgecy md one of the last
of 1he smgical gilmts. The force of his persolllllity was always evi.deDt beDea1h his impeccable gentlemanly
persona. He will be missed by us and by 1he Sl.l%gical world as a whole.
Gary G. Wind, M.D.
R. James Valentine, MD.
Dispel from your mind the thought that an understanding ofthe human body
in every aspect ofits structure can be given in words; for the more thoroughly
you describe, the more you will confuse... I advise you not to trouble with
words unless you are speaking to blind men.
-Leonardo da Vmci
xiII
The last two decades have witnessed a sw:ge of interest in catheter-based vascular in-
tervention, with a corresponding decrease in the number of open vascular procedures
currently being performed. As the clinical experience with open vascular exposure
declines, we believe that there is an enduring need for a comprehensive text that
features vascular anatomy from a swgical point of view. The original purpose ofthis
book has not changed-it is intended to be a detailed and practical guide for exposing
blood vessels with minimal tJauma to swrounding structures. The volume of recent
literature regarding novel exposure techniques and refined indications for specific
approaches has provided the impetus for a third edition.
Based on favorable response to the previous editions, we have maintained an
emphasis on clinical anatomy, focusing on detailed illustrations rather than extensive
written descriptions. A key feature of this book is that all of the illustrations were
drawn by a single artist, who is also a sur:geon and anatomist This unifo:nnity has
allowed inclusion of more detail in each illustration for maximal educational benefit
A major enhancement in this third edition is the use of full color for the anatomic
illustrations, giving a greater appreciation of three-dimensional relationships. The
procedural text and clinical references have been updated to reflect current concepts.
New sections on foreann compartment syndromelfasciotomy and vascular exposure
of the lumbar spine have been added. In addition, references to web-based three-
dimensional anatomy resources have been included.
As before, chapters are divided into anatomic overview and surgical exposure
sections. The text is written from a swgeon's point of view, using practical descrip-
tions based on key anatomic relationships. Trivial and esoteric details have been
avoided. Related clinical discussion is based on a thorough review of the modem
literature.
Perhaps, the most important point to be made about this book is that it is in-
tended to have lasting applicability. Human anatomy will not change in the fore-
seeable future. Vascular procedures may wax and wane in popularity, but exposure
techniques remain a standard part of any present or future operation.
Development of the Blaad Vessels remodeling that extends through the second and
final month of the embcyonic period. Development
at the cephalad end of the embryo proceeds more
rapidly than at the caudal end as the arteries and
Between the third and eighth week of embryonic veins change and interact with the growing thora-
gestation (measured in postovulatory days1 the coabdominal mgans, parietes, and extremities. The
blood vessels form and evolve into an approxima- incredibly complex bioarchitectwal development
tion of the definitive human circulatory pattern. To- and reorganization take place while the embryo is
ward the end of the third week, primitive circulation between 3 mm and 3 em in size (crown-to-rump
begins, propelled by the newly fused heart. Rapid length; Fig. 1). The next significant change in the
changes in the fourth week set the stage for extensive vascular pattern occurs at birth.
20mm
6week8
5mm
4week8
1 an.
Amrionic cavity
Neural fold
Fig. 2 At the onset of angiogenesis, the embryonic plate lies in a polypoid excrescence
within the chorionic vesicle.
Z I INTRODUCTION
AmntaniC caVIty
EldraambrycniC
coalam
Endoderm
"'lkaac
VItelline v's Vltalllna a'll
Fig.l The first two sets of primitive vessels attach to the ends of1he newly fused heart tube.
EMBRYOLOGYOFTHEARTERIESAND VEINS I3
During the fourth week, the embryo attains a become the celiac, superior mesenteric, and inferior
length of 4 to 5 mm, develops a full complement mesenteric arteries. Paired pre- and postcardinal
of somites, and begins a series of changes in vas- veins form in the body wall and attach via common
cular morphology {Fig. 4). The paired aortas fuse cardinal veins to the caudal horns of the heart, now
for much of their length and develop numerous known as the sinus venosus.
dorsal, lateral, and ventral branches. A series of By the end of 4 weeks, four limb buds are
five additional pairs of arterial arches pass laterally evident, with the cephalad set more advanced. The
around the pharynx between the developing bran- remnants ofthe vitelline veins are forming sinusoids
chial outpouchings, connecting the cephalad apex in the developing liver and coalescing to form the
of the heart to the remaining unfused dorsal aortas. portal venous system. The subsequent simultaneous
The cephalad arches regress as fust as caudal arches developments in the arterial and venous systems of
are added, and the six arches undergo evolutionary the trunk and extremities merit separate description,
changes during weeks 5 to 7 (see below). The mul- keeping in mind the parallel time course of these
tiple vitelline arteries regress, leaving three that will events.
POS'tearctlnal v.
Fig. 4 In the 4-week embryo, aortic fusion has begun. arches are forming, the umbilical
vessels are well defined, and the (;ardinal veins are formed, laying the foundations for the
rapid changes of the second month.
4 I INTRODUCTION
AortlcArtbes the third arch to form the internal carotid arteries.
The external carotid arteries arise as new branches
Six sets of aortic arches have penetrated the cores of the aortic sac and by differential growth migrate
of successive branchial arches, and the first, second, distally onto the third arches {Fig. 6). The roots of
and rudimentaJy fifth have largely regressed by the the third arches, therefore, become the common ca-
beginning ofthe fifth week when the embryo is 6 mm rotid arteries. The external carotid arteries follow the
in length {Fig. 5). The dorsal aortas persist at the level muscles derived from the first two branchial arches
of the first two arches, retaining their connection to in their migration to the face and head.
Internal carotid a.
Fig. 7 Selective resmption of the remaining arches results in a definitive aortic and
pulmonary pattern.
6 I INTRODUCTION
of serial inteDegmental branches to the body wall
and extremities, genitourinary branches in the
While the arches are reforming at the cephalad end nephrotome region, and ventral visceral branches.
ofthe embryo, the dorsal aorta is elaborating dorsal, The dorsal branches divide into dorsal and
lateral, and ventral branches {Fig. 8). These consist ventral rami. The dorsal rami in the cervical region
Domml~e~men~la
(v~ral branch)
Fig. 8 The fused dorsal aorta elaborates segm.eatal dorsal and lateral branches and retains
single ventral visceral branches descended from 1he vitelline arteries.
EMBRYOLOGYOFTHEARTERIESAND VEINS I7
form longitudinal fusions that persist when all but arteries. Two longitudinal precostal fusions similar
the most caudal segmental dorsal nm1us resorb, to the dorsal branch fusions form the thyrocervical
leaving the vertebral arteries (Fig. 9). The vertebral trunks cephalad to the subclavian arteries and the
artery and subclavian arrery have a common origin costocervical trunks caudal to the subclavian arter-
from the seventh cervical intersegmental artet:y. The ies. The axial vessels of the limb buds are also de-
ventral rami constitute the intercostal and lumbar rived from dorsal intersegmental branches.
Vertebral a.
Fig. 9 Longitudinal fusion of the cervical and upper1horacic dorsal branches results in 1he
vertebral arteries and costocervical trunks.
8 I INTRODUCTION
Multiple lateral branches extend to the neph- single when the aortas fuse.& the yolk sac regresses,
rotome region supplying the mesonephros, gonads, the number ofvessels decreases. Near the end ofthe
metanephros, and adrenal glands (Fig. 10). A3 the fifth week, when the embryo is 8 mm in length, the
mesonephros involutes, the number ofbranches also celiac, superior mesenteric, and inferior mesenteric
decreases, leaving the renal, adrenal, and internal arteries are left. In addition, the original continuity
gonadal vessels. The phrenic arteries are also defini- of the umbilical arteries with the virelline system is
tive lateral branches. lost, and the umbilical arteries connect to an adja-
The ven1ral branches of the aorta are deriva- cent dorsal intersegmental branch that becomes the
tives of the paired vitelline arteries that become common iliac arteiy (see below and Fig. 14).
Fig. 10 Lateral branches in the nephrotome region supply the gonadal ridge, the meso-
nephros, and metanephros (definitive kidney).
EMBRYOLOGYOFTHEARTERIESAND VEINS I9
bud is fed by seveml dorsal intersegmental arteries
(Fig. 12). One stem assumes a dominant position,
The limb buds arise in the 3- to 4-mm embryo, with and the others regress. The veins also form a domi-
the upper extremities developing more precociously nant channel, which takes the form of a maJgin.al
(Fig. 11). The base of the buds spans several seg- vessel lying under the apical growth ridge of the
ments, and the diffuse initial capillary plexus of the primitive limb paddle.
7-emm
33daya
11-14mm 16mm
~days 41 days
17-20mm 25-27mm
47-48days 54 days
Fig. 11 The upper extremity leads the lower extremity in developmental maturity.
10 ! INTRODUCTION
R. subclavian a.
Apical growth
ridge
Postcardinal v.
Fig. 12 The primitive axial arteries of the limbs are conneded by a fine vascular mesh to
a substantial marginal vein that drains initially into the postca.rdinal veins.
EMBR.YOLOGYOFTHEAKTERIESANDVEINS I 11
Brachial a.
11-14mm
41 days
25-27mm
54 days
17-20mm
48days
Fig. 1! Radial and ulnar arteries branch from the axial vessel and replace an intermediary
median artery to supply the forearm and vascular arcade of1he band.
Anastomotic a.
Common iliac a.
Fig. 14 The umbilical arteries shift their bases w dorsal intersegmental roots in the fourth week.
1Z I INTRODUCTION
The subclavian artery, which arose in con- common and internal iliac arteries. These root ves-
cert with the changes in the aortic arches, forms sels give rise to the primitive axial vessels of the
the axial artery of the upper extremity in the lower extremities, sciatic arteries, and external iliac
5-mm, 4-week embryo. This original axis per- arteries.
sists as the brachial and interosseous arteries of The sciatic arteries arise from the new dor-
the arm and forearm (Fig. 13). The brachial artery sal roots of the umbilical arteries in the 9-m:m,
gives rise to three branches to the vessels of the 5-week embryo. The external iliac arteries arise
hand: the median, ulnar, and radial arteries. The from the same vessel segment as the sciatic, and
median artery regresses, leaving the other two. the two vessels interconnect, selectively resorb,
Because of the relatively caudal initial position and branch to form the definitive arteries of the
of the upper extremity buds, the venous arch first lower extremities (Fig. 15). The anterior and pos-
drains into the postcardinal vein. The cranial mar- terior tibial vessels are derived from the popliteal
gin of the venous arch regresses, and the caudal remnant of the sciatic artery and from the femoral
margin remains as the basilic, axillary, and sub- artery, respectively.
clavian veins. By this stage, differential growth The marginal vein in the lower extremity forms
has shifted the drainage of the subclavian into the later than in the upper extremity, commensurate
precardinalregion. with the caudal developmental lag. As in the upper
In the fourth week, the umbilical arteries extremity, the cephalad or tibial connection of the
anastomose with adjacent dorsal intersegmental marginal vein regresses, leaving the fibular branch.
aortic branches (Fig. 14). This secondary connec- The latter interconnects with the great saphenous
tion quickly becomes dominant, and the original vein, which arises independently of the postcardinal
aortic connection is lost. The new dorsal roots of vein. The two vessels give rise to the definitive ve-
the umbilical arteries are destined to become the nous drainage ofthe leg.
Inferior
; - ~uteal a.
17-20mm
47-48days
23mm
52 days
Fig. 15 The axial sciatic artery of the leg and the external iliac trunk intenl.ct to form the
mature vascular pattern of the lower extremity.
EMBR.YOLOGYOFTHEAKTERIESANDVEINS I 13
The establishment of the final vascular pattern The vitelline veins pass from the yolk sac
of the lower extremity lags behind that of the up- through the septum transversarum. to enter the
per extremity, being complered in the third mont~ sinus venosus alongside the foregut In their course
whereas the upper extremity has a mature pattern by through the septum transversarum, they interweave
the end ofthe eighth week. The middle sacml artery with the ingrowth ofliver buds and become hepatic
is the remnant of the dOI~al aorta distal to the iliac sinusoids (Fig. 17). Part of the sinusoidal system
arteries. contributes to the ductus venosus (see below), and
the suprahepatic branches on the right become the
hepatic veins. The infrahepatic vitelline veins are
TbeYeins paired by 4 weeks (5 mm.) and lie on each side of
the duodenum. Through cross-anastomosis and
In the third week, when the embryo is 3 mm. long partial resorption of the vitelline veins, the por-
and the neural tube begins to close, three sets of tal vein is formed with a serpentine route around
paired veins become established (Fig. 16). The ear- the duodenum. The superior mesenteric vein is a
liest are the vitelline veins from the yolk sac, then replacement of the vitelline veins connecting to
the umbilical veins from the chorion, followed by the portal vein. Cephalad to the liver, the left vi-
the cardinal veins dmining the body proper. Venous telline vein and the left hom of the sinus venosus
developmental changes are more complex than disappear.
arterial, involving additions, deletions, interconnection, The umbilical veins initially pass from the
position, and flow changes. body stalk through the lateral body walls on each
Umbilical v.
Fig. 16 Three pairs of veins give rise to the definitive venous pattern of1he body.
14 I INTRODUCTION
side of the liver mass to reach the sinus veno- toward the midline and lies in the free edge of the
sus. As the liver expands, vascular connections falciform ligament.
between the umbilical veins and the hepatic sinu- The paired pre and postcardinal veins estab-
soids are established. Flow is progressively chan- lished in the 5-mm. embryo at 4 weeks of age un-
neled through more direct pathways to the heart dergo a series of changes leading to the mature
until the ductus venosus is established. By 4% venous drainage pattern of the body. The precardi-
weeks, all the umbilical vein blood in the 6-mm. nal veins mature into the veins of the superior vena
embryo flows through the liver. The entire right caval drainage basin, and the postcardinal veins,
umbilical vein and the proximal extrahepatic por- supplemented by two sets of parallel channels, be-
tion of the left umbilical vein regress, leaving only come the inferior vena caval system of the lower
the left umbilical vein. The remaining vein shifts body.
Sinus
Common
carclnalv.
Vltellinev.
5mm
Umbilical v.
Communication
of 18ft
umbilical v.
with hepatic
sinusoid&
Fig. 17 The vitelline veins interdigitate with the developing liver buds to become hepatic
sinusoids. The left umbilical vein (;ODnects secondarily to 1he intrahepatic plexus, and the
major ductus venosus channel is established.
EMBR.YOLOGYOFTHEAKTERIESANDVEINS I 15
During the eighth we~ an oblique venous The postcardinal veins lie dorsal to the meso-
channel connects the precardinal veins lying ven- nephroi, which they drain along with the legs and
trolateral to the brain (Fig. 18). The root of the body wall (Fig. 19). The distal ends of the postcar-
left precardinal regresses, leaving the root of the dinals interconnect early, before the postcardinal
right as the superior vena cava and the cross- tnmks regress along with the mesonephroi. This dis-
connection as the left brachiocephalic vein. The tal connection at the level of the leg vein entry will
cephalad portions ofthe precardinal veins become become the left common iliac vein (Fig. 20). The
the internal jugular veins. External jugular and root ofthe azygous vein is the only other remnant of
subclavian veins develop independently and at- the postcardinal veins.
tach to the precardinal veins. The segment of right The subcardinal veins arise after the postcar-
precardinal vein between the right subclavian dinal veins, but while the latter are still in place,
and left brachiocephalic vein becomes the right and lie ventromedial to the mesonephroi. Intercon-
brachiocephalic vein. nections through the mesonephroi occur between
The evolution of the caudal venous system the subcardinal and postcardinal veins. A central
is not quite as straightforward. During the second subcardinal anastomosis arises that is destined to
month of embryonic life, the postcardinal veins become the stem of the left renal vein. The subcar-
are supplemented by the subcardinal and supra- dinal veins quickly lose their cephalad connection
cardinal veins, successively. A3 the sets of veins with the postcardinals, and the right subcardinal
partially regress in the order that they appeared, connects with a caudal extension of the hepatic
multiple interconnections lead to the mature vas- veins, forming the future subhepatic, suprare-
cular pattern. nal portion of the inferior vena cava. The adrenal
Internal
)ugularv's
Azygousv.
Rg. 18 A diagonal branth (;ODnects the pre(;ardinal veins in 1he eighth week, forming the
left brachiocephalic vein.
16 I INTRODUCTION
and gonadal veins are remnants of the subcardinal
veins.
The supracardinal veins appear last and
lie dorsomedial to the postcardinal veins. A3 the
kidneys develop and assume their final position, the
supraca:rdinal veins anastomose with the subcardinal
veins at the level ofthe developing renal veins, fonn-
ing a portion of the left renal vein. The connection
on the right becomes the continuation ofthe inferior
vena cava below the renal veins, leading into the
persistent caudal portion of the right sup:racardinal
vein. The latter connects to the persistent early
cross-connection of the postcardinal veins that will
constitute the iliac confluence. The disconnected
cephalad portions of the supracardinal veins cross-
connect, forming the azygous and hemiazygous
veins. The intercostal and lumbar veins that initially
drain into the postcardinal veins ultimately drain into
the derivatives of the supracardinal veins. Thus, the
cephalad body wall branches drain into the azygous
Rg. 19 The postcardinal veins lie in the dorsal sub- system, and the lower lumbar veins drain into the
stance ofthe mesonephric ridges, shown here in a 4-week distal inferior vena cava.
embryo.
4weeks &weeks
Sub-
cartfiiWI v.
Fig. 20 Complex interactions between the postcardinal veins and their subcardinal
and supracardinal derivatives result in the definitive venous drainage of the lower part of
the body.
EMBR.YOLOGYOFTHEAKTERIESANDVEINS I 17
Frtrd Clrculatltm tmd Birth At birth, the pulmmwy vascular circuit sud-
denly fills, retuming lmger volumes of blood to the
During the remaining 7 months of gestation, the left atrium at the same time as the umbilical circula-
fetal period, oxygen-rich blood from the um- tion ceases. The result is a reve:n~al in right and left
bilical vein passes through the liver, mostly via atrial pressures, closing the foramen ovale and ending
the ductus venosus (Fig. 21 ). It is mixed in the the interatrial shlDll The ductus arteriosus is closed
heart with desaturated, waste-laden blood from by muscular contraction and ultimately fibroses along
the fetal body. Flow dynamics and preferential with the ductus venosus and umbilical vessels.
shunting through the foramen ovale and ductus The vestiges of the specialized fetal circula-
arteriosus favor oxygen delivery to the cephalad tory channels are the ligamentum arteriosum, liga-
end of the body. Contaminated blood returns to mentum venosum, and round ligament of the liver
the placenta from the descending aorta via the in the chest and upper abdomen and the medial um-
common iliac to internal iliac to umbilical artery bilical ligaments on the inner surface of the lower
route. abdominal wall.
Ductus lnferfor
venoeus vena cava
18 ! INTRODUCTION
Bibliography 5. Sadler TW. Langman's Medical Embryology.
Baltimore, MD: Lippincott Williams & Wilkins; 2009.
1. O'Rahilly R, Muller F. Developmental Stages in 6. Stewart JS, Kincaid OW, Edwards JE. An Atlas
Human Embryos. Washington, DC: Carnegie of Vascular Rings and Related Malformations of
Institution of Washington, DC; 1987. Publication the Aortic Arch System. Springfield, IL: Charles
637. C Thomas; 1964.
2. Arey LB. Developmental Anatomy. Philadelphia, 7. Senior liD. Development of the arteries of the hu-
PA: WB Saunders; 1963. man lower extremity. Am J Anat. 1919;25:55-95.
3. Gray SW, Skandalakis JE. Embryology for Surgeons. 8. SeyferAE, WindG,MartinR Studyofupperextrem-
Philadelphia, PA: WB Saunders; 1991. ity growth and development using human embryos
4. Moore KL. The Developing Human. Philadelphia, and computer reconstructed models. J Hand Surg.
PA: WB Saunders; 2008. 1989; 14A:927-932.
Visceral
CClmpar1ment
23
the anterior longitudinal ligament of the thoracic
spine. Posteriorly, it attaches along a midline seam
The supple cervical spine is surrounded by a central to the ligamentum nuchae of the cervical spinous
group of muscles attached to the ribs, to the base processes. The prevertebral fascia covers the ori-
of the skull, and to adjacent vertebrae (Fig. 1-2). gins of the cervical nerves and the phrenic nerve
These include small intrinsic muscles and power- arising from them. At the base of the neck, the pre-
ful erector spinae muscles posteriorly, the small vertebral fascia takes a more complex form. Fan-
longus colli and longus capitis muscles anteriorly, ning out laterally, it covers the roots of the brachial
and the levator scapulae and scalene muscles lat- plexus and the subclavian artery and fOIIIlli a neu-
erally. This paraspinal grouping is wrapped in a rovascular wrap called the axillary sheath. The vis-
discrete fibrous layer called the prevertebral fas- ceral components of the neck lie along the center
cia. Anteriorly, this fascia runs from the base of of this delta-shaped anterior sheet of prevertebral
the skull down the vertebral bodies to blend with fascia.
_ _ _ Semispinalis
caplllsm.
_ _ _ Longissimus
caplllsm.
_ _ _ Splenius
capitism.
_ _ _ Levator
scapulae m.
1
Pnwertebral
laacla
Fig. 1-2 The musculoskeletal pillar of the ned is wrapped in the prewrtebral fascia that
extends into the shoulder u the axillary sheath.
Fig. 1-l The visceral compartment is surrounded by its own fascial layer. The portion
immediately appoaed to the tw:hea is called preaacheal fascia. The fascia around the strap
muscles is sometimes called the middle layer of deep cervical fascia.
CAROTID ARI'ERIES I 25
skirting the posterior base of the skull, the zygo-
matic arch, and the lower border of the mandible.
Wrapping the neck into a neat bundle is the best The lower margin attaches to sternum, clavicle, ac-
defined and most superficial layer of the deep fas- romion, and the spine of the scapula. The parotid
cia, the investing fascia (Fig. 1-4). It attaches to the and submaxillary glands are also enclosed within
ligamentum nuchae in the posterior midline and layers of this fascia.
splits to invest the trapezius and sternocleidomas- The flat sternocleidomastoid muscles form the
toid muscles within its laminae. The investing fas- final, lateral boundary of the space containing the
cia forms a complete sheath, with its upper margin carotid sheath.
) Investing
,_V fascia
Fig. 1-4 The broad sternocleidomastoid and trapezius muscles are enclosed in the most
superficial layer ofthe deep cervical fwM:ia, which is alrK> called the investing fisscia.
Superior cervical
sympathetic ganglion ---~~~.1
f~~~~l-+---- Superior
Vagus n. - - - - - - --=H thyroid a.
Internal jugular v. - - - -
Carotid a.------:-:!~ 1~--++--- Ansa
cervlcalls
Cerotic sheath-----+
Fig. 1-5 The carotid sheath is a loose network of fucia containing the carotid arteries, the
internal jugular veins, and the vagus nerves.
CAROTID ARI'ERIES I 27
-. SllpBfidalFtlsda Cutaneous nerves and superficial veins lie in
the well-defined cleavage plane between the pla-
The superficial &icia of the neck contains two flat tysma and the investing &icia. A cross section of the
sheets of muscle, the platysma (Fig. 1~). These neck at the level of the thyroid cartilage (Fig. 1-7)
muscles represent the remnant of the more exten- demonstrates the relationships of these and the other
sive panniculus camosus of other maunnals with fascia-bound anatomic groupings. With this back-
which they shake their coats. The muscles of fa- ground, the remainder of the chapter focuses on the
cial expression are specialized modifications ofthis carotid artery and its relationship to surrounding
layer. structures.
Fig. 1-6 The platysma m\UICle lies in the superficial fascial layer and lends substance to
tlris plane for purposes of surgical dissection.
Anterior
jugularv.
jugularv.
Vertebral a.
Fig. 1-7 A cross section of the neck shows the discrete boundary between 1he musculo-
skeletal elemeot of the neck and 1he other components.
CAROTID AIUERIES I 29
structures of the head, gives off several branches
before its terminal bifurcation into the internal
The common carotid artery ucends in the neck maxillary and superficial temporal arteries. These
medial to the internal jugular vein and normally are the superior thyroid, ascending pharyngeal,
has no branches (Fig. 1-8). Occasionally, the su- lingual, facial, occipital, and posterior auricular
perior thyroid artery arises proximal to the bifur- arteries. The internal carotid artery proceeds pos-
cation into internal and external carotid arteries. teromedially to enter the carotid canal at the base
The bifurcation is usually located at the level ofthe of the skull without giving off any branches. On
superior border ofthe thyroid cartilage. Variations the medial side of the bifurcation lie the small,
in the levels at which the carotid bifurcates are oval carotid body, a chemoreceptor, and the ca-
more often above this position than below. The rotid sinus, a pressure receptor intrinsic to the
external carotid artery, supplying the extracranial wall of the common and internal carotid arteries.
Common carotid a . -
Flg.l-1 The common carotid artery ascends two-thirds of the length ofthe neck without
branches until it bifim:ates. The external c1110tid bas multiple extracranial nmifications
while the internal carotid i8 branchless.
External
~--Jugularv.
lf+-:-..;;::-ii!::!!~--Anterlor
jugularv.
Fig. 1-9 The internal jugular vein lies immediately beneath the sternocleidomastoid mu.s-
cle and is paralleled by the smaller external jugular vein crossing the superficial swface of
that muscle. The pattern of the smaller venous branches is more variable than that of the
corresponding arteries.
CAROTID AIUERIES I 31
cervical plexus emerge from the prevertebral filscia
deep to the sternocleidomastoid muscle and then
There are three groups of nerves in the neck: the cra- pierce the investing filscia at the posterior border of
nial nerves, the nerves of the cervical plexus, and that muscle.
the nerves of the brachial plexus (Fig. 1-10). Only The nerve roots of the brachial plexus emerge
the fim group is of major concern when considering between the anterior and middle scalene muscles
approaches to the di8tal carotid artery. Of the cra- and lie lateral to the course of the common carotid
nial nerves, the facial (VTI), glossopharyngeal (1X), arteries. This relationship is examined in more detail
vagus (X), spinal accessory (XI), and hypoglossal in Chapter 4.
(XII) are intimately related to the distal internal ca- The final key to understanding the approach to
rotid artery and are discussed further below. In the the carotid bifurcation and internal carotid arteiY is
midneck, the vagus, cervical sympathetic chain, and knowing the relationships of the pharynx, the cta-
ansa cervicalis (also called ansa hypoglossi) share nial nerves mentioned above, the vessels, and the
the carotid sheath. The cutaneous branches of the mmus of the mandible.
cervical n. ~
\
Supraclavicular n.
Middle constrtctor m.
Fig. 1-11 The pharynx and its related m:uacles constitute the deep surtilce on which the
carotid vessels lie.
CAROTID ARI'ERIES I J]
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The lntemal t111d Ertrmol CtiiOtidArtetles complex of the larynx by passing between the
digastric and stylohyoid muscles laterally and the
The internal carotid artery passes deep to the sty- styloglossus and stylopharyngeus muscles medi-
loid process and all associated structures to reach ally. Beneath the posterior belly of the digastric
the base of the skull (Fig. 1-12). The external muscle, the occipital artery crosses the distal inter-
carotid artery divides the posterior suspensory nal carotid artery.
'="""=~----Stylohyoid m.
:-----Internal carotid a.
-s--+- - - - External carotid a.
Flg.l-12 The iDtema1 c:arotid artery passes deep to the posterior suspensory musc:les of
the plw:ynx. to te.rm:inaw medial to 1he styloid process, while the continuation of the exta-
nal c:a.rotid passes between these mUKles.
Fig. 1-11 1b.c intemal jugular vein runs posterolateral to the internal carotid artery and
follows a similar course. The superficial veins of the fiK:e drain via the relatively conatant
facial vein, which crosses the carotid bifun:ation to reach the internal jugular.
CAROTID ARI'ERIES I 15
tahir99 - UnitedVRG
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-. Clanlal Nerves Revascularization vs. Stenting Trial,1 which was
lower than the 8.6% of 1,415 patients nrndomized
The immediate extracranial portions of the cranial to surgery in the North American Carotid Endarter-
nerves mentioned above intertwine with the muscu- ectomy Trial reported two decades prior.3 The fre-
lar and vascular structures we have been discussing, quency of cranial nerve injury is higher in patients
putting them at risk for injury during carotid sur- undergoing repeat carotid endartarectomy.4 The
gery (Fig. 1-14). Although most iatrogenic nerve in- frequency of individual nerve injuries remains con-
juries resulting from carotid surgery are temporary troveiSia~ but most authors report that either the hy-
and subtle, careful examination will reveal such poglossal nervel or the recurrent laryngeal nerveM
injuries in 5% to 21% of patients.t..s Detailed post- is most commonly injured. The glossopharyngeal
opemtive evaluations by neurologists documented nerve is among the least frequently injured, but per-
cranial nerve injuries in 4.7% ofthe 1,240 patients manent damage is associated with severe impair-
randomized to the surgical arm of the Carotid ment due to swallowing difficulties.
Superior
larygeal n. --":----t-1
Fig. 1-14 The hypoglossal nerve swinging down superficial to the carotid vessels is often
visualized during carotid surgery. The limb of the aDSa cervicalis running with the hypo-
glossal nerve is often sacrificed with no ill effect during carotid surgery.
Faclaln.
Accessory n.
Meclal
pterygoid
Fig.1-15 An understanding of the emergence ofthe cranial nerves atthe bue of the skull
helps prevent injwy to these nerves dwing operations on the distal internal carotid artery.
CAROTID AIUERIES I 37
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The marginal mandibular branch of the facial The vagus nerve and sympathetic chain lie
nerve (ramus mandibularis) emerges from behind posteriorly in the groove between the intemal jugu-
the parotid gland and nms below the angle of the lar vein and the internal and later common carotid
mandible before turning upwards to run parallel artery (Fig. 1-17). Occasionally, the vagus nerve is
with the mandibular ramus (Fig. 1-16). Although located in a more anterior position in relation to the
the nerve is usually within one finger's breadth of carotid artery at the base of the neck. The superior
the inferior border of the mandible,6 variants can and inferior laryngeal branches of the vagus supply
course significantly below this level, making them the muscles of the lacynx, and varying degrees of
prone to injury during carotid endarterectomy. The dysphonia result when they are injured. The supe-
nerve innervates the muscles of the lower lip; in- rior laryngeal nerve accompanies the artery of the
jury results in the inability to draw the angle of the same name from its origin high in the neck and is
mouth downward, with compensatory drooping of at direct risk from mobilization of the artery. The
the contralateral lip.67 The ramus mandibularis is recurrent laryngeal nerve, arising low in the neck, is
prone to injury from longitudinal incisions that are at indirect risk from injury to the main vagal trunk
placed too far anteriorly and from retractors that in the midneck. In rare cases, a nonrecurrent laryn-
are placed on the angle of the mandible.5 Position- geal nerve may branch directly from the vagus at
ing retractors superficial to the platysma and curv- the level ofthe carotid bifurcation and course medi-
ing the longitudinal incisions posteriorly toward the ally behind the carotid bulb to reach the larynx. This
mastoid process may help to reduce injmies to the anomaly is usually seen on the right side, associated
ramus mandibularis. with an aberrant right subclavian arteJ:y.
Marginal
mandibular n.
Flg.l-16 The ramus mandibularis branch of the facial nerve runs below the edge of1he
mandible and is prone w injury during carotid endarterectomy.
Glossopharyngeal n. --:-4::!'-~='""'!!!:~1/
Digastric m.
(p:lSterior belly) :"'---~ ~~J
Fig. 1-18 The distal internal carotid artery is cramped in a nmow space behind and deep
to the ramus of the mandible, making access difficult.
Fig. 1-19 A conceptual division of the ned into three zones helps to determine appropri-
ate surgical approaches to different regions ofthe carotid arteries.
