HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dominique Grunenwald Lorenzo Spaggiari Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Grunenwald, D. Articles by Spaggiari, L. Search for Related Content PubMed PubMed Citation Articles by Grunenwald, D. Articles by Spaggiari, L.

Ann Thorac Surg 1997;63:563-566
© 1997 The Society of Thoracic Surgeons

---

How To Do It

Transmanubrial Osteomuscular Sparing Approach for Apical Chest Tumors

Department of Thoracic Surgery, Institut Mutualiste Montsouris, Paris, France

Accepted for publication September 16, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Comment References

 
The transclavicular approach improved the treatment of apical chest tumors. However, removing the internal half of the clavicle and sectioning its muscular insertions led to serious postoperative alterations. We propose a transmanubrial approach, through a manubrial L-shaped transection and first costal cartilage resection, which allows retraction of an osteomuscular flap including but sparing the clavicle and all its muscular insertions. The elevation of the osteomuscular flap affords excellent access to the subclavicular region with safe control and resection of neurovascular outlet structures during the resection of apical chest tumors. Shoulder articulations and stability of the scapular girdle are respected, thus avoiding functional and cosmetic consequences of clavicle resection.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Comment References

 
Anterior transcervical approach (ATA), described by Cormier in 1970 [1] and subsequently proposed by Dartevelle and colleagues [2], improved the radical treatment of the apical chest tumors, permitting better subclavian vessel control and resection than performed through Paulson's approach, and a safe brachial plexus dissection. However, use of this approach has been associated with deformities. The ATA is performed by resecting the medial half of the clavicle, the insertions of sternomastoid and major pectoral muscles, and sometimes the external branch of the accessory nerve. These osteomuscular resections could lead to serious postoperative alterations in the shoulder mobility and cervical posture, particularly when associated with cervical vertebral resections; moreover, when these resections are associated with extensive chest wall resection, a respiratory insufficiency might develop. With the aim to avoid these deformities and to maintain the advantages of the ATA, we developed a transmanubrial technique that spares the osteomuscular components of the cervical and shoulder articulations and maintains an excellent exposure of thoracic outlet and cervical structures, thus permitting a safe approach to anteriorly situated apical chest tumors.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Comment References

 
Technique
The skin incision is performed through an L-shaped cervicotomy with the upper line on anterior part of sternomastoid as far as the angle of manubrium and two fingers below the clavicle (Fig 1). The sternomastoid muscle is dissected along its anterior part from cervical tissue up to internal jugular vein, the major pectoral muscle is spared, and the sternal manubrium is exposed (Fig 2). The internal thoracic artery is divided and 25% of the superoexternal part of the manubrium (2 by 2 cm) is sectioned through an L-shaped incision, thus respecting the sternoclavicle articulation; subsequently, the first costal cartilage is resected (Fig 2). This permits mobilization of an osteomuscular flap that is progressively elevated by means of a lace around the manubrial "edge" (Fig 3). A safe dissection without vascular problems becomes possible, following the posterior part of the clavicle, leaving the subclavian muscle on subclavian vessels. Afterward, starting from the internal jugular vein and Pirogoff confluence, the subclavian vein is carefully dissected from the subclavian muscle. Venous branches must be cautiously divided to mobilize the main venous axis and to expose the phrenic nerve and the anterior scalene muscle. The subclavian artery is then carefully dissected, and the brachial plexus and the posterior part of the first rib are isolated, if necessary (Fig 4). At the same time, the laterocervical vascular vessels (carotid arteries) can be controlled; partial manubrial resection and first rib resection permit control of the mediastinal great vessels as well as the superior vena cava and main aortic branches. Moreover, this approach gives excellent access to the anterior part of the C-3 to D-3 vertebral bodies. At the end of the dissection, manubrium osteosynthesis is performed by means of two separate steel threads.

View larger version (116K): [in this window] [in a new window]   Fig 1. . L-shaped cervicotomy.

