Preoperative Planning

It may be appropriate in revision settings to get a preoperative otolaryngology consult to evaluate vocal cord paralysis.¹⁵ If a vocal cord paralysis exists, the approach should be made on the ipsilateral side to avoid a potential bilateral paralysis. An approach on the right side may put the recurrent laryngeal nerve at more risk, while a low approach on the left side may put the thoracic duct at risk.

Preoperative Imaging

The preoperative radiographs are examined to identify unique anatomic features. The proper identification of existing instrumentation is especially important to ensure that all needed equipment will be available. Knowledge of the ventral osteophytes can help the surgeon to identify the proper levels during the approach by intraoperative palpation and visualization. The vertebrae are labeled by level, and the anterior-to-posterior distance of the vertebral body (minus the magnification factor) is measured to estimate the graft and screw size. Anatomically “short” necks where the lower cervical levels are at or below the level of the clavicle may alert the surgeon to potential difficulty accessing these lower levels during a standard approach. It may be helpful to list the patient’s symptoms (especially left versus right, radiculopathy and/or myelopathy), surgical plan (levels of discectomy), and important comorbidities (smoker, diabetic, etc.). The axial MRI or CT scan should be carefully reviewed for the vertebral artery position, and any anomalies should be carefully noted. The operative site is marked in the holding area.

Intraoperative Procedures

The anesthesiologist administers 10 mg of intravenous decadron to minimize ventral swelling and prophylactic antibiotics (usually cefazolin 1 g) to minimize the risk of infection.

The patient is placed supine on the operating table. Neck flexion should be minimized in moving a patient with a large cervical disc herniation and myelopathy. A folded sheet or an intravenous bag is placed underneath and across the shoulders; sometimes, two sheets will be better. The sheets under the shoulders and the foam doughnut under the head are adjusted to obtain ideal neck extension (it is important to be careful in using two sheets, which may overlordose the cervical spine). It is rare that any support other than the foam doughnut is needed under the head. An unrolled Kerlix is placed around both wrists (NYOH stockinette-style knot) and hung off the bottom of the table to allow pulling down of the arms and shoulders for intraoperative radiographs. Plastic self-adhesive drapes are placed just above the nipple line and along both sides of the neck as low as possible. The side drapes are placed dorsal to the ear and around the circumference above the chin. The upper thorax should be accessible in case of emergency (e.g., vertebral artery injury and necessity for exposure of subclavian artery for proximal control). A half sheet is placed down over the patient’s body and legs to prevent accidental contamination via the surgeon’s gown touching the bed or patient. Sterile towels are placed over the sterile field and moved away from the center. The inferior towel is usually at the sternal notch; the superior towel is around the chin; the ipsilateral towel is as low as possible; the contralateral towel is several centimeters lateral to midline to accommodate a midline-crossing incision. The carotid tubercle, thyroid cartilage, and cricoid cartilage can be palpated as landmarks. The incision location can also be based on the location of the mandible and clavicle on preoperative radiographs. An incision is marked in a neck crease if possible, crossing midline as needed. Perpendicular lines help during closure. Larger transverse incisions with less retraction (skin stretching) tend to heal better than a smaller incision with stretched skin edges. Vertical incisions leave unappealing scars and can be avoided. The incision should be located in the inferior third of the levels to be decompressed because it is easier to mobilize skin in a cephalad rather than a caudad direction and the disc spaces angle cephalad. The skin is injected with 0.25% Marcaine with epinephrine as early as possible, since the epinephrine takes time to work (ideally 10 minutes). Cut strips of adhesive barrier drape (Ioban) are used to seal the edges after the incision is marked.

