J Thorac Cardiovasc Surg 1995;110:1765-1766
© 1995 Mosby, Inc.
SUPRACLAVICULAR LUNG BIOPSY
Francis Robicsek, MD
Charlotte, N.C.
From the Department of Thoracic and Cardiovascular Surgery and The Heineman Laboratary for Research, Carolinas Medical Center, Charlotte, N.C.
Accepted for publication May 31, 1995.
Open lung biopsy, however technically simple, carries a significant degree of postoperative discomfort. Because of the severe underlying disease in most patients, it also carries appreciable surgical morbidity and even mortality. Recently introduced video-assisted thoracoscopic techniques alleviated this problem somewhat, but they certainly did not eliminate it. To significantly decrease postoperative discomfort and shorten recuperation time, we recommend that "supraclavicular technique"described here be considered in patients in whom the apexes of the lung are pathologically involved.
A transverse 5 to 6 cm incision is made just above the superior margin of either the right or the left clavicle, depending on the planned biopsy site. The subcutaneous fat is dissected off, and the anterior scalene muscle is exposed and divided. In this process, careful attention is given to identifying and protecting the phrenic nerve. The subclavian artery is retracted downward, exposing the anterior portion of the first rib. A 3 to 4 cm segment of the exposed first rib is stripped of its periosteum and resected. At that point, the surgeon will already see the apex of the lung under the cupola of the parietal pleura. The pleural cavity is then entered and the apex of the lung is inspected. Usually there is no difficulty in viewing most, if not the entirety, of the upper lobe. An appropriate site is selected on the lung, grabbed with a forceps, and brought through the surgical incision (Fig. 1). A tissue sample from the lung of appropriate size is then excised, and the excision site is either "tied off" or sutured. A 28F rubber catheter is inserted through the surgical incision into the pleural cavity and connected to a water-sealed drainage. The incision is closed layer by layer. If there is no continued air leakage the catheter may be conveniently removed at the end of the procedure after 2 to 3 hours.
Throughout the years we have used this method in more than a dozen patients in whom open biopsy of the upper portion of the lung was required. We have found the approach to be convenient and well tolerated, even by patients with severe respiratory insufficiency. The disadvantage of the approach is that it traverses an area rich in important anatomic structures. Injury of these structures, especially the phrenic nerve, may be disastrous in patients who already have severely compromised respiratory function. Only surgeons with good knowledge of the anatomy of the thoracic inlet should use this approach.
Footnotes
J THORAC CARDIOVASC SURG 1995;110:1765-6 