CAROTID ARI'ERIES I 41
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&posul! afthe Ctntld Bifurcation In fllr Nett extending from the clavicular head to the retro-
CltNJeiO mandibular area (Fig. 1-20). The incision should
be curved slightly and extended just inferior to the
The neck is slightly extended, and the head is lobe of the ear at its distal end. This posterior dis-
turned opposite the side of the intended incision placement of the incision helps avoid injury to the
and placed upon a gel ring. Elevation of the shoul- marginal mandibular branch of the facial nerve. 11
ders with a rolled sheet will enhance neck exten- Alternatively, a transverse cervical incision may
sion, especially in patients with short, broad necks. be used, but this oblique incision is associated with
The upper chest, lower face, and lower ear are limited carotid exposure and a higher risk of injUJy
prepped and draped. to the marginal mandibular nerve.11
A longitudinal incision iB made along the an- The incision is deepened through the pla-
terior border of the sternocleidomastoid muscle, tysma muscle, and the investing layer of the deep
Fig. 1-20 Postaaricular extension of the <:ephalad end of the longitudinal neck iru:ision
avoids illjury to the ramus m.andibularis of the facial nerve.
Rg. 1-21 Posterior retraction ofthe sternocleidomastoid m:uscle exposes the carotid sheath.
CAROTID AIUERIES I 43
ofthe common facial vein {Fig. 1-22). The common to be dissected before manipulation of the athero-
facial vein is usually well-defined, and its division sclerosis-prone bifurcation. The common carotid
can be likened to the of a trap door, immediately artery is isolated first, using sharp dissection. The
exposing the carotid arreries. vagus nerve usually lies posterior to the common
Dissection of the common carotid artery and carotid artery, but it is occasionally found anterior
its branches is performed next. It is important to and lateral to the artery.11 The recurrent laryngeal
use exact and careful movements during arterial nerve is usually located in the tracheoesophageal
mobilization to prevent dislodgement of small em- groove, well removed from injury during carotid
boli from irregular luminal sur&.ces. We favor the dissection. However, a nonrecurrent laryngeal
isolation of the common carotid and its branches nerve anomaly may be present that renders it
away from the bifurcation, which is dissected last. more susceptible to injury. Although this anomaly
This allows vessels with relatively normal surfaces is usually associated with aortic arch anomalies,
Fig. 1-22 After division of the facial vein. 1he jugular vein can be mobilized posteriorly
to expose 1he carotid bifun:ation cephalad to the anterior belly of1he omohyoid muscle.
Fig. 1-23 Proximal and distal CODtrol is obtained before the carotid bifurcation is mobilized.
CAROTID AIUERIES I 45
The external carotid artery is isolated at the bi- reflex increase in vagal nerve function, resulting in
furcation and encircled with an elastic vessel loop hypotension and bradycardia.1718 In order to inter-
(Fig. 1-24). The superior thyroid arteiy requires iso- rupt the reflex arc between the baroreceptors and
lation when it branches directly from the common the vagus nerve, some authors advocate inactivating
carotid artery. The superior laryngeal nerve cOUl'Ses the carotid sinus nerve by injecting local anesthesia
behind the external carotid arte:ry16 and is avoided at the carotid bifurcation or by dividing the nerve
by encircling the arte:ry at its most proximal point. plex.us containing the carotid sinus nerve posterior
If not previously identified, the hypoglossal nerve to the bifurcation area. 17 18 Citing a propensity to-
can be avoided by dissection in the periadventitial ward development of hypertension after these ma-
tissues. neuvers, other authors do not routinely inactivate
The carotid bifurcation area can now be dis- the nerve but do so only after the development of
sected from surrounding tissues. A great deal of vagal hyperactivity.19 Once the decision to anes-
attention has been paid to the carotid sinus nerve thetize the carotid sinus has been made, the carotid
(nerve of Herring). The carotid sinus is a collec- bifurcation should be mobilized completely to fa-
tion of pressure receptors located at the junction cilitate endarterectomy. Previous isolation of the
of the common and internal carotid arteries. It has common carotid arte:ry and branches greatly facili-
been suggested that changes in these baroreceptors tates dissection and minimizes injury to surround-
induced by endarterectomy are associated with a ing nerves and veins.
Fig. 1-24 Periadveutitial dissection minimiz.es risk to adjacent cranial nerve branches.
CAROTID ARI'ERIES I 47
The optimal technique for temporary fixation de- the common and internal carotid arteries proceeds as
pends on the presence of adequate dental stability, above. The hypoglossal nerve should be identified
and a number of wiring options have been described and protected, sometimes necessitating division
by Simonian et al.26 Yoshino et al. have recently of the occipital artery and ansa hypoglossi to al-
described a less invasive method of subluxation us- low optimal mobilization. In isolating the internal
ing a mouthpiece made by a dentist to stabilize the carotid artery, care should be taken to identify and
mandible in the subluxated position.27 The patient ligate small crossing branches of the jugular vein.
is positioned and surgically prepared as above, and The lower edge of the parotid gland is retracted
the incision is made along the anterior border ofthe anteriorly during this maneuver.
sternocleidomastoid muscle. The incision should Division of the posterior belly of the digas-
be extended as high as possible and curved poste- tric muscle allows exposure of the internal carotid
riorly just behind the lobe of the ear. Exposure of artery within 2 em of the skull base (Fig. 1-26).
Facial n.
Hypoglossal n.
Occipital a.
SUperior
laryngeal n.
Fig. 1-26 Division ofthe posterior belly of the digastric muscle and of the occipital w:tery
allows cephalad mobilization of the hypoglossal nerve. If the styloid process is divided,
dissection must adhere closely to the bone to avoid injwy to the immediately subjacent
glossoplw:yngeal nerve.
CAROTID ARTERIES I 49
26. Simonian GT, Pappas PJ, Padberg FT Jr, et al. posterolateral anatomic approach. J Vase Surg.
Mandibular subluxation for distal internal carotid 1988;8(5):618-622.
exposure: technical considerations. J Vase Surg. 29. Rosenbloom M, Friedman SG, Lamparello PJ, et al.
1999;30 :1116-1120. Glossopharyngeal nerve injury complicating carotid
27. Yoshino M, Fukumoto H, Mizutani T, et al. Mandib- endarterectomy. J Vase Surg. 1987 ;5 :469-4 71.
ular subluxation stabilized by mouthpiece for distal 30. Thomassin JM, Branchereau A. ln1rape1rosal inter-
internal carotid artery exposure in carotid endarter- nal carotid artery. In: Branchereau A, Berguer R, eds.
ectomy. J Vase Surg. 201 0;52: 1401-1404. Vascular Surgical Approaches. Armonk, NY: Futura;
28. Shaha A, Phillips T, Scalea T, et al. Exposure of 1999:15-20.
the internal carotid artery near the skull base: the
Fig. 2-2 The vertebral artery penetrates and lies bwied beneath the delta of prevertebral
1111d scalene muscles.
Longus
capll!sm.
L. carotid a.
Fig. 2-S The great vessels at the root ofthe neck overlie the vertebral arteries and must be
mobilized during surgical approaches w the vertebral arteries.
VERTEBRALAIUERIES I 53
The venous tributaries that accompany the transverse processes housing the vertebral arteries.
distal vertebral artery converge to form a single The middle cervical sympathetic ganglion lies at
vertebral vein on emerging from the sixth trans- about the level of the carotid tubercle, and the infe-
verse process (Fig. 2-4). The vein enters the prox- rior ganglion lies posteromedial to the origin of the
imal subclavian vein just distal to the internal vertebral artery. The inferior ganglion gives off fi-
jugular vein. On the left side, the thoracic duct bers that wrap around and ascend with the vertebral
emerges from the posterior thorax, arches over artery.
the subclavian artery, and enters the subclavian The costocervical trunk arises posteriorly
vein between the internal jugular and vertebral from the subclavian. Its cervical division as-
veins. cends in the deep posterior cervical muscles
The cervical sympathetic chain lies an the and communicates with the vertebral along its
prevertebral fascia anterior to the longus colli and course and with descending branches of the
capitis muscles, which in turn lie anterior to the occipital artery.
Middle
cervical -~---....::=
ganglion
Middle
cervical
cardiacn.
Inferior
~~--=+f-..;.._--::----~!!-f-- cervical
ganglion
SUbclavian v.
Fig. 2-4 In this lateral view of the proximal left vertebral artery, the scalene fat pad has
been removed to show relationships to the thoracic duct, venous, and neural structures.
Thoracic
duct \-::--~--..,.
Fig. 2-5 This cut-away view shows the major anatomic landmarks that tDUJt be negotiated
to reach the vertebral artery.
VEIUEBRALARI'ERIES I 55
At the level of the posterior groove, the arter-
ies give offbranches to the deep muscles of the neck
Between the traruJverse processes of the atlas and that anastomose with ascending cervical, occipital,
axis vertebrae, there is more space for access to and deep cervical arteries . Medial to the articular
the vertebral arteries than in other interspaces due facets, the arteries give off branches that descend
to the decreased bulk of the bony arches poste- within the vertebral cana], supplying vertebml bod-
riorly (Fig. 2-6). After emerging through the fo- ies and meninges. Prior to converging at the level of
ramina of the atlas, the arteries take a sharp bend the pons, small descending branches fuse to form
backward and lie in grooves encircling the pos- a midline vessel along the venttal surface of the
terior rims of the bony articular plateaus. They medulla.
then course anteriorly, medial to the atlantooc- The tortuous tenninal extmcrania.l vertebral
cipital articulation, and pass through the foramen arteries lie deep within the suboccipital muscu-
magnum. lar triangles and are difficult to expose (Fig. 2-1).
Basilar a.
Fig. 2~ The space between the transvecse processes of the atlas and axis vertebrae affords
the best exposure of the distal vertebral artery. The arterial segment above the atbs is the site
ofcollateral arterial connections and is surrounded by a. prohibitively dense venous plexus.
Rectus
capitis
posterior--:-----:=
majorm.
OI:Jiiquus
capitis -.J~;o:-
inferiorm.
Fig. 2-7 The depth of the vessel in the posterior cervical tri1111gle is shown in this view.
VERTEBRALAIUERIES I 57
An anterolateral approach to the Cl to C2 segment
is possible by detaching the levator scapulae origins
from the tips of the transverse processes (Fig. 2-8).
After passing around the posterior part of the
articular process, the vertebral artery penetrates fim
the atlantooccipitalligament and then the dura on its
way to the foramen magnum (Fig. 2-9).
V4-c
w-[
V2 -
V1 -
Fig. 2-1 0 The surgical segmeuts ofthe vertebral arteries are shown.
VEIUEBRALARI'ERIES I 59
supraclavicular approach is employed for elective
operations involving vertebral artery reimplantation
There are two main options for exposure of the into the adjacent common carotid artery, and the
most proximal portion of the vertebral artery: the anterior cervical approach is favored during emer-
tnmsverse supraclavicular approach and the verti- gency explorations for suspected vertebral artery
cal anterior cervical approach. Although the su- injwy.l-4
praclavicular approach affords excellent exposure
of the vertebral artery at its origin, the exposure is
relatively limited and requires tnmsection of the Supradaviallar Approach
sternocleidomastoid muscle. The anterior cervical
approach does not require muscular tnmsection, and The patient is supine, and the head is turned away
it permits rapid extension of the incision for vascu- from the side of surgery. The incision is made ap-
lar control of more distal vertebral artery segments. proximately 1 em above the clavicle, beginning at
However, exposure of the vertebral artery is more the clavicular head and extending laterally for a
difficult through a cervical incision. In general, the distance of 7 or 8 em (Fig. 2-11). The incision is
Stemocleldomastold m.
(clavlaJiar head)
Fig. 2-11 The tnm.svene 8\JjJl'BClavicular incision is carried down through the cla-
vicular head of1he sternocleidomastoid mUJCle.
lntemal
jugularv.
)
Vagus n.-~.,._....:::::..~~'7-~~~
Carotid 8 .-~~-----lo~.........
Thoracic --''14----4~~
duct ''""''~=
{divided)
Fig. 2-12 Omohyoid muscle, external jugular vein. and thoracic duct (on the left) are di-
vided, and the carotid sheath is mobilized medially.
VERTEBRALAIUERIES I 61
The medial margin of the scalene fat pad is and is usually found coursing near the muscle's
next mobilized, and the fat pad is retracted later- medial border (Fig. 2-13). Edwards and Edwards2
ally. Careful sharp dissection is required in order note that visualization of the phrenic nerve and
to identify superficial vascular structures cours- anterior scalene muscle should alert the surgeon
ing within the fat pad, which must be individually that the dissection has proceeded too far later-
ligated to ensure good hemostasis. Mobilization ally. However, identification of these structures
of the fat pad exposes the underlying anterior helps to insure that the phrenic nerve will not be
scalene muscle. The phrenic nerve is located on inadvertently injured from a poorly positioned
the ventral surface of the anterior scalene muscle retractor.
)
lnfertor cel"'ltc81
sympathetic ganglion
Fig. 2-13 Careful medial to lateral dissection of the scalene fat pad reveals the sympathetic
chain, anterior scalene muscle, and phrenic nerve. The inferior 1b:yroid artery and vertebral vein
overlie the proximal vertebral artery.
I
~
Flg.2-14 Division of1he inferior thyroid artery and vertebral vein exposes the artery.
VERTEBRALAIUERIES I 63
Ant:rriot Cerrk.rllAppmach fascia to reach the anterior fibers of the sternoclei-
domastoid muscle. This muscle is dissected away
The patient is placed in the supine position with the from the underlying carotid sheath and retracted
neck extended and head turned away from the side laterally (Fig. 2-15). The superior belly of the
of the intended incision. A vertical incision is made omohyoid muscle may be divided at this point to
along the anterior border of the sternocleidomas- achieve adequate exposme in the inferior aspect of
toid muscle, extending from the retromandibular the wound. The carotid sheath and its contents are
area to the clavicular head. The incision is deep- carefully freed by vertical dissection along the lat-
ened through the platysma muscle and investing eral border of the internal jugular vein. Great care
Fig. 2-15 An anterior longitudinal neck incision can be used to expose all three cervical
segments ofthe vertebral artery.
Fig.2-16 Medial mobilization ofthe <:arotid sheath and proximal neck dissec;tion as previ-
ously described exposes the proximal vertebral artery.
VERTEBRALAIUERIES I 65
Exposure oftht Interosseous Vft'tf!~Nol A1tely performed in the extraosseous (V1) segment (see
(V2 Segmfllf) above).
The patient is placed in the supine position with
Control of hemorrhage is the most common indica- the neck slightly extended and turned away from the
tion for exposure of the vertebral artery segment side of operation. The same anterior cervical ap-
lying within the foramina ofthe cervical transverse proach is used as shown in Figures 2-15 and 2-16.
processes. Although the majority of vertebral in- A vertical incision is made along the anterior border
juries are now treated using endovascular means, of the sternocleidomastoid muscle from the clavicu-
there are still situations such as severe hemorrhage lar head to the mastoid process. The superior incision
or endovascular failure when surgical control is should be curved posteriorly at its uppermost mar-
necessa:ry.11 Ligation of vertebral arteries injured in gin, such that it passes just inferior to the lobe ofthe
this segment is appropriate and has not been as- ear. The incision is deepened through the platysma
sociated with worsening neurologic sequellae.3,10 muscle and investing fascia. The sternocleidomas-
Distal ligation is performed one transverse process toid muscle is freed from medial attachments and
above the injured interosseous vertebral artery, or retracted laterally to expose the underlying carotid
higher if necessa:ry. Direct exposure of the verte- sheath. The carotid sheath, pharynx, and larynx are
bral artery is best performed within the bony canal next freed from the prevertebral fascia by clearing
by unroofing the transverse process, as originally attachments between the visceral and prevertebral
described by Shumacker.U Proximal ligation is fasciae in the retropharyngeal space. The carotid
Fig. 2-17 Medial retradion of the cmotid sheath and cervical viscera exposes 1he cervical
vertebrae covered by the anterior longitudinal ligament.
Fig. 2-18 ~~ ret:nu:tion of anterior longitudinal ligament and anterior paraspinous mus-
cles unroofs the transverse processes encasing the vertebral artery and veins.
VERTEBRALAIUERIES I 67
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The vertebral artery lies directly behind the segments.3 The increased exposure afforded by en-
bone forming the anterior border of the canal in the tering the bony canal provides safer control of the
transverse process. The artery is most conveniently artery. The bony canal is opened by removing the
controlled within the bony canal rather than between bone forming its anterior border. This can be accom-
the transverse processes because of the multiple ve- plished with a small rongeur, woiking from cepha-
nous tributaries that surround the artery in the latter lad to caudad' {Fig. 2-19).
Fig. 2-19 Optimal access to the vertebral artery is obtained by removing the IIDterior arch
ofthe transverse process.
Fig. 2-20 The longitudinal incision is used for exposure of the distal vertebral artery.
VEIUEBRALARI'ERIES I 69
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The distal incision should be curved posteriorly just have found this to be unnecessary. Our dissec-
beneath the lobe of the ear to cross over the mas- tions would strongly suggest that partial or com-
toid. The incision is deepened through the platysma plete detachment ofthe sternocleidomastoid origin
muscle and investing fascia, and the sternoclei- greatly enhances exposure (Fig. 2-21). With either
domastoid is dissected free and retracted later- technique, it is important to identify the spinal ac-
ally. The carotid sheath and contents are retracted cessory nerve, which usually enters the sternoclei-
medially as before. Some authors314 prefer to de- domastoid 2 to 3 em below the mastoid tip.411 The
tach the sternocleidomastoid and splenius capitis nerve should be mobilized and gently retracted
muscles from the mastoid process, but others12 anteriorly.
Fig. 2-21 Access to the upper two transverse processes is greatly facilitated by detaching
the insertion of the stemocleidomasWid muscle, especially in a thick, short neck.
Fig: 2-22 With the ac:cessory nerve retracted anteriorly, the highest slips of 1he levator
scapulae IIDd splenius cervicis are detached from the Cl transverse process to expose the
vertebral artery between Cl and C2.
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Postrtlor ExptlsUI'f Dfthe SUbtJcdpltrll Vnlmd downward and extended for 2 to 3 em parallel to
ArtRty(V4) Stg111ent the posterior border of the sternocleidomastoid
muscle (Fig. 2-23).
Bergu.er has described a now-classic approach to The incision is deepened by cutting the fibeni
the portion of the V 4 segment between the trans- of the trapezius, splenius capitis, semispinalis ca-
verse process of Cl and the base of the skull. u pitis, and longissimus capitis muscles. The greater
This technique is applicable to treat rare patho- occipital nerve (dorsal ramus of C2) courses~
logic lesions such as dissections or aneurysms in- ward over the semispinalis capitis muscle and may
volving the most distal portions of the extracranial require division as it is encountered approximately
vertebral artery. The posterior approach also al- 2 em lateral to the posterior midline (Fig. 2-24). The
lows exposure of the distal internal carotid artery, sternocleidomastoid muscle should be divided at
which can be used as a source of inflow in these its mastoid insertion and reflected inferiorly. This
cases. will expose the internal jugular vein and the acces-
The patient is placed in the prone position sory nerve in the lateral wound. Palpation of the
with the head turned toward the operative side. Ber- transverse process of Cl will aid in identifying the
guer has recommended placing the patient in the obliquus capitis superior muscle, which attaches to
"park bench" position, with the temple contralat- the superior margin of the bony prominence. The
eral to the operative side resting on the forearm.15 large condyloid emissary vein should be ligated and
A curved transverse incision is made beginning divided near the muscle's medial border (Fig. 2-25).
at the occipital protuberance in the midline of the Partial division of the rectus capitis posterior major
posterior neck and extended horizontally to the tip muscle lying in the medial wound will expose the
of the mastoid process. From there, it is curved vertebral artery.
Fig. 2-ll The incision for posterior exposure of the suboccipital vertebral artery is shown.
Splenius
capHis
Trapezius
GA:~ater
occipital n.
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A large venous plexus overlies the artezy at Care should be taken to avoid injwy to the ventral
this level (Fig. 2-26). Meticulous ligation and di- ramus of the Cl root, which courses below the ver-
vision of bridging vein segments will allow the tebral artery in this location. The distal internal ca-
plexus to be dissected away from the arterial ad- rotid artery can be isolated in the lateral wound for
ventitia. Branches of the suboccipital nerve should use as inflow. 15 The artery can be exposed in the
be divided as they cross the vessels at this level. plane medial to the sternocleidomastoid muscle and
The vertebral artery can then be mobilized to the isolated between the hypoglossal and vagus nerves
level of the atlantooccipital membrane (Fig. 2-27). (Fig. 2-28).
Fig. 2-28 The distal intemal carotid artery can be isolated in the lateral wound and used as
inflow for bypass to the suboccipital vertebral artery.
VEKI'EBRAL.AIUERIES I 75
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77
/"'> )
Fig. S-1 The short span ofthe mediastinum is packed with vital structures connected via
major conduits traversing 1he superior thoracic aperture.
Fig. S-2 At the level of the superior mediastiJium, the anterior half of the A-P chest
diameter is occupied by the great vessels, trachea, and esophagus.
79
The parietal pleura surrounds the pulmonary descending segments ofthe aorta are approached by
hilum, forming a short, broad-based bundle, and is reflecting the lung away in the appropriate direction.
reflected onto the medial lung surfaces (Fig. 3-3). Between the pleura and pericardium, the phrenic
The leaves ofpleura surrounding the lung hila extend nerves descend to the diaphragm accompanied by
caudally between the lung and mediastinum to form thin pericardiophrenic vessels (Fig. 3-4). The latter
the inferior pulmonazy ligaments. The aorta frames arise from the brachiocephalic vessels and/or from
the left lung root, and the ascending, transverse, and the internal thoracic (internal mammary) vessels.
Llnferlor
pulmonary v. ---=~--:--:----=--==--HI!~
Fig. 3-3 The closely applied parietal pleura encloses the mediwrtinum. laterally IIDd
surrounds the hitar stalks ofthe lungs.
Fig. S-4 The phrenic and vagus nerves lie beneath the parietal mediastinal pleura. The
distal part of the phrenic nerve lies between pleura and pericardium.
THORACIC AORTA I 81
The second set of major nerves traversing the aortic arch. Here the left recurrent laryngeal nerve
mediastinum is the right and left vagus (Fig. 3-S). diverges to pass beneath the aortic arch behind
These are worth considering separately. The right the ligamentum arteriosum. The vagus descends
vagus passes in front of the subclavian artery just to reach the left side of the esophagus. At their
lateral to its origin from the brachiocephalic artery. junction with the esophagus, the vagi shift posi-
The right recurrent laryngeal nerve turns posteri- tion, with the left moving anteriorly and the right
orly beneath the subclavian artery and ascends in moving posteriorly. Both trunks break up into mul-
the tracheoesophageal groove, while the vagus tiple branches, which freely anastomose around the
descends behind the right main stem bronchus to esophagus. This plexus coalesces into two major
reach the esophagus. The left vagus nerve passes and several minor nerves at the distal esophagus.
between the left subclavian artery and left bra- The major trunks lie anterior and posterior to the
chiocephalic vein to reach the lateml side of the esophagus.
Middle
cervical
ganglia Recurrunt
laryngeal
Fig. SS The vagus nerves pass posterior to the lung roots to reach the midesophagus
where they form an interconnecting plexus.
L. braehlooephallc v.
Fig. S-6 The most posterior part ofthe mediastiJium is occupied by the thoracic duct and
1he vessels supplying the chest wall.
THORACIC AORTA I 83
remnant of the thymus gland. Flanking the sternum
on either side are the internal thoracic vessels, which
The ascending aorta lies beneath the stemomanu- are tethered at their origins proximally. The medial
brialjoint and is accessible directly through the ster- pleural reflections closely approach the midline over
num (Fig. 3-7). The only intervening tissue is the the ascending aorta. The apex of the aortic arch lies
Internal
thoracic a. and v.
Flg.l-7 The relationships of1he vessels and lungs beneath 1he sternum are depicted.
Fig. l-8 The oblique axis of the aortic m:ch relative to the transverse plane of the chest
places 1he origin of the left subclavian artery posteriorly.
THORACIC AORTA I 85
A3 these vessels ascend and diverge, they right. The left brachiocephalic ve~ on the other
surround the trachea and esophagus on three sides hand, arches anteriorly over the origins of the left
(Fig. 3-9). The arteries in tum are covered by an common carotid and brachiocephalic arteries in its
outer layer of major venous trunks. The superior descent from left to right (Fig. 3-11). On the right
vena cava lies lateral and pamllel to the ascending side, the azygous vein drains into the superior vena
aorta (Fig. 3-10). At the bifurcation of brachioce- cava just above the upper limit of the pericardium.
phalic veins, the right branch lies in the same coro- On the left, the accessory hemi.azygous vein drains
nal plane as the vena cava, inclined slightly to the into the brachiocephalic vein.
Fig. S_, The ascending and descending great vessels swround the trachea.
R. subclavian
a. and v. ---~;..:;;..;
\~~___.,':"""""'l~- Arrtsrior
scalenem.
lnternaltJoracic
a.andv.
Fig. 1-12 The domes ofthe l q apices rise above the rim ofthe superior thoracic apertW'e
md support the arching vessels and descending brachial plexus nerves. Sibson's fucia and
pleura are removed in this illustration.
ScaJenemm.
~- Posterior
,..,~...,.:-- Middle
l
~--------~
Fig. l-13 The viscera of the superior t~ic aperture axe covered by an inverted cone of
muscles.
THORACIC AORTA I 89
Beyond the arch, the proximal descending exploration is indicated in unstable patients.1 Standard
aorta lies to the left of the thoracic vertebral bodies open smgical approaches remain the standard of care
(Fig. 3-14). It becomes progressively more midline to treat blunt and penetrating injuries ofthe aortic arch
as it approaches the aortic hiatus at the level of the branches because the long-term stent graft durability
twelfth thoracic vertebra. These relationships deter- is unknown in the trauma population. 1.2
mine the optimal surgical approaches to the great The aortic arch branches include the left sub-
vessels of the chest for control of hemorrhage in clavian, left common carotid, and bracbiocephalic
trauma and for elective surgical procedures. arteries. Adequate exposure ofthese arteries without
a thoracic incision is virtually impossible. Injuries to
vascular structures at the base ofthe neck (zone I, see
Exposure of the Aortic Arch Branches Chapter 1) are also difficult to manage without ex-
posure of more proximal arteries in the chest. Early
The importance ofobtaining vascular control proximal thoracotomy or sternotomy and rapid proximal arte-
and distal to an arterial injwy is nowhere more evident rial control in the chest can significantly reduce the
than inthe mediastinum. Rapid exsanguination, ainvay mortality associated with injuries to the vessels of
compromise, and cardiac tamponade threaten patients the mediastinum and base of the neck.l-s Although
who have sustained injuries to the major branches of repair of aortic arch injuries almost always requires
the aortic arch. Although endovascular management hypothermic cardiac arrest and or/cardiopulmonary
may have a place in the treatment of highly selected bypass, arch vessels can usually be repaired without
patients with contained hematomas, immediate open extracorporeal circulatory support or arterial shunts.6
THORACIC AORTA I 91
A vertical incision is made over the sternum to the periosteum of the sternum. The linea alba
from the suprasternal notch to a level S em caudal in the inferior wound is divided to the tip of the
to the xiphoid process. The incision is extended xiphoid process, allowing development of a plane
superiorly along the anterior border ofthe left ster- between the peritoneum and the posterior rectus
nocleidomastoid muscle when exposing the left sheath. Using blunt finger dissection, this plane
carotid artery, or along the right sternocleidomas- is extended behind the xiphoid and lower sternum
toid muscle when exposing the brachiocephalic (Fig. 3-16). A similar plane is developed behind
artery and its branches. The cervical incision is the upper sternum at the suprasternal notch. It
deepened through the platysma, and the sternal is not necessary to connect the two retrosternal
incision is deepened through subcutaneous tissue planes.
THORACIC AORTA I 93
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the lungs. 14 After hemostasis is obtained, a sternal on its medial surface. The underlying stemoth)'Toid
retractor is carefully positioned and opened a few and sternohyoid muscles are divided. Lateral retrac-
turns at a time to avoid sternal fractures (Fig. 3-18). tion of the sternocleidomastoid muscle will expose
The carotid sheath is exposed through the cer- the internal jugular vein. After mobilizing the inter-
vical extension of the sternotomy (Fig. 3-19). The nal jugular vein and retracting it late:Ially, the com-
investing fascia is incised along the anterior border mon carotid artery can be identified and isolated
of the sternocleidomastoid muscle, which is freed (see Chapter 1).
Fig. 3-18 The sternal retracWr is opened slowly to allow strain to dissipate and avoid
fracture. For clarity, all exposures are shown without laparotomy pads beneath retractors.
Fig.l-19 A cervical extension ofthe sternotomy incision allows exposure ofthe carotid shea1h.
THORACIC AORTA I 95
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Exposure of the aortic arch and its branches be identified by retracting the left brachiocephalic
proceeds through the sternotomy mc1s1on vein superiorly. During mobilization of the brachio-
(Fig. 3-20). The thymus gland is divided vertically cephalic artery, care should be taken to identify the
in the midline and ligated. The left brachiocephalic right vagus and recurrent laryngeal nerves. The right
vein is identified, mobilized, and encircled with a vagus nerve courses along the lateral aspect of the
silastic loop. Although there are numerous venous right carotid artery, crosses anterior to the right sub-
tributaries that serve as collateral channels ifthe left clavian artery near its origin, and descends into the
brachiocephalic vein is occluded, intentional divi- mediastinum posterior to the right brachiocephalic
sion of this vein is usually not required. Instead, the vein (Fig. 3-21). The recurrent laryngeal branch of
inferior thyroid vein and other tributaries of the left the right vagus nerve loops around the inferior bor-
brachiocephalic vein should be divided to permit der of the proximal subclavian artery and courses
wide mobilization of the bracbiocephalic vein. The medially to ascend in the neck between the trachea
bracbiocephalic artery is identified superior to the and esophagus. These nerves are best preserved in
left brachiocephalic vein; its origin at the aorta can the periadventitial tissues. Lateral retraction ofthese
L brachlocephallc v.
Fig. S-20 Complete mobilization of the left brachiocephalic vein exposes the proximal
brachiocephalic artery and left common carotid artery.
R. braehloeephallc v.
'l<m.--- L.lnternal
thoralcv.
L. brachiocephalic v.
-
Fig.l-21 On the right side, exposure of the bifurcation of 1he brachiocepbalic a:rtery and
1he proximal right subclavian and common carotid arteries requires mobilization of the
vagus nerve.