A scalpel is used to incise the epidermis and dermis. Leaving an intact corner of dermis at the ends of the wound protects against stretching, thereby allowing for a more cosmetically pleasing closure. Subcutaneous bleeders can be cauterized but will often tamponade with a gently placed Weitlaner retractor that is spread gradually during exposure. Using the cut function on the electrocautery will minimize charred tissue, but small veins will often need the coagulate function. The platysma is cut transversely in line with the incision; sometimes, veins run in the platysma layer and can be dissected bluntly with Metzenbaum scissors or directly coagulated with the cautery. The platysma is undermined cranially and caudally with spreading scissors, blunt finger dissection, and cautery. When multiple segments are being exposed, the platysma should be undermined from the corner of the mandible to the clavicle along the length of the sternocleidomastoid. The interval between the sternocleidomastoid and medial strap muscles is identified. The external jugular vein may be mobilized either laterally or medially. Preserving the sternocleidomastoid fascia by starting the dissection closer to the strap muscles will minimize bleeding. Spreading scissors, blunt finger dissection, and cautery are used to dissect through the interval between the alar fascia (carotid sheath) and the visceral fascia (trachea and esophagus). The carotid pulse can be palpated and kept lateral. In the interval, the ventral cervical spine and longus colli muscles can be palpated. Blunt finger dissection can widen the defect longitudinally, although there may be less bleeding with the spreading scissors technique. Crossing nerves that should be preserved include the glossopharyngeal and hypoglossal nerves at the very top of the approach and the superior laryngeal nerve above the superior thyroid artery. The recurrent laryngeal nerve may be at the bottom of the approach, especially on the right side. It is acceptable to take the inferior, middle, and superior thyroid vessels if necessary. Larger crossing vessels may need to be tied. A wall bleeder can be very difficult to stop if it represents a side-opened vessel; in this case, a bipolar technique will often slow bleeding enough to allow packing with a hemostatic agent and cottonoid patty. A hand-held retractor is placed medially to pull the trachea and esophagus over the midline to see the ventral aspect of the cervical spine. The omohyoid muscle crosses the field around C6 and can be divided with lower-level dissections with no adverse effects. The muscle can be elevated with Metzenbaum scissors underneath and then divided with electrocautery.

The carotid tubercle, usually at C6, and ventral osteophytes can be palpated to estimate levels. The prevertebral fascia is cleared off the discs (hills) and vertebral bodies (valleys) using scissors and forceps with a nick-and-spread technique. The hand-held retractor is then replaced under this layer (Fig. 76-1).

FIGURE 76-1 Prior to elevating the longus colli muscle, one can mark the midline with a Bovie electrocautery. This helps in keeping the decompression centralized and also helps to keep the plate straight.

Once the radiology technician is present, a bent 12-mm, 14-mm, or 16-mm spine needle (based on preoperative radiographic measurement) is placed in the disc space of choice. The carotid tubercle and/or ventral osteophytes can be used to predict the level (Fig. 76-2). Dissection can continue while the film is being processed. The sterile draped microscope is then brought into the field. The “valley” of the ventrolateral aspect of the vertebral body above and below the suspected disc is cauterized to get the segmental arteries and perforating branches. The longus colli is elevated off the vertebral body “valley” by using coagulate (cranial and caudal enough to place the plate comfortably) and then off the ventral disc “hill.” The safe (nonanomalous) position of the vertebral artery should be confirmed on the preoperative axial MRI or CT prior to elevation of the longus. The longus colli in the upper cervical spine (i.e., C3-4 and higher) is less muscular and less well defined. A Penfield 2 can be used to safely elevate the longus at the vertebral body out laterally over the transverse process. Bleeding bone on the front side of the vertebral body under the elevated longus can be coagulated with bone wax used as needed. If bleeding starts from the undersurface of the longus or out laterally, a hemostatic agent and a large cottonoid patty can be used. The self-retaining (Shadowline or similar) retractors are placed underneath the elevated layer of the longus colli. The hand-held retractor is used to move the esophagus so that the self-retaining retractor blade can be safely placed under the longus. An assistant’s hand on the medial self-retaining retractor handle can stabilize downward and keep it correctly positioned (Fig. 76-3). The vertebral body just cranial and caudal to the disc space is prepared for insertion of the Caspar retraction posts. Prior to insertion of the Caspar pins, a rongeur or bur is used to remove the ventral osteophytes until they are flat with the ventral surface of the vertebral body. Caspar pins (usually 14 mm or 16 mm based on preoperative and localizing radiographs) are inserted by hand. Careful insertion is important if the patient is very myelopathic or stenotic. The superior post should be farther away from the cranial inferior end plate, but the inferior post is just below the caudal superior end plate. This is due to the angled shape and orientation of the cervical vertebral bodies, and will allow good purchase of the screws. The Caspar pins can be inserted slightly diverging to allow for lordosis. Proper insertion of the Caspar posts is critical. The posts must both be in the center of the vertebral bodies, since going off center with one post may result in vertebral twisting and scoliosis after the Caspar retractor is placed. If the posts are not placed in the center but are both off to one side, the distraction of the interspaces will be asymmetrical and lead to uneven end-plate preparation while the posts are retracting. Excellent visualization of the bodies before placing the posts will help to avoid errors at this step. Centering with reference to the spine is more reliable than centering with reference to the patient’s chin and sternal notch. The cranial angulation of the disc space should be parallel to the path of the Caspar pin in the sagittal plane. It can be helpful to identify the disc space with a Bovie or #15 blade if the surgeon is unsure of the location or angle. The posts must diverge or be parallel when inserted to lordose the spine and prevent the cephalad post from entering the end plate, given the upward sloping nature of the end plate. If the Caspar pins are not placed divergently, the threads of the cephalad post may be encountered while burring out the end plate.

