The ordinary precautions for surgical cleanliness are to be observed,
and general anæsthesia employed. The incision should be made along the
posterior border of the sterno-cleidomastoid muscle, starting at the
mastoid process and running downward to within an inch of the clavicle.
The sternomastoid is separated from the adjacent muscles, the spinal
accessory nerve cut, and the carotid sheath reached. This dissection is
made with the fingers. The carotid sheath should always be opened in
order to locate the pneumogastric nerve. I consider this very important
because: 1. The nerve is sometimes outside the sheath, as happened in my
second case, in which the pneumogastric was much atrophied and was
external to the sheath. 2. Differentiation of the cervical sympathetic
from the vagus is sometimes difficult. Often, in operating on the
cadaver, I have found both nerves inclosed in the same fascia. It is
needless to say that excision of the vagus instead of the sympathetic
would not only defeat the object of the operation, but would add a
serious complication. Differentiation of these nerves after opening the
carotid sheath is not usually difficult, for in working upward the
operator comes upon the ganglionic expansion of the sympathetic. The
ganglion is seized with forceps and stripped. Its branches are cut
first, then the cord passing below is severed, and lastly the ganglion
is cut above, as high as possible. It is best to use curved scissors and
to have the finger under the ganglion while traction is made, thus
cutting on the finger and avoiding injury to the underlying structures.
If the middle ganglion is to be removed, it will be best to excise it
first and then work upward. If the entire chain of the sympathetic is to
be removed, as is done for epilepsy, and as is now advised in
exophthalmic goiter by Jonnesco, the operation is one of great
difficulty, owing to the location of the inferior ganglion. This is
situated near the neck of the first rib. One of my friends, who is a
skillful surgeon, in removing this ganglion ruptured the vertebral
artery near its origin and was obliged to tie the subclavian to check
the hemorrhage. After the latter has ceased the wound is closed with
superficial sutures. The hemorrhage in removal of the superior ganglion
is usually trifling, only a few small vessels being cut. The external
jugular vein was cut in my first case, but not in the others. The
patient leaves the hospital on the eighth or ninth day.
Jonnesco’s method, according to his latest communication on the subject,
is different. He always employs the premastoid route where only the
superior ganglion is to be removed, reserving the postmastoid for the
excision of the entire chain. The carotid sheath is split, the internal
jugular vein and sternomastoid drawn outward by a retractor; a second
retractor draws the vagus and internal carotid inward. In the space made
the superior ganglion is found. The deep vertebral fascia is opened, all
the branches of the ganglion isolated and cut by blunt, curved scissors;
when this has been done the ganglion is attached only by nerve strands
above, a strong pull is made, and the ganglion gives way. The excision
is then completed by cutting the inferior strands. In closing the wound,
he uses both deep and superficial sutures.
He mentions a transient dysphagia and pain in the cranio-mandibular
joint as occurring after this operation.