THORACIC AORTA I 97
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Umltttl UpptrStc!rnfltomy abdomen are prepped and draped completely in the
Full median sternotomy is recommended fur most event a full sternotomy should become necessary. A
operations involving exposure of the aortic arch vertical skin incision is made from the sternal notch
branches, especially in emergency situations when to a level 2 em below the angle of Louis. The ster-
the exact location of injury has not been identified. num is divided in the midline from the manubrium
In extremely limited circwnstances, a complete to the third intercostal space using an oscillating
sternotomy may not be necessary to expose the bra- saw (Fig. 3-22). The sternum is then transected
chiocephalic and left common carotid arteries in horizontally in the third intercostal space to form
the chest. Sakopoulos15 has described a "minister- an inverted ''T" incision, taking care to avoid in-
notomy'' exposure fur direct treatment of brachio- jury to the nearby internal mammary vessels. Af-
cephalic and left common carotid lesions in elective ter hemostasis is obtained, the upper sternum is
circumstances. This less invasive approach is useful gently opened using a pediatric sternal retractor.1'
for amenable aortic arch branch lesions but should (Fig. 3-23) The underlying thymus is divided and
be avoided in patients with more extensive disease ligated to expose the left brachiocephalic vein.
and in emergency circumstances. Identification and exposure of the brachiocephalic
The patient is placed supine with the anns and left common carotid arteries proceeds as above
drawn into the sides. The neck, chest, and upper (Fig. 3-24). This approach is particularly suited for
Fig. S-22 The upper sternum is divided, then transected horizontally at the level of the
third intercostal space to form an inverted ''T.,
THORACIC AORTA I 99
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A
100 I VESSELSOFTHECHEST
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direct repair of proximal brachiocephalic artery thoracotomy and the "trap door'' thoracotomy. The
lesions (Fig. 3-25). former approach is optimal for emergency proxi-
mal control of the left subclavian artery and can
be combined with a separate supraclavicular inci-
sion for definitive repair (see Chapter 5). The latter
Mediastinal exposwe of the left subclavian artery approach is a radical extension of the anterolateral
is indicated in control of proximal injuries, which thoracotomy and is ideal for control and repair of
often result from penetrating trauma to the left me- left subclavian artery injuries near the sternocla-
diastinum or base of the neck. Mediastinal control vicular joint. The "trap door'' incision is limited in
may also be urgently indicated in more distal sub- exposure, however, and should be reserved for inju-
clavian arteiy injuries heralded by expanding su- ries in the left side of the superior thoracic aperture.
praclavicular hematomas. The need to expose this
segment of the artery in cases of chronic occlusion Antmlfltfltll'I'IJomt:omy
has been superseded by the advent of extrathoracic The patient is placed in the supine position. A rolled
bypass procedures, which are both durable and sheet or pad should be placed behind the left scapula
safe.8 and hip to bring the left chest approximately 20 up-
The posterior location ofthe left subclavian ar- ward. The entire anterior and lateral chest, shoulder,
tery relative to the other aortic arch branches renders ax.il]a, and neck are prepped and diaped.
it ex.tremely difficult to ex.pose through a median A left transverse curvilinear incision is made
sternotomy (see Fig. 3-9). There are two surgical over the fifth rib, just below the nipple. The incision
approaches that permit optimal exposure of the may be made along the lower conrour of the pecto-
left subclavian artery at its origin: the anterolate~al ralis major muscle to enhance cosmesis (Fig. 3-26).
Rg. 3-26 Landmarks for a left anterolateral thoracotomy incision are demonstrated.
Pectoralis maJor m.
Fig. l-27 The fourth interspace is entered over 1he top ofthe fiflb. rib.
102. I VESSELSOFTHECHEST
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By retracting the superior lobe of the left lung
downward, the aortic arch can be readily seen un-
der the glistening sheen of the mediastinal pleura
(Fig. 3-28). The mediastinal plewa should be incised
over the aortic arch at a point posterior to the left
vagus nerve. The incision is then carried vertically
L. subclavian a.
Fig. S-29 The mediastinal pleura is opened over the arch and left subclavian artery poste-
rior to the vagus nerve.
104 I VESSELSOFTHECHEST
'Trtlp Dotlt"1bonlccrtomy aperture, particularly when the surgeon has already
This approach combines the left anterior thoracot- performed a left anterior thoracotomy in an unstable
omy with a left supraclavicular incision and an in- patient.
terconnecting upper median ~motomy (Fig. 3-30). The patient is placed in the supine position.
The chest wall is not folded back as sugge~d by the The entire chest, neck, and left shoulder are prepped
nomenclature; rather, it is spread at the sternal divi- and draped.
sion using a standard retractor. 18 Despite the criti- The anterolateral thoracotomy is performed
cisms1920 concerning the prolonged time involved in first, as described above. We favor entry into the
making the incision, pleural entry, excess bleeding, pleural space through the fourth inte:rspace and per-
and a propensity for rib fractures, the 'imp door" form an infra-areolar incision accordingly. Initial
thoracotomy remains an important option for ex- performance ofthis part ofthe incision permits early
posure of left-sided injuries at the superior thoracic and rapid control of the left subclavian artery while
~~~ -
Sternocleidomastoid
Internal
jugularv.
L. subclavian a.
106 I VESSELSOFTHECHEST
Inferior thyroid a.
Fig. SU Retraction of 1he carotid shea1h and scalene fat pad exposes the subclavian
vessels and antuior scalene muscle.
Fig.l-ll The antuior Kalene musde is divided close to the scalene tubercle of1he first rib.
108 I VESSELSOFTHECHEST
associated with reduced morbidity and dUJation of
hospitalization,l4.l' the durability of thoracic stent
grafts in trauma patients who tend to be younger and The patient is placed in a true lateral position, with
resistant to follow-up remains unknown. Further- the right side down. A roll is placed beneath the right
more, a recent analysis suggests that survival in pa- axilla. The right ann is placed on an armboard per-
tients with blunt aortic injuries is determined by the pendicular to the patient, and the left arm is sup-
extent of associated injuries and not influenced by ported with pillows or on a Mayo stand. The right
the type or timing of surgical repair.26 The follow- leg is flexed to 900, and the left leg is extended and
ing discussion describes exposure of the descending supported by pillows placed between the patient's
thoracic aorta for open repair, which is best obtained knees (Fig. 3-35). Stabilization of the pelvis is en-
through a posterolateral thoracotomy. sured with wide tape that is brought from one side
Fig. 3-35 Patient position for a left posterolateral thoracotomy incision is shown.
Trapezius m.
~""7-----'~<ff'---.!Hff'-4---- Latissimus
dorsi m.
Fig. S-36 Trapezius, latissimus, and serratus muscles are divided in twn.
Fig. l-37 Proximal and distal control is demonstrated for lesions ofthe proximal descend-
ing aorta.
THORACICAORTA 1 111
References Sabiston Textbook ofSurgery. 19th ed. Philadelphia,
PA: Elsevier Saunders; 2012:1650-1678.
1. ArthursZM, SobnVY, StamesBW. Vasculartrauma: 14. Robicsek F, Masters TN, Littman L, et al. The embo-
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2. Hershberger RC, Aulivola B, MUiphy M, et al. 15. Sakopoulos AG, Ballard JL, Gundry SR Minimally
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jury to the aortic arch and great vessels. J Trauma. reconstruction. J Vase Surg. 2000;31 :200--202.
2009;67:660--671. 16. Schaff HV, Brawley RK. Operative management of
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4. Meredith JW, Hoth JJ. Thoracic trauma: when 17. Kirschner RL. Management of penetrating injury
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5. Hyre CE, Cikrit DF, Lalka SG, et al. Aggressive 18. Graham JM, Feliciano DV, Mattox KL, et al. Man-
management of vascular injuries of the thoracic out- agement of subclavian vascular injuries. J Trauma.
let. J Vase Surg. 1998;27:880--885. 1980;20:537-544.
6. Pretre R, Chilcott M. Current concepts: Blunt 19. Symbas PN. Surgical anatomy of the great ar-
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1997;336:626-632. 1974;54:1303-1312.
7. McCoy DW, Weiman DS, Pate JW, et al. Subclavian 20. Robbs JY, Baker LW, Human RR, et al. Cervicome-
artery injuries. Am Surg. 1997;63:761-764. diastinal arterial injuries: a surgical challenge. Arch
8. Berguer R, Morasch MD, Kline RA, et al. Cervical Surg. 1981;116:663-668.
reconstruction of the supra-aortic trunks: a 16-year 21. Robbs N, Reddy E . Management options for pen-
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9. Matsumura JS, Lee WA, Mitchell RS, et al. The and superior mediastinum. Surg Gyneeol Obstet.
Society for Vascular Surgery Practice guidelines: 1987;165:323-326.
management of the left subclavian artery with 22. Starnes BW, Lundgren RS, Gunn M, et al. A new
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2009;50:1155-1158. J Vase Surg. 2012;55:47-54.
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13. Gopaldas RR, Chu D, Bakaeen FG. Acquired heart of thoracic endovascular aortic repair (TEVAR) in
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The superior opening of the bony thorax has come The superior thoracic aperture is bounded by the
to be called the thoracic outlet. The anatomic term first ribs, which connect the spinal column poste-
superior thoracic aperture and the term thoracic out- riorly with the sternum anteriorly (Fig. 4-1). The
let will be used interchangeably in this chapter to vertebral bodies indent the oval shape of this open-
designate the regional anatomy. ing. The manubrium of the sternum rises above the
Compression ofupper extremity neurovucular plane of the first ribs to articulate with the heads of
structures, collectively called the thoracic out- the clavicles. The mobile sternoclavicular joint is
let syndrome, encompasses considerably more the only osseous connection between the axillary
anatomy than the cephalad aperture of the bony skeleton and the bones of the upper extremity. The
thorax. The vessels exiting the chest and the nerves mobility of the clavicle is important in determining
emerging from the spinal column pass between the amount of space available for passage ofthe sub-
the scalene muscles above the rim of the superior clavian vessels and brachial plexus draped over the
thomcic aperture. They then pass through the tri- first rib. The costoclavicular ligament as well as the
angle fonned by the first rib, clavicle, and scapula sternoclavicular joint attach the clavicle medially.
and nm beneath the coracoid process on their way The transverse processes ofthe cervical vertebrae
to the brachium. are trough-shaped and contain central apertures. The
The following discussion considers all of the vertebral arteries normally enterthe sixth transverse fo-
structures that can compress and comptomise the mmen and traverse the upper five fimunina to reach the
nerves and blood vessels of the upper extremity. base ofthe skull. The transverse process ofthe seventh
The basic surgical approaches to correcting such ceiVical vertebra is often quite laige. Rarely, a cervical
compression are addressed in the second part of the no may be present, which attaches to 1his transverse
chapter. process and lies in the path of the bl:achial plexus.
113
Fig. 4-1 The bony landmaril:s associated with the thoracic outlet include the obliquely
angled face of the superior 1horacic aperture between the spinal column posteriorly and the
manubrium anteriorly. The clavicle and Kapula constitute the pectoral girdle.
Scale09 musciQS
~--Anterior
:'""'!!!!~--Middle
Fig. 4-2 The scalene muscles form struts between the cervical spine and the first ribs. The
nerves to 1he upper extremity pass between the anterior and middle scalene muscles.
C4
C5 /
I
c//
Phi'WIIc n. / : "'
\t r::?
~--La18ral
~~-- Posterior
Long
thoracic n. - - - - - I :
ThOnacodOI'Sal n. ------=:;
Ma<lian n. ---~~~
/
lntercostobradtial n.
Fig. 4-3 The relationship between the brachial plexus and subclavian/axillary arteries is
depicted in this illUJtration.
~\
'S v
((?r;~~~J
I -'
Fig. 4-4 The great mobility ofthe pectoral girdle affects the amount of space available for
the nerve and vascular trunks to 1he upper extremity.
Prevertebral fascia
Pectoralis minor m.
Axillary lu:ia
Rg. 4-S The clavipectoral and axillary fasciae form anterior and lateral walls of the
axillary space.
Coetodalltcular
ligament SUbclavius m.
Fig. 4-6 Oblique fibers of the pectoralis minor and major 1111d the latissimus dorsi make
1he distal clavicle a lever that closes the costoclavicular angle.
Trtcepsm.
Lateral
thoracic a. and v. --:~--~-""""'~".:......,
Jl""i 1 Thoracoepigastric
~~~
~
Fig. 4-7 Several nerves and vessels cross the axillacy space and lie in the way ofaccess to
the fust rib from below.
Naaodllary
:-\ b~hJ ~ - 'THgemlnal n.
~~- : ~
~~
Pupillary
(.'p
\T-- Carotid plexus
1
dllalnr
1
J\L,
)L
!) uv
Supertor cervical
/t ~
ganglion
Grvy rami
(unf'TIY81ii"MIIIId
poslgllngllonlc
11bers)
WhitB ramus
r-----=---- (f'TIY8Iinated preganglionic
fibers)
Fig. 4-1 Each sympathetic ganglion may have one to fom communicating rami that con-
nect to both contiguous spinal nerves and adjacent nerves. Interruption of the sympathetic
trunk at the lower part of the stellate ganglion's thoracic component blocks the majority of
sympathetic effereots to the upper extremity while preservjDg enough sympathetic innerva-
tion to prevent Homer's syndrome.
Ansa
subclavla.
Fig. 4-9 The stellate ganglion lies dorsal to the vertebral artery.
122 I VESSELSOFTHECHEST
Exposure of the TlloradcOutlet The presence of first n'b anomalies, fibromuscular
bands, or abnormal muscular insertions can result in
Compression syndromes involving neurovascu- a fibromuscular vise that compresses the subclavian
lar structures in the thoracic outlet have been rec- vessels and brachial plexus in this area.2-4 The costo-
ognized for many y~. The anatomic situation clavicular passage is a second triangle made up ofthe
underlying compression in this area is the normal subclavius muscle and clavicle anteriorly, the first
existence of four narrow spaces through which the n'b posteromedially, and the scapula and subscapu-
neurovascular bundle must pass in coursing from laris muscle posterolaterally. This area is a common
the neck to the axilla: the mperior thoracic aperture, site of subclavian vein compression in patients with
interscalene triangle, costoclavicular passage, and effort thrombosis. 5.6 A third anatomic triangle exists
subcoracoid space. Thyrom.egaly, thymic lesions, or in the subcoracoid space, where the neurovascular
adenopathy may reduce space availability within the bundle passes between the coracoid process and
superior thoracic aperture1 (Fig. 4-IOA). The inter- the pectoralis minor tendon. A tight band of supe-
scalene triangle is a narrow confine bordered by the rior clavipectoral fascia, the costocoracoid ligament,
anterior scalene muscle anteriorly, the middle sca- may narrow the subcoracoid space during shoul-
lene muscle posteriorly, and the first rib inferiorly. der abduction. Hypertrophy of the pectoralis minor
muscle in athletes may also cause subcoracoid space
narrowing.' More laterally, an accessory muscle
that crosses the axilla from the latissimus dorsi to
the pectoralis major muscle, Langer's axillary arch
(Fig. 4-lOB), has been reported to cause upper limb
deep vein thrombosis from compression.
Middle
scalene
band
Fig. 4-11 Several different pathologic conditions are associated with the thoracic outlet
syndrome. These include cervical ribs (usually embedded within the middle scalene
muscle) and middle scalene bands (A); anomalous muscle insertions, fascial bands, and
clavicular compression (B); and osseous anomalies and traumatic malformations (C).
B
\
Middle scalene
band
---
Fig. 4-12 The compression from a variety of causes responds to removal of the body of
the first rib.
Fig. 4-13 The im:ision for 1he supraclavicular approach to the first rib is shown. The ideal
exposures shown in the following illustrations for clarity are seldom achieved in reality due
to the funnel-like depth ofthe operative field.
Platysmam.
Sternocleidomastoid
m. (clavicular
head)
Subclavian v.
Fig. 4--14 The clavicular head of the sternocleidomastoid muscle and 1he omohyoid
muscle are divided, and the scalene fat pad is sepw:ated from 1he internal jugul11r vein. The
fat pad and vein are retracted in opposite directions, and the thoracic duct is ligated and
divided on the left side.
Suprascapular a.
Fig. 4-15 The phrenic nerve is proteaed as the anterior scalene muscle insertion is divided.
Fig. 4-16 The middle Kalene mUKle posterior to the brachial plexus is cautiously
separated from the first rib (A), keeping in mind the location of the long thoracic nerve.
The most anterior fibers of the middle scalene muscle may be approached between the
subclavian artery and the lower nerve trunk as shown or may be approached between 1he
seventh and eighth ner:ve roots w avoid undue traction on the brachial plexus (B).
Fig.4-16 (Continued)
Fig. 4--17 In the extraperiosteal approach shown here, the iDtercostal and scalene muscles
and endothoracic {as(:ia are sepm:ated from the rib before it is divided anterior to the costal
angle.
1]2 I VESSELSOFTHECHEST
be seen, it is better to leave the posterior rib rem- anterior scalene tubercle. This portion of the rib is
nant in place.24 The subclavian artery is carefully exposed by elevation and retraction of the clavicle
separated from flimsy periadventitial attachments and subclavian vein, with posterior retraction ofthe
to the top ofthe first rib, and the intercostal muscle subclavian artery (Fig. 4-18). If exposure is too dif-
and pleura are separated from the rib's underside ficult or if the saw or rongeur cannot be visualized,
using the ex.traperiosteal technique. The rib is now an infraclavicular counterincision can be made to
completely free ofall attachments and ready for an- allow rib division at the costochondral junction
terior division, which is performed in front of the (see below).
Fig. 4-18 The posterior no is held as a lever while the subclavian artery and vein are
sepamted for a clear view of the llllterior division site.
Fig. 4-19 A true lateral position with the affected extremity left free is used for the
transaxillary approach to the first no.
134 I VESSELSOFTBECHEST
The ipsilateral arm remains free and is held and posi- released on an intermittent basis during the opera-
tioned by an assistant throughout the operation. The tion to prevent ann ischemia and brachial plexus in-
axilla, back, chest, shoulder, and arm are prepped jury. As an alternative, IlliglO has recently described
and draped. A stockinette covers the distal ann. a method of passive arm elevation using a shoul-
The second assistant elevates the arm and der suspension kit in which the arm is elevated by
shoulder using the double wristlock described a weighted nylon cord suspended over a "shower
by Roosll {Fig. 4-20). Ann rettaction should be curtain" assembly.
/) \
JI ~ I I
Fig. 4-20 The assistant holding the ann uses a wrist lock position for security and to
minimize fatigue.
Intercostobrachial
Pectoralis major
Fig. 4-21 Superficial axillary vessels are divided. The intetcostobrBCbial nerve is
mobilized or divided as necessary.
1]6 I VESSELSOFTHECHEST
Roos25 has noted that there is a cul-de-sac of thoracic outlet. From anterior to posterior, one
fascia at the lateral border ofthe first rib that sepa- should identify the axillary vein, anterior sca-
rates the axilla from the thoracic outlet. This tis- lene muscle, axillary artery, brachial plexus, and
sue should be opened bluntly along the top of the middle scalene muscle. The long thoracic nerve
first rib to expose the outlet structures (Fig. 4-22). emerges dorsal to the brachial plexus and should
Gentle elevation of the shoulder by the second as- be avoided as it passes along the lateral surface
sistant and retraction of the pectoralis major will of the serratus anterior muscle in the posterior
greatly enhance exposure of the structures at the wound.
Axillary a.
Brachial
plexus
ma;orm.
SupA:~me thoracic 'Thoracodorsal
a. andv. n.,a., andv.
Intercostobrachial n. Long
lhorecoeplgastrlc v. 1tloreelc n.
Fig. 4-22 The axillary fascia is opened. and the pectoralis major IllUSCle is retracted to
visualize 1he vessels and b.nu:hial plexus at the apex of1he axilla.
Fig. 4-23 Division of the subclavius muscle insertion allows elevation of 1he clavicle for
improved visibility.
1]8 I VESSELSOFTHECHEST
The anterior and middle scalene muscles hemostat can be used to retract the anterior sca-
are next separated from their attachments to the lene away from its surrounding vessels, and its
first rib. During division of the anterior scalene division is best performed a few fibers at a time.
muscle, care should be taken to avoid injuring the The phrenic nerve passes medial to the muscle
subclavian artery that passes posterior and deep to insertion. The middle scalene muscle is easily
the muscle at this level (Fig. 4-24). A right-angled pushed offthe first rib with a blunt-tipped elevator
Long 1ttoraclc n.
Anterior
scalene m.
Fig. 4-24 When the anterior scalene insertion is isolated and divided, care must be taken
not to injure the phrenic nerve.
Fig. 4-25 Division of the middle S<:alene muscle insertion and separation of loose
attachments between the first rib and the vessels completes the cephalad mobilization. The
long thoracic nerve is again protected.
140 I VESSELSOFTHECHEST
Fig. 4-26 After separation of the remaining
muscular and fascial attachments to the cau-
dad and deep rib surfaces, the rib is divided
posteriorly.
Fig. 4-28 The subclavian vein can be compressed within the costoclavicular sp8'!e by
bony or ligamentous abnormalities.
142 I VESSELSOFTBECHEST
rib may be indicated; the infraclavicular approach subclavian vein, preserves shoulder function, and is
affords direct exposure of this segment.* This ap- cosmetically superior to claviculectomy.
proach may also be required for visualization of the The patient is placed supine with the arms
proximal subclavian vein to allow complete venoly- drawn inward. A transverse skin incision is made
sis, as recommended by Thompson et al.37 Medial 2 em below the clavicle, extending approximately
claviculectomy is another option that provides di- 5 em from the lateral border of the sternum
rect exposure of the subclavian vein, but clavicu- (Fig. 4-29). The incision is deepened through the
lar resection has been associated with bothersome pectoral fascia, and the pectoralis major muscle is
symptoms in up to half of patients.22 The i:n.fracla- split in the direction of its fibers to expose the junc-
vicular approach allows excellent exposure of the tion between the first rib and the stemum..36
Fig. 4-29 The incision for infraclavicular approach to the first rib is made 2 em below the
clavicle.
Costoclalltcular
IIg.
Fig. 4-30 The subclavius muscle is divided and excised. The nearby costoclavicular
ligament should also be divided, since medial fibers may contribute to vein compression.
144 I VESSELSOFTHECHEST
Fig. 4--31 The subclavian vein is freed using circumfereotial dissection.
Fig. 4-32 The anterior end of the first rib is divided under direct vision.
146 I VESSELSOFTHECHEST
Fig. 4-ll Downward traction on the anterior end of first rib helps expose 1he anterior sca-
lene muscle. The phrenic nerve should be identified and carefully protected during m:uscle
division.
Fig. 4-34 The rib is divided at least 1 em behind 1he subclavian artery.
Stellate
ganglion
Subclavian v.
Parietal pleura
150 I VESSELSOFTBECHEST
References 20. Maxwell-Armstrong CA, Noorpuri BSW, Haque SA,
et al. Long-term results of surgical decompression of
1. Pollak EW. Surgical anatomy of the thoracic outlet thoracic outlet compression syndrome. J R Coli Surg
syndrome. Surg Gyneeol Obstet. 1980;150:97-102. Edinb. 2001;46:35-38.
2. Sanders RJ, Hammond SL, Rao NM. Thoracic 21. Gol A, Patrick DW, McNeel DE. Relief of costocla-
outlet syndrome: a review. Neurologist. 2008;14: vicular syndrome by infraclavicular removal of first
365-373. rib: technical note. J Neurosurg. 1968;28:81-84.
3. Mackinnon SE, Novak CB. Thoracic outlet syn- 22. Green RM, Waldman D, Ouriel K, et al. Claviculec-
drome. Curr Prob Surg. 2002;39:1070-1145. tomy for subclavian venous repair: long-term func-
4. Fodor M, Fodor L, Ciuce C. Anomalies of the tho- tional results. J Vase Surg. 2000;32:315-321.
racic outlet in human fetuses: anatomical study. Ann 23. Sanders RJ, Raymer S. The supraclavicular approach
Vase Surg. 2011;25:961-968. to scalenectomy and first rib resection: description of
5. Doyle A, Wolford HY, Davies MG, et al. Manage- technique. J Vase Surg. 1985;2:751-756.
ment of effort thrombosis of the subclavian vein: to- 24. Reilly LM, Stoney RJ. Supraclavicular approach
day's treatment. Ann Vase Surg. 2007;21 :723-729. for thoracic outlet decompression. J Vase Surg.
6. Illig KA. Management of central vein stenosis and 1988;8:329-334.
occlusions: the critical importance of the costocla- 25. Roos DB. Transaxillary first rib resection for tho-
vicular junction. Semin Vase Surg. 2011;24: 113-118. racic outlet syndrome: indications and techniques.
7. McCarthy WJ, Yao JST, Schafer MF, et al. Upper Contemp Surg. 1985;26:55-62.
extremity arterial injury in athletes. J Vase Surg. 26. Roos DB. Transaxillary approach for first rib resec-
1989;9:317-327. tion to relieve thoracic outlet syndrome. Ann Surg.
8. Magee C, Jones C, Mcintosh S, et al. Upper limb 1966;163:354-358.
deep vein thrombosis due to Langer's axillary arch. 27. Fulford PE, Baguneid MS, Ibrahim MR., et al. Out-
J Vase Surg. 2012;55:234-236. come oftransaxillary rib resection for thoracic outlet
9. Brantigan CO, Roos DB. Etiology of neurogenic tho- syndrome-a 10 year experience. Cardiovasc Surg.
racic outlet syndrome. Hand Clin. 2004;20: 17-22. 2001 ;9:620-624.
10. Sanders RJ, Hammond SL. Etiology and pathology. 28. Leffert RD, Perlmutter GS. Thoracic outlet syn-
Hand Clin. 2004;20(1):23-26. drome: results of 282 transaxillary first rib resec-
11. Roos DB. The place for scalenectomy and first- tions. Clin Orthop. 1999;368:66-79.
rib resection in thoracic outlet syndrome. Surgery. 29. Karamustafaoglu YA, Yoruk Y, Tarladacalisir T, et
1982;92:1077-1085. al. Transaxillary approach for thoracic outlet syn-
12. Juvonen T, Satta J, Laitala P, et al. Anomalies at the drome: results of surgery. Thorae Cardiovasc Surg.
thoracic outlet are frequent in the general population. 2011 ;59:349-352.
AmJ Surg. 1995;170:33-37. 30. Illig KA. An improved method of exposure for transax-
13. Brooke BS, Freischlag JA. Contemporary manage- illary first rib resection. JVasc Surg. 201 0;52:248-249.
ment of thoracic outlet syndrome. Curr Opin Card. 31. Dale WA. Thoracic outlet compression syndrome:
2010;25:535-540. critique in 1982. Arch Surg. 1982;117:1437-1445.
14. Sanders RJ, Hammond SL, Rao NM. Diagno- 32. Lokanathan R, Salvian AJ, Chen JC, et al. Outcome
sis of thoracic outlet syndrome. J Vase Surg. after thrombolysis and selective thoracic outlet de-
2007;46:601-604. compression for primary axillary vein thrombosis.
15. Adson AW. Surgical treatment for symptoms pro- J Vase Surg. 2001 ;33:783-788.
duced by cervical ribs and the scalenus anticus mus- 33. AngleN, Gelabert HA, Farooq MM, et al. Safety and
cle. Surg Gynecol Obstet. 1947;85:687-700. efficacy of early surgical decompression of the tho-
16. Rocbkind S, Shemesh M, PatishH, et al. Thoracic out- racic outlet for Paget-Schroetter syndrome. Ann Vase
let syndrome: a multidisciplinary problem with a per- Surg. 2001;15:37-42.
spective for microsurgical management without rib 34. Caparrelli DJ, Freischlag J. A unified approach to ax-
resection. Acta Neurochir Suppl. 2007; 100: 145-147. illosubclavian venous thrombosis in a single hospital
17. Clagett OT. Research and prosearch. J Thorac Car- admission. Semin Vase Surg. 2005;18:153-157.
diovase Surg. 1962;44:153-166. 35. Illig KA, Doyle AJ. A comprehensive review
18. McCarthy MJ, Varty KV, London NJM, et al. Experi- of Paget-Schroetter syndrome. J Vase Surg
ence of supraclavicular exploration and decompres- 2010;51:1538-1547.
sion for treatment of thoracic outlet syndrome. Ann 36. Molina JE. Anew surgical approach to the innominate
Vase Surg. 1999;13:268-274. and subclavian vein. J Vase Surg. 1998;27:576-581.
19. Axelrod DA, Proctor MC, Geisser ME, et al. Out- 37. Thompson RW, Schneider PA, Nelken NA,
comes after surgery for thoracic outlet syndrome. et al. Circumferential venolysis and paracla-
JVasc Surg. 2001;33:1220-1225. vicular thoracic outlet decompression for "effort
Coracoid
process
Clavicle
Humeral
head --~f---.
155
its origin on the medial border of the deep scapu-
lar surface. The coracoid process arches over the
The axillary artery is anatomically defined by the axillazy neurovascular bundle and gives origin to
lateral margin of the first rib proximally and the lat- muscles that lie anterior to the vessels. One of these,
eral edge of the teres major muscle distally. Along the pectoralis minor muscle, is used as a landmark
this span, the artery lies within a cleft formed by to divide the axillary artery into three parts which
muscles originating on the scapula (Fig. S-2). The are medial to, behind, and lateral to the muscle.
broad subscapularis, converging toward the head of The coracobrachialis, a small muscle analogous to
the humerus, forms the majority ofthe posterior bed the adductors of the thigh, and the short head of the
on which the vessel lies. The lowest segment of the biceps brachii also originate from the tip ofthe cora-
artery crosses the teres major and latissimus dorsi coid process. The neurovascular bundle parallels the
insertions. course of these muscles. The pectoralis major adds
The medial wall of the cleft consists of the ser- the final anterior blanket of muscle over the axillary
ratus anterior, wrapping around the upper nos from space.
Trapeztidlig.
Coracoacramial lig.
""7~. -1
Costa-
- - clavicular
lig.
Bleeps brachll m.
(short head) _ ........---=~----=~
Coraco-
bractielis m.........-=~---~=-
Biceps ---+-
(long head)
1'8c1Dralls
major m.
lnser11on
Latissimus dol'lll m.
Subscapularis m. mimrm.
Fig. 5-2 The axillary amtents are enclosed by pectoral girdle muscles.
l.atll rallhoracic .
Thoracoecromial a.
Medial
humeral
circumflex a .
humeral
circumflex a.
Clrcumftex ac::apular a.
I...Bteral pec:IDral n.
Deep
bractlial a.
Tl'lor'acodlnal n.
Fig. 5-4 The brachial plexus nerves surround the axi11ary artery within the axillary sheath.
Cephalicv.
Pectoralis
mlnorm.
lntermusct~lar
septum
Fig. 55 The clavipectoral fascia is the outer en:velope ofthe axillary conteuts.
Fig. 5-6 The three parts of the axillary artery are marked by the borders of the pectoralis
minor muscle.
Fig. 5-7 The arm is abducte<l90 for the infraclavicular approach to the ax.il.lary artery.
Cephallcv.
a. Coracoici
process
Brachial a.
Fig. S-1 The pectoralis fibers over the first portion ofthe axillary artery are separated.
Lateral pectoral n.
Cephalicv.
Cfalllpectoral fascia
Fig. 5_, Clavipectoral fascia is opened to expose the axillary sheath. Pectoral nerves and
vessels as well as cephalic vein are seen in the operative field.
Axillary a.
Fig. 5-10 The axillacy vein is gently retracted to dearly expose the axillary artery.
Fig. 5-U The graft should be routed parallel to 1he axillary artery for a short distance
before it is directed inferiorly to reath the (;hest wall.
Axillary &heath
Bleeps brachll m.
Long Short Pectoralis
head head
Coracobrachialis m.
Fig. 5-14 The deep fascia at the lateral border of the pectoralis major muscle is opened,
and the muscle is retracted medially.
Medlann.
Rg. 515 The axillary sheath is opened, and the median nerve is carefully mobilized away
from its position in front ofthe artery.
lhoraooacromial a.
I I
I \ ' \
r , ,
((' 1
~~~!;1. :: 1\1. ,
'. .. . ..
I
Ceph8Jicv.
Pectoralis
majorm.
Insertion
AXILLARYARTERY 1 171
visible. The third part of the axillary artezy is ex- axillary sheath. The third part of the axillary artery
posed by incising the clavipectOial fascia along the can be exposed by widely mobilizing the median
inferior border ofthe coracobrachialis muscle in the nerve and retracting it cephalad. It is important not
distal wound up to the coracoid process (Fig. 5-20). to mobilize more than a few centimeters of the cord
The neurovascular bundle is located in the areolar junction to avoid undue nerve tension. The artery
tissue beneath the clavipectoral fascia. The junction can be encircled with vascular tapes after careful
of the medial and lateral cords funning the median isolation from the ulnar nerve and axillary vein near
nerve is the most superficial structure within the its medial border (Fig. 5-21).
~,___ _ _ _ Pectoralis
majorm.
Mediann.
Fig. 5-20 To expose 1he third part of the axillary artery, the clavipectoral fascia is opened
lateral to the pectoralis minor.
Meclan n.
Pbsterior
oord
Fig. 5-21 The medial cord of the b.rathial plexus is reflected lllterally, and the artery is
mobilized.
Pectoralis
minor Insertion
(cut)
Fig. 5-22 The second part of the artery is exposed by dividing the pe<:toralis minor
insertion.