View larger version (115K): [in this window] [in a new window]   Fig 2. . After the dissection of the sternomastoid muscle, the internal jugular vein is exposed. The major pectoral muscle is spared, and this permits isolation of the first cartilage and the internal thoracic vessels that will be subsequently divided. The figure shows the L-shaped incision on the manubrium and the limit of the first cartilage section.

View larger version (136K): [in this window] [in a new window]   Fig 3. . After the L-shaped resection of the manubrium and the first cartilage section, the flap is progressively retracted; the dissection follows the posterior part of the clavicle, leaving on the subclavian vessels part of the subclavian muscle, which becomes an optimal dissection plane.

View larger version (128K): [in this window] [in a new window]   Fig 4. . Exposure obtained through the transmanubrial osteomuscular sparing approach. A lace around the manubrial edge is used to elevate the flap. Starting from the venous confluent, the subclavian vein is mobilized; subsequently, the scalene muscle is sectioned and the subclavian artery and related branches are progressively controlled. At this point, all thoracic structures can be safely controlled and, when necessary, resected.

From March to July 1996, 6 patients were operated on for apical chest tumor using the TMA. Table 1 reports the main characteristics of these patients and of 2 additional patients who underwent TMA but for different pathologies.

View larger version (141K): [in this window] [in a new window]   Fig 5. . Patient at discharge. No postoperative alterations in the shoulder mobility were observed. This patient was operated on for lung cancer. He underwent transmanubrial approach with first and second rib resections, posterolateral thoracotomy with pneumonectomy, and laparotomy for omentoplasty.

	Comment

Top Footnotes Abstract Introduction Material and Methods Comment References

Until now, our surgical attitude for the apical chest tumor has been to combine anterior and posterior approaches. We believe that the double approach allows safe control and resection of thoracic outlet structures, of pulmonary hilar elements, and of the posterior thoracic wall (invaded ribs and vertebral transverse processes), along with extended lymph node dissection (ie, laterocervical, subcarinal, and inferior pulmonary vein) [5]. As previously described, when vertebral bodies are invaded, we add a third posterior midline approach [6].

The present transmanubrial approach provides the same surgical advantages as the anterior transclavicular approach, avoiding its functional and aesthetic disadvantages that limited the acceptance and the worldwide diffusion of the ATA for apical chest tumors. The transmanubrial approach affords excellent exposure of the apex of the lung and safe control and resection of thoracic outlet structures, leaving in situ the clavicle without muscular sacrifice and maintaining full shoulder girdle movement with important early and long-term postural advantages associated with excellent aesthetic results (see Fig 5).

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Comment References

 
Address reprint requests to Dr Grunenwald, Department of Thoracic Surgery, Institut Mutualiste Montsouris, 6, place de Port au Prince, 75013 Paris, France.

	References

Top Footnotes Abstract Introduction Material and Methods Comment References

 

1. Cormier JM. Voie d'abord: abord de l'artère sous-clavière. In: Patel J, Léger L, eds. Nouveau traité de technique chirurgicale. Tome V. Paris: Masson et Cie, 1970:107–40.
2. Dartevelle PG, Chapelier AR, Macchiarini P, et al. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg 1993;105:1025–34.[Abstract]
3. Masaoka A, Ito Y, Yasumitsu T. Anterior approach for tumor of the superior sulcus. J Thorac Cardiovasc Surg 1979;78:413–5.[Abstract]
4. Bains MS, Ginsberg RJ, Jones WGH, et al. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg 1994;58:30–3.[Abstract/Free Full Text]
5. Grunenwald D, Mazel C, Baldeyrou P, Girard P. En bloc resection of lung cancer invading the spine. Ann Thorac Surg 1996;61:1878–9.[Free Full Text]
6. Grunenwald D, Mazel C, Girard P, Berthiot G, Dromer C, Baldeyrou P. Total vertebrectomy for en bloc resection of lung cancer invading the spine. Ann Thorac Surg 1996;61:723–6.[Abstract/Free Full Text]

