VESSEL ligation

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  • 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

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  • DefinitionWhy 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 FLOWIN WOUNDS OF ARTERIES WHERE HAEMMORRHAGE CANT BE CONTROLLED IN SECONDARY HAMMORAGHE WHERE THEY CANT BE CONTROLLED BY OTHER MEANSIN LOCAL HYPERTROPHIES TO ARREST THE NUTRITIONAL SUPPLY TO THAT AREA

    Amputation means removal of a body partHypertrophies means increase in size of cell or a muscle etc.*

  • IN CASE OF ANEURYSMSIN CASE OF MALIGNANT TUMOUR TO STOP THE BLOOD FLOWIN ACUTE INFLAMMATION WHERE NEITHER RESECTION NOR AMPUTATION IS POSSIBLEIN VARIOUS OPERATIVE PROCEDURES WHEN WE ENCOUTER VESSELS TO REDUCE BLOOD FLOW TO THAT REGION .

    Aneurysm an excessive localized swelling of the wall of an artery.*

  • EXPOSE THE SHEATH OF VESSEL

    ISOLATE THE VESSEL

    PLACE THE LIGATURE

  • LIGATION OF EXTERNAL CAROTID ARTERY

  • EXPOSED AT TWO SITES

    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)

  • INCISION

    A 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 CARTILAGEAFTER 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 SEENIN 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 SEENMANIPULATION 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 FORMATIONINFECTION

  • ADVANTAGES:SIMPLERLESS 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

  • EXPOSUREAFTER 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 VISIBLEABOVE THIS- STYLOID PROCESS & STYLOMANDIBULAR LIGAMENT IS PALPATEDNOW MOVING THE JAW FORWARD ENTRANCE TO RETROMANDIBULAR FOSSA IS WIDENED & PULSE OF ECA IS FELT, ISOLATE & LIGATE IT

  • LIGATION OF LINGUAL ARTERY

  • INCISIONINCISION 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 LIGATEDFIBERS 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

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  • DIFFICULT TO LIGATE

    SUBLINGUAL ARTREY MAY BE A BRANCH OF

    LINGUAL ARTERY SUBMENTAL ARTERY

  • INCISION

    IN THE SUBLINGUAL GROOVE STRUCTURES IN CLOSE ASSOCIATION

    SUBLINGUAL GLAND(MED. &INF.)SUBMANDIBULAR DUCTLINGUAL NERVE(MED.& INF.)HYPOGLOSSAL NERVE AND SUBLINGUAL VEIN

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  • LIGATION OF FACIAL ARTERY

  • INCISION 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 MOLARDURING BUCCAL SPACE INFECTION THE ARTERY IS DISLOCATEDAVOID 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 HOMEOSTASISAPPROACHES: CAN BE DONE BY TRANSANTRAL APPROACH & INTRAORAL APPROACH

  • TRANSANTRAL APPROACH

    BY CALD WELL LUC APPROACH

    PROCEDURE

    A LATERALLY BASED U SHAPE MUCOSAL INCISION IS CREATEDPOSTERIOR WALL OF MAXILLARY SINUS IS IDENTIFIED

    POSTERIOR MAXILLARY WALL IS REMOVED

  • EXPOSURE & LIGATIONAREA 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 TUMORTO 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 METHODS

    TRANSANTRAL LIGATION

    ENDOSCOPIC LIGATION

  • TRANSANTRAL APPROACH

    DESCRIBED BY SIMPSON et al. IN 1982APPROACH CALD WELL LUCAVOID ENTANCE TO PTERYGOPALATINE FOSSAMEDIAL, POSTERIOR & INFERIOR WALL IS REMOVEDSPHENOPALATINE & VIDIAN NERVE IS DISSECTED & LIGATION OF ARETRY IS DONE

  • DESCRIBED BY WHITE (MODIFICATION OF SIMPSONS TECH)APPROACH THROUGH

    MEATAL ANTROSTOMY & CANINE FOSSANOT USING WIDELY AS COSTLYADVANTAGES

    REDUCE PATIENT DISCOMFORT AND DURATION OF HOSPITALIZATION

  • LIGATION OF GREATER PALANTINE ARTERY

  • ENDANGERED DURING MINOR SURGERY PROCEDURES AND DURING DENTAL TREATMENTINCISION

    --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

  • INDICATION WHEN LOCAL HAMEORRHAGE CANT BE CONTROLLD BY OTHER MEASURESTO 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 ELEVATEDTHE FRONTOETHMOIDAL SUTURE LINE IS FOLLOWED IN A POSTERIOR DIRECTION ABOUT 14-22mm TO THE ANTERIOR ETHMOIDAL ARTERY AND ITS FORAMENTHE 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:

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