Alright, so- yeah, today we're doing a left carotid endarterectomy, so typically, the way I prep and drape is essentially to expose the ear lobe, and we'll try to- we're sort of limited based on the patient's position. Rotate the head. And essentially have the midline exposed and the angle of the mandible, and then essentially the entire jaw exposed. I do typically a 5 quadrant prep with draping, but today we're doing a 4. Do you want to do this next? Yeah. Okay. So, I will mark the patient in a moment, but all the appropriate landmarks are currently exposed. Come out a little bit further. So just to delineate the anatomy, here's- sternal notch. Ear lobe is over here. and then essentially the sternocleidomastoid is here. And so our incision's essentially going to be along the anterior border of the sternocleidomastoid.
So we're just starting with the incision with the landmarks previously just described. I'll take this side. Okay. So we're starting off with the subcutaneous layer. Skin, dermis- and the first muscle layer will be the platysma. Which we can sort of start seeing now. Want to just grab a knife and just go sharply? So we're cutting through the platysma now. Okay, so here's- sternocleidomastoid, so we can try the... Exactly, so there's SCM.
Yeah, so stay right here on this sort of anterior border. Okay. I think this is the anterior border. Yeah, that is. And I'm going to grab this now, because I think that's... Sure, yeah, you could take the larger bite. Do you think this is… It's sort of splayed a little bit, but it's okay. Yeah, I kind of want to grab this. So yeah, I want to grab this and now I can sort of see the… This I'm still- want to come my way. Yeah, that's fine. So we're just mobilizing the SCM laterally. So now we're essentially trying to enter the carotid sheath. Do you want a sharp? Yeah, I mean I could do a little bit sharp, you know? Yeah. Yeah. Nice. And cut over here. Nice. Nice, yeah, that's gotta be it. I'm just trying to see where the… So now we're essentially entering the carotid sheath and identifying the carotid artery. Once we have the vagus nerve identified, we'll let you know. Is this it? It's right here. It's right there. Yeah, so there's- yeah, that's the vagus nerve, which is typically running posterior and lateral to the carotid. Okay. Looks like we can see some plaque at the bifurcation. Yeah, so it looks like here's the- exactly, here's the bifurcation. Let's open this up. Yeah, let's just take that. So as we get superior, we're looking for the posterior belly of the digastric and the hypoglossal nerve. Sharply doing everything, yeah? Yeah. Okay. Let's get a Rich. Alright good. Okay. So now we're essentially identifying the external carotid and getting control of it, followed by the internal carotid and the common carotid. Typically, we would do the common carotid first in a real patient. That's pretty much completely exposed currently. I'm looking for, right now, branches of the external carotid, which I don't see any major branches. Good. So now, let's just come- here- exactly. We could get that plane between the two. Okay. So this is the external carotid artery, which goes towards the patient's face, which has several named branches. And then… Let's take- let's actually just get a right angle and get a loop around it because then we could retract it medially. Yup. Right there. So that's one, so do a big spread- once you get in there, and just do a big spread just to open up that plane. Yeah, you can already see my instrument is… Yeah, it's already… That's pretty good. You know, it's really- at this stage just looking for... Vagus, Vagus, you know, which… Okay. Let's flip it this way. Exactly. I think you're good- yeah, you're good. I think - yeah, we're good. Okay. And then, in a typical carotid, we would do the common carotid first, followed by the external, and the internal, and do a no-touch technique to essentially not touch the area of disease and the bulb, which this patient has some disease, so that's going to be interesting when we open it. Let's see. Typically, the internal carotid has no branches- until you're intracranial. Let's see, let's just get a little bit higher on it. Alright, I'll take that Rich back. Actually, that looks more like tendon now. Yeah, that's definitely tendon. It's a little bit thick for the... A little thick. Yeah. Okay. So I don't see any branches of this- this- the external carotid, which is common. Usually you can see a- a superior thyroid branch, but that's not evident right now.
So right now, just to identify everything- let's re- let's fix that lower Weitlaner. So, here- what we identified earlier was essentially, here's the vagus nerve running posteriorly. This is the common carotid, this is external carotid, this is the internal carotid. There's some disease in the bulb of the internal carotid. And then, typically there's the- essentially the baroreceptor's nerve of- of cranial nerve IX comes right here and is typically right in this location, which may be that that goes directly to the bifurcation, ANSA is likely this structure over here, which if we trace that all the way up to- the hypoglossal. Let's open the artery up. Okay, that sounds good.
That should be good. So just come- we typically do our arteriotomy anteriolaterally. So, I'll steady the artery for you, So you just go here, just extend it up this way. Oh, wow. Pressurized- fluid. Can I use the Potts now? Yes, if you have them, if- Metz is fine, yeah. Or, a Metz. So typically we'd use Potts scissors and extend our arteriotomy- anteriolateral surface towards the internal carotid artery. And there's really minimal disease. There's some calcific disease here, but there's really no bulky, atheromatous disease in the internal carotid artery. Alright. So that's really the extent of the dissection, right here, when we do the endarterectomy, we'd find a plane and we essentially take the plaque out, leaving- really the adventitia layer, and we take- we do an eversion technique to pull the plaque out of the external carotid, and then we would sew a patch in to make artery wider. So, it's pretty straightforward anatomy. The hardest part I think of this case was the- muscles were all fused together. Yeah. So we just had to just sort of go right through it to get to it.
Good. And send that that way. Perfect. Okay. So, I would go... Should I start here? Outside-in down this, and then just go outs- you know, inside-out here, and then we'll anchor it on the ICA side. Alright. Nice. So what we're doing now is a- what they call a patch angioplasty, we're using PTFE. You typically use bovine pericardium for this part of the case after you do your endarterectomy. And we're sewing it in on the internal carotid side first. And, in real life, we actually use 3, you know, mattress sutures on this side and then secure it, and then we run the outer mattress sutures to the midpoint where these tacking sutures are. Sorry. Okay. Long tie. So then, take your SNaP off, and let's just bring this down. Okay. Okay? Okay. Do you want to- I guess we'll meet in the middle for each? Yeah. Okay. I think the easier side to do is going to be the lower side. Yeah, I think so. So do you want to do the upper side first? Yeah, let's do the upper side first. So right now we're sewing on the medial side of the patch. So right now we're doing the lateral side of the- patch, along the internal carotid artery. So now we're doing the common carotid side and completing the patch. So, typically we could use a larger needle and larger Prolene suture on this side. Given this is the common carotid, and I'm going to follow in the orientation the needle's going, which is essentially away from us. So now we're doing the lateral side of the common carotid, finishing up the patch. So at this stage I would perform flushing maneuvers, since there's only about 3 bites left. And I would then add hep saline into the lumen of the vessel. Watch your clamps. Okay, one more. Yeah.
So now we're taking all of our pseudovascular clamps off. And now we're assessing for hemostasis in the case, there would be significant bleeding throughout the suture-line, as there always is. And now, we're- ready to close.