This article has been cited by other articles:

				D. H. Grunenwald Editorial comment: En bloc vertebrectomy for lung cancer invading the spine: surgical serenity and optimism warrant innovation Eur J Cardiothorac Surg, September 1, 2011; 40(3): 654 - 655. [Full Text] [PDF]

				P. S. Ge, T. A. Imai, and T. L. Van Natta Versatility of a Mini-Trapdoor Incision in Upper Mediastinal Exposure Ann. Thorac. Surg., March 1, 2011; 91(3): 938 - 940. [Abstract] [Full Text] [PDF]

				F. P. Caronia, E. Ruffini, and A. I. Lo Monte The use of video-assisted thoracic surgery in the management of Pancoast tumors Interact CardioVasc Thorac Surg, December 1, 2010; 11(6): 721 - 726. [Abstract] [Full Text] [PDF]

				G. Di Rienzo, C. Surrente, C. Lopez, and A. L. Urgese Transmanubrial osteomuscular sparing approach: different indications Interact CardioVasc Thorac Surg, October 1, 2010; 11(4): 482 - 484. [Abstract] [Full Text] [PDF]

				W. Truin, J. Siebenga, E. Belgers, and E. C. M. Bollen The role of video-assisted thoracic surgery in the surgical treatment of superior sulcus tumors Interact CardioVasc Thorac Surg, October 1, 2010; 11(4): 512 - 514. [Abstract] [Full Text] [PDF]

				P. A. Linden Video-assisted anterior approach to Pancoast tumors J. Thorac. Cardiovasc. Surg., September 1, 2010; 140(3): e38 - e39. [Full Text] [PDF]

				G. Lebreton, J.-M. Baste, M. Thumerel, F. Delcambre, J.-F. Velly, and J. Jougon The hemiclamshell approach in thoracic surgery: indications and associated morbidity in 50 patients Interact CardioVasc Thorac Surg, December 1, 2009; 9(6): 965 - 969. [Abstract] [Full Text] [PDF]

				M. Tamura, M. A. Hoda, and W. Klepetko Current treatment paradigms of superior sulcus tumours Eur J Cardiothorac Surg, October 1, 2009; 36(4): 747 - 753. [Abstract] [Full Text] [PDF]

				C. Cheng, S.-C. J. Yeung, F.-t. Zhong, Y. Xiong, H.-h. Luo, S. Ji, and J. Pan Aneurysmal Bone Cyst in the First Rib Ann. Thorac. Surg., June 1, 2008; 85(6): 2118 - 2120. [Abstract] [Full Text] [PDF]

				G. Di Rienzo, C. Surrente, C. Lopez, and A. L. Urgese Modified transmanubrial osteomuscular sparing approach for resection of T1 vertebral tumor Eur J Cardiothorac Surg, November 1, 2007; 32(5): 810 - 812. [Abstract] [Full Text] [PDF]

				M. de Perrot and R. Rampersaud Anterior transclavicular approach to malignant tumors of the thoracic inlet: Importance of the scapulothoracic articulation J. Thorac. Cardiovasc. Surg., September 1, 2007; 134(3): 801 - 803. [Full Text] [PDF]

				V. W. Rusch, D. J. Giroux, M. J. Kraut, J. Crowley, M. Hazuka, T. Winton, D. H. Johnson, L. Shulman, F. Shepherd, C. Deschamps, et al. Induction Chemoradiation and Surgical Resection for Superior Sulcus Non-Small-Cell Lung Carcinomas: Long-Term Results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160) J. Clin. Oncol., January 20, 2007; 25(3): 313 - 318. [Abstract] [Full Text] [PDF]