FIGURE 76-2 A safe way to elevate the longus colli muscle is to cauterize it with a bipolar electrocautery and then to elevate it using a Penfield 2 elevator. A spine needle marks the disc space. If one is not sure about the level, it is preferable not to place a needle into a disc space, since that can result in premature disc degeneration if it happens to be at the wrong level. Instead, one can place a pin into the vertebral body or even a staple next to the disc space.

FIGURE 76-3 One way to gently retract the trachea and the esophagus is to place a 4 × 4 sponge cranially and caudally. This helps to slightly retract the trachea and the esophagus away from the operative site. The metal retractor then places less force on the trachea and esophagus at the operative site. The sponge going in (A) and the sponge in place (B).

A #15 blade is used to cut the width of the ventral anulus (the cutting portion of a #15 blade is 11 mm exactly). Multiple passes are made through the disc, going no deeper than the cutting portion of the blade while turning the blade vertically at the lateral edges of the disc space. The lateral border of the vertebral body is a reasonable guide to determine the location of the vertebral artery. A Penfield 4 can be placed around the edge of the body just for conceptualization. A pituitary rongeur is used to remove initial disc fragments. The Caspar retraction can be increased once the ventral anulus has been excised. A curette (Codman Microsect 4B) can be held like a dagger or a pencil while scraping the disc thoroughly. A side-to-side motion is safe as far lateral as the uncovertebral joint allows. The path of the curette should be smile-shaped during the initial passes, not just horizontal. Resting the hand on the patient with all maneuvers will give stabilization and control. A pituitary rongeur is again used to remove numerous pieces of disc and bone and cartilaginous end plate from the field. Keeping the nondominant hand on the patient and using two hands to control the pituitary rongeur will avoid plunging into the canal. A smaller curette (Codman Microsect 2B) can be used to get into foramen by first using a twisting or scooping motion to get the cartilage out of the uncovertebral joint and then using an upward pulling motion to get the uncovertebral process to break and come out of the foramen ventrally. The curette tip should always be kept against the superior vertebral bone medially to prevent accidental injury to an artery. The microscope should be tilted to angle into the intervertebral space optimally. Suction in the nondominant hand should rest on the patient for control and stability while in the disc space. A bur is used to remove the inferior end plate of cephalad vertebrae ventrally. Constant irrigation will keep the field clear. The goal is to make the end plates bleed and flat. The end plates are burred centrally back to the posterior longitudinal ligament (PLL). The last anular fibers can be burred away, leaving longitudinally oriented PLL fibers. The disc space can be squared off by going laterally and taking down some of uncinate bilaterally. The smaller curette can be used to remove any remaining dorsal anular fibers and dorsal osteophyte/PLL if necessary. The PLL may need to be removed only if the surgeon is going after extruded disc. Any remaining dorsal lip of vertebral body can be removed with the bur before the PLL is taken, as the PLL serves as a safety backboard (Fig. 76-4). Inadequate foraminal decompression may lead to residual radicular symptoms. For unciatectomy or wide foraminotomy, the uncinate can be identified by carefully going out of the joint laterally with the 2B curette and turning caudally. A Penfield 4 and then a Penfield 2 can be used to identify the lateral aspect of uncinate (protecting the vertebral artery). With the Penfield held by the assistant, the uncinate can be burred in a ventral-to-dorsal direction. A medial-to-lateral direction is more dangerous, because the bur is then moving toward the vertebral artery, which lies lateral to the uncinate (Fig. 76-5).