Clavipectoral
fascia
I
Medial
pectoral n.
Rg. S-2S The first part of the axillary artery is approached medial to the pectoralis minor.
Posterior
Meclal
Bleeps bracbll m.
Long head---+~-
Pectoralis major m.
Insertion-----+
Extensor compartment
Bicepsm. + - - - - - - - - - - M e d i a l epicondyle
insertion ~~~
.'i::F-='--------------------- Ulnar n.
Fig. 6-1 The deep fascia and supracondylar septa of the arm contain the flexor muscles
anteriorly and the triceps complex posteriorly. The brachial artery and mediiiD nerve
are enshea1hed in the anterior compa:rtmeut, while the radial and ulnar nerves switch
compartments through the intermuscular septa in the distal arm.
177
sends a major nutrient vessel to the middle of the
humeral shaft.
Each major neiVe of the arm is accompanied by The brachial artery is usually accompanied
an artery. As noted above, the brachial artery runs by two veins. The basilic vein runs in a subcuta-
with the median neiVe through the medial side of neous position from the antecubital fossa to the
the anterior compartment (Fig. 6-2). Proximally, medial aspect of the midbrachium where it pen-
the profunda branch of the brachial artery joins the etrates the deep fascia to join one of the brachial
radial DeiVe and follows it through the lateral in- veins. The brachial veins make numerous deep
termuscular septum, at which point it is called the and superficial anastomoses before uniting at the
radial collateral artery. The superior ulnar collateral level of the teres major to form the axillary vein.
artery arises from the midpoint of the brachial ar- The cephalic vein is superficial along its entire
tery and accompanies the ulnar nerve through the course to the deltopectoral groove. The vein ac-
medial intermuscular septum. A second ulnar col- companying the deep brachial artery empties
lateral branch penetrates the septum more distally. into the transition between brachial veins and the
In addition to muscular branches, the brachial artery axillary vein.
Supreme
A ...-----:.r-- thoracic a.
Anterior humeral
circumflex a. ---~~__.~7/P
Pos1llrlor humeral - - -+"iil'- :!VI'/'.
cl n::umil a. and
axillary n.
LAr!Bral
intermuacular--~
septum
Medial intBrmuscular
rl-+-- - - - - - - - - - s e p t u m
Racial
rc~;-~-----------ulnar n.
- =-.:,......---------- --ulnar recurrent a.
Fig. 6-2 The branches of 1b.e bracllial artery accompany the nerve trunb and make
collatenl connectiODJ around the shoulder and elbow.
Fig. 6-l The coracobracbi.ali.s and bracbialis muscles, the deep ID.UJCles of the brac:bium.,
are supplied by the lllU8CUlocutaneoua nerve, which penetrates the fmmer and then nms
between the bncbialis and bi(:eps.
BRACHIALARTERY 1 179
The biceps brachii muscle covers the length strong tendon inserting on the bicipital tuberos-
of the humerus anteriorly (Fig. 6-4). Proximally, ity of the radius. From the distal muscle, a broad
the heads of the biceps are restrained by the ten- secondary tendinous expansion runs medially to
don of the pectoralis major muscle crossing to attach to the deep fascia of the forearm flexors.
insert into the lateral lip of the bicipital groove This band bridges over the brachial artery and
of the humerus. Distally, the biceps tapers to a median nerve.
Pectoralis major
m. insertion ---'""=""'~'"
Biceps
brachii m.---,~
11=1~---Triceps m..
Fig. 6-4 The biceps 'b.nu:bii crosses both the shoulder and elbow joints and is bordered
medially by the 'b.nu:hial artery and median nerve.
Fig. 6-5 The lateral and medial (or deep) heads of the triceps muscle originate from the
homerus, leaving a spiral deft between them which BCcommodates the deep brachial artery
and radial nerve.
BRACHIALARTERY 1 181
head of the triceps accompanied by the superior
and inferior ulnar collateral branches of the bmchial
arteiy. When the arm is abducted and extended, the neu-
The three heads of the triceps muscle merge rovascular bundle is visible as a cord-like struc-
over the distal humerus and imert on the olec- ture between the flexor and extensor compartments
ranon of the ulna by a broad, strong tendon (Fig. 6-7). Note the mass ofmuscles forming a hood
(Fig. 6-6). over the proximal humerus.
Brachloradlalla m.
Tricepsm.,
medial (deep)
head
Coracobrachialis m.
Neurovascular
/
bundle
Bleeps
brachllm.
ma)orm.
Fig. 6-7 The coracobrachialis muscle and adjacent neurovascular bundle form a cord-like
ridge between biceps and triceps. The cephalic vein marks the deltopectoral groove.
BRACHIALARTERY I 183
Laterally, the course of the radial nerve is course of the radial nerve and deep brachial arte:ry.
covered by the lateral head of the triceps (Fig. 6-8). The distal insertion of the deltoid and the proximal
The lateral intermuscular septum is evidenced by a origin of the brachioradialis divide the humeral
ridge running proximally from the lateral epicon- shaft into thirds. The penetration of the radial nerve
dyle. The depression between the deltoid and the through the lateral intermuscular septum occurs just
long head of triceps marks the beginning of the distal to the start of the brachioradialis.
/.~
--~~1----
Triceps m.,
long head
Triceps m.,
lateral head
/
Lateral
intermuscular
=""
septum
Fig. 6-& The dimple between the deltoid and long head of1he triceps marks the IO<:ati.on of
the deep brachial artery and radial nerve proximally.
BRACHIALARTERY I 185
The neurovascular bundle is exposed by incis- retracting the vein into the posterior wound, the
ing the deep fascia at the medial border ofthe biceps brachial sheath is opened. The median nerve is the
muscle, which is ret:racU:d anteriorly (Fig. 6-10). most superficial structure encountered upon enter-
The basilic vein should be identified cours- ing the brachial sheath. The nerve should be widely
ing medial to the brachial sheath. After carefully mobilized and gently retracted into the anterior
Rg. 6-10 The deep fascia at the medial border of the biceps muscle is incised, exposing
the neurovascular bundle enclosed in its fascial shea1h. The basilic vein penetrating the
deep fascia is preserved.
Fig. 6-11 The vessels and nerves are exposed, the median nerve is retracted gently, and
vein branches are divided, allowing the artery to be mobilized.
BRACHIALARTERY j 187
References 4. Brahmamdam P, Plummer M, Modrall JG, et al.
Hand ischemia associated with elbow trauma in chil-
1. Franz RW, Goodwin RB, Hartman JF, et al. Manage- dren. J Vase Surg. 2011;54:773-778.
ment of upper extremity arterial injuries at an urban 5. Korompilias AV, Lykissas MG, Mitsionis GI, et al.
level I trauma center. Ann Vase Surg. 2009;23:8-16. Trea1ment of pink pulseless hand following supra-
2. Stone WM, Fowl RJ, Money SR. Upper extremity condylar fracture of the humerus in children. Int
trauma: current trends in management. J Cardiovase Orthop. 2009;33:237-241.
Surg. 2007;48:551-555. 6. Bergman RA, Thompson SA, Afifi AK. Catalogue of
3. Topel I, Pfister K, Moser A, et al. Clinical outcome Human Variation. Baltimore, MD: Urban & Schwar-
and quality of life after upper extremity arterial zenberg; 1984: 108-114.
trauma. Ann Vase Surg. 2009;23:317-323.
,.,
SUpBfidal Veins andNIIIW5 veins draining the medial forearm and penetrates
the deep fascia on the medial side of the brachium.
The superficial veins of the distal forearm are The basilic vein is separated from the underlying
highly variable, but as they converge toward the brachial artery and median nerve by the biceps ten-
antecubital space they assume a more predictable don in the antecubital fossa and by the deep fascia
pattern (Fig. 7-1). The most constant vein in the in the distal brachium.
distal forearm is the cephalic, which starts along Two superficial nerves run the length of the
the lateral prominence of the radius. Before con- volar forearm and provide cutaneous sensation
tinuing up the ann along the lateral side of the for two-thirds of its cin:umference. The medial
biceps, it divides in front of the biceps tendon. antebrachial cutaneous nerve originates from the
There it sends a major tributary, the median cubi- medial cord of the brachial plexus and accompa-
tal vein, diagonally across the biceps tendon to join nies the brachial artery to the midbrachium. There
the basilic vein. The basilic vein is formed from the it exits the deep fascia through the same opening
Median cubital v.
La!eral antebractllal
cutaneous n.
Medial antebrachial
cutaneou n.
Fig. 7-1 The superficial veins and nerves of the volar forearm are depicted. The axially
oriented medial and lateral antebrachial cutaneous nerves provide sensation for two-thirds
of the foreBI'ID cin:um.ference.
Lateral
antebrachial
cutaneous n.
Fig. 7-2 The posterior antebrachial cutaneous branch of the radial nerve supplies the
remaining extensor surface of the foreann.
Flexor digitorum
superficialis---~"----*-::!-"~!!::!1!!!~
SUplnator----:1-----~
Biceps brachii _,
---+---1"::~..-
- - - - - : : ' - - - - Pronator 'lervs
(ulnar head)
Flexor dlglto.rum
superficialis ---+----:=~""'I
(radial origin)
Flexor
Pronator 1Brvs
--~-~-------d~ftorum
(ii1S8rtion) ---!--~'
profundus
Flexor p::al:::liet=:..._~-/;:.:::::;t;:.~~IM\1
longus
Pronator quadratus
.Qiigioa
Common Supinator
flexor
tendon
Racial
Ulnar~
\ , ,/' /
Blc:eps
brachll 18ndon
~~~:....,__ _ _ _ _ _ Flexor
digitorum
profundus m.
'!!!!!!!!!'~'--- Pronator
quadrstus m.
Flexor
cllgHorum
superficialIs
m.
Brachloradlalls-~
m.
Extensor
carpi
radialis
longus m. - "*'""""""::::0:::::::::1
Fig. 7-5 The superficial forearm flexors fan out from a common tendon of origin at the
medial epicondyle of the humerus.
~ii:~~~~~- Supina1Dr m.
Exteneor Indicia m.
Fig. 7-' The extensor muscle complex alliO consists of superficial and deep layers.
Posterior branch,
profunda brachll a.
Superior
ulnar
Radial collateral br. V"~+-- collatBral .
of profunda brachll a. ---+-~~
Superficial br.
radial n. --~r----!1
recurrent a.
Common
lnterosaeous a.
DoiHI iniBrosseous a.
Musculocutaneous n.
Brad'liOradiaJiS
Pronator
1 ~!1-:"----Common
llaxor
origin
Pronator teres
(ulnar head)
Ulnar recurrent a.
FI6XDr dlgltorum
superficiaJiS m.
f~~
Fig. 7-8 The iDterdigitation of nerves, vessels,
and muscles in the cubital fossa is shown.
Flexor
digitorum
superficialis
Ulnar a. and n.
Fig. 7-10 The radial and ulnar: arteries be(;ome superficial between the tendons ofthe wrist.
Bicipital
aponeurosis
Fig. 7-12 The basilic vein and medial antebrachial cutaneous nerve are retracted, expos-
ing the deep fuscia and bicipital aponeurosis over 1he brachial artery and median nerve. An
S-shaped incision has been depicted for clarity.
Blclpl!al
Brachial a. Meclan n.
Fig. 7-11 The fascia is opened, revealing 1he artery and nerve medial to the biceps tendon.
The artery is accompanied by two veins 1bat inten:ommunicate.
Fig. 7-14 The bifim:ation of1he brachial artery can be exposed by retracting the pronliWr
teres and flexor muscle mass. The radial artery can be followed the length of the incision.
but 1he larger ulnar artery dives between the heads of the FDS.
Brachloradlall&
Fig. 7-15 The radial artery in the midforeaml can be easily exposed beneath the
brachi.oradialis.
Fig. 7-16 The incision for exposing the radial artery is shown. A more lateral incision also
gives access to the cephalic vein for creation of arteriovenous fistulu.
~
~I
.....___
--.I
----I
~I;
Fig. 7-17 The radial artery at the wrist lies just deep to the deep fascia between the flexor
carpi radialis tendon and the insertion ofthe brachioradialis.
Flexo r carpi
ulnaris m.
Fig. 7-18 The ulnar arte.ry in the midforeiiilD. is reached between the FCU md FDS.
Fig. 7-19 The incision over the ulnar artery at the wrist is shown.
Palmaris longus
Rexor
digitorum
profundus
Extensor
carpi radialis
brevis
DORSAL
Superficial
volar
Radial neurovascular c:<~mpartment
bundle
Lateral
Do1'881 compartment
Fig. 7-21 The three main compartments of the right forearm are shown at midforearm.level.
I
I
I
I
I
1\
I '
I '
I?
The anatomy of the hand is complex, and the ramifi- The superficial innervation of the hand is relevant
cation of the blood vessels within the tightly packed to the vascular surgeon in choosing an approach to
musculoskeletal structures is difficult to visualize. the underlying vessels. Sensation is more critical to
The following discussion presents hand anatomy the function ofthe hand than to any other area ofthe
as a framework for understanding the paths of the body. All three major nerves ofthe arm provide sen-
blood vessels. sation to areas of the hand, and the nerve branches
in adjacent territories interconnect.
217
On the volar surface of the hand (Fig. 8-1), two branching from the main trunks of the median and
major areas are supplied by the median and ulnar ulnar nerves beneath the palmar fascia. The super-
nerves. The division lies along the middle of the ficial palmaris brevis muscle at the base of the hy-
ring finger. A palmar cutaneous branch arises from pothenar eminence is innervated by the ulnar nerve.
the median nerve in the midforearm. This branch The radial side of the thenar eminence and dorsal
penetrates the deep fascia at the wrist and supplies thumb is served by the lateral branch of the superfi-
the skin over the thenar eminence. The remainder cial radial nerve.
of the palm and the volar surface of the fingers are The dorsum of the hand is supplied by the ul-
innervated by the common and proper digital nerves nar and radial nerves. The dorsal branch ofthe ulnar
Fig. 8-1 The distribution of cutaneous nerves to 1he hand is shown. A: volar; B: dorsal
SUperficial branch
of radial n. ------=-~.J
Lateral antBbrachial
cutaneous n. - - - - - ------=----===-- cutaneous
Posterior antebrachial
n.
Hg.8-1 (continued)
HAND VESSELS I 219
BDneJ llftM Ht11Jd tunnel for the flexor tendons is closed by a dense
transverse ligament extending from the trapezium
The key to understanding the bony ftamework of and scaphoid tubercle radially to the pisiform bone
the hand is the carpal arch (Fig. 8-2). The deep vo- and hook of the hamate bone on the ulnar end of
lar concavity of the carpal bones forms the channel the arch. Note that the pisiform bone and hook of
through which the major tendons pass from fore- the hamate bone are not aligned axially relative
arm to hand and establishes the foundation for op- to the ulna but angle toward the base of the third
position between the thumb and little finger. The metacarpal.
Transverse
carpal----~~~~
lig.
Ha~-----~~~~~
Fig. 8-2 The catpal bones form a deep arch that cradles the long flexor 1endons. A: volar;
B: proximal view.
B Scaphoid
Fibrous digital
flexor sheath
Superficial
transverse
metacarpal I!g. I
I
Palmaris longus
tendon (reflected)
Palmaris
brevis m. -....1,-1!!=
Superficial
....,:...........~~~--- radial a.
Flexor carpi
~~~~------~~radial~te~
Mediann.
Fig. 8-S The volar cw:palligament is a thickening of the deep fils cia and is superficial to
1he 1ransverse carpal ligament, which closes the CaJ:Pal arch.
Deep
ttansvera&
metacarpalllg.
lnterdigital
Flexor
pollids
-t--:~~1-- longus
ten clan
Hypo1henar - --+
fascia
Ulnar
bursa
'nanswra&
carpalllg.---+--=;....._~
Adductor
,...,.,"""'"!'!,.;.......,~~-pollicis m.
Flexor
pollicis
~~~f--brevis m.
Opponens
2::::::!:::-4---- polllcls m.
OpponensdlgHI-~-~~--=~
mlnlmlm. -~- '-:!:::=--==~-- SUperfldal br.
of radial a.
Flexor carpl--~
ulnarfs
Medlann.
Fig. &-S The iDtrinsic muscles of the band form a cup to contain the ceutral tendons,
nerves, and vessels.
Extensor pollicis
longus ------:f--+-
Flrat dorsal
Extensor polllcls
brevis-----,'----+
Abductor
pollicia
longua-~.....,....1
Fig. U The radial artery tums around the lateral border of the carpal bones and passes
between the first two metacarpals to reach the palm.
Princeps
~~"+-polllds a.
Deep palmar--~~-~-~~
arl:h
Fig. 8-7 The ndial artery gives off two digital branches (shown with a common trunk)
deep to the adductor pollicis muscle.
Deep palmar
arch
Radialis
indicisa.
Transverse
-~---':7=-------t'---- calp8llig.
Abductor pollicis
WI~~-- longus tendon
Flexor dl~rum~~~l-:i-l+
profundus
Flexor carpi---!~
ulnarlsm.
Fig. 8-1 The long digital flexors, lumbrical muscles, and digital nerves lie between the
two palmar arches.
HAND VESSELS 1 n7
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and flexor tendons {Fig. 8-9). The ulnar end of the branch of the radial arteiy. Remember that the arch
arch starts in the cleft between the volar carpal liga- is penetrating both the hypothenar and thenar septa
ment and transveDe carpal ligament, crosses the connecting the palmar fascia to the first and fifth
base of the hypothenar muscles, and turns across metacarpals in its course across the palm. The digi-
the central palmar structures to meet the superficial tal vessels lie superficial to the nerves near the arch
Fig. 8-9 The superficial arch lies just beneath the palmar aponeW'Osis.
Rg. 8-10 There is a rich iDtercommunication among the vessels of the hand.
Extensor
polllels
b~s----~-H~~~~
Dorsal carpal
branch
Fig. 8-12 The fascia is opened to expose 1he radial artery, and the dorsal cw:pal branch is
divided.
HAND VESSELS I D1
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vip.persianss.ir
&posul! aftbe RadialArt!tyIn t11r DlsftllHand pollicis longus muscle and extend approximately
3 em. Superficial veins should be preserved and
The patient is positioned and prepped as previoWJly retmcted in the subcutaneous tissue to expose the
described. A longitudinal incision is made paral- deep fascia. The fascia is incised between the two
lel to the second metacarpal on the dorsal swface heads of the first dorsal interosseous muscle, which
of the first interosseoWJ space (Fig. 8-13). The are carefully separated and retracted to expose the
incision should begin at the level of the extensor radial artery.
Fig. 8-13 The segment of radial artery beyond the extensor poUicis longus tendon is
exposed.
Fig. 8-14 The ulnar artery and nerve beyond the canal of Guyon are exposed benea1h 1he
palmaris brevis muacle and hypothenar fascia.
HAND VESSELS 1 n1
tahir99 - UnitedVRG
vip.persianss.ir
fibers of the palmar aponeurosis, the artery can be Digital branches of the median nerve course be-
traced beyond the fifth digital artery branch, where neath the superficial palmar arch in this area and
it becomes the superficial palmar arch (Fig. 8-15). should be preserved.
Fig. 8-15 The cODtiuuati.on ofthe ulnar artery toward the superficial palmar arch is exposed
by opening through the hypothenar compartment septum into 1he palmar aponeurosis.
Parietal peritoneum
vena cava
Fig. 9-1 The upper abdominal organs are arrayed around the central core of the great
vessels. Note the relationship ofthe anterior renal fascia to the vessels intheretroperitoneum..
In its short span, the abdominal aorta is the center of The aorta occupies a central position in the abdomi-
some of the most complex anatomic relatiOlUihips in nal cavity. In the upper abdomen, the major orgaru~
the body. The unique problems of access to the vari- are arranged in a semicircle arowd the great vessels
ous segments are dealt with separately in the follow- and fill the domes of the diaphmgm beneath the rib
ing chapters. Before focusing on regional details, it cage (Fig. 9-1). The vessels lie within the continua-
iB useful to review the disposition of the abdominal tions of anterior and posterior renal fascia (Gerota's
aorta in the context of the whole abdomen. fascia) across the midline.' The viscera on the left
D7
side can be mobilized in the plane between the pan- central location overlying the first to fourth lumbar
creas and anterior renal fascia. To mobilize the kid- vertebme, the aorta sends branches to the whole
ney along with the other viscera, the anterior renal abdomen.
fascia must be opened. The abdomen consists of bony and muscular
The profile of the midabdomen is flattened walls capped by diaphragms at each end and lined by
and relatively shallow from front to back (Fig. 9-2). transvenalis fascia. Contained within the abdominal
The prominent vertebral bodies of the lumbar spine cavity is the envelope of parietal peritoneum sur-
further impinge on the anterior-posterior diameter. rounding most ofthe abdominal mgans (Fig. 9-3).
Thus, the abdominal aorta, which caps the ridge of The posterior wall of parietal peritoneum is in-
the lumbar spine, lies remarkably close to the an- vaginated in a complex pattern by the roots of the
terior abdominal wall in thin individuals. From its small bowel and the transvene and sigmoid colon
Lumbar
venous plexus
Quadratus
Ureter lumborum m.
Psoasm.
Fig. t-2 The vessels cap the crest of the lumbar spine in the central abdomen.
Splenorenalllg.
Right colon
r8fteation
ll'answl1'9&
Left colon mesocolon
reflecton
Right 1riangular
llg.
Quadratus
lumboNmm.
lllacusm.
Psoum.
Dlaphntgm
Fig. 9-4 The posterior parietal periwneum. is interrupted by numerous invaginations for
colonic and mesenteric attachments.
Suparior
masantaric a.
Right
crus
Fig. 9-7 The origins and neurovascular IJUPPly of the diaphragm are shown.
242 I VESSELSOFTBEABDOMEN
each side. These vessels are transected when the The esophageal hiatus is muscular and consists
costal margin is divided. The internal thoracic ar- primarily of fibers from the right crus. Note the as-
teries penetrate the diaphragm between the sternal cending arrangement of aortic, esophageal, and in-
and costal slips. ferior vena cava openings.
Posteriorly, the diaphragm originates from the The topography of the diaphragm is best
lateral and medial lumbocostal arches spanning the appreciated when viewed from above (Fig. 9-8).
quadratus lumborum. and psoas muscles, respec- The rim of the diaphragm reflects the inverted V
tively. The final components of the origins are the of the costal margin anteriorly, runs transversely
crura, which originate from the anterior surfaces around the posterior flanks, and appears to sprout
and anterior longitudinal ligament of the first three from the roots of the crura. The domes present a
lumbar vertebrae on the right and the first two on bilobed mammillation depressed centrally at the
the left. seat of the heart and indented posteriorly by the
The main blood supply on the undersurface of vertebral column and aorta. In this view, the ap-
the diaphragm consists of paired inferior phrenic ar- plication ofthe crura to several centimeters of ter-
teries that have a variable origin from the aorta or minal thoracic aorta above the aortic hiatus can be
its first major branches. These vessels have anterior appreciated.
and posterior divisions on each side. The veins fol- The inferior vena caval aperture is the most
low the arterial pattern and drain into the vena cava. cephalad and lies at the junction of the middle and
Fig. t-8 The undulating diaphragmatic contours wrap around the aorta and vertebral
bodies.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 243
right lobes of the central tendon, directly beneath divides into anterior and posterior branches on the
the right atrium. The esophageal hiatus lies at an in- undersurface. The left phrenic follows a similar pat-
termediate level between the vena caval orifice and tern at the apex of the heart on the left.
the aortic hiatus, slightly to the left of midline. It is Viewed from behind, the enfolding of the
surrounded by muscular fibers ofthe right diaphrag- aorta by the diaphragmatic crura is evident, as
matic crus. is its anterior-posterior proximity to the lower
The motor innervation to the diaphragm is via esophagus (Fig. 9-9). The surest way to identify
the phrenic nerves, which also cany sensory fibers. the esophageal hiatus on abdominal exploration
Additional sensory fibers from the lower intercostal is to locate the pulsations of the aorta transmitted
nerves serve the periphery. The right phrenic nerve through the esophageal walls. The aortic passage
sends a branch to the cephalad surface of the dia- posterior to the diaphragm lies between the me-
phragm and then penetiates the right leaf ofthe cen- dian arcuate ligament connecting the crura anteri-
tml tendon just lateral to the vena caval orifice. It orly and the body of the T12 vertebra posteriorly.
=~w ~
Right (posterior)
i:--::i:====----lhoraclc duct
~:;!:!!!!~--........-Azygousv.
Fig. H The diaphragmatic aura separate 1he intraabdominal esophagus from the lower
thoru.cic aorta.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 245
simple abdominal incU!ion. 12. 13 Such exposure Ui
most commonly gained by simultaneously enter-
ing the abdominal and left thoracic cavities, the so- The patient is placed in the supine position, and the
called left thoracoabdom.inal approach. The unique chest, abdomen, groin, and thighs are prepped and
characteristics ofvascular disease in this area and the draped. A longitudinal incision is nwle in the ab-
detrimental physiologic effects of thoracoabdomi- dominal midline from the xiphoid process to the um-
nal incisions have been chronicled elsewhere.1+-16 bilicus. The peritoneal cavity is entered through the
The following discussions concern the limited linea alba, and the abdominal viscera is packed into
transabdominal exposure ofthe supraceliac aorta, the the lower half of the abdomen. The left lobe of the
II10ie extensive tebopmtoneal exposure ofthe visceml liver is retracted superiorly and to the patient's right.
aorta, and the complete thomcoabdominal approach to Increased exposure may be gained by dividing the left
the lower thoracic and visceJal aortic segments. Expo- triangular ligament ofthe liver (Fig. 9-11) and folding
sure ofthe infrar:enal aorta is discussed in Chapter 12. the left lobe ofthe liver under a la!ge Deaver retractor.
Left triangular
lig.
Ol.aphragm
Eeophagophrenlc
IIg.
Left lobe
ml~r ----------~~~~
Fig. ,.., When dividing the left triangular ligameot to mobilize the lateral segment of 1he left lobe,
keep in mind the proximity of the hepatic veins and vena cava at the dome of the liver.
Posterior
peritoneum -----rni'i-'rnr~-+-Mn~:H
of lesser
sac
Fig. t-12 Opening the gastrohepatic omentum exposes the right crus ofthe diaphragm.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 247
this vessel runs in the cephalad portion of the gas- posterior peritoneum of the lesser sac. The aorta is
trohepatic ligament {Fig. 9-13). Retraction of the exposed by incising the posterior peritoneum and
esophagus and stomach to the left exposes the separating the two limbs of the right crus to cre-
right crus of the diaphragm, which lies beneath the ate a 5-cm opening over the anterior aortic wall
Fig. 9-11 In 100/o to 1S% of individuals, a replaced or accessory left hepatic artery arises
from the left gastric artery and runs in the cephalad portion of the gastrohepatic ligament.
Thoracic
aorta ----J-+-i'-f--m-1-Hl!~
Fig. 9-14 The lower 1horacic aorta can be exposed between the limbs of the right CIUs.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 249
placed above and parallel to the fingers and pushed and arterial branches that cross this area, but care
posteriorly toward the vertebral column for aortic should be taken to avoid transecting a replaced left
occlusion (Fig. 9-15). hepatic artery (see above).7 Once divide!.\ the muscle
Complete exposure of the supraceliac aorta is tissue is dissected laterally to expose a 5- to 7-cm
performed by vertically incising the median arcuate segment of aorta. The segment above the median
ligament and the right crus over the anterior aorta arcuate ligament is actually the descending thoracic
(Fig. 9-16). The incision is continued superiorly into aorta in the posterior mediastinum. The inferior
the posterior mediastinum until the entire crus has phrenic arteries arise from the aorta at variable levels
been divided. It is often necessary to divide venous in this area and should be identified to prevent injury.
Fig. t-15 Proximal control for operations on 1he supraceliac abdominal aorta is obtained
by clamping the exposed thoracic aorta.
Fig. t-16 Division of1he aortic hiatus through the crura provides wider exposure of the
aorta.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 251
should be positioned so that the midpoint between the
left costal ID.aJgin and the left iliac crest is centered
The patient is placed on a beanbag awa:catus and the over the break in the table, then the table is jackknifed
left chest is rolled upward so that the scapula is el- to widen the space between the costal IIl8Jgin and
evated approximately 90 from the table. The pelvis is pelvic brim17 (Fig. 9-17). After air is evacuated from
twisted posteriorly to lie as flat as possible, and the left the beanbag to make it fum, the left chest and pelvis
arm is placed on an overhanging support. The patient should be f.Urther secured with wide adhesive tape.
Fig. f-17 Patient positioning for retroperitoneal exposure of the visceral aorta. A: The
torso is twilrkd such that the pelvis lies horizontally and the left shoulder is rotated 900
from the operating table. B: The table is jackknifed to widen the space between the costal
margin and pelvic brim.
252 I VESSELSOFTBEABDOMEN
To expose the most proximal portion of the interspace.17 The incision is deepened through sub-
abdominal aorta below the diaphragm, the incision cutaneous tissues, the external abdominal oblique
should begin in the 1Oth interspace, extending from aponeurosis, and the anterior rectus sheath. The ex-
the posterior axillacy line to the abdominal midline ternal abdominal oblique muscle is split in the di-
approximately 1 em below the umbilicus. Lower aor- rection of its fibers, and the internal oblique and the
tic exposw-e can be accomplished through the 11th left rectus muscles are divided using electrocautery
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 253
(Fig. 9-18). Branches ofthe epigastric vessels cours- The retroperitoneal plane is most easily entered
ing posterior to the rectus abdominis should be care- in the latentl wound by stripping the peritoneum
fully ligated. away from the abdominal wall using blunt finger dis-
The transversalis fuscia is incised next, but the section. To enhance exposure, the peritoneum should
medial portion of the incision should stop 2 to 3 em be dissected from the abdominal wall as far superi-
lateral to the midline because the underlying perito- orly and inferiorly as possible. Several small veins
neal surface may be adherent to the posterior rectus will be seen crossing the extraperitoneal space in the
sheath in this area. To fu.cilitate exposure in the lateral lateral wound and should be cauterized during this
wound, we have found it advantageous to remove the maneuver. Dissection of the peritoneum proceeds
11th (or 12th) rib as far posteriorly as possible. The posteriorly, over the psoas muscle. To expose the
rib should be divided cleanly with a rib cutter, taking visceral aorta on its anterolateral surface, the kidney
care to avoid injuring the neurovascular bundle that should be mobilized anteriorly, allowing the ureter
courses just underneath the inferior rib margin. to be swept into the medial wound along with the
Fig. g..1a The incision is begun in 1he lOth iDterspace and cwved inferomedially to 1he
abdominal midline below the umbilicus.
Left AJnal v.
Fig. 9-19 Anterior mobilization of 1he left kidney requires careful ligation of a large
lumbar vein.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 255
left lateral, and posterior surfaces. Proximal expo- accomplished by confining dissection to the ante-
sure to the level of the supraceliac segment is read- rior and posterior surfaces; circumferential control
ily obtained by dividing the diaphragmatic crus risks injwy to the vena cava or other large venous
(Fig. 9-20). Vascular control of the aorta should be structures. 18
Hg. t-20 By incising the crus anterior to 1be supraceliac aorta (A), direct exposure
can be obtained to the level of the lowest thoracic segment (B).
