Ann Thorac Surg 2000;69:1961-1963
© 2000 The Society of Thoracic Surgeons
How to do it
The modified "hemi-clamshell" approach for tumors of the cervicothoracic junction
Michele Rusca, MDa,
Paolo Carbognani, MD, PhDa,
Paolo Bobbio, MDa
a Department of Thoracic Surgery, University of Parma, Parma, Italy
Address reprint requests Dr Rusca, Department of Thoracic Surgery, University of Parma, Via Gramsci 14, 43100 Parma, Italy
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Abstract
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The anterior approaches proposed for treatment of the apical chest tumors (anterior transcervical, transmanubrial, and hemi-clamshell) have precise advantages and limits. To avoid these limits we have modified the hemi-clamshell with the resection of the first costal cartilage and the costoclavicular ligament. This allows a wider opening of the sternocostal flap, with safe control of the entire subclavian vessels as well as easier access to the T1 to T3 vertebral bodies and the posterior chest wall.
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Introduction
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Tumors of the pulmonary apex involving the structures of the cervicothoracic junction have, in the last decade, stimulated surgeons to find solutions that permit safe technical resection in the absolute respect of the oncologic criteria. The impulse was provided by Dartevelle and colleagues [1], who adopted in 1981 and popularized in 1993 the approach of Cormier and colleagues [2] for the subclavian vessels. Referring to the anterior transcervical approach of Dartevelle and associates, in 1997 Grunenwald and Spaggiari [3] published a technique that aimed to maintain the sternoclavicular joint. Different was the experience of the thoracic surgeons of the Memorial Sloan-Kettering Cancer Center, reported in 1994 by Bains and coworkers [4] and in 1998 by Korst and Burt [5], which found the hemi-clamshell approach very useful for the cervicothoracic tumors. Practicing what we call the European and American approaches we have focused the features of each technique. The European approaches permit very good exposure and control of the structures of the thoracic inlet but not of the pulmonary vessels at the hilum, necessitating a separate thoracotomy also for chest wall resection below the second rib. In comparison, the hemi-clamshell (or American approach) gives a very good exposure of the pulmonary hilum; however, the inlet structures, particularly the distal part of the vessels, are not completely controlled and posterior chest wall resection would be difficult. Therefore we have tried to combine the particular advantages that the two approaches offer in the surgical treatment of the tumors of the cervicothoracic junction, proposing a modified hemi-clamshell that provides a wide exposure of the pulmonary hilum and complete control of the thoracic inlet structures.
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Technique
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The first step is an anterolateral thoracotomy. The hemithorax is entered at the fourth intercostal space and the pleural cavity explored. The skin incision is then completed from the anterior border of the ipsilateral sternocleidomastoid muscle to the middle of the sternum as far as the thoracotomy. In the neck the internal jugular vein is dissected to the thoracic inlet. The median partial sternotomy is made to join the opened intercostal space after ligation of the internal thoracic vessels. After partial retraction of the obtained sternocostal flap we dissect the jugular-subclavian junction. At this point we take off a part of the sternal margin of the major pectoral muscle only, to expose the first costal cartilage, which is resected using the Gigli saw. Having control of the jugular-subclavian junction and of the proximal part of the subclavian vein, the resection of the costoclavicular ligament is the crucial maneuver that permits wide elevation of the sternocostal flap. The resection of this ligament is made easier by the progressive upward traction of the sternocostal flap. The sternoclavear junction is left untouched (Fig 1). Afterward we continue the dissection of the subclavian vein, dividing the venous branches (including the cephalic vein) to mobilize the main venous axis and to expose the anterior scalene muscle, phrenic nerve, and proximal and distal parts of the subclavian artery. This vessel is entirely mobilized after having divided its branches, pointing out the brachial plexus (Fig 2). The widened sternocostal flap, set free from the first rib, also permits complete control of the subclavian vessels as well as complete control of the mediastinal great vessels, superior vena cava, and main aortic branches, and gives an easy access to the anterior part of the C3 to D3 vertebral bodies, the pulmonary hilum, and the posterior chest wall (Fig 3). At the end of the procedure the sternotomy and the thoracotomy are closed in the usual manner.
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Fig 1. The resection of the first cartilage (11) and of the costoclavicular ligament permits the progressive elevation of the sternocostal flap; the internal jugular vein (9), left brachiocephalic vein (10), and subclavian vein (3) are evident. The resected sternum and the lung are marked as 8 and 6, respectively.
