| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
J Thorac Cardiovasc Surg 2009;137:245-247
© 2009 The American Association for Thoracic Surgery
Brief Communication |
a Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, Va
b Division of Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, Va
Received for publication December 2, 2007; accepted for publication December 16, 2007. * Address for reprints: Benjamin D. Kozower, MD, University of Virginia Medical Centre, General Thoracic Surgery, PO Box 800679, Charlottesville, Virginia, VA 22908. (Email: bdk8g{at}virginia.edu).
Complete resection of thoracic outlet tumors is challenging because of limited access and close proximity of vital neurovascular structures. We present a hemiclamshell approach with removal of the first rib to facilitate resection of a bilobed mass compressing the right subclavian artery and brachial plexus.
A 31-year-old African-American man presented with a 1-year history of increasing shoulder pain and right forearm paresthesias. He denied any upper limb weakness, weight loss, fever, or dyspnea. Clinical examination revealed a firm, nontender mass in the right supraclavicular fossa without lymphadenopathy. Upper limb strength was normal, but the right radial pulse was not palpable.
Magnetic resonance imaging (MRI) revealed a 4.7 x 5.6 x 9.8-cm dumbbell-shaped thoracic outlet mass extending from the neck to the posterior right hemithorax (
Figure 1). The right subclavian artery was occluded over a 3-cm segment, with reconstitution via collaterals distally. The brachial plexus was compressed, but there was no extension of the lesion inside the neural foramina. The mass was thinly septated with a homogenous high signal, consistent with a lipoma or liposarcoma. Ultrasound-guided core needle biopsies showed no sarcomatous features.
|
A supraclavicular transverse incision was made, the scalene fat pad was dissected, and the phrenic nerve was protected. After scalenus anterior division, the lesion was visualized tenting up the cords of the brachial plexus. It was dissected using bipolar electrocautery. After complete cervical mobilization of the mass, the incision was extended to a full hemiclamshell approach via the third intercostal space. The mass was divided into 2 lobes by the first rib. The subclavian artery and vein were mobilized from the superior aspect of the first rib, which was then resected subperiosteally. The totally dissected tumour was removed en bloc inferiorly via the third interspace; the brachial plexus prevented its delivery supraclavicularly (
Figure 2). The hemithorax was drained with thoracostomy tubes, and the incision was closed.
|
Thoracic outlet lesions usually present as an enlarging neck mass or with nondescript upper limb or shoulder pain. They may also present with brachial plexus compressive symptoms, venous thrombosis, or rarely arterial insufficiency.1 Lipomas are usually distributed haphazardly. However, there may be a symmetric distribution (Madelung's neck) or associated pain (lipoma dolorosa). A lipoma typically grows by simple expansion. Tissue infiltration is more characteristic of liposarcomas. Despite lipomas being benign tumors, surgical excision may be challenging because of their anatomic location. Computed tomography and MRI are the best modalities to demarcate the lesions' anatomic boundaries. MRI is especially useful for evaluating the brachial plexus and excluding neural foramina extension.
There are several surgical approaches for thoracic outlet pathology. These include supraclavicular, transaxillary, and posterior thoracoplasty for first rib excision in thoracic outlet syndrome. For Pancoast tumors, an anterior (Dartevelle), posterior (Shaw-Paulson), and hemiclamshell or Masaoka approach have been described.1-3 The Masaoka approach involves a transverse cervical collar incision and proximal median sternotomy extended to the third or fourth anterior intercostal space. We used this approach, and it provided excellent exposure. We resected the first rib subperiosteally from inside the chest, as described by Nomori and colleagues.4 This improves exposure by facilitating lateral retraction of the anterior chest wall flap and avoids the need to divide or resect the medial third of the clavicle, which can lead to postoperative shoulder girdle dysfunction. Vanakesa and Goldstraw5 reported that the anterosuperior approach provides excellent exposure for tumors at the base of the neck. It was associated with low morbidity, a short postoperative stay, and adequate exposure for subclavian vessel resection or reconstruction.
We present the resection of a large bilobed thoracic outlet mass. We recommend an anterior hemiclamshell surgical approach because it provides excellent exposure for tumor removal, first rib resection, and vascular reconstruction. Bipolar electrocautery is essential to avoid any iatrogenic neuropraxias when dissecting the brachial plexus or should any bleeding be encountered around the neural foramina. Monitored somatosensory evoked potentials and free running electromyelogram similarly decrease the risk of neurologic injury.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