				A. Marra, W. Eberhardt, C. Pottgen, D. Theegarten, S. Korfee, T. Gauler, M. Stuschke, and G. Stamatis Induction chemotherapy, concurrent chemoradiation and surgery for Pancoast tumour Eur. Respir. J., January 1, 2007; 29(1): 117 - 126. [Abstract] [Full Text] [PDF]

				L. Spaggiari, M. D'Aiuto, G. Veronesi, F. Leo, P. Solli, M. Elena Leon, R. Gasparri, D. Galetta, F. Petrella, A. Borri, et al. Anterior approach for Pancoast tumor resection MMCTS, January 1, 2007; 2007(1018): mmcts.2005.001776 - mmcts.2005.001776. [Abstract] [Full Text] [PDF]

				M. B. Marshall, J. C. Kucharczuk, J. B. Shrager, and L. R. Kaiser Anterior surgical approaches to the thoracic outlet J. Thorac. Cardiovasc. Surg., June 1, 2006; 131(6): 1255 - 1260. [Abstract] [Full Text] [PDF]

				N. Durrleman and G. Massard Clamshell and hemiclamshell incisions MMCTS, January 1, 2006; 2006(0810): mmcts.2006.001867 - mmcts.2006.001867. [Abstract] [Full Text] [PDF]

				S. Endo, F. Murayama, S.-i. Otani, K. Tetsuka, T. Hasegawa, Y. Sato, and Y. Sohara Alternative Surgical Approaches for Apical Neurinomas: A Thoracoscopic Approach Ann. Thorac. Surg., July 1, 2005; 80(1): 295 - 298. [Abstract] [Full Text] [PDF]

				V. C. Archie and C. R. Thomas Jr. Superior Sulcus Tumors: A Mini-Review Oncologist, September 1, 2004; 9(5): 550 - 555. [Abstract] [Full Text] [PDF]

				C. C. M. Pitz, A. B. de la Riviere, H. A. van Swieten, V. A. M. Duurkens, J.-W. J. Lammers, and J. M. M. van den Bosch Surgical treatment of Pancoast tumours Eur J Cardiothorac Surg, July 1, 2004; 26(1): 202 - 208. [Abstract] [Full Text] [PDF]

				M. Alifano, M. D'Aiuto, P. Magdeleinat, E. Poupardin, A. Chafik, S. Strano, and J. F. Regnard Surgical Treatment of Superior Sulcus Tumors: Results and Prognostic Factors Chest, September 1, 2003; 124(3): 996 - 1003. [Abstract] [Full Text] [PDF]

				L. Spaggiari Anterior approach versus posterior approach in apical chest tumor: surgeon's choice or oncological need? Ann. Thorac. Surg., February 1, 2003; 75(2): 633 - 634. [Full Text] [PDF]

				N. Isowa, S. Hasegawa, M. Mino, K. Morimoto, and H. Wada Mediastinal epithelioid hemangioendothelioma resected by hemi-plastron window technique Ann. Thorac. Surg., August 1, 2002; 74(2): 567 - 569. [Abstract] [Full Text] [PDF]

				E. Martinod, A. D'Audiffret, P. Thomas, A. J. Wurtz, M. Dahan, M. Riquet, A. Dujon, R. Jancovici, R. Giudicelli, P. Fuentes, et al. Management of superior sulcus tumors: experience with 139 cases treated by surgical resection Ann. Thorac. Surg., May 1, 2002; 73(5): 1534 - 1539. [Abstract] [Full Text] [PDF]

				D. H. Grunenwald, C. Mazel, P. Girard, G. Veronesi, L. Spaggiari, D. Gossot, D. Debrosse, R. Caliandro, J.-L. Le Guillou, and T. Le Chevalier Radical en bloc resection for lung cancer invading the spine J. Thorac. Cardiovasc. Surg., February 1, 2002; 123(2): 271 - 279. [Abstract] [Full Text] [PDF]

