In this case the portion of the vein brought into the neck is usually also filled with blood. After isolating it from the deeper tissues by packing strips of gauze round it, the vein is deliberately opened just above the ligature. The bleeding usually stops after a moment or two, but if it cannot be controlled, the lumen of the vein must again be closed by a ligature, the end of the vein being allowed to project on to the neck.
Fig. 250. Method of suturing the Open End of the Internal Jugular Vein in the Neck.
If there be no bleeding from the lower portion of the lateral sinus and jugular bulb, it means that the vessel is completely thrombosed at this point. The clot should now be removed by curetting through the sinus from above downwards towards the jugular bulb, and also from below upwards through the open end of the jugular vein.
The venous channel is afterwards syringed through from above downwards. To do this, a piece of rubber tubing is inserted into the opening in the lateral sinus and some warm saline solution is injected through it with a syringe. If the clot be not firmly adherent it can usually be washed out through the opening in the vein. No force should be used. If gentle syringing be not sufficient to expel the clot, the attempt must be given up. The chief objection against syringing is the possibility of particles of the septic thrombus being forced into the veins communicating with the jugular bulb. A small drainage tube is inserted within the sinus.
In order to keep the lumen of the vein in the neck open, it should be stitched to the edge of the wound surface by several catgut sutures (Fig. 250). If the bleeding necessitated plugging of the lower end of the sinus and retention of a ligature on the vein in the first instance, syringing should be postponed until the first dressing; the portion of the vein left protruding through the skin wound in the neck is then cut across, and the edge of the vein sutured to the margin of the wound under cocaine.
The mastoid cavity is lightly plugged with gauze and a dry dressing applied. The wound in the neck is similarly treated.
After-treatment and progress of the case. There is frequently considerable shock after the operation, especially if exposure of the jugular bulb has been undertaken, partly owing to the duration of the operation and to hæmorrhage. If the patient be very collapsed, a continuous saline injection, to which some brandy may be added, may be given per rectum according to Moynihan’s method. After the primary shock has passed off, the immediate result is usually satisfactory.
If the jugular vein has not been ligatured, the first dressing should be performed within forty-eight hours, the gauze packing being removed, the wound syringed out, and afterwards repacked. The plugs of gauze, which were pressed in between the outer wall of the sinus and the overlying bone in order to obliterate the lumen of the latter, should not be interfered with for at least six days. If the case progresses favourably, the temperature becomes normal within a day or two, the patient feels well, and the wound assumes a healthy appearance. If, on removal of the gauze plugging, hæmorrhage takes place, then the plugging must be renewed and not touched again for three or four days. After it is possible to remove these plugs, the wound is treated as has already been described in Schwartze’s operation or in the complete operation in which the posterior wound was left open.
If the jugular vein has been ligatured, the sinus and vein should be syringed through daily, and this should only be stopped after all secretion has ceased, usually a matter of a week or ten days.