BRIEFS

A TECHNIQUE FOR SAFE INTERNAL

JUGULAR VEIN CATHETERIZATION
Michael G. Sarr, MD
Baltimore, Maryland

A simple and safe technique for catheterization of the internal jugu- sternal division) is palpated, a 11/2
lar vein is described. This approach avoids the possibility of arterial inch, 22-gauge needle and syringe
puncture or pneumothorax. are used to locate the internal jugu-
lar vein which lies lateral to the ca-
Sophisticated hemodynamic mon- the sternal and clavicular divisions rotid artery, immediately beneath
itoring requires insertion of a cen- of the sternocleidomastoid muscle. the medial border of the clavicular
tral venous or a Swan-Ganz cathe- While the medially located carotid division. The needle should enter
ter. The basilic and external jugular artery (which courses under the the skin at a 30 to 450 angle directed
approaches to percutaneous central
venous access are often unreliable,
while the infraclavicular or supra-
clavicular techniques of subclavian
vein catheterization are frought
with the risk of pneumothorax,
even in the hands of the experi-
enced. With the method outlined
below, percutaneous catheteriza-
tion of the internal jugular vein can
be performed safely and reliably,
without risk of pneumothorax or
arterial puncture.
The patient is placed in the
Trendelenburg position with his or
her head turned to the contralateral
side (Figure 1). The physician 3Q0
to
stands above the patient on the 4,50
contralateral side of the bed, and a
large skin wheal is raised with local
anesthetic over the junction of

From the Department of Surgery, Johns

Hopkins Hospital, Baltimore, Maryland.
Requests for reprints should be ad-
dressed to Dr. Michael G. Sarr, Depart-
ment of Surgery, Johns Hopkins Hospital,
Baltimore, MD 21205.
Figure 1. Catheterization of the internal jugular vein. The needles are in-
serted in a lateral direction over the junction of the sternal and clavicular
divisions of the sternocleidomastoid muscle

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 1, 1983 105
BRIEFS

laterally toward the midclavicle,
thereby avoiding possible puncture
of the carotid artery. On entering
the vein, the syringe is disengaged
but the needle is not removed; it
remains in the vein to serve as a
direct visual guide to the underly-
ing vein. The large-bore needle (for
introduction of the catheter or
guide wire) can then be inserted
without trepidation 0.5 cm above
and parallel to the 22-gauge needle.
The smaller needle demonstrates
the exact location and depth of the
vein, and avoids complications (eg,
arterial puncture or pneumothorax)
of blind probing with a large-bore
needle. Use of the 22-gauge needle
with the patient in the Trendelen-
burg position also renders the risk
of air embolus negligible.

SALPIINGO OOPHORECTOMY
IN WOMEN WITH PREVIOUS
HYSTERECTOMY
Enrique Hernandez, MD, and Neil B. Rosenshein, MD
Baltimore, Maryland
Laparotomy for suspected adnexal pathology is performed in ap- sected bluntly and a medium-sized
proximately 3 percent of women who have had hysterectomy without Deaver retractor placed in this
salpingo-oophorectomy. The removal of these ovaries is often a diffi- space at the cephalad end of the
cult surgical procedure because of anatomic distortion and adhesions. incision.
The retroperitoneal identification and isolation of the infundibulo- The infundibulopelvic ligament
pelvic ligament and ureter, as described here, is a simple and safe and ureter are identified on the me-
way of approaching these cases. dial peritoneal flap. The infundibu-
lopelvic ligament is isolated, doubly
clamped, divided, and ligated. The
adnexa is sharply dissected from
Approximately 3 percent of ter and infundibulopelvic ligament the lateral pelvic wall while main-
women who have had hysterectomy facilitates removal of the abnormal taining constant visualization of the
without salpingo-oophorectomy re- adnexa and decreases the morbid- ureter (Figure 2). Because the ini-
quire reexploration for suspected ity associated with the procedure. tial step is the ligation of the blood
adnexal pathology.' At the time of supply, blood loss is minimal.
exploration the pelvic surgeon may TECHNIQUE
be faced with distorted anatomy, Adequate pelvic exposure is man-
with the adnexa commonly found datory. This is achieved by using a DISCUSSION
to be adherent to the lateral pelvic self-retaining retractor and packing We have performed this opera-
peritoneum. Retroperitoneal isola- the intestines into the upper abdo- tion in over 50 consecutive cases
tion of the ovarian vascular supply men with moist laparotomy packs. without an incident of ureteral
with direct visualization of the ure- The peritoneum overlying the psoas injury. Other important structures
muscle, three cm lateral to the in- that may be encountered in this dis-
fundibulopelvic ligament, is picked section and that should be carefully
From the Division of Gynecologic Oncol- up and incised parallel to the liga- identified are the common, exter-
ogy, Department of Gynecology and Ob- ment. The incision starts at the pel- nal, and internal iliac vessels. We
stetrics, The Johns Hopkins Hospital,
Baltimore, Maryland. Requests for re- vic brim and extends cephalad for have not had a case of injury to
prints should be addressed to Dr. Enrique ten cm (Figure 1). The medial edge these vessels.
Hernandez, Division of Gynecologic On-
cology, Department of Gynecology and of the peritoneum is held toward The technique of retroperitoneal
Obstetrics, The Johns Hopkins Hospital, the midline with a long Kelly clamp. isolation and identification of the
600 North Wolfe Street, Baltimore, MD
21205. The retroperitoneal space is dis- ureter and infundibulopelvic liga-

106 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 75, NO. 1, 1983