History-taking model
Kaji Sritharan, Vivian A Elwell, Sachi Sivananthan in Essential OSCE Topics for Medical and Surgical Finals, 2007
Optimal site for intravenous cannulation Non-dominant upper limb is the optimal site.Lower limb has increased risk of thrombophlebitis.Avoid veins which cross a joint line, as movement at the joint will be restricted by the cannula.Choose a distal site so that if vein ‘tissues’, the line can be sited more proximally.Avoid the arm if it is being considered for haemodialysis.If no extremity vein can be found, the external jugular vein can be used. Place the patient in reverse Trendelenburg position to help to distend the vein.
How should aggressive chyloreflux (e.g., chyluria, chyloascites, chylothorax, chyle leakage) be handled?
Byung-Boong Lee, Peter Gloviczki, Francine Blei, Jovan N. Markovic in Vascular Malformations, 2019
Chylous ascites is also indicated for percutaneous embolization of retroperitoneal lymphatics, which is preferred as the first-line therapy for symptomatic chylous ascites. However, it requires various combinations of the treatment, following the diagnostic puncture, with intermittent drainage by serial paracentesis, a specific diet with MCT, and octreotide. But if it persists, it requires surgical intervention; a complementary option is a peritoneal-venous shunt (e.g., Degni and Le Veen bypass valves and Denver shunt), shunting the fluid from the peritoneal cavity to the internal or external jugular vein. They should not be used before the age of 7–10 years, and the possible coagulation alteration should be controlled judiciously. They give only an interim temporary solution but do not solve the pathology1, 4 (Figure 71.5).
Neck dissection
John Dudley Langdon, Mohan Francis Patel, Robert Andrew Ord, Peter Brennan in Operative Oral and Maxillofacial Surgery, 2017
Development of skin flaps. It is usual to raise skin flaps in a subplatysmal plane. Local anaesthetic solution may be injected to facilitate this process. The flaps can be raised using monopolar diathermy (Colorado needle), scalpel or scissor dissection. With all of these techniques, but particularly when diathermy is used, care should be taken in the upper skin flap to minimize damage to the marginal mandibular nerve, which lies just deep to the platysma muscle in the deep cervical fascia. It can be readily identified as it crosses the facial vessels (FVs) and great care should be taken to preserve this nerve. It is sometimes possible to preserve the great auricular nerve as it crosses the SCM although the roots (C2,3) are often transacted later on in the dissection. In both the submental and posterior triangles, the platysma muscle often fades away and care should be taken to ensure that the skin flap does not become too thick or thin in these areas. It is sometimes surprising just how superficial the accessory nerve can be! The external jugular vein is easily damaged when the inferior skin flap is being raised as it lies immediately deep to the platysma muscle and may need to be ligated. The flaps should be developed beyond the boundaries of the neck dissection to be performed. For a MRND, the flap should be extended to the trapezius muscle in the posterior triangle. The muscle can be brought into view by having an assistant pushing it upwards and forwards. In bulky disease, it may be necessary to leave the platysma on the metastatic nodes, or even include skin in the resection if clinically indicated. In these cases, it is important to plan skin incisions to facilitate subsequent closure.
Use of a biopsy punch for end-to-side anastomosis in free-tissue transfer
Published in Journal of Plastic Surgery and Hand Surgery, 2020
Jae-Ho Chung, Sung-Min Sohn, Hi-Jin You, Eul-Sik Yoon, Byung-Il Lee, Seung-Ha Park, Deok-Woo Kim
In free tissue transfer for head and neck reconstruction, a number of studies reported the versatility of the ETSA technique in vein anastomosis. In the head and neck region, the external jugular vein, the anterior cervical vein, and the sizable concomitant veins of arteries, such as the facial and lingual veins, are commonly used as the recipient vein. However, the lack of appropriately sized and located veins has frequently caused problems in flap surgery [7]. In these circumstances, ETSA to the internal jugular vein can solve the problems. Yamamoto et al suggest that the internal jugular vein has the broad capacity to be the recipient of two or more ETSAs, so it can be effectively used for free flap procedures in which two or more drainage veins can be included [8]. In addition, a study by Acland suggested that the voluminous blood flow in the internal jugular vein can wash away small thrombi at the anastomotic site and can decrease the incidence of thrombus formation [9]. At our institution, ETSA to the internal jugular vein is the primary option for most cases of head and neck reconstruction.
Unfavorable outcomes in microsurgery: possibilities for improvement
Published in Journal of Plastic Surgery and Hand Surgery, 2019
Paolo Cariati, Almudena Cabello Serrano, Fernando Monsalve Iglesias, Maria Roman Ramos, Jose Fernandez Solis, Ildefonso Martinez Lara
It is important to emphasize that only 8 of the 65 (12.3%) oncological patients received RT before reconstructive surgery in our series. Specifically, five patients from Group 1 and 3 patients from Group 2 had previously been treated with ablative surgery and postoperative radiotherapy. Hence, the quality and quantity of the vessels was acceptable in most cases. In Group 1, the facial artery was used in 86.7% of cases (n = 46), followed by the cranial thyroid artery (11.3%; n = 6), and external carotid artery (1.8%; n = 1). All arterial anastomoses were end to end. Regarding the veins, the facial vein was the most used followed by the external jugular vein. We tried to use two veins whenever possible. Also, all venous anastomoses were end to end. In Group 2, the facial artery was also the artery most frequently used (77.7%; n = 14) followed by the external carotid artery (22.2%; n = 4). No arterial anastomoses were performed with the cranial thyroid artery in this group. The external carotid artery was used after an intraoperative spasm of the facial artery in two cases and in the salvage surgery of a fibula flap 12 h after primary reconstructive surgery. In only one case was the first choice. The facial vein was the one most commonly used, followed by the external jugular vein. All arterial and venous anastomoses were end-to-end also in this group.
Distension of the maxillary vein with hepatojugular reflux
Published in Journal of Community Hospital Internal Medicine Perspectives, 2019
Kelly T. Le, Bruce F. Sabath
Bedside estimation of central venous pressure (CVP) was described in 1930 by Sir Thomas Lewis who observed that the top of the jugular veins was similar to the top of the fluid column in a CVP manometer. While the internal jugular vein is preferred because it lacks valves and is more in line with the right atrium, the external jugular vein can be used, particularly in cases of extremely elevated venous pressure because the top of the internal jugular vein courses intracranially and cannot be visualized. The hepatojugular reflux maneuver is performed by applying pressure of 20–30 mmHg at the mid-abdomen for 10–30 seconds. If CVP rises >4 cm throughout the maneuver, this correlates with elevated right atrial pressure. In patients with significant volume overload, distant tributaries of the external jugular vein can become distended as well (video).
Related Knowledge Centers
- Angle of The Mandible
- Deep Fascia
- Skull
- Sternocleidomastoid Muscle
- Subclavian Vein
- Parotid Gland
- Face
- Retromandibular Vein
- Posterior Auricular Vein
- Angle of The Mandible
- Subclavian Triangle