**6. Exposure and surgical steps (Figure 4)**

**Figure 2.** Staging algorithm for patients prior to resection of a Pancoast Tumor. MRI of the thoracic inlet may yield

**Figure 3.** Root of neck anatomy, depicting carefully the relationship of the most important neurovascular structures to

further information's on the status of vertebra involvement.

114 Principles and Practice of Cardiothoracic Surgery

the scalene musculature and the first rib.

We favour a modified Dartevelle approach [24] an L shaped incision at the anterior edge of Sterno-cleido-mastoid (a). Division of the upper sternum extended into 2nd intercostal space (b). This is a modified access something between Grunenwald [25] and Klima et al [33] approach. Grunenwald has described a trans-manubrial approach, which avoids division of the clavicle. Klima and colleagues suggested extending the L-shaped section of the manubrium down to the first intercostal space. We prefer to divide the sternum down to the angle of Luis and then extend the incision horizontally along the 2nd intercostal space, thus allowing the surgeon to lift the clavicle, subclavian muscle, and transected part of the manubrium and superior body of the sternum without dividing the first costal cartilage and ligament. The internal mammary artery is encountered and divided during the horizontal intercostal incision.

Mobilisation & excision of the supra-clavicular fat pad (c), allows exposure of the structures at the thoracic inlet; further division of the subclavious, omohyoid with preservation of the accessory nerve is carried out.

The distal part of the jugular veins is divided to expose the subclavian and innominate veins. If the subclavian vein is affected then it is resected. Following this, the scalenus anterior muscle is divided by taking care to preserve the phrenic nerve (d) & (e). The subclavian artery is mobilised by, dividing most of its branches. Care is taken to preserve the vertebral artery and resection of the vessel is done only if it is involved with the tumour and no substantial extracranial occlusive disease can be detected on preoperative Doppler ultrasound.

If the subclavian artery is taken up by tumour, the affected portion is resected and recon‐ structed, usually with a 6-8 mm PTFE vascular graft. Small dose of heparin is usually admin‐ istered during vascular clamping.

Following anterior traction of the subclavian artery, the scalenus medius muscle comes into good view. The muscle is divided above its insertion on the first rib, giving access to the branchial plexus. Familiarity with the anatomy of the plexus is important. At this stage, the anterior surface of the vertebral bodies of C7 and T1 are in view. The sympathetic chain and stellate ganglion are lying in front of the anterior surface of the vertebral bodies of C7 and T1.

last part of the resection consists of the upper Lobectomy (f). The access to perform a lobectomy and mediastinal lymph node clearance through the anterior incision is usually limited, therefore like others [34] we perform a traditional postero-lateral thoracotomy through the 5th inter-costal space. Routine coverage of the bronchial stump with an intercostal or serratus muscle flap is advocated by some groups [18] to counteract any potential damage on the stump from the neoadjuvant radiation. Chest wall reconstruction may be necessary in up to 40% of

Superior Sulcus Tumour with some Emphasis on the Anterior Approach

http://dx.doi.org/10.5772/55724

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For Pancoast carcinomas affecting the spine, a posterior midline approach can be added by a neurosurgeon, for multilevel unilateral laminectomy[35], nerve root division inside the spinal canal, and vertebral body division along the midline. The tumour then is removed en bloc with the lung, ribs, and vessels through the posterior incision. Fixation of the spine is mandatory.

According to Machiarini et al [36] one of the major advances in the treatment of Pancoast tumours has been the introduction of anterior approaches for resection. These approaches increase the likelihood of complete resection and permit resection of tumours that were

Furthermore anterior approach facilitates: 1) Direct visualisation of major structures (eg. Subclavian artery, superior vena cava) thus allowing control and elective sacrifice of the artery if necessary and reconstruct directly to a safe outcome. 2) Excellent exposure of the brachial plexus, sympathetic chain, and stellate ganglion. 3) Carry out hemi-vertebrectomy if the anterior body of the vertebra are involved. 4) Resection of the lower parts of the Brachial plexus, especially of the C8, T1 roots; however T1 root resection results in diffuse weakness of the intrinsic muscles of the hand, whereas resection of the C8 nerve root of the lower trunk of the brachial plexus results in permanent paralysis of the hand muscles. 5) Optimal access, for resection of the chest wall. 6) Oncological clearance of the structures of the Thoracic inlet, because the tumour is the last to be encountered. 7) Lower morbidity than the posterior

Moreover as per Vanakesa et al [28]the cervical-trans-sternal approach has several advantages, chiefly that of avoiding disfigurement and loss of function of the pectoral girdle, whilst providing excellent exposure of the brachial plexus, sympathetic chain, and stellate ganglion. Such an approach results in a short postoperative stay (3–6 days), and yet allows extension as

Removal of transverse processes and the head of the ribs in order to disarticulate them, could be difficult with the anterior access; furthermore more posterior seated tumours with vertebra

per Grunenwald [25], or by a high, anterior thoracotomy if necessary.

involvement may require a complimentary posterior incision.

**7. Anterior approach: Advantages and dis-advantages**

previously considered technically unresectable [37].

the cases [34].

**7.1. Advantages**

approach.

**7.2. Disadvantages**

**Figure 4.** Step by step resection of a Pancoast tumor through an Antero-cervical approach. Incision at the anterior edge of Sterno-cleido-mastoid (a). Division of the upper sternum extended into 2nd intercostal space(b). Mobilisation-Excision of supraclavicular fat pad (c). Exposure of the structures at the thoracic inlet by dividing the subclavius, omohyoid with preser‐ vation of the accessory nerve. Division of the Scalenus anterior with preservation of the phrenic nerve (d) & (e). Right upper Lobectomy (f): can be performed through the neck incision or a posterolateral thoracotomy.

The C8 and T1 nerve roots are visualised and dissected medially up to the lower trunk of the brachial plexus. The C8 nerve component of the plexus is preserved if possible, for better functional outcome of the upper limp.

Care is taken then, to access tumour invasion and plan with the neurosurgeon the "spinal component" of the operation.

Chest wall resection is carried out by dividing the first 2-3 ribs at the sternal-costo-chondral junction following by disarticulation of the ribs from the transverse processes at the back. The last part of the resection consists of the upper Lobectomy (f). The access to perform a lobectomy and mediastinal lymph node clearance through the anterior incision is usually limited, therefore like others [34] we perform a traditional postero-lateral thoracotomy through the 5th inter-costal space. Routine coverage of the bronchial stump with an intercostal or serratus muscle flap is advocated by some groups [18] to counteract any potential damage on the stump from the neoadjuvant radiation. Chest wall reconstruction may be necessary in up to 40% of the cases [34].

For Pancoast carcinomas affecting the spine, a posterior midline approach can be added by a neurosurgeon, for multilevel unilateral laminectomy[35], nerve root division inside the spinal canal, and vertebral body division along the midline. The tumour then is removed en bloc with the lung, ribs, and vessels through the posterior incision. Fixation of the spine is mandatory.