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 257
TlrDIYictHlbdominallndsion for Extensive Exposurr ofthe anesthesiologists routinely advocate cerebrospinal
Aorta, lnduding the Upper Abdominal and LDwerTharadc fluid drainage,1619.w epidural cooling,2122 distal aor-
Partfons tic perfusion,23 or a combination of techniques. Un-
fortunately, none of these adjunctive procedures is
Preoperative planning is extremely important to universally protective against paraplegia.24
minimize the morbidity of this approach. In addition After intubation, the patient is placed in the
to restoration of intravascular volume, all patients supine position on a beanbag apparatus. The left
should undergo optimization of cardiac and pulmo- scapula is elevated approximately 60" away from
nary parameters. A central venous catheter should the operating table so that the trunk is twisted.
be placed to monitor cardiovascular dynamics; de- The left arm is placed on an overhanging support,
pending on the experience of the anesthesiologist, and the beanbag is deflated. The left chest is fur-
monitoring with a pulmonary artery catheter or ther secured with wide adhesive tape (Fig. 9-21).
transesophageal echocardiography may be desirable. This unusual position has two advantages over the
Use of a double-lumen endotracheal tube enhances more traditional lateral thoracic position: it allows
exposure of the thoracic aorta during the procedure access to the femoral arteries should exposure at
by allowing the left lung to collapse while maintain- this level become necessary, and the trunk torsion
ing adequate right lung ventilation. To lessen the tends to widen the incision and lessen retraction
risk of spinal cord ischemia, many surgeons and requirements.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 259
The precise location and extent of the tho- renal arteries. A type ll aneurysm, the most exten-
racoabdominal incision should be dictated by the sive, descends from the left subclavian artery to the
specific area of aorta to be exposed. In most cases, inftarenal aorta. A type Ill aneurysm extends from
this is determined by the extent of aneurysmal dis- the middescending thoracic aorta to below the renal
ease. The most widely used classification of thora- arteries, and a type IV aneurysm extends from the
coabdominal aneurysms was originally proposed diaphragmatic aorta to the iliac bifurcation. In the
by Crawford et al.25 (Fig. 9-22). A Crawford type modified classification proposed by Safi et al.,26 a
I aneurysm begins just distal to the left subclavian type V aneurysm extends from the middescending
a:rteiy and extends to the viscetal aorta above the thoracic aorta to above the renal arteries.
I ~
Fig. 9-23 The optimal level for the thoracic portion of the incision is determined by the
proximal ex:teut ofthe aneurysm.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 261
The length and location ofthe abdominal inci- extended to the abdominal midline to expose thora-
sion are determined by the distal extent of the an- coabdominal aneurysms involving the visceral aorta
emysm. If limited exposure of the abdominal aorta (Fig. 9-24B). Type ll, DI, and IV aneurysms require
below the celiac artery is required (e.g., anemysm more extensive exposure of the infrarenal abdomi-
types I and V), then the upper abdominal aorta can nal aorta; a more formal thoracoabdominal incision
be exposed through a modified thoracoabdomi- should be extended down the abdominal midline
nal incision26 (Fig. 9-24A). The incision should be (Fig. 9-24C).
Rg. 9-24 The abdominal portion of the incision is determined by the distal extent of the
1111eurysm. A: The abdominal incision may terminate in the upper abdomen for anemysms
that do not extend distal to the <:eliac artery. B: The incision should be extended to the
abdominal midline for aneurysms involving the visceral aortic segment. C: An extended
abdominal incision is required for anewysms extending to the infi:arenal aorta.
c
The incision is begun in the appropriate in- the anterior rectus sheath. The external abdominal
terspace, continued across the costal margin, and oblique muscle is split in the direction of its fibers,
extended obliquely to the abdominal midline and the underlying internal oblique and transversus
(Fig. 9-25). More distal exposure can be gained by abdominus muscles are divided between the costal
continuing the abdominal incision in the midline to margin and lateral edge of the rectus sheath. The
the level of the symphysis pubis. The abdominal left rectus muscle is divided, taking care to ligate
incision is deepened through subcutaneous tissue, branches of the epigastric vessels that course poste-
the external abdominal oblique aponeurosis, and rior to the muscle within the rectus sheath.
External
oblique m.
Rectus
abdominus m.
I
~~
'0;)/1/
Fig. 9-25 The layers of abdominal and chest walls are divided.
Fig. t-26 For the extraperitoneal approach to the abdominal aorta, the peritoneum is
sepamted from the undersurf.u:e of the diaphragm. and the chest is entered across the costal
liW'gin.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 265
opening the left thorax and dividing the diaphragm. complications; however, additional exposure of the
The intercostal muscles are divided, and the pleural aorta at the hiatus will be required. Complete divi-
cavity is entered on the superior border ofthe ninth sion proceeds from the divided costal margin to the
(or sixth or seventh) rib. Resection of the lower rib aortic hiatus. Some su:rgeons perform the incision ra-
aids in exposure and reduces pain associated with dially,28 while others29 prefer partial or complete di-
rib fracture from forceful retraction. It is important vision ofthe diaphragm in a circumferential fashion
to locate the intercostal vessels to prevent injury approximately 3 em from the internal costal margin
during rib resection. A rib retractor is used to widen to avoid cutting major branches of the phrenic nerve.
the interspace, and the costal margin separating the The circumferential incision avoids transecting the
thoracic and abdominal wounds is divided. phrenic nerve branches, theoretically leading to ear-
The wound is further widened by incising the lier return of diaphragm function. This advantage
diaphragm, either partially or completely (Fig. 9-27). may prove extremely important because ventilatory
Partial incision through the muscular portion of the failure is one of the most common complications of
diaphragm with preservation of the central tendi- thoracoabdominal incisions. However, advocates of
nous portion has been recommended to minimize the radial incision technique have noted that circum-
respiratory complications.27 Preservation of the dia- ferential division is cumbersome, difficult to close,
phragm has been associated with reduced pulmonary and associated with equivalent results.28
Fig. t-27 The diaphragm can be divided partially (A) or completely using radial (B) or
circumferential (C) incisions.
Fig. 9-28 The anterior renal fascia is opened, and the kidney is mobilized along with the
upper abdominal organs on the left.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 267
sac in the distal wound and ligating the inferior vessels can be exposed through a separate right
mesenteric artery at its origin (Fig. 9-29). Exposure flank incision (see Chapter 12).
of the more distal left iliac artery or any portion If the transperitoneal approach to the retro-
of the right iliac artery is technically difficult us- peritoneal tissue plane is chosen, the peritoneum
ing the extraperitoneal approach; revascularization should be opened for the full length of the abdominal
of these vessels should be performed at the level wound, up to the costal ma:rgin. A relatively avas-
of the femoral arteries. Alternatively, the right iliac cular plane is developed posterior to the left colon
Fig. t-29 Further mobilization in the extraperitoneal plane along the left gutter exposes
the lower abdominal aorta.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 269
deflate and be retracted superomedially (Fig. 9-31). The segment of the aorta immediately proxi-
The parietal pleura is incised directly over the seg- mal to the celiac artery is exposed by dividing the
ment ofthoracic aorta to be exposed, gaining access left crus ofthe diaphnlgm. By extending the incision
to the lateral periadventitial plane. Using blunt dis- from the lateral side of the aortic hiatus through the
section, the aorta is carefully encircled at a level de- left crus to the posterior margin of the circumferen-
sired for proximal control. This is performed most tial incision, the entire thoracoabdominal aorta can
easily between intercostal arterial branches. be exposed.
Inferior
pulmonary
Inferior
pulmonary lig.
Fig. 9-S1 The lower thoracic aorta is exposed by dividing 1he inferior pulmonary ligament
up to the inferior pulmonary vein.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS I 271
Splenic v. ---+-+--fli~..;.;....-*~~M
TranaveJH
,,.~-r..!::)lj;~~~~~~~----::: renal a.
~------~~~- Left renal v.
-+..~-:HI:-..-...~--~------- Duodeoom
-~~--~~~~~------ l meoor
mesenteric a.
~~~~-~~~--~------Aaic
bifurcation
~~-......,~--~---':~----Left common
lilac a.
Fig. 10..1 The origiruJ of the major mesenteric vessels are shown in relation to the adjacent
vertebral bodies.
272 I VESSELSOFTBEABDOMEN
Surgical Anatomy of the Mesenteric Vessels superior mesenteric arteries, arise within centime-
ters of each other at the level of the fust lumbar ver-
Three lmge, tmpaired midline vessels supply the tebra (Fig. 10-1). The third, the inferior mesenteric
majority of OigaDS enclosed by the outer envelope artery, arises from the anterior wall of the aorta at
of parietal peritoneum. Two of these, the celiac and the level ofthe third lumbar vertebra.
273
Crllac Trunk the celiac trunk. Inside the omental bursa lies a final
covering membrane, the posterior parietal perito-
The celiac trunk is closely flanked by the median neum. Beneath the peritoneum, the celiac trunk is
arcuate ligament of the aortic hiatus above and the surrounded by lymphatic and nerve plexuses.
superior border of the pancreas below (Fig. 10-2). The celiac trunk is almost perpendicular to the
Vtewed from an anterior perspective, the celiac aorta. The three branches of the celiac trunk most of-
trunk lies beneath the overlapping edges ofthe liver ten form a trifurcation (see variations, Chapter 19).
and stomach. On separating these two organs, the One significant vein, the left gastric (or coronary)
connecting gastrohepatic ligament, which forms the vein, crosses over the celiac trunk in its coume from
anterior wall ofthe omental b'lma, is seen overlying the lesser cmve of the stomach to the portal vein.
=--~-~~:------ Celac1Nnk
Splenic a.
-4~------ Superior
meantertc a.
-----:-----=---Lef t renal v.
RVrt gastric .
Fig. 10-:Z The gastrohepatic omentum and posterior peritoneum of the omental bursa have
been removed to e:llpose the celiac trunk.
274 I VESSELSOFTBEABDOMEN
The hepatic artery passes to the right beneath of the spleen, it gives off short gastric branches and
the posterior peritoneum ofthe omental bursa, entenJ the left gastroepiploic artery that run in the gastro-
the hepatoduodenalligament just cephalad to the py- splenic ligament and the gastrocolic ligament, re-
lorus, and ascends to the hilum of the liver on the left spectively (Fig. 10..3).
side ofthe common bile duct The terminal branching The left gastric artery ascends a short distance
of the hepatic artezy is highly variable, and alternate beneath the peritoneum to reach the lesser curve of
origins ofhepatic artery lmmches are not uncommon. the stomach at the gastroesophageal junction. It is
The splenic artery descends beneath the peri- accompanied by the left gastric {coronary) vein and
toneum to undulate along the cephalad border of the celiac branch ofthe posterior vagus nerve. When
the pancreas where it gives off a significant dorsal the esophagus is mobilized, the left gastric artery
pancreatic branch and a few smaller branches. After limits the surgeon from sliding a finger further down
dividing into four to five branches near the hilum the posterior wall ofthe stomach.
Fig. 10..3 Anastomoses of celiac branches around 1he stomach are shown.
Gastroduodenal a.
Anterior
superior '\
panci1Nl1!oo-
duodenal a.
~~~-~--~::;-----':""""Superior
Anterior mesentertc a.
inferior
panci1Nl1!oo-
duodenala.
~::-a:--l-1-i~-~:::--=-=------+- Superior
mesentertc v.
Fig. 1CJ..4 The superior me8enteri(: artery and vein lie together over the third portion oftbe
duodenum and uncinate process of the pancreas.
276 I VESSELSOFTBEABDOMEN
this mesentezy to the right for exposure of the aorta 5 em of its origin, the artery first gives off a left
(Fig. 10-5). colic branch and then several sigmoidal branches
into the mobile sigmoid mesentery and finally ter-
lnfetlorMesenteticArtery minates as the superior rectal branch. The latter
crosses over the left iliac vessels to reach the pos-
The inferior mesenteric artery emerges near the terior wall ofthe upper rectum (Fig. 10-1). In some
lower border of the third portion of the duodenum cases of superior mesenteric occlusive disease,
where the latter crosses the aorta (Fig. 10-1). It is mesenteric channels between the left colic and mid-
closely applied to the aorta as it passes to the left dle colic arteries hypertrophy to form a meandering
into the fused mesentery of the left colon. Within mesenteric artery (described by Riolan, see below),
Esophagus
Hepatoduodenal---=------===-~
lig.
Root of
tmn~~---~----~~~~~~~~
mesocolon
Root of
small
bowel
mesentery---+---~-;..-----~,.~
.......-:== ==""'...................._.? .................;:?~ Inferior
mesenteric a.
Fig. 10..5 The superior meseuteric artery can be located where the roots ofthe transverse
mesocolon and small bowel mesentery meet.
Pancrea11oodLIOdanal
arcade
~---1-4~::i!:""-=-4--Meandenng
m&Sentertc a.
(arc of Riolan)
Cellae branch of
~~~~~~~~~--..-~~posterior vagus n.
Median arcuate
llg. ------+-H+~If-h1\WI
~~~~~~..~-:+~~- I.Gftgastrica.
Cellae
ganglion
Left gastric
(coronary) v.
dMcied
Hepa1lca.
Splenicv.
Pancreas
Fig. 1O.t The posterior parietal peritoneum and median arcuate ligament are opened to
gain access to the celiac trunk.
Lymph node
Flg.10.10 The celiac ganglion must be cleared to fully expose the celiac tru11k.
Fig. 10.11 The superior meseoteric artery origin can be exposed by retracting the superior
border of the pancreas (:audally.
214 I VESSELSOFTBEABDOMEN
tahir99 - UnitedVRG
vip.persianss.ir
The segment of superior mesenteric artery
between the middle and right colic artery bnmches
is readily isolated from surrounding lymphatics and
autonomic nerve fibers. It is important to preserve
any jejunal branches seen before proceeding
with the embolectomy {Fig. 10-13). Extreme care
should be taken not to injure the fragile superior
mesenteric artery or its branches during isolation.
Exposure of more proximal segments is possible
by judicious cephalad ret:racti.on of the inferior
pancreatic border.
Fig. 10..14 For bypassing a chronic superior meseuteric artery stenosis, the fourth portion
of the duodenum is mobilized to expose both the subpancreatic portion of the mesenteric
w:tery and subjacent aorta.
Flg.lG-15 A short, wide synthetic graft from the aorta to the superior meseuteric artery
creates a retrograde bypass.
Left IVrBI v.
Fig. lG-18 The inferior mesenteri<: artery is exposed by in<:ising the posterior peritoneum
below the mobilized duodenum, staying to the right of midline.
Fig. 10..19 The hepatic artery is approached 1hrough a right subcostal incision.
290 I VESSELSOFTBEABDOMEN
tahir99 - UnitedVRG
vip.persianss.ir
The area of the hepatoduodenal ligament is left side of the common duct. The artery should be
exposed by retracting the right lobe of the liver su- carefully mobilized and encircled with elastic ves-
periorly and packing the intestines and right colon sel loops on both sides ofthe gastroduodenal artery.
into the inferior wound with moist laparotomy Bypasses may be anastomosed to the side of the
packs (Fig. 10-20). The hepatoduodenal ligament hepatic artery either proximal or distal to the gastro-
is incised transversely near the superior wall of the duodenal artery,rT or the gastroduodenal artery can
duodenum, and the hepatic artery is located on the be sacrificed and used as a direct source of inflow.2!)
Right gastric a.
Fig. 10..20 The hepatic artery is exposed by incising 1he gutroduodenal ligament above
the pylonJS.
~ ~ '-----
..__\\~ ~
\ \ \ \ \' "'"'"'
,\
Ill'-'
\.'-"
-~,cd
it is ~~i:~spleen and left colon.
for splenorenal bypass, the splemc
' artery 1.S - " T -
~toneally mo
F.... lG-21 Whenby
295
column and the kidneys rest in the adjacent gutters, Ftudae
the angle formed by the renal vessels with the aorta
is almost 90 (Fig. 11-2). The position of the aorta The kidneys are embedded in a layer of flt.t and en-
to the left of midline makes the right renal artery closed by fascial layers in front and back. These an-
longer than the left. terior and posterior renal fasciae fuse laterally with
lnfedor
panctea.ticoduodenal a. and v.
Right renal v.
Fig. 11-2 The renal arteries drape posteriorly over 1he spinal column. The right renal
arteiy often divides behind the inferior vena cava.
Flg.11-3 The kidneys and perinephric fat are enclosed by an envelope ofrenal fascia that
tapers around the adrenals above and the lU'eten below.
RENALAIUERIES I 297
the fascia over the right kidney is covered by the of the anterior renal fascia not in contact with the
second portion of the duodenum and the hepatic peritoneum is covered by the tail ofthe pancreas, the
flexure of the colon {Fig. 11-4). On the left, the part spleen, and the splenic flexme of the colon.
Fig. 11-4 The relationships of1he renal arteries and kidneys to overlying orgllllS are shown.
Fig. 11-5 The brm(:hes ofthe renal arteries md veins are shown.
RENAL.AIUERIES I 2t9
Exposure of the Renal Arteries After routine exploration of the peritoneal cav-
ity, the transverse colon and omentum are packed
Surgical exposure of the renal arteries may be nec- in moist laparotomy pads and lifted onto the ante-
essary to treat traumatic injuries, aneurysms, or rior abdominal wall at the superior end of the inci-
chronic stenoses. A common indication for isolation sion. The small intestine is eviscerated and packed
of the renal artery in the traumatized patient is to in moist laparotomy pads or placed in a bowel bag
obtain vascular control before exploring a parenchy- and mobilized to the right side of the incision. The
mal injury. Vascular repair of a renal artery injury infrarenal aorta is exposed by incising the ligament
is indicated only for pseudoaneurysms or dissection of Treitz and other duodenal attachments, allowing
with preserved flow. Because most injuries result mobilization of the distal duodenum and proximal
in thrombosis and irreversible ischemia, reported jejunum to the right side. The posterior parietal
outcomes for vascular repair are similar to nephrec- peritoneum overlying the aorta is opened, and inter-
tomy.12 The indications for repair of renal artery vening lymphatics are ligated to prevent the devel-
aneurysms are detailed elsewhere. 34 These lesions opment of lymphoceles or chylous ascites. 1011 When
are often located in the distal arterial branches or the the anterior periadventitial plane is reached, expo-
renal hilum; therefore, advanced techniques such as sure proceeds superior to the level of the left renal
extracorporeal repair should be available when sur- vein (Fig. 11-6). The left renal vein crosses anterior
gery is indicated.5 Chronic renal artery stenoses may to the aorta in approximately 97% of cases,12 and
be due to fibromuscular dysplasia (10%) or athero- its superior border is nearly always superimposed
sclerosis (90%). Percutaneous balloon angioplasty on the origin of the left renal artery. 13 It is impor-
without a stent is considered the treatment of choice tant to recognize several venous anomalies that oc-
for renovascular hypertension due to fibromuscular cur in this area, including circumaortic left renal
dysplasia. 6 Regardless of the type of intervention, veins (up to 8. 7%), retroaortic left renal veins (up to
long-term cure rates are lower for atherosclerotic le- 3.4%), left-sided venae cavae (0.2% to 0.5%), and
sions. The clinical evidence summarizing the effec- double inferior venae cavae (1% to 3%) ( see also
tiveness of angioplasty versus medical therapy for Chapter 19). 12 To expose the left renal vein as far as
treating atherosclerotic renal artery stenosis is pub- the left renal hilum, the posterior peritoneal incision
lished elsewhere. 7 Many surgeons favor open renal can be extended to the left along the inferior border
artery revascularization over angioplasty and stent- of the pancreas (Fig. 11-7). The inferior mesenteric
ing, especially after failed percutaneous therapy.8.9 vein should be ligated during this maneuver.
The following discussions concern exposure of the Mobilization of the left renal vein is neces-
renal arteries using midline and lateral approaches. sary to expose the origins of both renal arteries. The
As sources of inflow, exposure of the aorta and iliac inferior border of the pancreas is retracted crani-
arteries is considered in Chapter 12. Exposure of the ally, allowing exposure and dissection of the supe-
splenic and hepatic arteries for extraanatomic by- rior border of the left renal vein. The vein should
pass is discussed in Chapter 10. be carefully encircled with a vascular tape for re-
traction. The left gonadal and left adrenal branches
Midline Exposure ofthe Renal Arteries at 11Jeir Origins should be ligated and divided to prevent avulsion
during the retraction. A large lumbar vein branch of-
The patient is placed in the supine position with the ten enters the posterior wall ofthe left renal vein and
entire abdomen, lower chest, and both groins prepped requires ligation to prevent injury during renal vein
and draped. The abdomen is entered through a long, retraction. The left renal vein can now be retracted
vertical midline incision made from the xiphoid pro- either superiorly or inferiorly to expose the origins
cess to a point 5 to 7 em below the umbilicus. As an of the left renal artery. In some cases, it may be nec-
alternative approach, some surgeons prefer to use a essary to divide the left renal vein. Many surgeons
transverse supraumbilical incision that extends into have stressed the importance of restoration of vein
both flanks. continuity14 at the completion of the procedure to
RENALAIUERIES I 301
reduce the risk of renal compromise and hematuria, Lateral retraction of the vena cava above or below
but at least one recent series suggests that this may the left renal artery, combined with respective in-
be unnecessary. 15 ferior or superior retraction of the left renal vein,
To isolate the right renal artery at its origin. the exposes the proximal right renal artery at the aortic
medial wall of the vena cava should be mobilized. junction (Fig. 11-8).
Rg. 11-8 The origins of both renal arteries ~an be approached between the left renal vein
and inferior vena cava.
Fig.11-9 A transverse supra.umbilital incision affords good expo~ of the renal artery
on each side.
RENAL.AIUERIES 1 303
medial reflection of the colon with its mesentery. colon, and mesocolon are reflected to the midline
The spleen is mobilized in the superior wound by over the aorta (Fig. 11-1 0).
dividing the splenopbrenic and splenorenal liga- The left renal vein can be located easily as it
ments. A plane between the posterior surface of the crosses anterior to the aorta. The vein is encircled
pancreas and the anterior surface of Gerota's fascia with a vascular tape and mobilized by ligating go-
is developed bluntly, and the spleen, pancreas, left nadal, adrenal, and lumbar branches to permit wide
LeflruiWI v.
Spleen
Fig. 11-10 Mobilization ofthe spleen. tail of the pancreas, and splenic flexure ofthe colon
provides retroperitoneal exposure of the left renal vessels.
RENALAIUERIES I 305
After routine peritoneal exploration is com-
pleted, the small intestines are wrapped in moist
The patient is placed supine, with the right flank laparotomy pads and retracted to the left. Lateml
elevated on a rolled sheet. The lower chest, abdo- peritoneal attachments of the right colon are in-
men, both groins, and anterior thighs are prepped cised from the cecum to the hepatic flexure, and
and draped. As noted above, the incision may be the right colon and mesentery are reflected medi-
midline or transverse. The transverne supraumbili- ally. The duodenum is similarly mobilized by incis-
cal incision is begun at the left midclavicular line ing retroperitoneal attachments to the level of the
and extended to the right posterior axillary line be- hepatoduodenal ligament superiorly (Kocher ma-
tween the costal margin and the superior iliac crest, neuver), permitting extensive medial reflection of
crossing the midline 3 to 5 em above the umbilicus. the duodenum and pancreas to the left (Fig. 11-12).
]06 I VESSELSOFTBEABDOMEN
This maneuver exposes the inferior vena cava. exposed, proximal isolation of the right renal artery
The right renal vein is easily identified and encircled should be carried out to its aortic origin. This re-
with a vascular tape. The right renal arte:ry can be quires careful leftward retraction of the late:ral wall
dissected and isolated in the retroperitoneal tissues ofthe vena cava, either directly above or directly be-
behind the right renal vein just lateral to the vena low the junction ofthe right renal vein (Fig. 11-13).
cava. To ensure that the main renal artery trunk is Lumbar veins entering the vena cava just below the
.H;~--:n'r----- Lumbarv.
(ligatgd)
Fig. 11-13 The right renal vein is mobilized, and the vena cava is retracted to 1he left to
expose the right renal a:rtery to its origin. Lumblll' branches of the vena cava are ligated as
necessary.
RENALAIUERIES I 307
renal veins should be carefully ligated. Bypasses to In cases involving correction of ostial le-
the right renal artery most often lie best when routed sions, the right renal artery can be isolated in the
behind the vena cava from the aorta or right iliac ar- small space between the inferior vena cava and the
tery. In some situations, the graft lies better in front aorta. This can be accomplished through either a
ofthe vena cava, routed posteriorly to the right renal midline transperitoneal approach (see above) or
artery beneath the caudal border ofthe overlying re- the right retroperitoneal approach described in this
nal vein (Fig. 11-14). section.
Flg.11-14 Several bypass options are available for renal arteryrevascularization. Bypass
grafts may originate from the aortoiliac system (A-E) or from branches of the celiac artery
(F-B) if significant aortic disease is present.
Fig.11-14 (continued)
RENALAIUERIES I 309
Fig. 11-14 (continued)
110 I VESSELSOFTHEABDOMEN
Fig. 11-14 (continue4)
'\
Common hepatic a.
.. D'W'"E'R.IES
RENAL.a.I.U~ I 311
Fig. 11-14 (continued)
112 I VESSELSOFTHEABDOMEN
References 8. Balzer KM, Pfeiffer T, Rossbach S, et al. Prospec-
tive randomized trial of operative vs interventional
1. Sangthong B, Demetriades D, Martin M, et al. treatment for renal artery ostial occlusive disease
Management and hospital outcomes of blunt re- (RAODD). J Vase Surg. 2009;49:667-674.
nal artery injuries: analysis of 517 patients from 9. Balzer KM, Neuschafer S, Sagban TA, et al. Renal
the National Trauma Data Bank. JAm Col/ Surg. artery revascularization after unsuccessful percuta-
2006;203:612--617. neous therapy: a single center experience. Langen-
2. Elliott SP, Olweny EO, McAninch JW. Renal beeks Arch Surg. 2012;397:111-115.
artery injuries: a single center analysis of man- 10. Garrett HE Jr, Richardson JW, Howard HS, et al.
agement strategies and outcomes. J Urol. Retroperitoneal lymphocele after abdominal aortic
2007;178:2451-2455. surgery. J Vase Surg. 1989; 10:245-253.
3. Pfieffrer T, Reiher L, Grabitz K, et al. Reconstruction 11. Williams RA, Vetto J, Quinones-Baldrich W, et al.
for renal artery aneurysm: operative techniques and Chylous ascites following abdominal aortic surgery.
long-term results. J Vase Surg. 2003;37:293-300. Ann Vase Surg. 1991;5:247-252.
4. Henke PK, Cardneau JD, Welling TH III, et al. Re- 12. Malaki M, Willis AP, Jones RG. Congenital
nal artery aneurysms: a 35-year clinical experience anomalies of the inferior vena cava. Clin Radial.
with 252 aneurysms in 168 patients. Ann Surg. 2012;67:165-171.
2001 ;234:454--462. 13. Valentine RJ, MacGillivray DC, Blankenship CL,
5. Crutchley TA, Pearce JD, Craven TE, et al. Branch et al. Variations in the anatomic relationship of the
renal artery repair with cold perfusion protection. left renal vein to the left renal artery at the aorta. Clin
J Vase Surg. 2007;46:405-412. Anat. 1990;3:249-255.
6. Olin JW. Recognizing and managing fibromuscu- 14. AbuRahmaAF, Robinson PA, Boland JP, et al. The
lar dysplasia. Cleve Clin Med. 2007;74:273-274, risk of ligation of the left renal vein in resection of
277-282. the abdominal aortic aneurysm. Surg Gynecol Obstet.
7. Eisenberg Center at Oregon Health & Sciences Uni- 1991 ;173:33-36.
versity. Management ofAtherosclerotic Renal Artery 15. Samson RH, Lepore MR, Showalter DP, et al. Long-
Stenosis. Comparative Effectiveness Review Sum- term safety of left renal vein division and ligation to
mary Guides for Clinicians. Rockville, MD: AHRQ expedite complex abdominal aortic surgery. J Vase
Comparative Effectiveness Reviews; 2007. Surg. 2009;50:500-504.
RENALARTERIES I 313
Common
lilac&.----:,..:.....----+
Fig. 12-1 The lower aortic segment rides 1he cn:st of1he lumbar vertebrae.
114 I VESSELSOFTHEABDOMEN
Surgical AnatamJ of the lnfrannal Aorta and Iliac fourth vertebral bodies. The fifth lumbar arteries
Arteries lie below the bifurcation and may arise from the
common iliac arteries or the middle sacral artery.
The lower aortic segment between the renal ar- The inferior mesenteric artery is the only vis-
tery origins at the cephalad end of the second ceral branch arising in this segment of aorta (see
lumbar vertebra and the bifurcation at the fourth Chapter 10).
lumbar vertebra lies slightly to the left of midline The common iliac arteries diverge from the
(Fig. 12-1). Paired lumbar arteries arise from the aorta and descend a short distance to the lip of
back wall of the aorta and girdle the first through the true pelvis where they bifurcate into internal
315
and external branches {Fig. 12-2). The internal Figs. 19-20 and 19-21). The external iliac arteries
iliac arteries dive into the bowl of the true pelvis hug the pelvic brim medial to the psoas muscles
where they immediately divide in a highly vari- and give off only the small inferior epigastric and
able pattern, sending branches to the pelvic viscera deep circumflex iliac branches near the inguinal
and the external pelvic muscles (see Chapter 19, ligament.
Middle
rectal a.
Inferior
vealclea. obturatDr a.
Fig. 12-2 The iliac vessels lie around the lip and in the bowl ofthe true pelvis.
116 I VESSELSOFTHEABDOMEN
lilac Veins elsewhere.' Adhesion between the bi.ftucations ofthe
aorta and vena cava is not uncommon, making ma-
The bifurcation of the aorta is separnted from the nipulation of these vessel segments hazardous. These
fomth lumbar vertebm by the left common iliac vein. vessel segments are also vulnemble to injury during
The vein crosses beneath the right iliac artery and posterior lumbar disc surgery when the rongeur inad-
joins the right iliac vein to form the vena cava on the vertently bites through the anterior longitudinal liga-
right side ofLS (Fig. 12-3). Left common iliac vein ment Arterial, venous, and combined injury resulting
compression from the overlying right common iliac in arteriovenous fistulae have been reported.2 The
artery can lead to venous hypertension and increased iliac veins lie medial and deep to the common and ex-
potential for thrombosis (May-Thurner syndrome), ternal iliac arteries, occupying a position deep in the
an anatomic variant that has been well descn"bed groove between the psoas muscle and pelvic brim.
-, Left common
lllacv.
Fig. 12-3 The more proximal aortic bifun:ation overrides the bifurcation of the vena cava
and may be adhcreot.
Right kidney
Aorta lnfer1or
mesenteric a.
vena Urutur
cava
SupeJtor
L.comman rectal a.
iliacv.
Sacral
promontory L. gonadal
V8898ls
R. external
lllacv. L. external
iliac a.
]18 I VESSELSOFTBEABDOMEN
fibrous arches between slips of psoas origin and the lateral border of the vena cava and psoas on
hug the vertebral bodies deep to the psoas mus- the right. The sympathetic trunks pass behind the
cles (Fig. 12-5). Occasional venous tributaries common iliac vessels into the sacral hollow ofthe
may overlie the sympathetic trunks. The lumbar pelvis.
sympathetic trunks lie more anteriorly on the ver- The paired lumbar veins are interconnected.
tebral bodies than do their thoracic counterparts. The major communications are the large ascending
The lumbar trunks occupy a position between lumbar veins that lie far posterior in the angle be-
the anterior edges of the psoas muscles and the tween the vertebral bodies and the transverse pro-
great vessels. Because of the offset arrangement cesses, deep to the psoas muscles. Smaller anterior
of the great vessels toward the right, there is a venous interconnections may lie superficial to the
slightly greater space between the lateral border sympathetic trunks and make access to the trunks
of the aorta and psoas on the left than between and ganglia more difficult.
Inferior Aorta
vena
cava
L. sympathe11c ttunk
Ascending lumbarv.
Fig. 12-5 The lumbar vessels lie between the vertebral bodies and the psoas muscles.
Aortic plexus
Quadralus--~=--
lumborum m.
Fig. 12-6 The spinal nerves pass behind the ascending lumbar veins and pass through the
psoas muscle.
llO I VESSELSOFTBEABDOMEN
-Iliohypogastric n.
-Lateral
femoral
cutaneous n.
+ - - - Lumbosacral
trunk
Fig. 12-7 The lumbar plexus lies within the psou muscle.
Aortic
plexus--~~====~
-++--.:.....:~----Sympathetic
ganglion
Inferior
mesenteric
ganglion-~~-=----::::---==--=:-
nr:a;.- -r -----Ascending
lumbarv.
