Name:
10 Subclavian Vessels
Description:
10 Subclavian Vessels
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Duration:
T00H04M43S
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Upload Date:
2022-03-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
In this video, we will discuss the proper techniques to expose the subclavian vessels, both proximally and distal.
Segment:1 Anatomy.
We will begin by reviewing the anatomy. On the right, the innominate artery originates directly from the aortic arch and subsequently branches into the right common carotid artery and the right subclavian artery. On the left, the subclavian artery originates directly off of the aorta. The subclavian vessels lie deep to the clavicle.
The vein lies anterior and inferior to the artery. The anterior scalene muscle inserts onto the first rib, and separates the vein from the artery.
Segment:2 Positioning and Incision.
Proper positioning of the patient is crucial to ensure maximal exposure. The patient is placed supine on the operating room table, with his or her head turned away from the side of injury. The ipsilateral arm is adducted to 45 degrees. The surgeon should identify the sternoclavicular junction and the deltopectoral groove as key surface landmarks.
A curvilinear incision is then made through the skin, connecting the two points.
Segment:3 Dissection.
The dissection proceeds with division through the underlying subcutaneous tissue until both the sternal and clavicular heads of the sternocleidomastoid muscle are identified. The clavicular head inserts onto the medial portion of the clavicle, and is subsequently divided. The division of the clavicular head is a key step in freeing the clavicle from its surrounding soft tissue in order to facilitate exposure of the vessels.
The next step is to remove the periosteum from the clavicle
Segment:4 Periosteal Elevation on Clavicle.
using either Bovie cautery or a periosteal elevator as seen here. Once the clavicle is freed from the surrounding tissue, it may be divided.
Segment:5 Division of Clavicle.
Either a Gigli Saw or a bone cutter may be used to divide the clavicle at the sternoclavicular junction. Once the clavicle is retracted out of the surgical field, the vessels will become visible. The anterior scalene muscle lies between the subclavian vein and the subclavian artery.
The phrenic nerve courses superficial to the muscle and care must be taken to avoid injuring the nerve while dividing the muscle. Injury to this nerve will result in ipsilateral paresis of the hemidiaphragm. This illustration shows retraction of the clavicle, division of the anterior scalene muscle, exposure of both the subclavian artery and vein, as well as preservation of the phrenic nerve.
Segment:6 Subclavian Exposure Combined Clavicular and Sternotomy Incisions.
If a clavicular incision does not provide adequate exposure, or the patient has a more proximal injury, it is best to perform a median sternotomy, in combination with a clavicular incision. This provides excellent exposure to both the proximal right and proximal left subclavian arteries. The median sternotomy may be performed using either a traditional electric saw or a Lesche knife. Division of the sternal head of the SCM is necessary to connect the two incisions.
A Finochietto retractor is placed to provide exposure. From this view, the subclavian vessels can be traced. The subclavian vein joins with the internal jugular vein to form the left innominate vein that will ultimately empty into the SVC. The left subclavian artery is seen coming directly off the aorta and giving off its first three branches the vertebral artery, the thyrocervical trunk, and the internal thoracic artery. The phrenic nerve courses lateral to the internal thoracic artery, whereas the vagus nerve courses between the left common carotid artery and the left subclavian artery.
Segment:7 Key Points.
In conclusion, a few key points should be reiterated. The anatomy of the right and left subclavian vessels differ. The clavicle must be divided and retracted in order to properly expose the vessels. Caution must be used when dividing the anterior scalene muscle in order to protect and preserve the phrenic nerve. Extension to a median sternotomy from a clavicular incision provides excellent exposure to the proximal subclavian vasculature. The left vagus nerve courses between the left common carotid artery and the left subclavian artery.