ABSTRACT
Once the jugular vein has been retracted and the CCA has been isolated, the carotid sheath is opened along the midportion of the vessel to expose all branches of the carotid tree. Exposure of a high bifurcation and a high plaque in the ICA is particularly difficult and may necessitate some rather extensive dissection. I dissect along the medial border of the jugular vein while coming up the ICA. In this case, the hypoglossal nerve and ansa hypoglossi complex have been isolated with several vessel loops and it was necessary to cut the digastric muscle to obtain a high exposure of the ICA. I have found that the digastric muscle can be coagulated with bipolar cautery and transected sharply with no ill effects, and in combination with a hinged Richards retractor, this maneuver yields a very nice exposure of the distal ICA. In the photograph, a blue line has been drawn along the carotid artery in preparation for surgical incision. It should also be noted that several 4-0 silk tacking sutures were used to hold the carotid sheath open, thereby lifting the carotid bulb somewhat out of its bed and facilitating the surgical approach to the vessel.