SUperior
t'tjpogastrtc
~exus-------F~
Hypogastric
nerves to
pelvic
~exus---~-----~:
Fig. 12-8 The lumbar sympathetic chains lie on the aJrteromedial portions ofthe vertebral
bodies.
I
\
\
~ A
Fig.12-9 Midline and transverse iDfraumbilical incisions provide adequate
transperitoneal exposure of the infrarenal abdominal aorta.
Fig. 12-10 The fourth portion ofthe duodenum is mobilized, and the aorta is exposed from
the left renal vein to the bifun:ation.
JW
Fig. 12-11 Torsion ofthe trunk. facilitates the retroperitoneal approach to the infrarenal aorta.
Inferior
mesenteric a.
Left renal v.
Left gonacial v.
Fig. 12-11 The inferior mesenteric artery and left gonadal vessels are divided to complete
retroperitoneal exposure ofthe aorta.
DuodBnum
Fig. 12-14 The peritoneal incision is extended to expose and cootroltbe right iliac vessels.
/
/
/ Extemal
lllaca. j
Internal ~y
maca. -----~rFI!~\~~~
lliacv's
Signold
mesentery
Fig. 12-15 Peritoneal retraction on the left side permits isolation of the left iliBC vessels.
Fig. 12-16 The left iliac vessels may also be approached by opening the lateral side of1he
root ofthe sigmoid mesocolon.
Fig. 12-17 A low, oblique anterior flank incision is used for extraperitoneal exposure of
the iliac arteries.
]]2 I VESSELSOFTBEABDOMEN
wound, gaining access to the retroperitoneal space attached to the posterior peritoneal surface, where it
(Fig. 12-18). The retroperitoneal space is most eas- is safely retracted along with the peritoneal sac into
ily entered in the wound's lateral aspect because the the medial wound. The external iliac artery can be
peritoneum may be fused to the transversalis fascia identified in the lower wound and traced proximally
near the midline. The peritoneum. is carefully stripped to identify the common and internal iliac segments.
from the lateral pelvic wall and retracted medially to Proximal exposure can be accomplished to the level
expose the psoas muscle and iliac vessels on the me- of the terminal abdominal aorta with further medial
dial side of the psoas muscle. The ureter is best left retraction ofthe peritoneum.
Fig. 12-19 The external iliac artery can be exposed through a more limited suprainguinaJ.
incision.
]]4 I VESSELSOFTBEABDOMEN
retroperitoneal space is gained laterally, and the peri- the peritoneal sac superomedially. Distal exposure to
toneum is carefully stripped away from the anterior the level of the inguinal ligament can be obtained by
abdominal wall in the inferior wound (Fig. 12-20). caudal retraction of the inferior wound ma:rgi:n. Care
Superior retraction of the peritoneum reveals the should be taken to avoid injuring the deep circum-
external iliac artery in the center of the wound; the flex iliac and inferior epigastric vessels during distal
external iliac vein lies on the artery's posteromedial dissection. Exposure of arterial segments below the
surface. Proximal exposure ofthe external iliac artery inguinal ligament should be performed through a sep-
can be gained all the way to its origin by retracting arate vertical groin incision {see Chapter 15).
Inferior
epigastric a. and v.
Fig. 12-20 Care is taken to avoid the small distal abdominal wall branches ofthe ex:temal
iliac artery during peritoneal retraction.
Fig. 12-21 A transverse midflank incision provides access to the lumbar sympathetic chain.
Fig. 12-22 The sympathetic chain is identified on the vertebral bodies between the anterior
edge of the psoas muscle and the aorta (or vena cava).
Genitofemoral n.
Fig. 12-23 The anatomy related to 1he lower lumbar spine is shown.
P~rior~ssh&mh
Areuatellne
---Rectus musde
Transversalis fascia
Anterior rectus sheath
Inferior epigastric
pedicle
Fig. 12-25 Lateral mobilization of the left :redus muscle exposes the lll'CUB.te line at the
termination of the posterior rectus sheath. Caudal to the arcuate line, only transversalis
fascia covers the preperitoneal fat plane. The inferior epigastric pedicle lies deep to the
caudal end of the rectus muscle.
~:~~----Inferior
mesentertc a.
- - - --=-:-Lateral
lllosacral v.
Medial
iliosacral v.
Fig. 12-28 The common position of the aortic and vena caval bifurcations
bracketing the UILS disc space is shown.
Fig. 12-29 Pin marker placement for fluoroscopic confirmation of the LS/Sl disc space
is shown.
]44 I VESSELSOFTBEABDOMEN
Fig. 12-31 (continued)
349
Inferior phrenic v's
Esophageal
hiatus
Right
adrenal v.
Abdominal
aorta
Cystema
SUbcostal v.
ctr.fli
Right
renal v. Left
adrenal v.
Left renal v.
Left gonadal v.
Psoas m. (cut)
Lumbarv.
Ascending
lumbarv.
Lumbarn.
Iliolumbar v.
Lateral
sacral v.
Fig. U-1 The inferior vena cava lies to the right of midline between the leveb of the
eighth tb.oracic and fifth lumbar vertebrae.
]50 I VESSELSOFTBEABDOMEN
lilac Veins The ureter, ductus deferens (male), and round liga-
ment of the uterus and ovarian vessels (female)
The external iliac veins draining the lower extremi- cross the external iliac vessels. The sympathetic
ties begin behind the inguinal ligaments and run trunk and obturator nerve from the llJlllbar plexus
around the brim of the true pelvis medial to the pass beneath the common iliac veins. The aortic bi-
psoas muscles. The internal iliac veins, which drain furcation is slightly more cephalad than that of the
all the pelvic viscera except the rectosigmoid area, vena cava. The iliac arteries cross the iliac veins in
join the external iliac veins adjacent to the sacro- such a way that the arteries end up straddling and
iliac joints to form the common iliac veins. The embracing the veins (Fig. 13 -2). The bifurcation of
common iliac veins ascend to unite in front ofL5. the inferior vena cava is crossed anteriorly by the
lnfllrtor
meaentertc
~~
~~~-=--....:.::-:--Gonadal a. and v.
~~""""'==--=-----:-:--- GenHolemond n.
Right
L.axtemal
iliac a.
Femoral n.
Ductua
deferens
~~j)
.. ~
Fig. 1l-2 The external iliac veins
are enfolded by the limbs ofthe iliac
arteries and lie medial to the arter-
ies beneath 1he inguinal ligamenta.
Anterior
intervertsbl'81
Flg.1S-S The lumbar veins communicate with an extensive paravertebral network ofveins.
The renal veins enter the vena cava at the level of The portion of inferior vena cava traversing the
L2 and are usually single. The right renal vein fol- liver is enfolded on three sides by liver substance
lows a short path anteromedially (see Fig. 11-2) (Fig. 13-4). There are several small branches
from the renal hilum. The left renal vein arches draining from the caudate lobe directly into the
across the aorta in the acute angle formed by the vena cava. At the dome of the liver, the vena cava
takeoff of the superior mesenteric artery and joins receives the large hepatic veins, usually three
the vena cava at a 90 angle. The anterior relation- in number. The hepatic vein-vena cava junc-
ships of this segment of vena cava are described in tion is located at the anterior angle of the dia-
Chapter 11. mond-shaped bare area bounded by the coronary
Hepat.Dduodenallig.
Portal v.
Gastrohepatic llg.
Renal
Impression
Gastric
Impression
Right
triangular llg.---~t:;-d!'
vena
cava
Fig.13-4 The retrohepatic segment of vena cava is partially embedded in the liver.
Fig. 13-5 The vena cava is accessible through a right flank approach.
-w9-:111Hbod---- Sympathe11c
chain
Fig. 1l-6 The periwneum. wi1h the ureter: attached is elevated to expose the vena cava.
Hepatic flexure
Duodenum
Hepatoduodenal
llg.
caudate
lobe
Fig. 11-7 The perirenal vena cava is umoofed by mobilizing the right colon, duodenum,
and head ofthe pancreas.
]56 I VESSELSOFTBEABDOMEN
In elective circumstances, the posterior wall of these vein branches permit full mobilization of
of the infrarenal vena cava can be exposed by roll- the infrarenal vena cava. 'Ibis maneuver is not rec-
ing the lateral surface anteriorly (Fig. 13-8). Care ommended for control of injuries to the posterior
should be taken to control the lumbar veins dJ:aining vena cava wall because awlsion of lumbar veins is
into the posterior caval wall; ligation and division likely. Such injuries may be repaired by enlarging
Fig.1l-& Ligating adjll(;eut lumbar veins allows a segment of the back wall of the vena
cava to be visualized.
Rg. Ut Posterior wounds of the inferior vena cava can be repaired from inside the
vessel
Ftg.13-10 Finn retraction of the lower rib cage i!l nece~~1131Y for expo!IUI'e of the perihe-
patic vena cava.
Fig.13-11 The right triangular and coronary ligaments of the liver are divided, and the
right lobe of the liver is gently rotated to the left to visualize the retrohepatic vena cava.
Fig. 13-12 The falcif0m1. and anterior coronary ligaments are opened, and the dome ofthe
liver is gently retracted downward to expose the hepatic veins and suprahepatic vena cava.
Fig. ll-13 The intrapericardial portion of the inferior vena cava can be isolated at its junc-
tion with the right atrium through a median sternotomy.
]62. I VESSELSOFTBEABDOMEN
References 7. Pappas PJ, Haser PB, Teehan EP, et al. Outcome
of complex venous reconstructions in patients with
1. Fairfax LM, Sing RF. Vena cava interruption. Crit trauma. J Vase Surg. 1997;25:398-404.
Care Clin. 2011;27:781-804. 8. Quinones-Baldrich W, Alktaifi A, Eilber F, et al.
2. Angel LF, Tapson V, Galgon RE, et al. Systematic Inferior vena cava resection and recons1roction
review of the use of retrievable inferior vena cava for retroperitoneal tumor excision. J Vase Surg.
filters. J Vase Interv Radio!. 2011 ;22: 1522-1530. 2012;55: 1386-1393.
3. Belenotti P, Sarlon-Bartoli G, Bartoli MA, et al. Vena 9. Caso J, Seigne J, Back M, et al. Circumferential re-
cava filter migration: an underappreciated complica- section of the inferior vena cava for primary and re-
tion. About four cases and review of the literature. currentmalignanttumors.JUrol. 2009; 182:887-893.
Ann Vase Surg. 2011 ;25:1141. e9--e14. 10. Perry MO. Injuries to the inferior vena cava. In: Thai
4. Shang EK, Nathan DP, Carpenter JP, et al. Delayed ER, Weigelt JA, Carrico CJ, eds. Operative Trauma
complications of inferior vena cava filters: case re- Management: An Atlas, 2nd ed. New York, NY:
port and literature review. Vase Endovascular Surg. McGraw-Hill, 2002:316-321.
2011 ;45 :290-294. 11. Bower TC, Nagomey DM, Cherry KJ Jr, et al. Re-
5. Wang GJ, Carpenter JP, Fairman RM, et al. Single- placement of the inferior vena cava for malignancy:
center experience of caval thrombectomy in patients an update. J Vase Surg. 2000;31:270-281.
with renal cell carcinoma with tumor thrombus ex- 12. Fullen WD, McDonough JJ, Popp MJ, et al. Sternal
tension into the inferior vena cava. Vase Endovascu- splitting approach for major hepatic or retrohepatic
lar Surg. 2008;42:335-340. vena cava injury. J Trauma. 1974; 14:903-911.
6. Helfand BT, Smith ND, Kozlowski JM, et al. Vena 13. Schrock T, Blaisdell FW, Mathewson C Jr. Manage-
cava thrombectomy and primary repair after radical ment of blunt trauma to the liver and hepatic veins.
nephrectomy for renal cell carcinoma: single-center Arch Surg. 1968;96:698--704.
experience. Ann Vase Surg. 2011;25:39-43.
Splenicv.
Portal Y.
Superior
m~ric~--------
Rl""
gastroepiploic v.------l-+---~,......;...---,:f--~/
Y l-t-:='------!---------f..,.......+--lnferior
mesenteric v.
Middle
colic v. ------------+-----.......;:.......,...tZ----:-----+.RI'I
Fig. 14-1 The main venous 1runks feeding into the portal vein are the superior and inferior mes-
enteric veins and the splenic vein.
164 I VESSELSOFTBEABDOMEN
Surgical AnatamJ of the Portal Vein veins at the level of the second lumbar vertebra.
Most commonly, the inferior mesenteric vein joins
The portal venous system dJains the viscera the proximal splenic vein, but it may alternatively
supplied by the celiac, superior, and inferior mes- join the superior mesenteric vein or form a common
enteric arteries and normally carries the blood to junction with the other two veins. These three veins
the liver (Fig. 14-1). The portal vein is formed by drain the areas supplied by their corresponding
the confluence of splenic and superior mesenteric named arteries.
365
Anatomically, the superior mesenteric and border of the gland. The splenic vein is cradled in a
splenic veins lie close to their corresponding arter- groove running the length ofthe upper border ofthe
ies (Fig. 14-2). The superior mesenteric vein lies to posterior surf.:lce of the pancreas (inset). Numerous
the right of the artery in the root of the small bowel small branches drain from the tail and body of the
mesentery and ascends over the third portion of the pancreas into the apposed surface ofthe vein.
duodenum and uncinate process of the pancreas. The inferior mesenteric vein lies deep to the
The vein passes behind the neck of the pancreas left posterior parietal peritoneum and ascends in
and is joined by the splenic vein near the cephalad close proximity to the underlying infrarenal aorta.
Splenic a. and v.
Right gastric v.
Superior
mesenteric v.
lnfer1or mesenteric v.
Middle colic v.
Left ranal v.
Fig. 14-2 The relationships of the main trunks of the portal system to the SUITounding
structures are shown.
Right gastric v.
Superior mesenteric
a.andv.
Splenic a. and v.
Fig. 14-l The gastric vein circuit consists of the right gastric vein along the lesser curve
of the stomach and the left gastric or coronary vein beneath the posterior peritoneum of
the lesser sac.
Short gastltc
arcade
\
Gastroeplplolc--*--+-.,.. .------H
~ ~~~~~-
I
\ 31
Middle colic vJ----l{: - - - - V
superior mesenteric v.~
.-. (
Midcle colic vJ
inferior 1118Hnteric v.
arcade
Fig. 1+4 Peripheral links between limbs of the portal system are shown.
]68 I VESSELSOFTBEABDOMEN
systemic venous circulations often become clini-
cally apparent
Portal hypertension occurs WJ a result of increWJed There are several peripheral connections be-
portal vein resistance or, on rare occasiom, from tween the portal system and the systemic circula-
increased portal vein flow. It is associated with a tion that become enlarged as a result of abnormally
number of hepatic and extmhepatic disorders that elevated portal pressure (Fig. 14-5). Peripheral dila-
have been well described e1Bewhere.1 Among other tion is most dangerous in the submucosal esopha-
consequences of increWJed pressure in the portal geal plexus connecting the portal circulation to the
system, the thin-walled veins become engorged. azygous system. Resultant esophageal varicosities
Normally small connectiom between the portal and are in danger of erosion and massive hemorrhage.
Caput
mwua~--~+---~--~~~~
Fig. 14-5 Important portosystemic OODDections are found in the esophageal, periumbilical,
and rectal veins. Multiple small retroperitoneal CQ1DDlunications are also found when portal
pressure is elevated.
Fig. 14-6 Surgical decompression of the portal system into the systemic venous system
is accomplished by oonneding the portal or superior mesenteric veins to the inferior vena
cava or the splenic vein to the left renal vein.
Fig. 14-7 Nonselective portacaval shunts are shown in 1he top row ofthree drawings, and
nonselective m.esocaval and central splenorenal shunts are shown in the two drawings on
1he lower left. Selective shunts in<:lude small-caliber variations of nonselective shunts and
1he distal splenorenal shunt shown on the lower right
Selective
Fig. 14-8 The selective distal splenorenal shunt isolates the drainage of the esophageal
venous plexus from the portal system, preserving portal flow to 1he liver undisturbed.
-----
-----..
\
)
Fig. 14-t An extended right subcostal incision provides good exposure ofthe portal vein.
Flg.14--10 Elevation of the right lobe of the liver and caudal retraction of1he hepatic flex-
me of the colon expose 1he hepawduodenalligament. The line of1he peritoneal incision for
mobilizing the duodenum is shown.
Gallbladder
I
Inferior
wnacava
Free edge of
~~~+--r-- hepatoduodenal
IIg.
Fig.14-11 The portal vein is exposed on the posterolateral surface of the hepatoduodenal
ligament.
Fig. 14-12 The portal vein is isolated, and venous tributaries draining into 1he origin ofthe
portal vein are ligated and divided.
Middle colic v.
Superior
mesenteric v.
Fig. 14--14 The superior meseuteric vein is coDtrolled, and branches are ligated to provide
space for the IIDBStomosis. The right colic vein may be divided, if necessary.
Superior
mesenteric v.
Fig. 14-15 Mobilization ofthe duodenum to the right ofthe superior mesenteric vein pro-
vides dire<:t access to the underlying inferior vena cava.
Right
- - colon
(mobilized)
Flg.14-16 The alternative approach of mobilizing the right colon provides wider exposure
of the inferior vena cava. The graft is then brought through a tunnel in the mobilized right
colon mesentery to reach the superior mesenteric vein over the uncinate process.
There are two popular approaches to the splenic The patient is placed in the supine position with
vein: a direct approach through the lesser sac12 and the lower chest and abdomen prepped and draped.
an inferior approach beneath the root ofthe mesoco- Warren and Millikan12 advocate a "hockey stick"
lon.n The former approach offers the advantages of incision 1 to 2 em below the left costal margin, ex-
simultaneous gastric venous devascularization and tending across the midline to the lateral border of
complete exposure of the pancreatic body and tail, the right rectus muscle {Fig. 14-17). An alternative
but dissection is often canied out through a deep, is the upper midline approach; thoracoabdominal
narrow hole into the retroperitoneum. The latter ap- incisions are too extensive and associated with
proach is associated with reduced retraction require- needless morbidity. On entering the abdominal
ments and a more central approach to the splenic cavity, the falciform ligament and the umbilical
vein, but isolation of the entire splenic vein to effect vein are ligated and divided. The lesser sac is en-
a complete splenopancreatic disconnection12 is more tered by dividing the gastrocolic ligament between
difficuh. the gastroepiploic arcade and the greater curvature
Fig.14-17 An extended left sulK:ostal incision provides good exposure of1he splenic vein.
Transwrse
mesocolon
Fig. 14-18 The gastroepiploic an:ade is disconnected from the stomach, and the right gas-
tric artery and vein are divided to approach the splenic vein through the lesser sac.
Fig. 14-19 The lower border ofthe pancreas is mobilized to expose the splenic vein.
- "---.._
Fig. 14--20 Multiple small pancreatic branches aJ:e divided to free the splenic vein.
Flg.14-21 The left renal vein is exposed. and the splenic vein is ligated and divided as
proximally u possible.
Fig. 14-22 The splenic and renal veins may also be reached tbrough the root ofthe transverse mesocolon.
]16 I VESSELSOFTBEABDOMEN
tahir99 - UnitedVRG
vip.persianss.ir
References 8. Fraga GP, Bansal V, Fortlage D, et al. A 20-year ex-
perience with portal and superior mesenteric venous
1. Rosemurgy AS, Zorros EE. Management of variceal injuries: has anything changed? Eur J Vase Endovasc
hemonhage. Curr Prob Surg. 2003;40:255-343. Surg. 2009;37(1):87-91.
2. Rana SS, Bjasin DK. Gastrointestinal bleeding: 9. LeeDY, Mitchell EL, Jones MA, et al. Techniques
from conventional to nonconventional. Endoscopy. and results of portal vein/superior mesenteric vein
2008;40:40--44. reconstruction using femoral and saphenous vein
3. Wright AS, Rikkers LF. Current management of during pancreaticoduodenectomy. J Vase Surg.
portal hypertension. J Gastrointest Surg. 2005;9: 201 0;51 :662--666.
992-1005. 10. Fleming JB, Barnett CC, Clagett GP. Superficial
4. Livingstone AS, Koniaris LG, Perez EA, et al. 507 femoral vein as a conduit for portal vein reconstruc-
Warren-Zeppa distal splenorenal shunts: a 34-year tion during pancreaticoduodenectomy. Arch Surg.
experience. Ann Surg. 2006;243:884--892. 2005;140:698-701.
5. Sarfeh U, Rypins EB, Fardi M, et al. Clinical impli- 11. Smith GW. Portal hypertension. In: Shackelford
cations ofportal hemodynamics after small-diameter RT, Zuidema GD, eds. Surgery of the Alimen-
portacaval H graft. Surgery. 1984;96:223-229. tary Tract. Philadelphia, PA: WB Saunders; 1983:
6. Johansen K, Eide B, Carrico CJ. Enhanced survival 513--604.
in patients with variceal bleeding after elective portal 12. Warren WD, Millikan WJ. Selective transsplenic de-
decompression. Am J Surg. 1983; 145:596-598. compression procedure: changes in technique after
7. Asensio JA, Petrone P, Garcia-Nunez L, et al. 300cases. ContempSurg. 1981;18:11-26.
Superior mesenteric venous injuries: to ligate 13. ZapolanskiA, SiminovitchJ, CoopermanAM.Asim-
or to repair remains the question. J Trauma. plified method and approach to the distal splenorenal
2007;62(3):668--675. shunt. Surg Gynecol Obstet. 1980;150:405-406.
Ten801' fuciu
lata& m.------~
Pectineal
llg. -------~-...;.:_--;~
Fig. 15-1 The femoral vessels pass beneath the inguinal ligament medial to the bulk of
the iliopsoas muscle. After crossing the pectineal line of the pubis, the vessels cross the
pectineus musc:le en route to the subsartorial femoral canal.
Psoas major m.
I ~
Flg.15-2 The femoral sheath enclosing the vessels is a coDtimlation ofthe endoabdominal
fascia. The components of this fascia contributing to the sheath are named transversalis,
iliac, and pectineal fascia. The femoral canal is the space within the shea1h medial to 1he
femoral vein.
Psoas major m.
~!:::::::!!~-Pectineal llg.
--......:...l!~~oooo::!!---lliac fascia
I
I
Deep circumflex
v---.......1!::=:-:-~:-- iliac a. and v.
Femoral canal
-:-:-~____;.~-----~-(distal end)
Fig. 1S3 The proximal end of the femoral canal is covered with loose fascia, which is
violated when a femoral hernia forms. The hernia dissects and breaches the medial femoral
sheath below the inguinal ligament to prolrude. Peritoneum overlies both the vessels and
the endoabdominal fascia.
Deep circumflex
iliac a. and v. ---ii--~~:----=
~iif----Ductus deferens
~:;t..f--:--lnferior epigastric
Superficial a. andv.
circumflex iliac a. ----:~---:!!!~-
Superficial external
puclenclal a. ---~~.:--~.......--.w~.:.r--e~~~\1f.l::
Deep extemal
puclendala.---~~~-~~~~~~-~~
Superficial femoral
a. andv. -----~~"""':""~-....,.-~~~
Fig. 15-4 Removing the pelvic fascia and femoral sheath reveals the relationships ofother
retroperitoneal structures to the vessels and exposes the small external iliac and common
femoral branches above and below the inguinal ligament, respectively.
Fig. 155 Flexion and external rotation of the thigh make the muscular margins of the
femoral triangle stand out. The siD'Wrius muscle for::ms the lateral boundary, and 1he adduc-
tor longus muscle fonns the medial border.
Deep circumflex
lilac a. andv. ---.:::--------:------:~ .,..- - - - - - - I n f e r i o r epigastric
a. andv.
Superficial circumflex
iliac a. andv.---....;_-------~
.o-.~~=-~!!!!!...,.....------Superficial epigastric
a. andv.
,-.....:;~~-------:-;.~-Superficial external
pudendal a. and v.
-----....;:..---Great saphenous v.
F-f-0
;---~----Deep external
pudendal a. and v.
Fig. 15-6 AIIteriorly, the fascia lata attaches to the inguinal ligament. It is perforated by
branches of the femoral artery and by cutaneous nerves. Venous channels reach the femoral
vein through the loosely capped fossa ovalis.
Flg.1S-7 The superficial inguinal. lymph nodes are clustered beneath the inguinal liga-
ment 1111d m:ound the fossa ovalis.
Transversus abdomlnls m.
Inferior epigastric-+:-:~-=:-----l:l\.
a. andv. Deep circumflex
a. andv.
--------Obturatorlntemus m.
---Levator ani m.
Fig. 15-& A medial view of the right superior pubic ramus stripped of peritoneum shows
the relationships of the femoral and obturaWr vessels.
Fig. 15-9 A surgically treacherous origin of1he obturator artery from the inferior epigastric
artery is found in nearly one-fifth of individuals.
Adcllctor
longusm.
~----Adcllctor
magnusm.
~----Graclllsm.
Fig. 1510 The relationships of obturator membrane, obturator canal, obturator ex:temus
muscle, and surrounding adductor muscle origins make the obturator membrane a practical
route for bypass grafts.
~~
~~
)
~~~~~----~---o~~r
membrane
.,~,w~~~~M'~~~~~~~~~Imeoor
gluteal a.
~~K_~ =--~~-Meclal
:1a~--~~~~~~~~~~~
a. fumo~ a.
circumflex
n?:~~~-Perforating
branch
~ ~~~~--Deep
femo~a.
Flg.lS-12 Branches of the gluteal arteries and the obturator artery supplem.eut the deep
femoral in providing blood supply to the thigh.
Sartorius m. ----=~~
Teneorfaselae
1atae m.------:~-
Vastus
lateralis m.--~f----~
Deep Medial
femoral a . - - - --!!: femoral
circumflex a.
Adductor
brevism.
Vastus
Intermedius m.----===~
Adductor
longus m.
Graclllsm.
Flg.151S In this medial view, the posterolateral origin ofthe deep femoral artery gives
rise to the medial and lateral femoral (;ircumflex arteries to the smrounding muscles. Either
or both may at times arise from the (;OIDIIWD femoral artery.
Deep femoral a.
Lateral
femoral
circumflex a.--l.....--;-""t""~
Lateral
femoral Medial femoral
circumflex v. circumflex a. and v.
Flg.lS-14 The origin ofthe deep femoral artery is crossed by the lateral femoral circum-
flex vein 1hat may be divided for exposure.
LataraJ tamoml
circumllex; a.
Ascending br.---+-~~.._,;
"''lllt!!tL-~~--1.~"'--f-- Medial femonll
circumflex a.
!-----+-+---~----Deep
femoral a.
Flg.lS-15 A: Anterior view of the rich collateral circulation around the hip joint and
prox:i:mal femur.
~-+---Lateral femoral
circumflex a.,
ascending br.
Sciatic vasa
MMONm---~~~~+-~~~~
Fig. 15-15 B: Posterior view of the rich collateral circulation around the hip joint 1111d
proximal femm.
Fig. 1519 In this view, the skin and subcutaneous fat have been removed to show the inci-
sion in the fascia lata along the medial border of the sartorius muscle.
COMMONFEMORALARTERY I 411
Further proximal exposure can be obtained by The common femoral artery divides into two
cephalad retraction ofthe inguinal ligament. major trunks, the deep (profunda) and superficial
Direct access to the common femoral arte:ry is femoral arteries, which are best exposed by dis-
gained by opening the femoral sheath (Fig. 15-20). secting distally on the anterior surface of the par-
Separation of areolar tissue is all that is necessary ent trunk. Few branches will be encountered on the
to encircle this vessel. One should take great care to anterior surface of the artery, and the deep femoral
avoid entry into the femoml vein that lies medial to artery will not be injured using this approach. The
the artery in the femoral sheath. On occasion, there superficial femoral artery is easily isolated in the
may be inflammatory changes within the femoral distal wound. The origin of the deep femoral artery
sheath that render the vessels difficult to separate. is most often found laterally about 3.5 em below the
Rg.15-20 The femoral shea1h is opened directly over the artery; the artery is mobilized
by bluut disse<:tion and encircled for cODtrol.
~~-m,n~ll--------~~-4~~
circumflex v.
Fig.15-21 The deep femoral artery normally arises laterally offthe common femoral trunk
about 3.S em distal to the inguinal ligament. Its origin is crossed by the lateral femoral
circumflex vein.
Fig. 15-22 The lateral or medial femoral circumflex arteries may arise from the common
femoral trunk and cause troublesome backbleeding if UJll'eCOgnized.
COMMONFEMORALARTERY I 417
long tunneling instrument (Fig. 15-26). The tunnel-
ing instrument should be guided so that it reaches
The route from the axillary artery to the ipsilateral the inferior border of the pectoralis major muscle
femoral artery is a long subcutaneous tunnel that anterior to the midaxillary line, where it is pushed
travenJes the lateral tnmk.10 Exposure of the axil- through the axillary fascia into the subcutaneous tis-
lary artery is considered in more detail in Chapter 5. sue ofthe lateml chest wall. An intermediate incision
Tunneling is best begun near the axillary artery and may be needed just below the costal ID.a.J:gin in cases
routed beneath the pectoialis major muscle with a in which the tunneling instrument does not reach the
Fig. 15-26 The axillofemoral bypass l'UI18 deep to the pecto.ra.lis major muscle proximally
and then in the subcutaneous plane to reach the groin. An intermediate incision between
costal margin and iliac crest facilitates formation of the tunnel. Many surgeons use a
trBDSverse jump incision. The graft may be brougbt laterally over the iliac crest when the
midgroin must be avoided (dashed line).
Fig. 15-27 The femorofemoral bypass is usually brought subcutaneously over the pubis.
Fig. 15-28 The bypass may also be placed deep to the rectus abdominis muscle for added
protection.
Fig. 15-SS A tunnel is made through the obturator intemus muscle to reach the center of
1he obturator membrane for the obturator bypass.
Fig. 15-34 The obturator bypass graft may be brought through the adductor longus muscle
to reach the superficial femoral artery in midthigh or through 1he adductor magnus muscle
to reach the popliteal artery.
Fig. 15-35 The obturator pathway may also be used w bring a graft laterally w avoid a contaminated medial groin
field. The deep femoral arteey is exposed and kept under direct vision w avoid injury as the tunneler is passed
through 1he adductor brevis muscle.
Adduct.Dr
brevis m.~-...1:---~~~-~
longusm.
--:""'~- Adcfuct.Dr
rnagnusm.
Fig. 16-1 The addueurr muscles ofthe thigh fan out to attach along the linea up era ofthe femur.
429
The posterior view of the adductor magnus The anterior compartment ofthe thigh consists
muscle (Fig. 16-2) shows the more horizontal direc- of the quadratus femoris muscle, which is made up
tion of the pubic fibers and the predominantly lon- offour heads: rectus femoris, vastus medialis, vastus
gitudinal ischial fibeD. The tendinous openings can lateralis, and vastus intermedius (Fig. 16-3). These
be seen along the linea aspera. muscles enla:rge from tapered origins proximally to
Gluteus
mklmusm.
c.
(J
Obturamr
lntarnus m. lllopsoum.
Quadratus
fafTIOI'Is m.
.....:-:-~r--A<Iductor
magnusm.
magnuam.
Vastus
intermedius m.----\- ........-
Rectus
Vastus famorism.
lataralis m.
~--jJ- Vastus
medlallam.
~
Y1tJ
v ~
-=-!---Gluteus
Gluteus medlusm.
maximus m.----::...:.:....
~~..!:---+-- Quacfrstus
femorism.
Ischial
tuberosity-~~'!::--
~~.;;_-+---Adductor
magnusm.
Adductor
magnus m.--+--.
Bioaps famgrjs m
-+---~-::!::!---Long head
VESSELSOFTHETHIGH I 431
The medial adductm compartment forms a su- (Fig. 16-6), the bulky adductmmagnus muscle has a
periorly based pyiaiDid between the quadriceps mus- rougblytriangularprofile, with a narrow linear medial
cle and the hamstrings (Fig. 16-5). In cross section attachment along the medial lip ofthe linea aspera.