				J. Deslauriers Current surgical treatment of nonsmall cell lung cancer 2001 Eur. Respir. J., February 1, 2002; 19(35_suppl): 61S - 70s. [Abstract] [Full Text] [PDF]

				L. Spaggiari and U. Pastorino Double transmanubrial approach and sternotomy for resection of a giant thymic carcinoid tumor Ann. Thorac. Surg., August 1, 2001; 72(2): 629 - 631. [Abstract] [Full Text] [PDF]

				M. Rusca, P. Carbognani, and P. Bobbio The modified "hemi-clamshell" approach for tumors of the cervicothoracic junction Ann. Thorac. Surg., June 1, 2000; 69(6): 1961 - 1963. [Abstract] [Full Text] [PDF]

				L. Spaggiari, U. Pastorino, and D. H. Grunenwald Transmanubrial approach reproposed Ann. Thorac. Surg., November 1, 1999; 68(5): 1888 - 1888. [Full Text] [PDF]

				U. Klima, A. Lichtenberg, and A. Haverich Reply Ann. Thorac. Surg., November 1, 1999; 68(5): 1888 - 1888. [Full Text] [PDF]

				L. Spaggiari, L. Calabrese, G. Gioacchino, and U. Pastorino Cervico-thoracic tumors resection through transmanubrial osteomuscular sparing approach Eur J Cardiothorac Surg, November 1, 1999; 16(5): 564 - 567. [Abstract] [Full Text] [PDF]

				L. Spaggiari and U. Pastorino Transmanubrial approach with antero-lateral thoracotomy for apical chest tumor Ann. Thorac. Surg., August 1, 1999; 68(2): 590 - 593. [Abstract] [Full Text] [PDF]

				T. Vanakesa and P. Goldstraw Antero-superior approaches in the practice of thoracic surgery Eur J Cardiothorac Surg, June 1, 1999; 15(6): 774 - 780. [Abstract] [Full Text] [PDF]

				M. Rusca, P. Carbognani, and P. Bobbio Cervicothoracic tumors: Results of resection by the "hemi-clamshell" approach J. Thorac. Cardiovasc. Surg., May 1, 1999; 117(5): 1040 - 1040. [Full Text]

				L. Spaggiari and U. Pastorino Anterior approach to the superior sulcus tumors: The transmanubrial osteomuscular sparing approach J. Thorac. Cardiovasc. Surg., May 1, 1999; 117(5): 1042 - 1044. [Full Text]

				G. Ladas, P. H. Rhys-Evans, and P. Goldstraw Anterior cervical-transsternal approach for resection of benign tumors at the thoracic inlet Ann. Thorac. Surg., March 1, 1999; 67(3): 785 - 789. [Abstract] [Full Text] [PDF]

				L. Spaggiari and D. Grunenwald Reply Ann. Thorac. Surg., July 1, 1998; 66(1): 309 - 310. [Full Text] [PDF]

				L. Spaggiari, M. Rusca, P. Carbognani, and P. Solli Hemivertebrectomy for Apical Chest Tumors: Is the Risk Justified by the Outcome? Ann. Thorac. Surg., May 1, 1998; 65(5): 1515 - 1517. [Full Text] [PDF]

				R. J. Korst and M. E. Burt Cervicothoracic Tumors: Results Of Resection By The "Hemi-Clamshell" Approach J. Thorac. Cardiovasc. Surg., February 1, 1998; 115(2): 286 - 295. [Abstract] [Full Text] [PDF]

				D. Grunenwald, L. Spaggiari, P. Girard, and P. Baldeyrou Transmanubrial approach to the thoracic inlet J. Thorac. Cardiovasc. Surg., May 1, 1997; 113(5): 958 - 959. [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dominique Grunenwald Lorenzo Spaggiari Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Grunenwald, D. Articles by Spaggiari, L. Search for Related Content PubMed PubMed Citation Articles by Grunenwald, D. Articles by Spaggiari, L.