LIGATION OF VESSELS IN

ORAL AND MAXILLO FACIAL

SURGERY Presented by – Sumit aman MDS- 1ST YearDept. Of Oral And Maxillofacial Surgery

Moderator :Dr. Neelima Gehlot

Definition Why ligate? Procedure

Individual artery ligation

-External Carotid Artery-Lingual-Sublingual-Facial-Maxillary-Sphenopalatine-Greater Palatine-Ant./Post. Ethamoidal-Internal Carotid Artery

LIGATION Means act of binding or tying of blood vessels with sutures or

wires is called Ligation… * First ligation was done by

AMBROSE PARE in amputation procedure.

• AMPUTATION : is the removal of limb

by trauma,medical illness or surgery .it is used to cntrl pain or a disease process in affected limb such in Malignancy or Gangrene…

WHY WE LIGATE VESSELS??? AFTER AMPUTATION TO ARREST

THE BLOOD FLOW IN WOUNDS OF ARTERIES

WHERE HAEMMORRHAGE CAN’T BE CONTROLLED

IN SECONDARY HAMMORAGHE WHERE THEY CAN’T BE CONTROLLED BY OTHER MEANS

IN LOCAL HYPERTROPHIES TO ARREST THE NUTRITIONAL SUPPLY TO THAT AREA

IN CASE OF ANEURYSMS IN CASE OF MALIGNANT TUMOUR

TO STOP THE BLOOD FLOW IN ACUTE INFLAMMATION WHERE

NEITHER RESECTION NOR AMPUTATION IS POSSIBLE

IN VARIOUS OPERATIVE PROCEDURES WHEN WE ENCOUTER VESSELS TO REDUCE BLOOD FLOW TO THAT REGION .

1. EXPOSE THE SHEATH OF VESSEL

2. ISOLATE THE VESSEL

3. PLACE THE LIGATURE

LIGATION OF EXTERNAL CAROTID

ARTERY

EXPOSED AT TWO SITES

1. IN THE CAROTID TRIANGLE -AT ITS ORIGIN FROM THE COMMON CAROTID ( ABOVE THE ORIGIN OF SUPERIOR THYROID ARTERY)

2. IN THE RETROMANIBULAR FOSSA HERE WE LIGATE IT BEHIND THE ANGLE OF LOWER JAW ( DEALS WITH THE HAEMORRHAGE FROM ONE OF THE BRANCHES OF MAXILLARY ARTERY)

INCISIONA SUBMANDIBULAR SKIN

CREASE INCISION IS MADE APPROXIMATELY TWO FINGER BREADTH BELOW THE ANGLE OF MANDIBLE EXTENDING FROM THE INFERIOR TO THE MASTOID PROCESS TO JUST SHORT OF MIDLINE (behind the anterior border of sternocledomastoid process)

CONTINUE DOWNWARDS / TO THE ANTERIOR BORDER UP TO THE LEVEL OF CRICOID CARTILAGE

AFTER PENETRATING SKIN, PLATYSMA SUPERFICIAL SHEATH OF STERNOCLEDIOMASTOID IS INCISED

EXPOSURE OF GREAT VESSEL

WITH BLUNT DISSECTION ANTERIOR BORDER IS EXPOSED, MUSCLE IS RETRACTED AND DEEP LAYER IS SEEN

IN THIS PART Internal Juglar Vein IS EXPOSED

THE JUGULAR VEIN IS MOBILIZED BY OPENING THE CAROTID SHEATH & FREE THE JUGULAR VEIN.

RETRACT POSTERIORLY VEIN TO VISUALIZE ARTERY

AS THE DISSECTION PROCEED POSTERIORLY THE CAROTID BULB IS IDENTIFIED AND BIFURCATION IS SEEN

MANIPULATION OF BULB AT THIS STAGE LEAD TO ARRYTHEMIA AND ANAESTHESIST SHOULD BE INFORMED

LIGATION EXTERNAL CAROTID ARTERY IS

IDENTIFIED & LIGATED ABOVE THE SUPERIOR THYROID ARTERY

CLOSURE OF WOUND A VACCUM DRAIN IS PLACED AND

WOUND IS SUTURED IN LAYERS

HAMEORRHAGE DUE TO IJV OR ECA( profuse bleeding)

DAMAGE TO VAGUS NERVE (posteriomedially) LIGATION OF ICA( contra lateral hemiplegia &

blindness on the same side) HEMATOMA FORMATION INFECTION

ADVANTAGES: SIMPLER LESS DANGROUS PROCEDURE

artery is ligated in the retromandibular fossa behind the angle of mandible & here artery crosses the stylomandibular ligament at lateral side so

