Fig. 248. Ligature of the Internal Jugular Vein low down in the Neck. The upper portion of the vein is dissected out and brought into the neck. A, A', Cut ends of the ligatured facial vein; E, Descendens noni nerve; F, Carotid sheath and internal carotid artery; G, Vagus nerve; H, Gland; J, Lower end of the internal jugular vein. The hook pulls aside the omo-hyoid muscle.
The next step in the operation is to get well below the point at which the jugular is thrombosed. If the thrombus be practically limited to the jugular fossa the vein may be ligatured above the common facial; if not, as low down the neck as possible. In ligaturing the vein low down in the neck, the skin incision must be extended downwards, and as the lower portion of the neck is reached, the omo-hyoid will have to be pulled aside. The probe should be passed all round the vein so as to make certain that it is freed from its sheath, and especially that it is separated from the vagus nerve which lies behind it.
An aneurysm needle threaded with silk is now passed around the vein from within outwards. The loop of silk is cut so as to form two ligatures, and the aneurysm needle then withdrawn; the lower ligature is first tied, its ends being cut short. The upper ligature is then tied a short distance above it, but in this case the ends are left long. The vein is raised from its bed by slight traction on this ligature and is cut across between the two, the lower portion being allowed to sink back into the wound. The upper portion is then carefully separated for some distance upwards. Lying behind the vein may be seen the vagus nerve (Fig. 248). Any tributaries are clamped between two forceps, cut across, and ligatured, the upper end of the vein being brought out into the upper angle of the wound. Care must be taken that enough of the vein is dissected out to allow of this being done, especially if the ligature is applied above the level of the common facial; in this case the facial need not be tied.
If there be no periphlebitis, inflammation of the soft tissues, or thrombosis of the vein itself in the neck, the wound may be closed by means of silkworm-gut sutures, excepting at its upper angle through which the open end of the jugular vein projects. If, however, the vein be thrombosed, and especially if there be periphlebitis, the wound should be left open, except perhaps at its lower angle, and should be lightly packed with gauze, as in these cases cellulitis of the neck may afterwards occur.
Fig. 249. Free Exposure of the Lateral Sinus, which has been incised, with Ligature of the Internal Jugular Vein. The lateral sinus is obliterated posteriorly by a plug of gauze pressed in between its outer wall and the underlying bone. The sinus is freely exposed almost down to the jugular fossa. The vein has been ligatured and its upper portion sutured to the skin wound in the neck. The arrow shows the direction along which the sinus and vein are syringed.
After completion of the operation in the neck the surgeon turns to the mastoid process. If the ligature of the vein has been the primary step, the mastoid operation is now performed and the lateral sinus is freely exposed for a considerable distance behind the thrombus. If, however, the mastoid operation has been the first stage, and the jugular has been tied as soon as exposure of the sinus showed it to be thrombosed, the operation on the mastoid is now completed and the sinus opened as already described (see [p. 444]). The next step is to incise the sinus freely from above downwards towards the jugular fossa and curette out the thrombus.
If there be considerable hæmorrhage, it means that the thrombus is probably parietal and situated within the jugular bulb, the bleeding presumably coming from the inferior petrosal sinus or other tributaries which enter the bulb or upper portion of the jugular vein. If the bleeding be excessive, the sinus is plugged after a moment or two, by inserting a piece of gauze into its lumen towards the jugular bulb.