Ligation of external carotid artery

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bleeding may not stop, or may start again from other vessels
• wound haematoma
• wound infection
• injury to nerves: hypoglossal (tongue weakness), vagus (hoarse voice), great auricular (numb ear lobe)
• injury to the internal jugular vein or carotid artery
• stroke (rare)
• loss of blood supply to the tissues supplied (ischaemia)
• blood transfusion

Pre-operative details for this operation

1. Source of bleedingMouth / tongueTonsil / oropharynxNose (lower two-thirds) / maxillary sinusHypopharynx / larynxTrauma to face or neckside
2. Measures already triedpressure, packing, cautery, suturing, embolisation considered or not available
3. Haemodynamic statuspulse, BP, Hb, blood loss estimate before OT
4. Bloodgroup, units cross-matched, units given before OT
5. AirwayIntubated in OTAlready intubatedTracheostomy present / planned
6. CoagulationPT/INR, platelets, anticoagulants

Anaesthesia and position

1. AnaesthesiaGeneral, endotracheal tube
2. PositionSupine, sandbag under shoulders, head turned to opposite side
3. Side operatedRightLeft

Operative findings

1. Carotid bifurcation levelusually at the upper border of the thyroid cartilage
2. Branches used to confirm the external carotidsuperior thyroid, lingual, facial, ascending pharyngeal: name at least one, preferably two
3. Hypoglossal and vagus nervesseen and preserved
4. Effect on bleeding after ligationBleeding stoppedReducedContinued

Procedure (steps)

1. IncisionTransverse skin-crease incision centred over the bifurcation at the upper border of the thyroid cartilageIncision along the anterior border of sternomastoidlength in cm
2. Platysma dividedgreat auricular nerve preserved
3. Deep cervical fascia opened along the anterior border of sternomastoidsternomastoid retracted back
4. Facial veinLigated and dividedRetracted
5. Carotid sheath openedcommon carotid, internal jugular vein and vagus identified
6. Bifurcation exposedposterior belly of digastric and stylohyoid retracted upward
7. Hypoglossal nerve identifiedcrossing lateral to both carotids
8. External carotid confirmedby at least one, preferably two, of its branches before any tie is passed; the internal carotid has no branches in the neck
9. LigationLigated in continuityDouble ligated and divided between tiesonly when no doubt remains about the vessel; record the level against the named branches (above or below the superior thyroid origin, which is usually just above the bifurcation, and below the lingual); strong silk or other non-absorbable
10. Ascending pharyngeal branchIncluded in ligationLigated separatelyNot relevantmust be included for hypopharyngeal bleeding
11. Bleeding site checked after ligationmouth / nose / pharynx inspected; packs placed or removed
12. Neck haemostasis

Closure, drains and dressing

1. Deep cervical fasciaapproximated to sternomastoid
2. Platysma and skinsuture material, interrupted / continuous
3. DrainSmall drain for 24 hoursNone
4. Dressing

Specimens and implants

1. Biopsy of bleeding lesionTaken for HPENot taken
2. ImplantsNone

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Vitalspulse, BP: frequency as per ICU chart
2. Watch the original bleeding sitemouth, nose or pharynx; suction ready at bedside
3. Neck woundswelling (haematoma), drain output
4. Neurological checkslevel of consciousness, limb power, speech: report any change at once
5. Tongue movement and voicehypoglossal and vagus function
6. Hb and transfusionrepeat Hb; further units if needed
7. Drain removalat 24 hours if output minimal
8. Plan for the causetreatment of the underlying lesion, oncology / palliative team

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery