Ann Thorac Surg 1996;62:1841-1843
© 1996 The Society of Thoracic Surgeons
Case Report
Transthoracic Forequarter Amputation and Left Pneumonectomy
Aroldo Fianchini, MD,
Aldo Bertani, MD,
Franco Greco, MD,
Alessandro Brunelli, MD,
Mauro Muti, MD
Departments of Thoracic Surgery, Plastic Surgery, and Orthopedic Surgery, University of Ancona, Ancona, Italy
Accepted for publication June 13, 1996.
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Abstract
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We describe a variation of the technique of transthoracic forequarter amputation, consisting of a completely anterior approach, removal of the left forequarter en bloc with the chest wall and lung, and sparing of the scapula. This latter bone is mobilized and is used, along with the transposition of the lower ribs, to stabilize the chest wall.
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Introduction
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Forequarter amputation is indicated for the treatment of malignant lesions of the arm, axilla, shoulder, and scapula. Originally, tumors spread through the chest wall were a contraindication to this operation, until the radical transthoracic forequarter amputation was reported by Stafford and Williams [1]. Since then, many variations of the technique have been described [2–4], which mainly differed by their methods of reconstruction.
A 65-year-old man, who had undergone seven previous operations for locally recurrent malignant histiocytoma, was admitted at our institution for a large, fungating, painful, and bleeding tumor in the left axilla. Computed tomographic scan of the chest revealed a mass extending from the axilla through the chest wall and invading the subclavian vessels, brachial plexus, and the left lung diffusely. Histologic examination confirmed the suspicion of recurrent malignant histiocytoma and the patient was scheduled for a transthoracic forequarter amputation.
With the patient supine and the left arm draped free, the incision was carried out over the clavicle and extended laterally over the deltoid muscle to create a flap to be used later on to close the defect (Fig 1
). The clavicle was then disarticulated, and the subclavian vessels and brachial plexus were divided. Following the humerus disarticulation, the glenoid, coracoid, and acromion were resected (Fig. 2). Subsequently, an anterior thoracotomy was performed at the level of the seventh intercostal space. The lung appeared diffusely involved by the disease, and an extended pneumonectomy was necessary. Ribs 1 through 7 were disarticulated from the sternum anteriorly, the hilar structures were isolated and dissected, and resection of the first seven ribs was finally completed posteriorly (Fig 3).
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Fig 1. . With the patient supine and the left shoulder lifted up to 30 degrees to the operating table, the incision begins at the sternoclavicular junction and runs laterally over the deltopectoral groove to reach the deltoid region, where it designs a deltoid-humeral flap. Medially, it is carried out over the sternum down to the xiphoid, where it curves laterally to perform an anterior thoracotomy at the seventh intercostal space.
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Fig 2. . Sternoclavicular disarticulation and division of the subclavian artery distal to the take-off of the vertebral artery are performed. The subclavian vein and the cords of the brachial plexus are similarly divided. Humerus disarticulation and resection of the glenoid, coracoid, and acromion are performed. Ribs 1 through 7 are disarticulated from the sternum, and the hilar structures of the left lung are prepared.
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Fig 3. . The pulmonary vessels and main bronchus are stapled and divided. Next, after ligation of the intercostal bundles, ribs 1 through 7 are resected at the level of the costotransversarian juncture, the incision is completed posteriorly, and the left forequarter is removed en bloc with the thoracic wall and the lung. The scapula is freed from its lateral muscular attachments to provide mobilization.
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The specimen, consisting of the left forequarter, chest wall, and lung, was removed en bloc. The scapula, freed from its muscular attachments, was then approximated to the spine, rotated anteriorly and medially, and its lateral margin was anchored to the sternum. Subsequently, ribs 8 and 9 were transected anteriorly, fractured posteriorly, and transposed upward to protect the heart (Fig 4). The defect was closed by advancing deltoid and lateral lumbar flaps (Fig 5).
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Fig 4. . The eight and ninth ribs are resected anteriorly, fractured posteriorly with their bundles left intact, rotated, and anchored to the sternum to protect the tip of the heart. The scapula is rotated anteriorly and medially to protect the aortic arch and the hilum.
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Fig 5. . A contralateral pectoral flap and homolateral deltoid and lateral lumbar flaps are advanced to close the defect.
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The patient recovered well from the operation with no respiratory complications, and he was discharged on postoperative day 14. He remained well and disease-free for the following 6 months, and died 1 month later of an intrathoracic contralateral unresectable recurrence.
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Comment
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We described a modification of the classic transthoracic forequarter amputation [1], with sparing of the scapula, which was used to stabilize the chest wall and, along with the upward transposition of the lower ribs, protect the heart and great vessels. When this bone does not appear to be involved by the tumor, or if a palliative operation is planned from the beginning, we regard the scapula as a better alternative than prosthetic materials for chest wall reconstruction after transthoracic forequarter amputation, in terms of stabilization and risk of infection, which are a major concern in this group of patients. This operation may be performed by means of a completely anterior approach, without resorting to posterolateral or axillary thoracotomy [2, 4], even if a left pneumonectomy is needed.
Although radicality in the most extensive tumors, like the case described here, cannot be anticipated, good palliation may be achieved, provided the patient, often psychologically debilitated by the knowledge of the presence of a nonresectable lesion, is highly motivated and the family strongly supportive. We firmly recommend psychological examination and counseling before deciding to undertake this operation.
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Footnotes
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Address reprint requests to Dr Fianchini, Department of Thoracic Surgery, University of Ancona School of Medicine, 60121 Ancona, Italy.
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References
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- Stafford ES, Williams GR Jr. Radical transthoracic forequarter amputation. Ann Surg 1958;148:699–705.[Medline]
- Wurlitzer FP. Improved technic for radical transthoracic forequarter amputation. Ann Surg 1973;177:467–71.[Medline]
- Mansour KA, Powell RW. Modified technique for radical transmediastinal forequarter amputation and chest wall resection. J Thorac Cardiovasc Surg 1978;76:358–63.[Abstract]
- Roth JA, Sugarbaker PH, Baker AR. Radical forequarter amputation with chest wall resection. Ann Thorac Surg 1984;37:423–7.[Abstract/Free Full Text]
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Abstract
Introduction