FIGURE 76-4 The central decompression has been completed, and a curette is being used to retract the posterior longitudinal ligament (PLL) in order to visual the dura. While many surgeons prefer to completely resect the PLL, in most discectomy cases, we prefer just to look behind the PLL and to leave it intact. The PLL then acts as a barrier to prevent intrusion of the bone graft and also provide some stability.

FIGURE 76-5 A, A Penfield 2 is seen at the top of this picture just lateral to the uncovertebral joint. This helps to protect the vertebral artery from injury as one is performing a foraminotomy. B, The foraminotomy has been completed, and the Penfield 2 is retracting the vertebral artery. C, The width of the decompression from left to right with a Penfield 2 on the right side and a Penfield 4 on the left side.

After the decompression is complete, a sizer is used to check for the size of interbody graft. A typical graft size is somewhere around 7 to 9 mm and can be estimated from preoperative imaging studies (especially of adjacent healthy levels). If the sizer is not going in smoothly, it is much safer to gently tap it into place with a mallet than to push toward the spinal cord in an uncontrolled manner (Fig. 76-6). In attempting to access C7-T1 when visualization is difficult because of the angle of the disc space and obstruction of the clavicle, it may be necessary to perform a greater end-plate resection of C7 or even a corpectomy if the added end-plate resection results in a weak surface for graft support.

FIGURE 76-6 A, We use a prefabricated allograft that is then packed with local autograft. The local autograft can be obtained from bone shavings as well as any small osteophytes that are removed with a Kerrison punch. With a wide decompression, it is possible to place two bone grafts side by side. By maximally filling the disc space with bone graft, one can achieve high fusion rates. B, The first allograft in place. C, The second allograft placed next to it.

The ventral vertebral bodies are refashioned with a rongeur to smooth out the ventral contour for plate placement. Typically, a structural interbody allograft is placed, followed by a ventral plate. It may be necessary to taper the edges of the graft to facilitate insertion and make it flush with the end plates. After graft placement, no space should be visible between the grafts and the end plates prior to releasing distraction. If necessary, the graft or the end plates can be touched up with the bur.

Once the plate has been inserted, all the landmarks are obscured, and it is very easy for the plate and screws to be misplaced. Some systems allow for drilling of the screw holes while the Caspar pins are still in place marking the midline. The correct plate size should be as short as possible, just spanning the height of the interbody graft, to avoid encroachment on the adjacent discs.

The retractors are then removed, and radiographs are taken. While radiographs are being processed, the wound is checked for bleeders, and hemostasis is obtained with hemostatic agents and cottonoids (see Fig. 76-3).

A drain is placed with the internal tip placed in the caudal portion of the wound and the trocar through the skin inferior to the incision. The authors close the platysma with interrupted 3-0 monocryl, and the skin is closed with interrupted 5-0 monocryl.

Postoperative Management

For single-level anterior cervical discectomy and fusion, an appropriately sized soft collar is placed before extubation, and the patient is instructed to wear it as needed for comfort. If the patient is osteoporotic or the construct is more than a single-level anterior cervical discectomy and fusion, a Miami J collar is typically used. Patients are instructed to remove it for eating and cleaning (approximately 1 hour a day) but otherwise to wear it for 6 weeks. Patients are observed overnight in the hospital with a continuous pulse oximeter to watch for airway compromise from postoperative hematoma/seroma. Diet and activity are allowed as tolerated. Drains are typically removed on postoperative day 1 (the goal is <20 mL per 8 hours), prior to discharge.

Preoperative Planning

Radiographic assessment is similar to that of ventral discectomy procedures. Imaging studies should be carefully reviewed for pathology and abnormal anatomy. Lateral disc herniations without significant uncovertebral spurring are a common indication for dorsal foraminotomy. Central disc herniations and “disc-osteophyte complexes” are relative contraindications to dorsal foraminotomy. Dorsal cervical wound complications may be reduced by asking the patient to clip the hair from the dorsal neck the night before surgery. Intravenous antibiotics should be administered within 1 hour of making the skin incision. The operative site should be marked in the holding area.