LIGATION OF CAROTID ARTEY AT THE STYLOMANDIBULAR LIGAMENT

INCISION STARTS THE TIP OF

MASTOID PROCESS AND CIRCLING THE MANDIBULAR ANGLE, CONTINUING FORWARD BELOW THE MANDIBLE FOR ABOUT ONE INCH

INCISION SHOULD BE AT EQUAL DISTANCE FROM THE POSTERIOR AND INFERIOR BORDER OF MANDIBLE

EXPOSURE AFTER THE BLUNT

DISSECTION OF SKIN, SOME POST. FIBERS OF PLATYSMA, RETROMANDIBULAR VEIN OR EJV IS LOCATED, CUT & TIED

BRANCHES OF GREATER AURICULAR NERVE IS CUT & TIED TO PERMIT THE MOBILIZATION OF CERVICAL LOBE OF PAROTID GLAND

ATTACHMENT OF PAROTID WITH STERNOMASTOID AT ANTERIOR BORDER IS SEVERED & GLAND IS RETRACTED ANTERIORLY & UPWARDS

UNDERNEATH THE PAROTID GLAND & POST. BELLY OF DIGASTRIC, SMALL THIN PART OF STYLOHYOID MUSCLE IS VISIBLE

ABOVE THIS- STYLOID PROCESS & STYLOMANDIBULAR LIGAMENT IS PALPATED

NOW MOVING THE JAW FORWARD ENTRANCE TO RETROMANDIBULAR FOSSA IS WIDENED & PULSE OF ECA IS FELT, ISOLATE & LIGATE IT

LIGATION OF LINGUAL ARTERY

INCISION INCISION GIVEN

BELOW THE LOWER BORDER OF

MANDIBLE AFTER PALPATING THE SUBMANDIBULAR GLAND

THE POSTERIOR PART OF INCISION

SHOULD BE TOWARDS THE TIP OF

MASTOID PROCESS AND ANTERIOR

SHOULD POINT TOWARDS THE CHIN

AFTER BLUNT DISSECTION SUBMANDIBULAR GLAND IS EXPOSED

POST BELLY OF DIGASTRICS IDENTIFIED, MYLOHYOID MUSCLE REACHED, HYPOGLOSSAL NERVE AND ACCOMPANYING VEIN IDENTIFIED

DIGASTRICS TENDON PULLED DOWNWARD , HYOGLOSSUS MUSCLE DISSECTED AND LINGUAL ARTERY IS FOUND AND LIGATED

FIBERS OF HYOGLOSSUS MUSCLE SHOWS VERTICAL COURSE (THIN & FINE) WHILE THAT OF MYLOHYOID SHOWS OBLIQUE COURSE (THICK)

INDICATIONS

INJURY IS OBSERVED WHEN SHARP INSUMENTS OR ROTATING DISC ARE SKIPPED ON FLOOR OF THE MOUTH

IN VARIOUS SURICAL PROCEDURE LIKE RANULA AND TUMOURS OF SALIVARY GLANDS

DIFFICULT TO LIGATE

SUBLINGUAL ARTREY MAY BE A BRANCH OF

1. LINGUAL ARTERY 2. SUBMENTAL ARTERY

INCISION

IN THE SUBLINGUAL GROOVE

STRUCTURES IN CLOSE ASSOCIATION

SUBLINGUAL GLAND(MED. &INF.)

SUBMANDIBULAR DUCT LINGUAL NERVE(MED.&

INF.) HYPOGLOSSAL NERVE

AND SUBLINGUAL VEIN

LIGATION OF FACIAL ARTERY

INCISION½ INCH BELOW & PARALLEL TO THE LOWER

BORDER OF MANDIBLE EXPOSURETHE SKIN, PLATYSMA MUSCLE AND DEEP FACIA

ARE CUT, SOFT TISSUE IS BLUNTLY CUT AND RETRACTED

LIGATION PULSE OF FACIAL ARTERY IS FELT &

ARTERY IS ISOLATED AND LIGATED FACIAL ARTERY CROSSES THE

LEVEL OF INFERIOR VESTIBULAR FORNIX IN THE REGION OF 1ST MANDIBULAR MOLAR

DURING BUCCAL SPACE INFECTION THE ARTERY IS DISLOCATED

AVOID DEEP INCISION, INCISION SHOULD BE DOWNWARDS & INWARDS INSTEAD OF STRAIGHT UPWARDS

LIGATION OF MAXILLARY

ARTERY

LIGATION CAUSES DECREASE IN INTRA VASCULAR PRESSURE GRADIENT, RESULTING IN HOMEOSTASIS

APPROACHES: CAN BE DONE BY1. TRANSANTRAL APPROACH & 2. INTRAORAL APPROACH

TRANSANTRAL APPROACH

BY CALD WELL LUC APPROACH

PROCEDURE A LATERALLY BASED U SHAPE

MUCOSAL INCISION IS CREATED POSTERIOR WALL OF

MAXILLARY SINUS IS IDENTIFIEDPOSTERIOR MAXILLARY WALL IS

REMOVED

EXPOSURE & LIGATION AREA IS ENLARGED,ARTERY IS

IDENTIFIED &LIGATED SUCCESS RATE 87% SUCCESS RATE

INTRA ORAL APPROACH

THIS PROCEDURE IS GIVEN IN 1984 BY MACERI & MAKILSKI

LIGATE INFRATEMPORAL PORTION OF MAXILLARY ARTERY

INDICATION:

