—This is best tied by making an incision 2 Cm. above the clavicle, beginning nearly at its sternal joint, and extending outward to the anterior border of the trapezius. In exposing it the cervical branches of the superficial nerves should also be divided. The external jugular lies here, near the posterior border of the sternomastoid, and winds around it to empty into the internal. Unless it can be avoided it should be carefully double ligated. The omohyoid should appear at the inner angle of the wound and may be drawn out of the way in either direction. The suprascapular artery and perhaps one or two other vessels may cross the wound and require retraction. It is usually necessary to remove considerable adipose tissue in which these vessels lie. The brachial plexus, of course, will be encountered. The scalenus anticus, which should be followed down to its tubercle of attachment on the first rib is of special importance. To its inner side is the internal jugular, with a somewhat bulbous enlargement. In front is the subclavian vein and behind the muscle is the artery. The phrenic nerve passes down upon the anterior surface of the scalenus anticus, and the thoracic duct ascends close to it, opening into the angle between the subclavian and internal jugular veins. While it is not impossible nor even impracticable to apply a ligature to the subclavian on the inner side of the scalenus anticus it is rarely necessary, and the ligation is almost invariably performed to its outer side, in the free part of its trunk. There must be sufficient space in which to work with safety, and, when necessary, adjoining muscles, i. e., sternomastoid and trapezius, may be divided to any necessary extent. The patient should always be placed in such a position that the shoulder is pulled well down, with the arm passed behind the back, while the neck is stretched by extending the head to the opposite side. The artery needle should be passed from above downward and from behind forward, the vein being carefully held out of its way. The patient should wear the Crile pneumatic suit, in the semi-elevated position, in order that the veins in the neck may be less engorged ([Figs. 165] and [166]).
The Axillary Artery.
—The axillary artery is practically tied in its third portion, beyond the lesser pectoral. The incision is made through the middle of the axilla, over the course of the vessel, the deep fascia exposed and divided, the coracobrachialis and musculocutaneous nerve retracted outward, and the artery recognized with the finger-tip. It should be so cleared, especially from the median nerve, as to be easily raised upon the blunt hook. The accompanying veins should not be enclosed in the ligature ([Figs. 167] and [168]).
Fig. 167
Fig. 168
Surgical anatomy of the axilla and ligation of the axillary artery. (Bernard and Huette.)
The Brachial Artery.
—The brachial artery is easily found in the middle of the arm, near the inner edge of the biceps, whose inner border is identified. The median and other nerves should not be brought into view. The parts will be relaxed by flexing the forearm. The venæ comites should be carefully excluded from the ligature ([Figs. 169] and [170]).