J Thorac Cardiovasc Surg 1997;113:960-961
© 1997 Mosby, Inc.
Endorsement for sparing the clavicle in the transcervical approach to the thoracic inlet
Philippe Dartevelle, MD,
Paolo Macchiarini, MD
Department of Thoracic and Vascular Surgery
and Heart-Lung Transplantation, Hôpital Marie-Lannelongue
(Paris-Sud University)
133, Avenue de la Resistance,
92350 Le Plessis Robinson, France
Reply to the Editor:
We read with interest the letters of Grunenwald and associates and Jaklitsh and Rego on the convenience of sparing the clavicle during the transcervical approach to the thoracic inlet and are pleased to reply. Our early experience with this operation began in 1980, and since then more than 90 patients have undergone resection for either bronchogenic tumors or other benign or malignant neoplasms invading the thoracic inlet. Several lessons have been learned and a brief review of them seems appropriate.
The horizontal part of the L-shaped incision starts about 2 cm below the clavicle and extends into the deltopectoral groove. This widens the operating field and permits the complete en bloc resection (including the performance of the upper lobectomy) through this approach alone without resorting to an additional thoracotomy. The resulting functional and esthetic benefits are evident.Great care is paid to avoid injury to the long thoracic nerve, because this and not the resection of the clavicle by itself causes winging of the scapula.As to whether sparing the clavicle is worthwhile, our surgical philosophy concerning this subject (including its mode of reconstruction) was extensively detailed in the August 1996 issue of this Journal. Perseverare diabolicum.Concerning the remarks as to whether the resection of the clavicle by itself can result in a cosmetic and functional compromise, we enclose a photograph of a 52-year-old patient whose bronchogenic tumor invaded the intervertebral foramen; he had a hemivertebrectomy (T1, T2, T3) through a combined anterior transcervical and posterior midline approach and resection of the clavicle without reconstruction. It does not appear to him or to us that he is cosmetically compromised (Fig. 1). This observation was the general rule among our study population.
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Fig. 1. A 52-year-old man operated on 24 months ago by an anterior transcervical and median posterior approach for a left bronchogenic tumor invading the intervertebral foramen. Note the perfect shoulder mobility even after resection of the clavicle and spinal fixation.
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For these aforementioned reasons, we strongly believe that sparing the clavicle does not reserve that much pourparler.
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