- IN CHILDREN AS AN ALTERNATE TO EMBOLIZATION & EXTERNAL ARTERY LIGATION FOR REMOVAL OF VASCULAR TUMOR

- TO CONTROL BLEEDING IN VARIOUS MAXILLECTOMY PROCEDURES WHERE CALD WELL LUC IS CONTRAINDICATED

PROCEDURE:

- BY EXPOSING THE POSTERIOR PORTION OF MAXILLA THROUGH A POST. GINGIVOBUCCAL INCISION

- A FINGER IS INSERTED INTO THE DEPTH OF WOUND TO PALPATE THE MAXILLARY ARTERY

- THE NERVE HOOK IS USED FOR LIGATION

LIGATION OF SPHENOPALANTINE

ARTERY

CAN BE DONE BY TWO METHODS1. TRANSANTRAL LIGATION

2. ENDOSCOPIC LIGATION

TRANSANTRAL APPROACH

DESCRIBED BY SIMPSON et al. IN 1982

APPROACH CALD WELL LUC AVOID ENTANCE TO

PTERYGOPALATINE FOSSA MEDIAL, POSTERIOR & INFERIOR

WALL IS REMOVED SPHENOPALATINE & VIDIAN

NERVE IS DISSECTED & LIGATION OF ARETRY IS DONE

DESCRIBED BY WHITE (MODIFICATION OF SIMPSONS TECH)

APPROACH THROUGH 1. MEATAL ANTROSTOMY & 2. CANINE FOSSA NOT USING WIDELY AS COSTLY ADVANTAGES1. REDUCE PATIENT DISCOMFORT AND 2. DURATION OF HOSPITALIZATION

LIGATION OF GREATER

PALANTINE ARTERY

ENDANGERED DURING MINOR SURGERY PROCEDURES AND DURING DENTAL TREATMENT

INCISION --FROM THE LINGUAL ROOT OF FIRST MOLAR

IN AN ANTERIO POSTERIOR LINE IT SHOULD BE AS NEAR TO THE FREE MARGINS OF THE GINGIVA AS POSSIBLE

--THE KNIFE EDGES SHOULD BE DIRECTED OUTWARDS AND UPWARDS , NOT STRAIGHT UPWARDS

ANTERIOR AND POSTERIOR ETHMOIDAL

ARTERY

INDICATION1. WHEN LOCAL HAMEORRHAGE

CAN’T BE CONTROLLD BY OTHER MEASURES

2. TO DECREASE BLOOD FLOW TO UPPER NASAL VAULT FROM THE INTERNAL CAROTID SYSTEM

GENERALLY PERFORMED IN CONJUGATION WITH MAXILLARY ARTERY OR ECA

FIRST DESCRIBED BY :

KIRCHNER et al. IN 1961

INCISION A CIRCUMLINEAR

INCISION IS NORMALLY MADE BETWEEEN THE INNER CANTHUS OF EYE AND MIDDLE OF NOSE(LYNCH INCISION)

PROCEDURE THE PERIOSTEUM IS

INCISED AND ELEVATED THE FRONTOETHMOIDAL

SUTURE LINE IS FOLLOWED IN A POSTERIOR DIRECTION ABOUT 14-22mm TO THE ANTERIOR ETHMOIDAL ARTERY AND ITS FORAMEN

THE POSTERIOR ARTERY IS LIES AT FURTHER AT VARIABLE DISTANCE

THE OPTIC NERVE LIES 4-7mm POSTERIOR TO POSTERIOR ETHMOIDAL FORAMEN

LIGATION OF INTERNAL

CAROTID ARTERY

GENERALLY IT IS NOT DONE AS THE CHANCES OF BRAIN DAMAGE (CONTRALATERAL SIDE HEMIPLEGIA) ARE THERE, BUT IN SOME SELECTIVE CASES WE HAVE TO LIGATE THE ICA AS IN CASES OF ICA ANEURYSMS AND HEAD INJURIES.

COLLATERAL CIRCULATION OF COMMON CAROTID OCCURS AS FOLLOWS:

1 OCCIPITAL ANASTOMOSIS--- B/W THE TRANSVERSE CERVICAL & DEEP

CERVICAL BRANCHES OF SUBCLAVIAN ARTERY AND OCCIPITAL ARTERY

2 ANASTOMOSIS IN & AROUND THYROID GLAND B/W SUPERIOR THYROID BRANCH & INFERIOR THYROID BRANCH

3 ANASTOMOSIS B/W MIDDLE LINE B/W THE BRANCHES OF EXTERNAL CAROTID ARTERIES OF BOTH SIDES

SICHER’S ORAL ANATOMY- 8TH EDITION

PRINCIPLES OF SURGERY BY EDWARD WARN

HEAD AND NECK SURGERY- OTOLARYNGOLOGY BY BYRON. J. BAILEY- 2ND EDITION

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