Intraoperative Procedures

Patients are placed prone on the operating table with the neck in flexion. Gardner-Wells tongs are used to apply traction (10 to 20 pounds) via a flexion vector. On the OSI table, three pins should be in place at the superior portion of the bed. The head of the bed should have the pin placed in the superiormost hole, and the foot of the bed should be placed lower in the H-bar to allow for maximum reverse Trendelenburg position (minimizes venous bleeding). Two traction ropes for intraoperative traction (one for flexion and one for extension) can be used if the plan is to instrument and fuse after the discectomy. The flexion vector is usually through the central portal, and the extension vector is over the central groove in the traction H-bar. The flexion position is used for the incision and closure as well as decompression (foraminotomy/discectomy). The extension rope is used in performing a concomitant instrumented fusion to allow lordosis. It can also be used to check the adequacy of the foraminal decompression with the patient’s neck extended. The full chest pad is placed in the appropriate position with two iliac crest pads placed at the level of the pelvis and a sling for the legs. A strap or tape across the buttocks will prevent caudal migration of the patient once in reverse Trendelenburg position.

Gardner-Wells tongs are applied symmetrically just above the ears. Pins should affix the bone 1 cm above the superior pole of the external ear. Pins that are placed too ventral will be in thinner bone and may cause a painful hematoma in the temporalis muscle.

After the patient has been flipped prone, a traction cord with 15 pounds of weight is attached to the flexion rope. The arms should be tucked with a sheet at the patient’s side with the hands in neutral position. The full chest pad should be at nipple level with female breasts tucked inferior and the chin and neck free from pressure. The iliac pads are placed just below the anterior superior iliac spine. The legs are placed on multiple pillows in the sling with the knees and ankles separated by foam padding. The abdomen hangs free with the patient in reverse Trendelenburg position to decrease venous pressure and minimize bleeding. The hands are checked to make sure they are not pressing directly on anything hard, and foam material is used to pad the hands and bony prominences accordingly. The shoulders are taped down using 3-inch silk tape from around the acromioclavicular joint, down the arms (supporting them from falling downward), then around the foot of the table. Overstretch with excessive force can cause a brachial plexus injury. The dorsal neck is clipped if the patient did not do this the night before, leaving adequate room for the plastic self-adhesive drape to attach without interfering with the exposure. Benzoin or other adhesive is applied prior to placement of the drapes. The surgical area is prepped widely. The warming blanket is taped to the undersurface of the table, ventral to the patient, allowing the heat to rise to the patient. After skin preparation, a half sheet is placed over the legs, and another half sheet is used to cover the end of the bed. Four blue towels are placed around the surgical field. The towels are placed close to the area of the incision. Then a half sheet is placed over the entire area and a small hole is cut out where the incision is to be made. The blue towels are then pulled back to expose the minimum amount of skin necessary to perform the operation. We prefer to prep the skin widely and then drape narrowly. Local anesthetic/epinephrine is injected into the area of the planned incision, and the surgical site is covered with Ioban strips.

A midline skin incision is made with a full-thickness scalpel cut, down into subcutaneous fat. The incision is deepened with electrocautery and while self-retaining retractors are inserted that will aid in hemostasis. Once below subcutaneous fat, it is very important to carefully stay in the midline fascia. The actual median raphe may deviate from the actual physical midline by quite a bit but is visible by carefully using the electrocautery on cut rather than coagulate. Care is used to avoid dissecting into the paraspinal muscles, which would lead to greatly increased bleeding and postoperative pain. Crossing bleeders from the venous plexus can be coagulated. The median raphe usually looks like a white band of fascia approximately 3 to 4 mm wide and can be better visualized with loupe or microscope magnification and lighting. In dissecting deep to the fascia, pink muscles fibers should be avoided. The separation between the paraspinal muscles can sometimes be very fine when they merge centrally in the raphe. At the level of the spinous processes, the muscles span the tips and can be preserved in performing a unilateral foraminotomy/discectomy without fusion. When the plan is to fuse or dissect previously fused levels, the interspinous tissue can be taken with the lateral soft tissue flaps so that only bone remains. This will minimize bleeding by staying out of the vascular muscle. The levels are localized with spine needles on the spinous processes percutaneously prior to incision and/or with a clamp on an exposed spinous process with intraoperative lateral radiograph. Once subperiosteal dissection has been completed with electrocautery down to the level of the lamina, a Cobb elevator is used to strip the soft tissues laterally with a scraping technique.