~1~
11
f1p Adductor Semimembranosus m. Semitendinosus m.
hiatus
Rg. 16-S The medial adductor compartment is iDteiposed between the quadratus femoris
and hamstring muscles. The body ofthe adductor magnus has been resected in 1his view.
Adductor longus m.
Adductor magnus m.
Flg.1 6-6 The adductormagnus muscle tapers medially to form a narrow linear attachment
along the linea aspera of the femur.
~....:....-~~-SUperficial
femoral a.
..........~'----Adductor
longusm.
Adductor
brevis m. _ _____;;;..--=,..,;,..,,...:....---"~ .....!;,........,~!L-......!o~~:__ Deep
femoral a.
,.;.;:....~~-Adductor
magnusm.
Fig. 16-7 The relationship between 1he branches of1he femoral artery and thigh musculature is shown.
VESSELSOFTHETHIGH I 433
The superficial femoral artery supplies the ad- At the apex of the femoral triangle, the su-
jacent adductor muscles and the quadriceps muscle perficial femoral artery enters a triangular fascia-
(Fig. 16-8). The deep femoral branch supplies the lined cleft, the adductor (Hunter's) canal, between
adjacent adductor muscles and sends three perforat- the vastus medialis, the sartorius, and the adductor
ing branches and its te:nnination through the tendon longus (upper portion) and adductor magnus (lower
of the adductor magnus muscle to supply the ham- portion) muscles. The canal takes a 90 twist as it
strings in the posterior compartment. descends toward the knee (Fig. 16-9). The roof of
Common
fllmorala.
Deep
fllmorala.
Adclictor
brevism. ' \
Adclictor
longus m. \ magnusm.
~
Superftclal
fllmorala.
Adductor
Adclictor
magnuam. (Hunter's)
canal
Sarmrfusm.
~~--vastus
medialis m.
t.+~++--Adclictor
hiatus
Fig. 16-i The deep and superficial femoral branches are Fig. 16-9 Hunter's canal twists 90 as it descends
separated by 1he adductor longus muscle. toward the knee.
Superficial Adductor
femoral a. longusm. Pectineus m.
Fig.16-10 The relationship of1he deep femoral vessels to the adductor muscles is shown.
VESSELSOFTHETHIGH I 435
Cross sections of the thigh show the relation- adhesion between the surface ofthe adductor longus
ships of the vessels to the muscular compartments muscle and the adjacent vastus medialis muscle that
(Fig. 16-11). The lateral intermuscular septum ofthe requires sharp dissection to separate. The remain-
thigh between the vastus lateralis and biceps femoris ing interfaces between muscle groups are less well
muscles is dense and well developed. There is firm defined.
Key:
a=artery
=
AB adductor brevis m.
=
AL adductor longus m.
AM =adductor magnus m.
B =bleeps femoris m.
(L) =long head
(S) =short head
G =gracilis m.
GM =gluteus rnaxlmus m.
PN =peroneal nerve
=
RF rectus femoris m.
=
S sartorius m.
=
SM semimembnmosus m.
=
SN sciatic nerve
=
ST semitundinosus m.
=
TN tibial nerve
v=vein
VI =vastus lntermeclus m.
VL =vastus lateralls m.
VM =vastus medialis m.
SM ST
Rg. 16-11 Cross-sectional (caudal) views ofthe thigh demonstrate the relationship ofthe
femoral vessels to the SUITOUDding musculature.
Femoral a.
Fernoralv.
Fig. 16-12 The posterior view shows the relationship between the femoral veins and their
accompanying arteries.
VESSELSOFTHETHIGH I 437
For purposes of clarification, Veith1 described includes the segment extending to the second perfo-
three anatomic subdivisions of the deep femoral ar- rating branch, and the distal zone extends from the
tery (Fig. 16-13). The proximal zone extends from second perforating branch to the artery's termina-
the artery's origin to the portion just distal to the tion. The sartorius muscle overlies the middle and
lateral circumflex femoral artery. The middle zone distal zones ofthe artery.
Flg.16-14 The incision is made parallel to the lateral border ofthe sartorius muscle.
VESSELSOFTHETHIGH I 439
the muscle on its inferomedial edge.7 The incision carefully protected during dissection to prevent sa-
is deepened through the fascia lata, and the sartorius phenous neuralgia (Fig. 16-16).
muscle is reflected medially to expose the underly- The superficial femoral vein should always be
ing roof of the adductor canal (Fig. 16-15). Entry mobilized proximally to the level of the common
into this overlying fascia exposes the superficial femoral vein confluence. If the vein is to be har-
femoral vessels. The vein and arte:ry can be care- vested for use as a bypass graft, it is critically impor-
fully separated using shup dissection to incise loose tant to transect and oversew the vein flush with the
areolar tissue. The superficial femoral vein has mul- deep femoral vein so that there is no residual stump
tiple large branches that require secure ligation with of superficial femoral vein that may serve as a nidus
double ligatures or transfixing sutures to prevent for a pulmona:ry embolus (Fig. 16-17). The vein can
disastrous bleeding complications when used in the be mobilized distally to the level of the knee joint
arterial circulation.8 The saphenous nerve is easily and transected just proximal to the popliteal vein
recognized within the adductor canal and should be confluence.
Fig. 16-15 Medial retraction ofthe sarto.rius exposes the fascial roof overlying the adductor canal.
VESSELSOFTHETHIGH I 441
Lltl!nllApprNcb to the Middle nd DbtllSfgmflltJ llfthf DHp sartorius muscle provides access to the deep femo-
FtmtmllArt.fiJ ral artecy distal to the femoral sheath. This technique
Each of the three segments of the deep femoral may also be preferred to the direct approach through
artecy can serve as an excellent source of inflow the femoral sheath in vascular procedures involving
for infrainguinal bypass procedures.9 Locating the graft infection, excessive postopemtive scarring, or
proximal anastomosis in the middle or distal seg- previous radiation to the groin. to, II
ments allows the bypass length to be shortened in The patient is placed in the supine position,
patients whose saphenous veins are inadequate to and the lower abdomen and entire leg are prepped
reach the groin. Direct exposure of the proximal and draped. A vertical incision is made paral-
segment of the deep femoral artery is best obtained lel to the lateral border of the sartorius muscle at
through a vertical groin incision (see Chapter 15). the lower end of the femoral triangle {Fig. 16-18).
A vertical incision along the lateral border of the After the wound is deepened through the fascia lata,
Sartorius m.
Femoral n.
Rectus
femorfsm.
Fig. 16-19 The deep femoral artery may be approached laterally between the sartorius and
rectus femoris muscles when a surgically compromised groin must be avoided.
VESSELSOFTHETHIGH I 443
laterally in the wound {Fig. 16-20). Division of the to the level of the second perforating branch, where
lateral femoral circumflex vein provides exposure the artery dives posterior to the adductor longus
of the 1runk of the deep femoral artery. Medial dis- muscle. Exposure of the artery between the level of
section exposes the origin of the deep femoral ar- the second perforating branch and its termination as
tery at its junction with the common femoral artery. the fourth perforator requires division of the adduc-
Dissection distal to the lateral femoral circumflex tor longus insertion on the linea aspera (Figs. 16-21
vein exposes the trunk of the deep femoral artery and 16-22).
Fig. 16-20 Retraction of femoral nerve branches and division of the lateral femoral cir-
cumflex vein expose 1he deep femoral artecy.
RF
VL
VESSELSOFTHETHIGH I 445
l'ostrrlerApptHdttotbtDHp Fmtmi/Artery
Secondary revascularizations are often required for
limb salvage in patients who have developed bypass
graft thrombosis. These procedures are complicated
by the presence of scaning or infection, mak-
ing novel bypass routes attractive. Bertucci et al. 12
described a direct posterior approach to the middle
and distal zones of the deep femoral artery. This
technique can be combined with posterior exposure
of the popliteal (see Chapter 17) or infrageniculate
arteries (see Chapter 18) for creation of an all-
posterior bypass.
The patient is placed in the prone position, and
the entire leg and ipsilateral buttock are prepped and
draped. The hamstring muscle group constitutes the
important landmark for this approach. A long verti-
cal incision is made parallel to the lateral edge of
the biceps femoris muscle, the most lateral muscle
in the hamstring group. The incision should extend
approximately 6 em superior to and 10 em inferior
to the gluteal crease12 (Fig. 16-23). The gluteus
maximus muscle is mobilized extensively along its
inferior border and retiacted superom.edially. This
maneuver exposes the proximal portion of the bi-
ceps femoris muscle and the sciatic nerve. The ad-
ductor magnus muscle is exposed in the deep wound
by retracting the biceps femoris muscle medially.
Gentle medial retraction of the sciatic nerve may
be required to improve visualization of the adductor
magnus muscle at this level.12 The distal segments
ofthe deep femoral artery are exposed by making a
longitudinal incision in the adductor magnus mus-
cle, using the muscular openings for the perforat-
ing branches as a guide (Fig. 16-24). Full exposure
requires longitudinal division of the adductor bre-
vis muscle lying just beneath the adductor magnus
muscle in this approach (Fig. 16-25).
VM
s
Vl
VESSELSOFTHETHIGH I 447
References 7. Valentine RJ. Harvesting the superficial fem-
oral vein as an autograft. Semin Vase Surg.
1. Veith FJ. Alternative approaches to the deep femoral, 2000; 13:27-31.
popliteal, and infrapopliteal arteries in the leg and 8. Smith ST, Clagett GP. Femoral vein harvest for vas-
foot: part I. Ann Vase Surg. 1994;8:514--522. cular reconstructions: pitfalls and tips for success.
2. Chung J, Clagett GP. Neoaortoiliac system (NAIS) Semin Vase Surg. 2008;21 :35-40.
procedures for the treatment of infected aortic graft. 9. Darling RC ill, Shah DM, Chang BB, et al. Can
Semin Vase Surg. 2011;24:220--226. the deep femoral artery be used reliably as an in-
3. D' Addio V, Ali A, Tim.aran C, et al. Femorofemo- flow source for infrainguinal reconstruction?
ral bypass with femoropopliteal vein. J Vase Surg. Long-term results in 563 procedures. J Vase Surg.
2005;42:35-39. 1994;20:889-895.
4. Brahm.anandam S, Clair D, Benja J, et al. Adjunc- 10. Naraysingh V, Karmody AM, Leather RP, et al. Lat-
tive use of the superficial femoral vein for vascular eral approach to the profunda femoris artery. Am
reconstructions. J Vase Surg. 2012;55:1355-1366. J Surg. 1984;147:813-814.
5. Jackson MR., Ali AT, Bell C, et al. Aortofem.oral 11. Nunez AA, Veith FJ, Collier P, et al. Direct ap-
bypass in young patients with premature atheroscle- proaches to the distal portions of the deep femo-
rosis: is superficial femoral vein superior to Dacron? ral artery for limb salvage bypasses. J Vase Surg.
J Vase Surg. 2004;40: 17-23. 1988;8:576--581.
6. Modrall JG, Hocking JA, Timaran CH, et al. Late 12. Bertucci WR. Maim ML, Veith FJ, et al. Posterior
incidence of chronic venous insufficiency after deep approach to the deep femoral artery. J Vase Surg.
vein harvest. J Vase Surg. 2007;46:520--525. 1999;29:741-744.
Supra-
genlculllte
~----Superior
genicular
branches
Mid- ~---Muscular
poplltaaf branc:hal
"""----lnfenor
genlcular
branches
Infra-
geniculate
449
Because the relationships of the adjoining of va:rying thickness known as the fascia lata
segments of artery and the muscle groups attach- (Fig. 17-2). It is particularly thick along the ilio-
ing around the knee are vital to understanding tibial band of the lateral thigh and around the knee
the approaches to the popliteal arte:ry, they are in- joint, where it serves as a retinaculum holding the
cluded as an integral part of the following anatomic hamstring tendons and the origins of the gastroc-
description. nemius muscle snugly around the popliteal neuro-
vascular bundle.
Two prominent septa connecting the fascia lata
to the supracondylar lines of the femur divide the
Beneath skin and superficial fascia, the lower quadriceps muscle of the thigh from the adductor
extremity is wrapped in an aponeurotic girdle muscles medially and from the hamstring muscles
~
~ 2~~~~~Superficial
femorala.
~-=H-- Adductor canal
~~+-Medial
intermuscular
Vastus septum
Intermedius m. --l!-'4-~~-:.~ Fasciala1a
Vastus lateralis m.-~~~~::-~
~---'~- vastus
medlallsm.
Deep femoral a.
~--Adductor
longus m.
Superficial
femoral a. --+-+----:--=::!~ Adductor
magnusm.
"'*'=H!-- Adductor
hiatus
Adwctor tubercle
Fig. 17-l The anterior quadru:eps II1U8Cle group and the medial adductor muscles of the
thigh cradle the superficial femoral artery at their common border.
POPLITEALAIUERY I 451
Several centimeters above the adductor tubercle, the The deep head of the biceps muscle originates from
tendon ofthe adductor magnus splits to fonn the ad- the lower third of the lateral lip of the linea aspera
ductor hiatus through which the superficial femoral and joins the superficial head to insert on the head
artery and vein pass to become the popliteal vessels. of the fibula. The semimembranosus muscle inserts
The hamstring muscles of the posterior thigh into the posterior lip of the medial tibial condyle.
originate at the ischial tuberosity and separate into The semitendinosus muscle, along with the gracilis
the medial semimembranosus and semitendinosus and sartorius muscles, insert on the anterior aspect
and the lateral biceps femoris muscles (Fig. 17-4). of the medial tibial condyle.
Addue!Dr
~~+--Biceps
femorism.
(short head)
A B
Fig. 17-4 The hamstring muscles of the posterior thigh fi:Bme the upper borders of the
popliteal fossa.
Small saphenous v.
((; ,
Fig. 17-5 The heads of the gastrocnemius muscle interdigitate with the insertions of the
hamstring muscles and form the lower borders of the popliteal fossa. The gutrocnemius
muscle is supplied by sural branches from 1he midpopliteal artery.
POPLITEALAIUERY I 453
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artery, which pierces the subsartorial fascial sling
along with the saphenous nerve (Fig. 17-6). The su-
At the distal end of the adductor canal, the superfi- perficial femoral vessels pass through the adductor
cial femoral artery gives off the highest genicular hiatus to reach the popliteal space.
Fascial root
of adductor
canal------!!--- - -...,...-
Highest
gericulara.----! -___;,_ _ _,..__~~
Saphenous n.----l~--....,.....,....=-...;.\
Adductor
hiatus -----7=""'!-"""'":~~~
Flg.17-7 The popliteal vessels are enclosed in a fum fibrous sheath and are separated by
a fat pad from the posterior face of the femur.
POPLITEALAIUERY I 455
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Muscular branches of the proximal popliteal sural vessels, arise from the midpopliteal artery and
artery to the lower hamstring muscles anastomose pass to the heads of the gastrocnemius muscle with
with terminal branches of the profunda femoris ar- the sural branches of the tibial nerve.
teiy (Fig. 17-8). Additional muscular branches, the
Hamstring branches
communicating with
deep
Descending
musculoarticular /..1/f.l:*-- - - Bleeps femoris m.
branch of highest
(short head)
genicular a.
Semitendinosus m. --!i:-:M!!i!-+.
~-----Gastrocnemius m.
Gracilis m. -~,ruu
t-"~~~ ~-----Medial gericulara.
OI:Jiique poplitllallig. ~~~~!-----Sural branches
to gastrocnemius m.
Fig. 17-8 The popliteal artery gives rise to muscular and articular branches.
Lateral femoral
circumflex-----:~
+----Femoral a.
Branches to
hamstrings--~~~
Fig. 17-9 The network of popliteal branches around the knee makes important collatual
CODII.e(;tiODS proximally and distally.
POPLITEALAIUERY I 457
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The short distal segment of the popliteal through a hiatus in the origin of the soleus
artery lies between the heads of the gastrocne- muscle.
mius and popliteus muscles (Fig. 17-8). There The path of the popliteal vessels behind the
are no major branches from this segment, and it knee can be visualized by dividing and reflecting
is approachable from both the medial and lateral the posteromedial thigh muscles and the medial
sides of the leg. The popliteal artery disappears head ofthe gastrocnemius muscle (Fig. 17-10).
Sanorius m.
Semitendinosus m. Gracilism.
Flg.17-10 Division of muscular attacbmeots on the medial side of the knee exposes the
full length of1he popliteal artery.
POPLITEALAIUERY I 459
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vip.persianss.ir
suprageniculate popliteal artery for patients who are
undergoing secondary vascular operations, when
This section of the popliteal artery is the preferred infection or smgical scarring render the medial ap-
position for the distal anastomosis of a femoropop- proach inconvenient.
liteal bypass, providing that the arterial tree below
this level is devoid of flow-limiting stenoses. Sur- Technique t11Medft4 Sllpfflffllit:JJhltt Expasure
geons generally favor autogenous tissue, such as The patient is placed in the supine position with
the saphenous vein, for the bypass graft. The use of the leg externally rotated and the knee flexed 30
synthetic graft material for bypasses to the popliteal (Fig. 17-12). The entire leg should be shaved and
artery above the knee is also acceptable,1- 3 but the prepped to facilitate movement during the dissection
ischemic consequences of a failed bypass are wmse and to ensure that other areas are available for dis-
with prosthetic graft than with autogenous vein.4 section should the popliteal arteiy prove inadequate.
The suprageniculate popliteal artery is most An incision is made in the distal third of the me-
easily approached through a medial incision. dial thigh along the anterior border of the sartorius
Veith et al.' popularized a lateral approach to the muscle.
Fig. 17-12 The incision for medial suprageni.culate exposure lies along the anterior border
of the sartorius muscle.
Adductor magnus
tendon
Semimembranosus m. Saphenous n.
superior genicular a.
Fig. 17-13 With the sartorius and gracilis muscles :ret:mcted posteriorly, the adductor mag-
nus tendon is separated from the semimembranosus muscle to expose the popliteal vessels
as they emerge through the adductor hiatus. The saphenous nerve and superior genicular
artecy emerge through the roof of 1he adductor canal and cross the edge of the adductor
magnus muscle to reach the cleft between the sartorius and gracilis muscles.
POPLITEALAIUERY I 461
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vip.persianss.ir
hiatus (Fig. 17-14). Fascial connections between opening the sheath. The vein is often paired,
the adductor magnus tendon and the medial inter- and connecting channels that bridge the artery
muscular septum anterior to it may require division must be carefully divided to obtain exposure
to expose the anterior surface of the adductor hia- (Fig. 17-15).
tus. Care should be taken to preserve the highest Grafts to the supmgeniculate popliteal artery
genicular artery and the saphenous branch of the are best brought through the adductor canal with a
femoral nerve. A tough fibrous sheath envelops the blunt tunneling instrument (Fig. 17-16). The graft
popliteal artery and vein. is thus situated in a natural anatomic plane where it
The artery is situated medial to the vein at is protected by the sartorius muscle and overlying
this level and therefore is encountered first on fascia lata.
Deep fascia
MeclallntermusctJiar
septum
Fig.17-14 The adductor magnus tendon can be divided to expose 1he proximal popliteal
vessels more completely. There is a fascial connection between the distal adductor tendon
and the medial intramuscular septum that must be divided to obtain 1he exposure shown.
Fig. 17-15 Within the vaswlar sheath, the artery must be carefully sepa:rated from sur-
rounding veins. Mobilization must be adequate for safe exposure and may be aided by the
use of soft vessel tapes.
POPLITEALAKI'ERY I 463
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vip.persianss.ir
Tfdlniqw flfl.ldmi Supmgmkullltf ApptotKb origin ofthe short head ofthe biceps femoris muscle
The leg is internally rotated and flexed at the knee ends several centimeters above the lateral femoml
(Fig. 17-17). A longitudinal incision is made in the condyle, leaving a loophole6 between muscle and
distal third of the thigh between the biceps femoris bone through which the vessels may be reached
muscle and the iliotibial tract. The fascia lata is in- (Fig. 17-19).
cised posterior to the junction of iliotibial tract and When this space is opened, the tibial and pero-
lateral intermuscular septum. An incision that is too neal nerves remain in a posterior plane bound to the
anterior leads into the vastus lateralis muscle in front hamstring muscles by loose fascia, and the vessels
ofthe lateral intermuscular septum (Fig. 17-18). The are found directly beneath the femur (Fig. 17-20).
Laterallntermusct~lar
septum
Iliotibial band
..
Biceps femoris m.
Short head----.../
Long head _ _ _ ___,
Bleeps femoris m.
Semimembranosus m. --:~~.,f.
Tlblal n. --!-'----~
Fig. 17-20 Above the knee, the tibial and
peroneal nerves are separated from the proxi-
mal popliteal vessels by loose fil.sda bridg-
ing the hamstring muscles. They are retracted
Semitendinosus m.
posteriorly wi1h the muscles in the lateral
approach to the vessels.
POPLITEALAIUERY I 465
The popliteal vein (which may be paired) is encom- with atherosclerotic plaque. The preferred conduit is
tered first in the vascular sheath. It is mobilized and ipsilateral saphenous vein, which has superior long-
retracted posteriorly with the biceps femoris muscle term patency compared with prosthetic graft.7 When
(Fig. 17-21). ipsilateral saphenous vein is unavailable, suitable
alternatives include contralateral great saphenous
E.rptlsu~e tlfthe lnfrtlgenkulllft Pop/JtetllArtery vein, arm vein, or spliced small saphenous vein seg-
ments. In the rare patient without suitable autoge-
The infrageniculate popliteal arte:ry is used more nous vein, use of prosthetic graft or endovascular
commonly in bypass surgery than the proximal pop- options may be preferable to amputation, even for
liteal segments because it is less likely to be involved TASC DD lesions.8--to
Fig. 17-21 The popliteal vein is encouutered first in the vascular sheath and is best
:retr:Bcted postmorly with the biceps muscle.
Flg.17-22 The incision for the medial infrageniculate approach lies approximately 1 em
behind the posterior border of the tibia. The proximity of the saphenous vein requires
careful dissection. The vein usually remains with 1he posterior flap.
POPLITEALAIUERY I 467
the tibia and is most conveniently retracted with the aspect of the incision (Fig. 17-24). More proximal
posterior wound edge. Anterior perfOiating branches exposure can be obtained by dividing the tendons of
from the saphenous vein may require ligation to en- the semitendinosus, gracilis, and sartorius muscles,
sure safe retraction. but the divided ends should routinely be marked
The crural fascia is incised 1 em posterior with suture tags and reapproximated at the end
to the tibia, and the fascial incision is extended of the procedure to preserve knee stability. More
proximally to the level of the semitendinosus distal ex.posure can be obtained by dividing the
tendon (Fig. 17-23). The underlying medial head of tibial attachments of the soleus muscle, which lies
the gastrocnemius muscle is retracted posteriorly, deep to the gastrocnemius muscle in the incision
exposing the neurovascular bundle in the proximal (Fig. 17-25).
Gastrocnemius m.
(medial head)
Fig. 17-23 A&r the a:ural fascia is incised, the underlying medial head of the gastrocne-
mius muscle is retracted posteriorly.
///J4JJJ; /j / ""
Anterior tibial a.
Rg. 17-26 The first structure encountered on eutering the neurovascular sheath is one of
the paired popliteal veins. After careful ~on, the artery is elevated into 1he incision
using soft v~el tapes.
Fig. 17-27 Grafts to the infrageniculate popliteal artery should be routed through the
adductor canal and tunneled posterior to the knee between the femoral condyles and
heads of the gastrocnemius muscle.
POPLITEALAIUERY I 471
overincision for thexi~=d of the fibula.
infrageniculate
Fig. 17-28. the head and pro
approach liesThe
Deep peroneal n.
SUperficial peroneal n.
Fig. 17-30 The peroneal nerve with its deep and superficial branches is carefully retracted
away from the fibula. The biceps tendon and fibular collateralligameut are divided to be-
gin mobilization of the head of the fibula.
POPLITEALAIUERY I 473
The upper third of the fibula is then removed deep to the fibula is enhanced by retracting the freed
from its bed This is most easily accomplished by fibular head into the wound (Fig. 17-31). The fibular
dividing the ligamentous attachments of the fibular shaft can then be transected with no shears and the
head and shaft, staying close to the bone. Blunt dis- bone removed from its bed. The popliteal artery is
section ofthe muscular and ligamentous attachments encountered just deep to the fibular bed (Fig. 17-32),
Rg.17-S1 The proximal thild of1he fibula is stripped of attachments to the soleus and pero-
neus longus muscles. A periosteal elevawr may aid in the disarticulation ofthe tibiofibularjoint.
Tmnssection of the fibular shaft with rib shears is aided by elevation of the proximal fibula.
Soleus m.
Gastrocnemius m.
Fig.17-l2 The lataal infrageniculate approach exposes 1he distal popliteal a:rtery and its
branches.
POPLITEALAIUERY I 475
and its superficial location facilitates separation from from the femoral artery are brought across the an-
the adjacent vein {Fig. 17-33). terior thigh {Fig. 17-34). To prevent kinking, grafts
Grafts brought to the popliteal artery using this should be routed such that they cross the knee at the
approach are best routed subcutaneously.SSypasses midpoint ofthe lateral femoral condyle. 11
Interosseous membrane
Fig. 17-33 The vessels are found deep to the fibular bed and posterior to 1he interosseous
membrane.
Fig. 17-34 The most direct route between the femoral vessels and the lateral infragenicu-
late incision is a subcutaneous path across the anterior thigh.
POPLITEALAKI'ERY I 477
the muscle boundaries of the popliteal fossa. The
need to reposition patients intraope.ratively adds to
There is a group of disorders peculiar to the sec- the inconvenience of this approach for procedures
tion of the popliteal artery that traverses the knee involving arterial bypasses.
joint (midpopliteal artery). These disorders include
popliteal entrapment syndrome, cystic adventitial TfchnlqwllfPostftlorApprNth
disease, and traumatic intimal flaps :from posterior The patient is placed in the prone position with
knee dislocations. Anewysms may sometimes be the knee slightly flexed. An S-shaped incision is
confined to the midpopliteal artery, allowing a rela- preferred to avoid the deforming scar contractures
tively limited dissection for correction ofthe pathol- associated with simple vertical incisions across
ogy. The posterior approach may also be useful in the posterior knee (Fig. 17-35). The superior lon-
cases of reoperative arterial swgery. 12 gitudinal portion of the incision is made on the
The use of the posterior approach is contra-
indicated in procedures designed to correct more
diffuse vessel pathology. Exposure of the suprage-
niculate and infrageniculate arteries is hampered by
Fig. 17-35 The incision for posterior exposure of the popliteal vessels is S shaped to
minimize scar contractures associated with simple vertical incisions.
Fig. 17-36 The small saphenous vein is identified in the subcutaneous tissuejust superficial
to the deep fascia.
POPLITEALAIUERY I 479
medial sural nerve is retracted for clear access to biceps femoris tendon obliquely toward the head of
the major neurovascular structures (Fig. 17-37). the fibula. Distal exposure may be enhanced at this
The tibial nerve is the most superficial major mid- point by retracting the two heads of the gastrocne-
line structure, and the peroneal nerve follows the mius muscle apart; this may require vertical division
Medial sural n.
Popliteal a. ----~--+-----tt;--f-,~
Popliteal v. ----~~~-fh""""'*~
Tlblal n. ------+--;r----o:;~~~
Fig. 17-37 A vertical incision of the deep fascia exposes 1he coDteDts of the popliteal
space. The medial sural cutaneous nerve should be divided for clear access to the major
neurovascular structures.
PopiHeala. --------t-.::-"""""-!it-~
Small
saphenous v.
(dMc:led) ----~-!-<H~+
Fig. 17-38 The tibial nerve is the most superficial major midline structure and should be
retracted laterally to expose the ensheathed popliteal vessels.
POPLITEALAIUERY I 481
References 7. The TransAtlantic Inter-Society Consensus (TASC)
Working Group. Management of peripheral arterial
1. Takaqi H, Goto SW, Matsui M, et al. A contemporary disease (PAD). J Vase Surg. 2000;31 :S217-S225.
meta-analysis of dacron versus polytetrafluoroethyl- 8. Parsons RE, Suggs WD, Veith FJ, et al. Polytetraflu-
ene graft for femoropopliteal bypass grafting. J Vase oroethylene bypasses to infrapopliteal arteries with-
Surg. 2010;52:232-236. out cuffs or patches: a better option than amputation
2. '!Wine CP, McLain AD. Graft type for femoropop- in patients without autologous vein. J Vase Surg.
liteal bypass surgery. Cochrane Database Syst Rev. 1996;23:347-356.
2010;12:CD001487. 9. Baril DT, Marone LK, Kim J, et al. Outcomes
3. Van Det RJ, Vriens BH, van der Palen J, et al. Dacron of endovascular interventions for TASC IIB
or PTFE for femoro-popliteal above-knee bypass and C femoropopliteal lesions. J Vase Surg.
grafting: short-and long-term results of a multicen- 2008;48:627-633.
tre randomized trial. Eur J Vase Endovasc Surg. 10. Baril DT, Chaer RA, Rhee RY, et al. Endovascular
2009;37:457-463. interventions for TASC TID femoropopliteallesions.
4. Jackson MR., Belott TP, Dickason T, et al. The con- J Vase Surg. 2010;51:1406-1412.
sequences of a failed femoropopliteal bypass graft- 11. Ouriel K, Rutherford RB. Femoral infrapopliteal
ing: comparison of saphenous vein and PTFE grafts. bypass with contralateral saphenous vein. In:
J Vase Surg. 2000;32:498-505. Ouriel K, Rutherford RB, eds. Atlas of Vascular
5. Veith FJ, Aster E, Gupta SK, et al. Lateral approach Surgery: Operative Procedures. Philadelphia, PA:
to the popliteal artery. JVasc Surg 1987;6:119-123. WB Saunders; 1998:34-39.
6. Henry AK. The backofthethighand the leg. In: Henry 12. Gelabert HA, Colburn MD, Machleder HI. Posterior
AK, ed. Extensile Exposure, 2nd ed. Edinburgh, exposure of the popliteal artery in reoperative vascu-
England: Churchill Livingstone; 1973:241-259. lar surgery. Ann Vase Surg. 1996; 10:53-58.
~~++-~---Interosseous membrane
~~~'++---- Postertor tibial a.
~L../o.ll.l~!---- Peroneal a.
Superior
peroneal
retinaculum ---+-+-~..,..
Inferior
peroneal
retinaculum ---+-+--L--
Fig. 18-2 A, B: Thickened bands of the dense crural fascia form restraining retinacula at
1he ankle over the extensor, flexor, and peroneal tendons. The two principal neurovascular
bundles lie beneath the extensor and flexor Ietinacula.
Flexor
re1fnaculum
~~~----~~~s
membrane
Superficial
posterior
compartment-----+~~ ~~-1-+------ Deep posterior
Lateral compartment
compartment----+-+--~_.
~-!-------Anterior
compartment
Rg. 18-3 Strong septa between the crural fascia and the bones of the leg separate the leg
into discrete compartments.
c-----~~~~~-1-:'--Anterlor
tibial a.
Peroneal a.--+------!-/
Posterior
tibial a. ----:tt~~~'LJJ
Fig. 18-4 The major arteries ofthe leg lie in the anterior and deep posterior compartments
and supply adjacent compartments through perforating branches.
Deep
peroneal "j~::::=~;;:::=-::tfj
Superficial
peroneal n.-+-~-~~
Posterior
tibial n. - + - - - --11-H
Lateral
compartment
Superficial
posterior
compartment
Fig.18-7 A septum of each compartment attaches tu the fibula, allowing universal com-
partment decompression by fibulectomy.
~.....,#.-Flexor
digitorum
longusm.
Flg.18-l The powerful gastrocnemius and soleus muscles occupy the superficial poste-
rior compartment of1he leg.
P~f--- Anterior
tibial a.
