Antero-superior approaches in the practice of thoracic surgery

Abstract

The anterior cervical-transsternal approach we previously described provides adequate exposure for the resection of neurogenic tumors originating in the brachial plexus and sympathetic chain, and for metastatic nodal disease at the base of the neck or in the superior mediastinum. We have found it to be associated with little morbidity, the postoperative stay has been short, and it has proven flexible enough to cope with the changed circumstances found at surgery. For Pancoast type bronchogenic carcinomas and other malignancies with extensive invasion of major structures at the thoracic inlet, we believe the best present option is the clavicle sparing antero-superior technique described by Grunenwald as a modification of the Dartevelle approach. When operating for lung cancer we presently feel that the antero-superior approach should be combined with a posterolateral thoracotomy, to accomplish complete intraoperative staging and undertake anatomical pulmonary resection under optimal conditions.

Transmanubrial osteomuscular sparing approach for lung cancer invading the anterior part of the thoracic inlet

“…9 Vanakesa and Goldstraw added posterolateral thoracotomy with a position change to carry out systematic nodal dissection. 10 Because the transmanubrial osteomuscular-sparing approach is less invasive and less damaging to the anatomical structures, we can simply include an additional approach with or without a position change if further thoracotomy is required for lobectomy with systematic nodal dissection or for another combined resection. As mentioned in the literature review, a hemi-clamshell incision with disconnection of the fi rst or plus a second costal cartilage is one of the ways of overcoming.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] The most commonly applied approach for SST is the high posterior lateral thoracotomy (posterior approach) reported by Shaw and Paulson. 4 Although several authors have insisted that subclavian vessels could be resected by the posterior approach, theoretically, these vessels are more easily accessible anteriorly owing to their location in the thoracic inlet.…”

“…10 Therefore, this method is classifi ed as subclavian area-not-opening approach. Actually, Vanakesa and Goldstraw applied the anterior-cervicaltranssternal approach mainly for benign tumors at the thoracic inlet, and if the tumor invaded major structures of thoracic inlet they converted their approach to Grunenwald and Spaggiari's transmanubrial osteomuscularsparing approach by sectioning the fi rst costal cartilage.…”

“…Actually, Vanakesa and Goldstraw applied the anterior-cervicaltranssternal approach mainly for benign tumors at the thoracic inlet, and if the tumor invaded major structures of thoracic inlet they converted their approach to Grunenwald and Spaggiari's transmanubrial osteomuscularsparing approach by sectioning the fi rst costal cartilage. 10 The transmanubrial approach used in Marshall's series for tumors not invading the chest wall was thought to be this type of approach. A hemi-clamshell incision combined with disconnection of the fi rst or plus the second costal cartilage reported by Rusca et al 17 and Ohtsuka and coworkers 16 is thought to be a kind of subclavian area-opening approach.…”

Navigating the thoracic inlet in children

“…A number of approaches to the inlet have been described, predominantly in the adult literature, but there is no unanimity with regard to the ideal approach [1][2][3][4][5][6][7]. We could identify only two previous reports in the literature of approaching the inlet in children with tumours [7,8].…”