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J Thorac Cardiovasc Surg 1997;113:958-959
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Transmanubrial approach to the thoracic inlet

Dominique Grunenwald, MD, Lorenzo Spaggiari, MD, Philippe Girard, MD, Pierre Baldeyrou, MD

Thoracic Department
Institut Mutualiste Montsouris
Paris, France

To the Editor:

We fully agree with Nazari's opinionGo 1 about the disadvantages of clavicle resection in the transcervical approach to apical chest tumors. Anyone who is familiar with the transclavicular approach has experience with the deformity (Fig. 1) and discomfort caused by (1) the shortening of the acromiosternal distance, (2) the paradoxic and painful movement of the free distal part of the clavicle, (3) the instability of the scapular girdle, of which the only point of attachment is the sternoclavicular joint, and (4) the disinsertion of the sternocleidomastoid and the pectoralis major muscles.



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  		Fig. 1. This patient was submitted to anterior transclavicular approach. The median half of the clavicle was removed and the sternomastoid muscle divided, as was the clavicular part of the major pectoralis muscle. The shoulder deformity is evident, and this caused an important deficit and patient discomfort.

 
Our approach to avoid these deformities is quite different, for three reasons.

  1. In our experience, the reinstallation of the disarticulated clavicle leads either to luxation of the sternoclavicular joint when fixed only with metallic stitches, because of the strength of the scapular movements, or to an arthrodesis, with important limitation of scapular mobility, when fixed with a screw or Sherman's plate.
  2. The sternomastoid muscle is the major component of cervical spine stability. Its disinsertion, even after careful reconstruction, leads in all cases to a progressive cervical scoliosis.
  3. The radical treatment of lung cancers, including apical tumors, must respect oncologic principles. At the very least an upper lobectomy, associated with a mediastinal lymph node dissection, is necessary. The access proposed by Nazari, pulling the clavicle downward, seems too limited for these procedures.

The transmanubrial approach that weGo 2 described recently, which spares entirely the osteomuscular components of the cervical and shoulder articulations (Fig. 2), affords an excellent exposure to the thoracic inlet and mediastinal great vessels. This approach, respecting the muscular attachments to the clavicle, progressively elevates an osteomuscular flap and even allows a regular lobectomy to be performed with lymph node dissection, provided that one is familiar with the anterior approach to the pulmonary hilum. Reposition and fixation of the manubrial "edge" is very easy and retains the clavicular mobility.



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  		Fig. 2. Transmanubrial L-shaped incision and section of the first cartilage.

 
This technique, addressing the same objective as Nazari's, seems to us even less harmful and permits an even better access to this complex area.

12/8/79873

References

  1. Nazari S. Transcervical approach (Dartevelle technique) for resection of lung tumors invading the thoracic inlet, sparing the clavicle. J Thorac Cardiovasc Surg 1996;112:558-9.[Free Full Text]
  2. Grunenwald D, Spagg iari L. Trans-manubrial osteo-muscular sparing approach for apical chest tumors. Ann Thorac Surg 1997;63:563-6.[Abstract/Free Full Text]



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