Tlbloperoneal------l~~~
trunk
Posterior
tibial a. -----+-!-~Hl
Flexor
dlgltorum
longus m. --~_,_.;~
hallucls
longusm.
a.'-r'--+-H- Flexor
retinaculum
Lateral
plantar a.
Flexor hallucis
brvvis m.
Abductor
hallucls m.
Fig. 18-10 Tendons of1he plantar flexor mUJCles pass behind the medial malleolus under
the flexor retillJiculum.
Peroneal n.
Anterior
tibial a. & v.
&deep
peroneal n. ~"""":!-~
Extensor
~~~~-dlgltorum--~
longusm.
Extensor
' ~~l+--halluc:la
longusm.
SUperior
peroneal
retinaculum Dorsalis pedis a.
Peroneus
tertius m.
Flg.18-12 Tendons of1he dorsiflexors are held at 1he allkle and foot by the superior and
inferior extensor retinacula.
Rg.18-1l Tendons of the foot evertors pass behind the lateral malleolus.
~-"":"'lil~--Anterior
tibial a.
Deep
peroneal n. ----~~=t
~!::'--Soleus m.
Soleusm. (fibular origin)
(tibial
~~~~-==~~Peroneal a.
origin)-~~
Flexor hallucls
Posterior ~~----longusm.
tibial a.--~~~
FlK:ia
of deep---.-.....:~ ~
posterior
compartment
Flexor digitorum -~~
longusm.
Peroneus
longusm.--~----~~-
Fig. 18-17 The path of the peroneal nerve and its branches is dissec;ted free of overlying
muscles to protect 1he nerve during mobilization of the fibula.
Fig.18-18 Along flap ofperoneal muscles is created by shaving the muscles offthe fibula
distally to proximally. The interosseous membrane strips best in the opposite direction.
Antertor
tibial a.
Lateral
compartment
Superficial
peroneal n. --+--Hf--+.g
Peroneal a.
Superficial
posterior
compartment
Flg.ll-19 In the midclllf: the neurovascular structures are grouped in 1he central portion
ofthe leg.
Deep peroneal n.
"nblalls
Anterior tibial a.
Extensor hallucls
longus
Superficial
peroneal n. br.
Sural n.------~-~~,.,(~~~~:)~
Small saphenous v.--~:--1!~'\)l l
Achilles tendon
Fig. 18-20 In 1he distal leg, 1he anterior and posterior tibial neurovascular structures
become more superficial.
Extensor
halluels
longus Deep peroneal n.
Dorsalis peels a.
Tibialis
anterior Peroneus tertius
Gruat
saphenous v.
Flexor
clgltorum
longus ~l~~~'-+-- Pel'lli'IGUS brevis
~~~V::~:::_+- Sural n.
Small saphenous v.
"nblal n.
Rg.18-21 Cross section demonstrates the anatomic relationships at the level ofthe ankle.
RIGKTLEG
MEDIAL
Soleus m.
(tibial head-~-.:.:.-~~
cui)
Tibialis
posterior m. -~-~~~~=
Flexor
dlgltol\lm
longus
1
Extensor \ \ .1
digilorum _lLl
longusm. _ j
Peroneus
longusm.
Peroneus
brevis m.---~-
Anterior
~--Superior
1ibial a . - - - --+!::--::-.1:--:=::"""':':!!
extensor
retinaculum
Inferior
ax1ansor
retinaculum----!!----+-
Fig. 18-21 The dorsalis pedis artery and deep peroneal nerve emetge at the ankle between
the tendons of the extensor digitorum longus and extensor hallucis longus muscles.
A-~DNm
longusm. ~l\
Flexor hallucls
longus m. - - --+.::---:----:-,...-:--
Tibialis
-=-- Peroneus
longusm.
posterior m. --~"-+
~~!+-- Peroneus
bi9Vism.
Fig. 18-24 The posterior tibial artery and tibial nerve lie posterior to the medial malleolus
in a groove between the flexor digitorum longus and flexor hallucis longus tendons.
Flexor hallucls
longus m.--~~~~~
Fig. 18-25 The peroneal a:rtery lies on the interosseous membrane on the medial side of1he fibula.
Perforating - - - f - ---7
br. ~.:---+-- Anterior
medial
malleolar a.
Antarlor
lat&ral
malleolar a.
Celcaneai---F--11-
plaxus
Lateral Medial
plantar a. plantar a.
Deep
"t----~- plantar
Arcuate a.
br.
Medial
plantar a.
Medial
tarsal a's.
Extensor
hallucls
longus --~-+
~ ~~~~~~'*"*~"~-- Extensor
cilgltorum
Extensor longus
hallucls tendons
b~sm.--~~~~
Arcuate a.
Tibialis
anterior ----+--\~
Medial
tarsal a. --~!:!!
tarsal a.
Dorsalis
pedis a. -----if-+.-~:-:.!1
~+-- Extensor
cigitorum
brevis m.
Tibialis
posterior - - - - - 1 : -\
Flexor
cilgHorum longus --~~
Posterior tibial a.
Tibial n.
Fig. 18-28 The dorsal foot arteries lie deep to
the extensor tendons of the wes.
Tibialis posterior m.
Posterior tibial a.
Flexor
retinaculum
Flexor
dl~rom
Quadrlllus brevis m.
plantae m.
Fig. 18-29 The lateral plantar artery courses deep to the flexor digitorum brevis muscle
and pierces the first metatarsal intmpace to anastomose with the deep plantar branch of
the donalis pedis.
-4--!!!~+-.1:--- Posterior
1lblala.
:;i;:!~~hi!-~f-- Flexor
clsjtorum
longus
Flexor hallucfslongus
~JI"J~ Flexor dlgltorum longus
'r1p Medial plantar a.
-+.+--Flexor
hallucis
longus
Adcl.ictor
halluclsm.
(oblique
_.,, 7'<. ....,..... ....,,,!,;--.=~;~ --.f.-~H!H-- head)
' ""='~-"
=-~~!-- Flaxor
",\'/A J~-.r.~~, hallucis
brevis m.
Abcl.ictor
hallucism.
Lateral
plantar a.
Quadratus ~~Tibialis
~~-Flexor
digitorum
Plantar brevlsm.
aponeurosis ---+~+-\\
Tibialis
ant&rlor m.
Small
sephenou v.
Fig. 11-32 Medial approaches to the posterior tibial artery also provide access to the great
saphenous vein when performing an in situ bypass.
Fig. 18-S3 The approach to the proximal posterior tibial artery first requires separation of
the gastrocnemius and soleus muscles to expose 1he distal poplitealii.I'tery penetrating the
origin of the soleus.
Fig. 1&-14 Division ofthe tibial origin of the soleus exposes the underlying proximal leg vessels.
VESSELSOFTHELEG I 517
The tibioperoneal trunk bifurcates approxi- the posterior tibial artery may be isolated and pre-
mately 2.5 em beyond the anterior tibial artery, al- pared for bypass at any point distal to the bifurcation
though this is variable. 12 The proximal segment of (Fig. 18-35).
Posterior
tibial a.
Rg. 1&-SS Careful dissection and judicious ligation of sw:tounding veins allow exposure
and isolation of1he posterior tibial artery.
Posterior
ttblala.
Fig. 18-36 The incision for approaching the posterior tibial artery in the midleg is illus1rated.
Fig.18-37 The posterior tibial artery is found on the surfilce ofthe flexor digitorum.longus
muscle benemh the thin fascia enclosing the deep posterior compartment The extensive
mobilization shown in the cross section for purposes of illustration would not be done
clinically to preserve important collateral branches.
Fig. 18-38 The incision for posterior exposure of the posterior tibial artery should be
IIlBde direaly over the small saphenous vein.
Tibia-
peroneal
trunk
Posterior
tibial a.
Fascia of
deep posterior
oompartmerrt
Flexor hallucis
longus
----+r::::::::""rlliifii'lllhl/
Anterior
~~r+--- medial
Peroneal a. malleolar a.
perforating -------+-fff!-~1:7
branch
Anterior ------~~\?[~
lateral
malleolar a.
Fig. 18-43 At the ankle, the anterior tibial artery crosses 1he anterior tibial surface beneath
the extensor retinacula.
Flg.1HS The medial approach to the peroneal artery uses 1he same incision as the medial
approach to the posterior tibial artery.
Flexor
digitorum
Tibia longus m.
~~~~JT~r--------- ~e~~
tibial a.
Soleusm. Flexor
hallucls
longusm.
Fig.18-46 By retracting the posterior tibial vessels and nerve posteriorly with the soleus
muscle, the deeper lying peroneal artery anterior to the flexor hallucis longus muscle is
exposed.
Flg.18-47 The peroneal nerve is isolated in preparation for the lateral approach to the
peroneal artuy.
Fig.18-48 The peroneal muscles aJ:e elevated to expose the fibula for excision.
Fig. 18-49 The proximal peroneal artery is located deep to the fibular bed.
Peroneal a.
Lateral
Tibialis
posterior
Flexor
hallucis ---\f-----\-'1'--if'~
longus
Achilles tendon
Peroneal a.
Flexor
dlgltorum
longus
Felxor
hallucis
longus
Extensor Anterior
hallucIs
longus
Extensor
dl~rum
1Qr1JU8 --.f.-1.1;"91
Flexor
dlgltorum
longue ---1---1-.!li----~~
Celcaneal
tendon
Posterior
Flexor tibial n.
hallucia
longus-------,r-~~~~~~,;_,.~
Fig. 11-51 The posterior tibial artery is found just deep to the crural fascia at the ankle and
is easily accessible for distal bypass (Cl'OS8 section of right leg. caudal view).
Posterior tibial a.
Flexor retinaculum
Latllral plantar a.
Medial plarrtar a.
Fig. 18-52 The ~i.sion for exposure of the posterior tibial artery branches is shown.
Flexor digitorum
longusm.
Flexor hallucis
longusm.
Abductor
hallucfsm.
(cut)
Fig. 18-53 The bifurcation ofthe posterior tibial artery is located on the superior border of
1he abductor ballucis muscle.
Superficial
peroneal n.,
moo~~..------~--~~~
branch
Lateral Mool.aJ
1Brsal a. -----e~,.,.,_~'---HI 1arsal a.
Deep
peroneal n.-------~~--....,...J~~ .
,~~ i-t'~----------- Extensor hallucis
Extensor----.......:~_,..~--:;;;;~..,.. longus tendon
hallucla
brevis m.
Arcuate a.
Fig. 18-54 The dorsalis pedis artery is exposed between the extensor hallucis longus
tendon and 1he extensor ballucis brevis muscle.
541
tahir99 - UnitedVRG
vip.persianss.ir
subclavian artery arising as the fourth branch of the
aortic arch. This vessel most commonly passes pos-
AlltlcAtrll terior to the esophagus and may cause esophageal
Anomalies of the aortic arches are rare and are usu- compression and dysphagia (dysphagia lusoria).3
ally the result of atypical segmental regression of Regression of the distal left arch results in a
the paired arches present at approximately the sev- right-sided aortic arch that is the mirror image of
enth embiyonic week1 (Fig. 19-1). Many of these the common pattern (Fig. 19-2C), and regression
anomalies are asymptomatic and are discovered in- of the left carotid-subclavian segment results in a
cidentally. Aortic rings, for example, are often to- right arch with an aberrant left subclavian a.rtery4
tally asymptomatic but may cause dysphagia and (Fig. 19-20). Partial persistence of any of the in-
dyspnea in the neonatal period. voluted segments as a hypoplastic channel or fi-
Aortic arch anomalies have been classified brous band results in a vascular ring surrounding
into four groups and 24 subgroups by Stewart et the trachea and esophagus. In addition, connec-
al 2 The variety of forms seems confusing at first tion of the sixth arch to the dorsal continuation of
glance but yields to logical analysis when one con- the fourth arch may persist on one or both sides,
siders the segments of the paired fourth arches that adding a variety of ductus arteriosus anomalies to
involute (Fig. 19-2). Regression of the distal seg- the basic aberrant arch patterns. The mirror image
ment of the right fourth arch results in the normal variants of each of these patterns accounts for the
pattern ofthe brachiocephalic, left common carotid, number of described anomalies. Although some
and left subclavian arteries arising from a left-sided variations of aberrant aortic arch branch patterns
arch (Fig. 19-2A). Regression of the right arch seg- are consequences of basic arch anomalies, many
ment between the common carotid and right subcla- others are seen with the common form of a simple
vian arteries (Fig. 19-2B) results in an aberrant right left-sided arch.
Fig. 19-1 Aortic arch anomalies usually result from disturbances of normal segmental
regression of the paired aortic arches in the 7-week. embryo.
Transverse lhyrocei'Yical
cervical a. trunk lntemal
1tloraclc a.
Suprascapular a.
Costocervical
Lateral
1tloracic
a.
Fig. 19-3 Collatual channels through Kapular and chest wall vessels enlarge in response
to the pressure gradient created by an aortic coazdation.
64.9%
2.5%
1.2%
~
1.1%
Fig. 19-4 In addition to 1he common aortic arch branch pattern, origin ofthe left common
clll'otid from 1he bracbiocephalic and left vertebral artery origin from the arch comprise
almost 95% of all lll'Ch patterns.
Fig. 19-5 When the right subclavian artery arises distally, it passes behind or between
1he 1rachea and esophagus to reach the right side (posterior view). The passage of the
subclavian artery through the scalene muscles may vary.
7%
88% C6
'\
\
'\
\ \
'
7%
Superficial arch
34%
13%
4%
Deepan::h
36%
13%
83%
12%
5%
0.01%
83%
11%
5%
0.02%
12%
10%
70%
8%
27%
13.1%
12%
4%
3%
Rg.lt-12 The right hepatic artery varies in position relative to the common hepatic duct
(top), and the origin and course of1he cystic artery vary (bottom).
75%
10%
5%
4%
Fig. 19-1l Anomalous gastroduodenal artery origins are often secondary to hepatic a:rtery
anomalies.
50%
()
Rg. 19-14 Variations in the origin ofthe right gastric artery are shown on a single hepatic
artery stem for simplicity.
Rl~
colic a. M
M ~
R -:; 0.4% L
Fig. 1t-15 Colic branches ofthe superi.ormeseuteric arteryvary by their absence ordup1i.cati.on.
72.1%
13% 11%
iJ 6%
~ 2.7%
~ 3%
Flg.19-17 Altern~ siws oforigin ofthe middle and inferior suprarenal arteries are shown.
Fig.19-18 The celiac trunk may be compressed by a low-lying median arcuate ligament.
Fig. 19-19 Compression of the duodenum by 1he superior mesenteric artery is poorly
understood.
Common
lilac a.
Internal
lilac a.
59%
Superior
gluteal a. (SG)
Internal JG
pudendal a. (P) 23%
p
~SG
p
k.
15%
1.2%
IG
Fig.19-20 Parietal branch patterns ofthe internal iliac artery are shown.
Common
iliac a.
Inferior
epigastric a.
External
iliac a.
20%
Superior gluteal a.
10%
Internal
pucienclala.
Fig. 19-21 Origins ofthe bigbly variable obturator artery include virtually every pelvic vessel.
Superior
gluteal a. _ _ ____,~,
Inferior
glutual a. ----..,...------1-~
Deep
Femoral a.
Fig. 19-22 Persistence ofthe sciatic artery may be associated with absence ofthe superficial
femoral artery.
60%
-+--- SUperficial
femoral a.
Medial
L818ral ---~ --femoral
femoral cirwmflex 8.
circumflex 8.
Descending
branch
12%
Genlctllate br.
Poetedor
tibial a.----uI!\r Peroneal a.
Anterior
tibial a. ----'t------.~~~.JJ.
Fig. 19-24 Branch patterns of the leg vessels include a high origin of 1he anterior tibial
artery that then passes deep to the popliteus muscle.
A B
Fig. 19-25 The nonnal popliteal co\U'Se is shown (A). The most common cause of
popliteal entrapment is medial displacement of the arteiy lll'ound a normal medial head of
the gastrocnemius muscle (B).
Flg.19-25 The vessel may be diverted by an abnormal muscle origin (C), pass 1brough the
muscle (D), or pass beneath the popliteus muscle (E).
Fig.19-25 (continued)
Absent
PT
(5%)
Rg.lt-26 Branch patterns ofthe leg arteries. In the most common form, the anterior tibial
and posterior tibial arteries are cODtinuous to the foot (A). Variations include the absence
of the posterior tibial artery with plantar vessels coDtinuing from the peroneal artery (B),
absence of 1he anterior tibial artery wi1h 1he dorsalis pedis artery continuing from the per-
forating branch of the peroneal artery (C). and the posterior tibial artery passing through
the interosseous membrane to join the anterior tibial artery, with plamar arteries cODtiuuing
from the peroneal artery (D).
DPfrorn
perfol81lng
br.af
peroneal Plantars
(4%) from peroneal
c D
Fig.19-26 (continued)
Fig. 19-28 Vena caval anomalies include doubling, left-sided position, and a circumaortic
renal venous collar.
16%
577
Scott-Conner CEH, Dawson DL. Operative Anatomy, Virtual Anatomy
Philadelphia, PA: Wolters Kluwer/Lippincott
Williams & Wilkins; 2009. http://www.visiblebody.com
Skandalakis JE, Skandalakis PN. Surgical Anatomy and http://www.anatronica.com
Technique. New Yolk, NY: Springer Sciences; 2008. http://www.interactelsevier.com/netter
Thorek E. Anatomy in Surgery, 2nd ed. Philadelphia, PA: http://www.anatomium.com
Lippincott Williams & Wilkins; 1962. http://www.primalpictures.com
http://www.anatomy.tv/default.aspx
http://www.nextd.com
Afusculoskeletal http://www.zygotebody.com/no_webgl.htrnl
http://www.3danatomy.co.uk
Hoppenfeld S. Surgical Exposures in Orthopedics: The https://www.biodigitalhuman.com/default.htrnl
Anatomic Approach. Philadelphia, PA: Lippincott
Williams & Wilkens; 1984.
578 I APPENDIX
Page numbers fOllowed. byfrekr to figures Antetlrachial euianeou.s nerve Axillary -vein, 79/, 120/, 137/, 13\f, 142/, 164/,
lateral,. 191if. 191/, 218/, 219/ 168f, 171{
A medial, 158/, 1~ 201/ development of, 13
posterior, 191/,219/ Axis, transverse process~ 71
Abdominal aorta, 236, 237-270, 350f Antegrade puncture, of fiml.oral artery, 407 Azygous vein, 79/, 83f, 87/, 244f
anatomic relationships of, 237-241 Anterior campartment, 475/, 5fflf development of, 16/, 17/
branches of, variation, 551 Anterola18ral thoracotomy, 101-104
coarctation, s51 in trap door thoracotomy, 105-108 B
exposu!.'e of, 24S-270 Aorta(s), 11/, 151if. 236/, 238/, 244f, 317f,
inftarenal 318/, 319/, 320/, 367{. See also Baroreceptors, 46
&xposu!.'e of, 323-335 Abdominal &Drill; Thoraci& aorta Basilar artery, S6f
intmperitoneel approach,. 323 deve!Dpml:nt of, 2, 4f. 8/, 17/ Basilic vein, 185/, 186/, 187f, 20 If
retropelitweal approach,. 323, darsal, 7-9, 11/ development of, 13
326-329 embl:yt:mic developJDnt of, 3/, 4f Biceps brachii muscle, 171if. 180/, 186/, 19lf.
transperi1oneal approuc:h, 323-326 ilrtl:rsegmental (dorsal and llm:ral) branches, 197/, 199/, 203/
surgical anatomy of, 315-323 7 lon,g head, 167/, 176/
r:etroperitoneal. relatialla'hips ~ 31~319 ventral viJlceral b.nmch,. 7 short head, 1S6f, 167f, 176/
supraceliac, 242-245 Aortil:: arch(es). 79/, 103/ Biceps brachii tendon, 193/
~ IZUitomy of, 237-245 branches of, exposure of, 9G-108 Biceps femoris muscle, 60/, 447/, 4S4f, 456/,
variations,SS1-S61 deve!Dpml:nt of, s-6, Sf, 6f 464j, 465/, 466/
Abdominal aortic aneuzysiDll, 323 primary branches of, variatioll8, S4S long heed, 431/, 4Slf. 46Sf
Abductor digiti millimi.m.uscle, 224.(, S14f Aortil:: bifurcation, 272/ shart head. 431/,452/, 456/, 465/
Abductor h.alluciJ muscle, 493/, 512/, 513/, Aortil:: plexus, 320/, 322/ Biceps femoris taldon, 471{
514{. S3Sj, S36/ Aortofemoral bypass, 415 Biceps m.uscle, 120/, 184f, 186/
Abductor pollicis longus m.uscle, 195/, anatomy of tunnel fur, 416-417 insertion, 176/
209/,225/ Apical growth rid,ge, 11f long.1S6/
Abductor pollicis longus tendon, 227/ Are ofRiolan. See Meandering mesenteric shart head. 172/
Accessory nerve, 32/, 36f, 37f, 39f, 48f, 70f artery Biceps tendon, 180/, 20lf. 473
Achille-s tencl.on. 503f, 533f Areuate artery, 509/,51(if. Sllf, S37f Bicipital aponeurosis, 180/, 199/,201/
Aeuie comp61'lmlmt syndrome, 209-210 Areuate ligament. median, 272/. 274f, 281/ Bi:rtb. cin:ulation at, 18, 18/
Adductor brevis muscle, 390f, 400/. Areuate line, 339/ Blood vessels
403f, 426/. 428/. 433f, 434f, Ascending pbaryngeal artery, 3Qf anatomic "Variations of, 541-574
435f,445f Atlantooccipi1al memhrane, 74, 74f development of, 1-14
Adductor canal (of Hunter), 434f, 440f, 450f posterior, 58f aortic arcb&S, 5-6, Sf, 6f
fascial roof of, 454f Atlas, transverse process of, 71 dorsal aorta,. 7-9, 7/, 8/, 9f
Adductor hllllucis muscle, oblique head, S14f Auricular artery, po618rior, 30f extremitie-s, IG-14, l(r, 11/, 12/, 13/
Adductor hiatus, 432/. 434f, 449/. 4S1f, 454f Auricular nerve, great, 32/ overview~ 1-2.1/
Adductor longus muscle, 390f, 394f, 40(if, Axial artery, llf primordial, 2-4, 2/, 3f, 4f
403f, 426/. 428/. 432/. 433f, 434f, Axilla Body stalk, lf. 3f
435f, 445f, 451/ fuaciae of, 159 Bookwalter retractor. See Omni retractor
Adductor m.agnus muscle, 40(if, 426/. 428/. muscular boundaries of, 156 Botulinum toxin A, 126
43(r, 431/, 432/, 433/, 434f, 435/, :zu:rves of, 15~159 Brachial artery, 162/. 176/, 177-187,
445/, 447/, 449/, 451/, 452/, 4S4f, .Axillary artay, 79/, 120/, 137/, 138/, 179/, 180/, 187/, 197/. 198/,
4SV,433/ 155-174, 162/, 164/, 168/, 201f, 203/
Adductor maguus tendon, 449/, 451/, 456/, 170/, 172/ deep, 157f, 181/, 182/
46lf, 462/, 46S/ anatomy of, 155-159 development of, 11/
Adductor muscle, 430/, 431/ branches of, 151 distal, exposure of, 20G-203
Adductor pollicis muscle, 224/ exposure of, 160-161 exposure of, 185-187
Adductor tubercle, 4S1/ axillmy approach to second and 1hird vuriations,S49-SS0
Adrenal, 9/ pam,167-169 Brachial cute:lleOus nerve, medial, 158/
Adrenal vein(s) covered steuts, 160 Brachialfucis, 1S9J, 177
devel.opmetrt ~ 16-17 deltopee1aral upproach. 17G-174 Brachial mUBcles, autmor, 179-180
left. 299/, 301/, 3SO/ inftaclavieular approach to first part, Brachial nerve, deep. 158/, 178/
rl',g1u, 299/, 3SQf 161-166 Brachial plexus, 24, 32/, SS/, 121/, 131if. 137/,
Allantois, 2/, 3/ injury, 160 138/,139/
Alveolar nerve, inferior, 36/ mobilization of, 1~166, 16-V cords
Amnion,2f sections of, 160 11111:ral, 116/, 158/, 172/, 176/
Amnionic cavity, 2f, 3f vari.ations,549 medial. 158/, 17lf.176/
Anastomotic artery, 12/ JWllary filscia,. 118/, 159/ pos1a'ior, 116/, 17lf.176/
Anatomic variations, 'VUCUlar, 541-574 JWllarynerve, 158/, 171lf, 181/ divisioas, 116/
Anconeus muscle, 195/ JWllary shea1h,. 24f, 159f, 167f, 168/ roots~ 11((
Ansa cervicalis, 27f, 29/, 32, 32/, 36/, 39f JWllary shea1h fascia,. 118/ trunks, 116/
Ansa hypoglossi. See Ansa cervi.c:alis JWllary spau, 118 Brachial sheath, I IV, 186/
Ansa subclavia, 82f, 122/ SU!gical view ~ 120/ Brachial vein, 178
579
Brachi.alis muscle, 179/, 184{, 192/, 193/, 197[. sixth, 54f Coracoacromialligament, 156/
199[.203/ transverse, 32/ Coracobrachialis muscle, 156[, 167/. 168/.
insertion, 176/ Cervical plexus, 32 172/, 179/. 180/. 183/
Bracm~~c~,7~8~8~9lf,9~ Cervical rib, 113, 124, 124{, 131, 140 Coracoid ligament, 1S6f
exposure of, 91-92 Cervical spine, 23 Coracoid process, 120[, 154{, 162/. 17:lf
mobilization of, 96-97 Cervical sympathetic chain, 27, 54, 122 Coronary ligament, posterior, right, 353/
variations of, 546 Cervical sympathetic ganglion Coronary sinus, 572/
Bracm~c vein(s) inferior, 32.f. 62/ Coronary vein, 249[. See also Gastric
development of, 16f middle, 32/. 12:if vein(s), left
left, 83.f. 87[. 94{, 96.f. 97/ superior, 27/, 37, 37[, 121/ Co~al artery, S44f
development of, 16/ Cervical sympathetic trunk, 29f Costocervical trunks, Sf, 54, 54{
right, 87[. 97f Cervical transverse process, 114{ Costoclavicular angle, 123/
Bracmomdialis muscle, 179/. 181/. 182/. 184{, Cervical vertebrae Costoclavicular compression, 125/
194{, 194{, 195/. 197/. 198/. 199/. CL See Atlas Costoclavicular ligament, 114{, 119[, 142/.
203[. 204[. 209/ C2. See Axis 144/, 145/. 156/
Bracmomdialis tendon, 206/ C6, 52/ Costoclavicular passage, 123/
Bracmum transverse process, 52, 122/ Costocoracoid ligament, 123
posterior, 181-182 C7, 114{ Cranial nerve(s)
surgical anatomy of, 177-184 Cervicothoracic sympathectomy, 148. See also emergence at base of skull, 37, 37/
Bronchus, left mainstem, 80/ Cervical sympathetic chain injury, in carotid surgery, 36
anterior transthoracic approach, 148 in neck, 32, 36-39, 36/. 37[, 38/, 39/
c dorsal
anterior supraclavicular approach, 148-149
Cnbriform fascia, 396, 396/
Cruciate anastomosis, 406/
Cl transverse process, 70f transaxillary approach, 1SO Crural fascia, 4 72f
palpation of, 72 posterior paravertebral approach, 148 Crus, right, 242/
Calcaneal plexus, 509/ Cervicothoracic sympathetic chain of diaphragm, 247/
Calcaneal tendon, 504[. 513[. 534f exposure of, 148-150 Cubital vein, medial, 190f
Capitate bone, 220/ Chorion,2f Cutaneous nerve, 121/
Caput medusa, 369/ Chorionic villi, 2/ Cysterna chyli, 245/, 281/, 282[. 350/
Cardiac nerves, 122/ Circulation. See also Fetal circulation
Carotid ~(ies), 23-49, 27/. 30.f. 55/. inception of, 2-4
61[. See also Common carotid Clavicle, 113, 123 D
artery(ies); External carotid~; Clavicular malunion, 125/
Deltoid muscle, 120/. 156/. 159[. 170[, 172[,
Internal carotid ~ Clavipectoral fascia, 118/, 119/. 159/. 162/.
176/. 183/. 184{
exposure of, 90--91 163/. 170/, 172/, 174{
Deltopectoral groove, 183/
extracranial, exposure of, 41-49 Colic ~(ies)
Descending branch, 565/
left, 53/ middle, 276/, 284/. 286/. 296/. 559/
Diaphragm, 240/. 242, 246/, 26S.f.
proximal, exposure of, 91 right, 272/, 27lf, 284{, 557/
right, 53f Colic vein, middle. See Middle colic vein 267/.268/
circumferential division of, 266/
Carotid bifurcation, 39 Colon
motor innervation to, 244
exposure of, 42-46 hepatic flexure of, 3 S6.f. 374
neurovascular supply to, 242/
Carotid body, 39 impression of, 353/
origins, 242/
Carotid plexus, 121/ left, 304/. 340/
topography, 243
Carotid sheath, 23, 23[. 27,27/, 29/. 61/ right, 238[, 306/
Diaphragmatic crus, 247/
Carotid sinus, 30, 39.f. 48f mobilization, for exposure of inferior
right, 242/
innervation, 39 vena cava, 380/
Carotid sinus nerve, 39 exposure of, 247/
transverse, 272/
Digastric muscle, 37/. 70/
Carotid triangle, 29 Colon reflection
divided, 33
Carotid tubercle, Sl.f. 52/, 66[, 122/ left, 240/
Carpal ligament posterior belly of, 29, 34{, 39/
right,240f
division of, 48/
transverse, 220/, 221/. 222/. 223/. 227/ Common bile duct, 274{
Digital~. 234{
volar,222f Common cardinal veins, development of, 4{,
Digital nerves, 218/
Caudate lobe, 353/. 356/ 14{, 15/. 16/
Digital palmar crease, 218/
Celiac artery Common carotid artery(ies), 30/. 34{, 542/
Digitorum longus muscles. See Extensor
development of, 9f development of, Sf, Sf
digitorum longus muscle; Flexor
orifice, 296/ left, 87/, 95.f. 96f
digitorum longus muscle
transperi.toneal exposure of, at origin, 280--283 origin of, 85/
proximal, exposure of, 90-91 Dorsal branch, medial, 537/
Celiac ganglion, 281/,282/
Dorsal rompartment, 210[. 214, 214{
Celiac trunk, 241/. 251/. 272/. 274{, 29lf variations of, 545
Dorsalis pedis ~. 494{, 495/. 504{, S06.f.
surgical anatomy of, 274-275 right, 87/, 97/
variation, 551-556 variations, 546 509/. 510/. 511/
exposure of, 537
Cephalic vein, 144{, 145/. 159/. 162/. 163/, variations, 546
Ductus arteriosus, 6/. 8/. 18/
170[. 172/, 183[, 190/, 206/. 230/ Common flexor origin, 194{, 197f
Ductus deferens, 351/. 394{, 398/
Cervical artery(ies) Common hepatic ~. 275/. 311/
Ductus venosus, 15/. 18/
ascending, 149/ Common hepatic duct, 353/
Duodenum, 272/. 277/. 296/. 306/. 325/. 329/.
superficial, 107/, 149/ Communicating branch, 508/
Compartment 35lf, 367/. 375/. 379/
transverse, 544/
Dura mater, 58/
Cervical cardiac nerve, middle, 54f anterior, 486/
Cervical ganglia, middle, 8:if deep posterior, 486/
Cervical ganglion lateral, 486/ E
inferior, 32/, 54{, 55/. 82/ superficial posterior, 486/
middle, 32[, 54{, 55[, 122, 122/ Condyloid emissary vein, 72, 73f Ectoderm, 3f
superior, 121/ Constrictor muscle Embolus, 279/
Cervical nerve(s), 29/ inferior, 33/ Embryonic period, vascular development in,
fifth-eighth, 116f middle, 33/ 1-13
second, 57[, 70f superior, 33/ Endoderm, 3/