In performing a foraminotomy, the interlaminar V of the lateral aspect of the desired laminar interspace is the starting point (Fig. 76-7). The interlaminar V points to the affected joint and disc level. A high-speed bur is used with one hand held like a pencil as close to the bottom of the bur as possible for better control. The surgeon’s fingers should point down into the wound as a result; the other hand holds a small Frazier suction tip, and the assistant irrigates. The bur is maneuvered in small, circular motions, getting gradually deeper (ventral); in-and-out motions are to be avoided. The inferior articular process of the superior vertebra is burred away, leaving the superior articular process of the inferior vertebra (Fig. 76-8). If the facet joints are arthritic and have large spurs, the foraminotomy hole can become quite deep. Frequent irrigation and suction will maintain visualization. Burring is stopped once soft tissue is seen protruding through the remaining bone at the “floor” or on the “walls” of the foraminotomy or the bone takes on a translucent appearance from becoming so thin (Fig. 76-9).

FIGURE 76-7 When performing a dorsal cervical foraminotomy, one must first identify the medial and lateral borders of the foramen. The interspace between the C5-6 lamina is shown as the interlaminar V on the left. On the right, an interoperative picture shows a ball-tipped probe marking the interlaminar V.

FIGURE 76-8 The first step of the foraminotomy. In the model, an L-shaped resection of the C5 inferior articular facet is to be made. This goes approximately 50% of the distance between the interlaminar V and the lateral margin of the facet. This is because if one resects 50% of the joint, this is approximately where the lateral margin of the pedicle is. The foramen is bounded by the C5-6 pedicles. If one performs a decompression lateral to the pedicle, the foramen will be completely free. On the right-hand side, as the model shows, this L-shaped area has been removed. One then sees the superior margin of the C6 facet.

FIGURE 76-9 A high-speed bur is used to resect the triangular piece of bone using an L-shaped trough. Any bone that is overlying the C6 pedicle is then resected.

It is preferable to complete the drilling laterally first, rather than medially, because if the medial cortex if perforated first, the engorged vein underneath protrudes while the surgeon is trying to complete the lateral drilling and causes considerable bleeding and difficult visualization.

The suction tip is maintained in the interspace when drilling, to protect the soft tissue overlying the cord in case of a sudden drill “kick” or movement. Alternatively, a curette can be placed into the interspace, hooked into the foramen, to protect the cord. The Codman-Karlin 2B curette is the ideal tool, since it can be held like a pencil, and with a pulling motion, the bone overlying the foramen can be lifted out; the 1-mm Kerrison rongeur is also useful.

The vein that overlies the nerve root tends to bleed profusely, so it is important to understand the maneuvers that can decrease bleeding. Reverse Trendelenburg positioning with the abdomen hanging freely is used to decrease venous pressure. Thrombin-soaked hemostatic gelatin (Gelfoam) and cottonoid patties are packed into the bleeding foraminotomy site, and the decompression is resumed when the bleeding has slowed down.

The thoroughness of the decompression is assessed by palpating the superior and inferior pedicles with the tip of the Codman curette or a nerve hook. Once the entire interpedicular region has been unroofed, the bony decompression is done(Fig. 76-10). The nerve root can be gently retracted superiorly and the disc material removed with a small nerve hook or pituitary rongeur. Resecting 50% of the cervical facet does not typically require fusion or stabilization (Fig. 76-11).

FIGURE 76-10 A, The arrows point to the C6 pedicle. The nerve is retracted cranially, and a right-angled ball-tipped probe is utilized to hook the herniated disc fragment. If there is no disc fragment and one is just performing a foraminotomy, after making sure that the foramen is completely open, one should recheck with the neck in full extension. This ensures that even with the patient’s neck in full extension, the foramen is still wide open. It should also be noted that the entire foraminotomy and discectomy procedure should be performed with the neck in maximal flexion, which opens up the foramen. B, The root is retracted cranially, and the small pituitary rongeurs are used to remove the disc fragment.

FIGURE 76-11 A, Postoperative CT showing a foraminotomy at C6-7. B, Three-dimensional reconstructed image of the foraminotomy.

In closing, a #1 absorbable suture is used for the fascia and muscle. Numerous sutures with small bites are placed in the fascia of the paraspinal muscles deep in an attempt to bring the muscles back together. This combats this incision’s tendency to invaginate during healing. It is helpful to tag clamp four to six sutures in the same layer and then tie them before proceeding to a more superficial layer. Meticulous hemostasis and closure of the dead space along with a deep and superficial drain help to prevent postoperative wound complications that are inherent to this approach.