Positioning

• Supine
• Arms Tucked at Side
• Neck Fully Extended with a Shoulder Roll and Rotated to the Contralateral Side

Incision

• Longitudinal Incision Along the Anterior/Medial Border of the Sternocleidomastoid (SCM) Muscle
• Can Extend the Incision as Needed from the Mastoid Process to the Sternal Notch
• Can Extend Exposure with a “U”-Incision for Transcervical Injuries – Bilateral Incisions Along the SCM Muscles Meeting at the Bottom and Lifting a Subplatysmal Flap Up

“Trail of Safety”

• Step 1. Sternocleidomastoid (SCM) Muscle
  • Divide the Platysma – The First Layer Seen Beneath the Skin
  • Expose the Anterior Border of the Sternocleidomastoid (SCM) Muscle
• Step 2. Internal Jugular (IJ) Vein
  • Retract the SCM Laterally to Expose the Working Area
  • Dissect Through the Middle Cervical Fascia Until the IJ is Identified
  • The IJ is the Most Commonly Injured Vascular Structure in Neck Exploration
• Step 3. Facial Vein
  • Described as the “Gatekeeper” to the Neck
  • Identify and Ligate the Fascial Vein – Seen Crossing Medially from the IJ
    • There May Be More Than One Small Vein That Requires Ligation
  • Ligation Allows Mobilization of the IJ for Exploration of Deeper Structures
• Step 4. Carotid Artery
  • Retract the IJ Laterally
  • Enter the Carotid Sheath and Identify the Carotid Artery
  • Identify and Protect the Vagus Nerve – Generally Lies Between the IJ and Carotid

Obtain Both Proximal and Distal Vascular Control in Virgin Territory Before Entering a Hematoma

• For More Proximal Control: Median Sternotomy
• For More Distal Control: May Require Mandible Disarticulation
• Control at the Bifurcation Includes Control of the Common Carotid Artery (CCA), Internal Carotid Artery (ICA), and External Carotid Artery (ECA)

Esophagus Exploration

• Left Cervical Incisions are Preferred for Esophageal Exploration if Able
  • The Esophagus is Slightly Left of Midline
  • The Left Recurrent Laryngeal Nerve is Longer and More Vertical than Right – Less Likely to Be Injured
• Explore the Esophagus by Dissecting Medial to the Carotid Sheath
  • Alternatively, Can Explore the Esophagus Posterior to the Carotid Sheath by Retracting the Sheath Medially – More Limited Exposure
• The Esophagus Will Be Posterior to the Trachea and Anterior to the Spine
• Have Anesthesia Place a Large-Bore Orogastric (OG) Tube to Assist in Palpation/Identification
• Exposure May Require Division of the Omohyoid Muscle, Middle Thyroid Vein, and Inferior Thyroid Artery
• Take Caution to Avoid Injury to the Recurrent Laryngeal Nerve – Travels in the Tracheoesophageal Groove