. Operative surgery. videdexactly in the median line from above downward, or better from below up-ward, by a sharp-pointed knife (Fig. 868). Then the dilator (Fig. 864) isintroduced, and the tube inserted andconfined in position after the trachealmucus and blood have been expelled(Fig. 869). All incisions, except theprimary one, should be directed upwardto avoid the great vessels at the root ofthe neck. The opening in the tracheashould be long enough to admit the easyexpulsion of all false membranes andforeign bodies (an inch in length is nottoo much for this purpose), and mustlikewise readily
. Operative surgery. videdexactly in the median line from above downward, or better from below up-ward, by a sharp-pointed knife (Fig. 868). Then the dilator (Fig. 864) isintroduced, and the tube inserted andconfined in position after the trachealmucus and blood have been expelled(Fig. 869). All incisions, except theprimary one, should be directed upwardto avoid the great vessels at the root ofthe neck. The opening in the tracheashould be long enough to admit the easyexpulsion of all false membranes andforeign bodies (an inch in length is nottoo much for this purpose), and mustlikewise readily admit the trachea Operation above the Isthmus(High Tracheotomy, Figs. 866 and867).—Make an incision of the usuallength, its center corresponding to thelower border of the cricoid cartilage(Fig. 866, &); divide and carefully separate the tissues as before; the loopof communication between the superior thyroid veins (Fig. 863) must becarefully drawn upward, the fascial attachment between the isthmus and. Fig. 869.—Tube in position. OPERATIONS ON THE NECK. 689 the cricoid cartilage divided, the isthmus pulled downward and drawn for-ward by a blunt hook, when the trachea can be opened beneath it frombelow upward, and the tube inserted with the same precautions as before. Tlie Operation through the Isthmus.—Tliis method is hardly of enoughpractical importance to be entitled to a detailed consideration, since theopportunities afforded above and below it will be sufficient. If, however,this position be selected for operation, the isthmus should be divided betweentwo ligatures to avoid the probability of troublesome haemorrhage. It some-times happens that the isthmus is small or too illy developed to be trouble-some after its division without ligature. Laryngo-tracheotoiny.—In laryngo-tracheotomy the larynx and tracheaare both opened by a continuous incision, which is usually made to increasethe space, that foreign bodies and false membrane may be removed. Theincision
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