VESSEL ligation

ligation of vessels

1. LIGATION OF
VESSELS IN


ORAL AND
MAXILLO FACIAL
SURGERY
Presented by – Sumit aman
MDS- 1
ST
Year
Dept. Of Oral And Maxillofacial Surgery
Moderator :Dr. Neelima Gehlot

2. Definition
Why ligate?
Procedure
Individual artery
ligation
-External Carotid Artery
-Lingual
-Sublingual
-Facial
-Maxillary
-Sphenopalatine
-Greater Palatine
-Ant./Post. Ethamoidal
-Internal Carotid Artery

3. 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…

4. 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

5. 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 .

6. 1.EXPOSE THE SHEATH OF VESSEL
2.ISOLATE THE VESSEL
3.PLACE THE LIGATURE

7. LIGATION OF
EXTERNAL CAROTID

ARTERY

8. 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)

9. 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)

10. 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

11. THE JUGULAR VEIN IS MOBILIZED BY OPENING
THE CAROTID SHEATH & FREE THE JUGULAR
VEIN.
RETRACT POSTERIORLY VEIN TO VISUALIZE
ARTERY

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. LIGATION OF LINGUAL
ARTERY

20. 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

21. AFTER BLUNT
DISSECTION
SUBMANDIBULAR
GLAND IS
EXPOSED
POST BELLY OF
DIGASTRICS
IDENTIFIED,
MYLOHYOID
MUSCLE
REACHED,
HYPOGLOSSAL
NERVE AND
ACCOMPANYING
VEIN IDENTIFIED

22.  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)

23. 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

24. DIFFICULT TO LIGATE
SUBLINGUAL ARTREY MAY BE A
BRANCH OF
1.LINGUAL ARTERY
2.SUBMENTAL ARTERY

25. INCISION
IN THE SUBLINGUAL
GROOVE
 STRUCTURES IN
CLOSE ASSOCIATION
SUBLINGUAL GLAND(MED.
&INF.)
SUBMANDIBULAR DUCT
LINGUAL NERVE(MED.&
INF.)
HYPOGLOSSAL NERVE
AND SUBLINGUAL VEIN

26. LIGATION OF FACIAL
ARTERY

27. INCISION
½ INCH BELOW & PARALLEL TO THE LOWER BORDER OF
MANDIBLE
EXPOSURE
THE SKIN, PLATYSMA MUSCLE AND DEEP FACIA ARE
CUT, SOFT TISSUE IS BLUNTLY CUT AND RETRACTED

28. 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 1
S T
MANDIBULAR MOLAR
DURING BUCCAL SPACE INFECTION THE
ARTERY IS DISLOCATED
AVOID DEEP INCISION, INCISION
SHOULD BE DOWNWARDS & INWARDS
INSTEAD OF STRAIGHT UPWARDS

29. LIGATION OF
MAXILLARY ARTERY

30. LIGATION CAUSES DECREASE IN INTRA
VASCULAR PRESSURE GRADIENT,
RESULTING IN HOMEOSTASIS
APPROACHES:
CAN BE DONE BY
1. TRANSANTRAL APPROACH &
2. INTRAORAL APPROACH

31. TRANSANTRAL APPROACH
BY CALD WELL LUC APPROACH
PROCEDURE
A LATERALLY BASED U SHAPE
MUCOSAL INCISION IS CREATED
POSTERIOR WALL OF MAXILLARY
SINUS IS IDENTIFIED
POSTERIOR MAXILLARY WALL IS
REMOVED

32. EXPOSURE & LIGATION
AREA IS ENLARGED,ARTERY IS
IDENTIFIED &LIGATED
SUCCESS RATE
 87% SUCCESS RATE

33. INTRA ORAL APPROACH
THIS PROCEDURE IS GIVEN IN
1984 BY MACERI & MAKILSKI
 LIGATE INFRATEMPORAL PORTION
OF MAXILLARY ARTERY

34. 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

35. 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

36. LIGATION OF
SPHENOPALANTINE
ARTERY

37. CAN BE DONE BY TWO METHODS
1.TRANSANTRAL LIGATION
2.ENDOSCOPIC LIGATION

38. 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

39. DESCRIBED BY WHITE (MODIFICATION OF
SIMPSONS TECH)
APPROACH THROUGH
1.MEATAL ANTROSTOMY &
2.CANINE FOSSA
NOT USING WIDELY AS COSTLY
ADVANTAGES
1.REDUCE PATIENT DISCOMFORT AND
2.DURATION OF HOSPITALIZATION

40. LIGATION OF GREATER
PALANTINE ARTERY

41. 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

42. ANTERIOR AND
POSTERIOR
ETHMOIDAL ARTERY

43. INDICATION
1. 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

44. 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)

45. 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

46. LIGATION OF INTERNAL
CAROTID ARTERY

47. 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.

48. 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

49. SICHER’S ORAL ANATOMY- 8
TH
EDITION
PRINCIPLES OF SURGERY BY EDWARD WARN
HEAD AND NECK SURGERY- OTOLARYNGOLOGY
BY BYRON. J. BAILEY- 2
ND
EDITION

50. THANK YOU