Controlling the surgical field during a large endoscopic vascular injury

Abstract

Since the advent of endonasal skull base surgery, internal carotid artery (ICA) injury has been considered the most dramatic and challenging intraoperative complication. A large vascular injury creates an immediately challenging surgical scenario with rapid blood loss that may result in exsanguination of the patient. Recently we have developed an animal model of the endoscopic, endonasal vascular injury. We describe important surgical steps required in managing the surgical field during a catastrophic vascular event. A total of 42 endoscopic carotid artery injuries and 25 endoscopic venous injuries were performed. Throughout the injuries, the "two-surgeon" technique was used to achieve surgical field control. Videoendoscopy was performed throughout the implementation of these surgical techniques. Techniques found useful in controlling the surgical field included the two-surgeon technique, careful selection of the most appropriate nostril for endoscope positioning, large bore suction placement, suction guidance of the vascular stream through the contralateral nostril, and avoidance of suction obstruction. Only once the surgical field could be controlled can the injury site be addressed. Controlling the endoscopic endonasal surgical field during vascular injuries relies on the cooperation of the surgical team and a step-based approach including careful endoscopic maneuvering within the nasal corridor, and appropriate suction selection and positioning with respect to the endoscope.