The side of the incision, left or right mainly depends on the surgeons' preference.
With a left sided approach the course of the recurrent laryngeal nerve is more predictable.
Be using a right sided approach the same nerve can be visualized and protected.
The transverse incision is made at the level required. A transverse incision will give a better cosmetic outcome.
Injuries of the esophagus can be associated with fractures or occur as a complication of the approach.
In addition to the tracheo tube a nasogastric tube should be inserted to better identify and thus help prevent accidental injury to the esophagus.
These are serious and potentially lethal complications. Consultation with thoracic or ENT surgeons should be obtained.
Platysma muscle is transected in line with the skin incision.
The deep cervical fascia is identified and divided along the anteromedial border of the sternocleidomastoid muscle.
A finger is then used for blunt dissection between the carotid sheath laterally and trachea and esophagus medially down to the prevertebral fascia.
Note: In case of carotid artery injury direct pressure should be applied and vascular surgery consultation requested urgently.
The prevertebral fascia is cut longitudinally allowing direct visualization of the vertebra and the longus colli muscle.
The level is verified with fluoroscopy.
The longus coli muscle is mobilized and distractors are placed.
The recurrent laryngeal nerve is identified and protected.
The platysma muscle is sutured followed by a subcutaneous and skin closure.
A wound drain is inserted through a separate stab incision.