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Fig 2. The sternocostal flap, free from the first rib, permits very good exposure of the structures of the thoracic inlet and of the posterior chest wall. The numbers mark the subclavian vein (3), subclavian artery (4), left common carotid artery (7), brachial plexus (1), and resected anterior scalenus muscle (2).
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Fig 3. The wide exposure of the thoracic cavity shows the left brachiocephalic vein (10), subclavian vein (3), internal jugular vein (9), posterior resected chest wall (4), and pulmonary hilum.
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From January 1997 to April 1999 we operated on 15 patients affected by tumors of the cervicothoracic junction. In the first patient we used the anterior transcervical approach proposed by Dartevelle and colleagues, whereas in the next 10 the technique chosen was the transmanubrial approach proposed by Grunenwald and Spaggiari. In both techniques, in all cases, we performed a posterolateral thoracotomy to complete the formal lobectomy.
From November 1998 to June 1999 we used the modified hemi-clamshell approach in 4 patients; all were male, with a mean age of 66 years (range, 60 to 74 years). All of the cases were adenocarcinomas. The first patient had a right apical tumor invading the first rib, and a right upper lobectomy with resection of the first rib was performed (pathologic stage IIB/T3, N0, M0). The second was a left apical tumor invading T1 to T3 vertebral bodies that was resected with the upper lobe (stage IIIB/T4, N0, M0) and the first, second, and third rib. The third patient had a left apical tumor invading the second and third rib posteriorly, which were resected with the upper lobe (stage IIB/T3, N0, M0). The fourth was a left apical tumor invading the first and second rib and subclavian artery and vein; an upper lobectomy with costal resection was done in this patient, as well as resection and reconstruction of the subclavian vessels (stage IIIB/T4, N0, M0). In all cases a mediastinal adenectomy was performed. The widening of the sternocostal flap is done progressively to avoid rib fractures. In following these patients we have found no functional deficit in the shoulder.
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Comment
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The technical proposals for surgical treatment of tumors of the pulmonary apex have focused on a region—the thoracic inlet—that is anatomically complex. What we have called the European approaches (which differ mainly for the resection or the preservation of the clavicle) give a very good exposure of the structures of the thoracic inlet but not on the pulmonary hilum and on the posterior part of the chest wall, below the second rib, in most of the cases requiring a thoracotomy to complete the resection. On the other side the hemi-clamshell incision offers a more complete vision of the apical and hilar structures, apart from the size of the tumor, but has the limit of the impossibility of controlling the distal part of the subclavian vessels (Fig 4). In our modified hemi-clamshell approach this limit is avoided with the resection of the first costal cartilage and of the costoclavicular ligament. This maneuver allows a wide opening of the sternocostal flap with safe control of the entire subclavian vessels, thus permitting their resection and possible reconstruction (Fig 5). Moreover, with its unique incision, our variation permits an easier access to the T1 to T3 vertebral bodies, as well as performance of a formal lobectomy with mediastinal lymphonodal dissection and resection of the posterior chest wall in the case of invasion. (The term "unique," for us, refers to one incision instead of two separate incisions.)
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Fig 4. The standard hemi-clamshell, because of less mobilization of the sternocostal flap due to of the integrity of the first cartilage and the costoclavear ligament, enables limited exposure of the distal part of the subclavian vessels. The inferior tape encircles the left brachiocephalic vein (10); the superior tape encircles the internal jugular vein.
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Fig 5. The distal control of the subclavian vessels permits the safe resection and reconstruction of a long segment of vein and artery.
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References
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Dartevelle P.G., Chapelier A.R., Macchiarini P., et al. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg 1993;105:1025-1034.[Abstract]
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Cormier J.M. Voie d’abord. In: Patel J., Léger L., eds. Nouveau traité de technique chirurgicale. Tome V. Paris: Masson et Cie, 1970:107-140.
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Grunenwald D., Spaggiari L. Transmanubrial osteomuscolar sparing approach for apical chest tumors. Ann Thorac Surg 1997;63:563-566.[Abstract/Free Full Text]
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Bains M.S., Ginsberg R.J., Jones W.G.H., et al. The clamshell incision. Ann Thorac Surg 1994;58:30-33.[Abstract]
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Korst R.J., Burt M.E. Cervicothoracic tumors. J Thorac Cardiovasc Surg 1998;115:286-295.[Abstract/Free Full Text]
Accepted for publication December 31, 1999.
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Abstract
Introduction
