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Treatment of adjacent segment disease after total disc replacement (TDR)
Published in Gregory D. Schroeder, Ali A. Baaj, Alexander R. Vaccaro, Revision Spine Surgery, 2019
The key principles of revision anterior cervical surgery are careful preoperative planning and meticulous dissection. Preoperative imaging should assure the surgeon that there are no anatomical nor index surgery anomalies. These anomalies can be planned for and hopefully avoided. Next is the approach dissection. Typically, little significant scarring occurs anterior to the pretracheal fascia. Posterior to the pretracheal fascia, the esophagus and the carotid sheath are vulnerable to injury. To avoid these structures, the surgeon should extend the dissection either proximal or distal to that of the index procedure. This extended dissection will allow a more normal plane between these structures to expose the anterior aspect of the vertebral bodies between the longus colli muscle masses. The dissection should be done bluntly to avoid visceral or vascular injuries. If exposure is initially required distally, the omohyoid muscle may be transected. The vascular supply for the omohyoid is in the cranial third of the muscle. Once the midline is exposed, sharp dissection can be used to elevate the vertebral body scar tissue. From there, surgery proceeds as with the primary procedures.
Head and neck
Published in Tor Wo Chiu, Stone’s Plastic Surgery Facts, 2018
The deep cervical fascia has four components: Investing fascia. This is the layer of deep fascia that lies beneath the subcutaneous fat and splits into superficial and deep layers as the parotid fascia surrounds the gland. A local thickening forms the stylomandibular ligament.Prevertebral fascia. This covers the muscles (splenius capitis, levator scapulae, scalenus posterior, medius and anterior) that form the floor of the posterior triangle, and forms a layer over which the pharynx and oesophagus can freely slide. It covers the brachial plexus trunks and subclavian artery but not the subclavian vein and is pierced by the four nerves of the cervical plexus.Pretracheal fascia. This separates the trachea from the overlying strap muscles to allow trachea gliding. It encloses the thyroid gland (pierced by the thyroid vessels) and blends laterally with the carotid sheath.Carotid sheath. This envelopes the carotid arteries (common and internal), the IJV (where it is thin) and vagus nerve. It is adherent to the deep surface of SM.
Developmental Anatomy of the Thyroid and Parathyroid Glands
Published in John C Watkinson, Raymond W Clarke, Louise Jayne Clark, Adam J Donne, R James A England, Hisham M Mehanna, Gerald William McGarry, Sean Carrie, Basic Sciences Endocrine Surgery Rhinology, 2018
The thyroid gland, together with the oesophagus and trachea, is invested in a visceral layer of deep fascia known as the pretracheal fascia.1 It is attached superiorly to the hyoid bone and extends inferiorly into the mediastinum, fusing with the fascia surrounding the aorta, pericardium and parietal pleura at the level of the carina. Laterally the fascia blends with the carotid sheath. Anteriorly the fascia forms a distinct layer separating the thyroid from the strap muscles and posteriorly it merges with the prevertebral fascia. On the posterior aspect of the isthmus the fascia is sometimes known as the anterior tracheal ligament and is perforated by small tracheal vessels, but at the upper part on each side it is much thicker and binds the gland firmly to the sides of the cricoid cartilage and first tracheal ring. This condensation is known as the lateral ligament of the thyroid or the ‘suspensory ligament of Berry’. Its fixation to the trachea causes the thyroid gland to move up and down on swallowing. During thyroid surgery it must be divided with care and by sharp dissection as the recurrent laryngeal nerve may lie lateral, medial or within the ligament just before it enters the larynx.
Suprasternal Transcatheter Aortic Valve Replacement: A Step-by-Step Video Description
Published in Structural Heart, 2019
Kyle W. Eudailey, Isaac George
See Video 1 for a step-by-step procedure. A 3–4 cm curvilinear incision is made just above the sternal notch. Similar to a mediastinoscopy approach, the platysma muscle is divided, and dissection is carried out between the sternocleidomastoid muscles. The dissection is continued down to the avascular between the sternothyroid muscles to the pretracheal fascia. Blunt dissection is carried out at this point down toward the aortic arch. A sweeping motion is made from left to right in the avascular plane underneath the innominate vein and towards the innominate artery. The innominate artery can be easily palpated from this exposure, which can be used to guide further dissection. The exposure is markedly improved with division of the right sternothyroid muscle. At this point, a right angle is used to encircle the base of the innominate artery, and a vessel loop is passed. The artery is then palpated to make sure that is free of calcium. Noninvasive cerebral saturations are monitored throughout the procedure to ensure that once the sheath is in place there is no relative cerebral ischemia secondary to right common carotid occlusion. Once the patient is fully heparinized, the vessel loop is pulled cephalad and tagged to the drape so as to retract the innominate artery up into the field and improve exposure. Next, two opposing 4–0 Prolene (Ethicon, Somerville, NJ) suture pursestrings are placed. Under direct vision, the innominate artery is punctured and using a J-wire a standard 7 French sheath used. The valve is then crossed in a standard fashion. This is then exchanged for a stiffer wire, and the larger delivery sheath is placed. During the sheath exchanges, the purse strings are tightened to minimize blood loss. Following the valve deployment, the sheath and wires are removed completely and the purse strings are tied under direct vision under rapid pacing. A completion angiogram confirms the absence of stenosis of the vessel. Using this method, patients may avoid any vessel access in the groin.