Post on 14-Dec-2015
transcript
Introduction
• Penetrating neck injury common in South Africa and the USA– TBH >500 per year– DBN >200 per year
• Less common in UK and Europe– Fear and trepidation: limited experience– Approaches are different to H&N surgery
Mechanism of Injury
• Most cases will be stabs and GSW• Both can cause major injury• Bullets often more injurious• May be combined blunt / penetrating injury –
impaled objects
Anatomy
• Dense collection of neuro-vascular and aerodigestive structures
• Multiple fascia layers• Extend upward into
the skull• Extend downward
into the mediastinum
Diagnostic Approach
• Does it penetrate?• All – unstable
– OPERATE
• Zone 1 & 3– Image– Attempt to use non-
operative options
• Zone 2– 2 Philosophies
• Explore all• Image and explore
selectively*
*BJS 1990: 908; World J Surg 2008: 2716; EMJ 2009: 106
Resus Room
• Don’t probe non-bleeding wounds• Be very wary with muscle relaxants• Fingers and Foleys are your friend• No blind clamping• Haematomas compress airways• Surgeon must be ready for surgical airway
when Anaesthetist intubates
Management of the airway
• Preferably in the OR if unstable• Non-drug assisted intubation best• Use a cardio-stable agent: Etomidate*• Have a difficult airway trolley
– Fibrescope– Gum elastic bougie– Surgical crico-kit (Scalpel and no 6ETT)– LMA as back-up
• Good suction• Surgeon Scrubbed and ready
*Hardcastle, SAJCC July 2008
Zone 1
• Drape widely• If in doubt –
sternotomy• High ANT for
proximal L-SCA• Beware of the BCV
– Oversew
• Get proximal control
Zone 1
• Access to:– BCA– L-CCA– L-SCA; actually better than HLAT– Heart
• Oesophagus below T1 better via R-Thoracotomy, also trachea/bronchi
Zone 2
• Standard neck incision
• Drape for extensions• Position is everything• Good haemostasis• Loop readily• Use the plains
Vascular injury
• Proximal and distal control• Heparinise• Debride and mobilise• Can often repair primarily• Vein grafts are best• PTFE is acceptable conduit• Veins can be readily ligated
Aero-digestive injury
• Repair true oesophagus – below C6• Pharynx can be safely drained• Avoid trachy with oesophagus injury• Muscle interposition for combined tracheal and
oesophageal injury• Single layer absorbable repairs• Drain – (not closed suction) for 8-10 days; place intra-
op NGT• Trachea – interrupted sutures; air tight
Zone 3• Tiger country!• I don’t like the jaw
transection!– Try muscle releases first– Bite-block in mouth gives
extra space– High Carotid – repair
distal first– Consider ligation if good
back-pressure• Watch out for the
hypoglossus – at the carotid bifurcation
Other options
• Endovascular therapy stents and coils
Requires catheter expertise or ready access to interventional radiology
BJS 2003: 1516 / J Vasc Surg 2008: 739 / Eur J Vasc Endovasc Surg 2000: 489 & 2008: 56 / J Endovasc Ther 2001: 529
Closure
• Sternotomy standard closure– Leave a mediastinal drain
• Neck– Close the platysma– Close the skin– Drain via a separate site– Trachy via a separate incision if needed
Post-operative care• ICU only if intubated / trachy• Mobilize early• LMWH post-op• Contrast study on D5 - 7• NGT for early feeding• Extubate around D3 if trachea repaired• Remove drains once tolerating oral diet• Beware swallowing incoordination is common• Only 3 doses of prophylactic AB
Outcome
• Non-operative– Minimal missed injury, seldom clinically significant
• Aerodigestive injury– Most will heal; leaks can be controlled fistula– Time to repair determinant
• Vascular– Repair within 24 hours good outcomes*
*Du Toit et al J Vasc Surg 2003: 257
Conclusions
• Penetrating injury to the neck can be challenging
• May be unfamiliar territory to many General Surgeons
• Know the approaches• Know the anatomy• Most patients will do well if principles
followed