24 May 2016
09 June 2016
05 August 2016 (eFirst)
Tumors in contact with the first rib, subclavian vessels, brachial plexus, or the first vertebral body pose unique problems for surgical access imposed by the spatial constraints at the thoracic inlet. In this article, Wang and colleagues present a large series of benign or low-grade malignant neoplasms in this region treated with surgical resection. With their preference for a minimal invasive approach, the authors manage to resect a majority of these lesions either by thoracoscopy or supraclavicular incision. The thoracic inlet is close quarters, and tumors there frequently compress subclavian vessels or the brachial plexus. Prioritizing a minimal invasive technique may have a price, as reflected in injuries to stellate ganglion, brachial plexus, or recurrent laryngeal nerve. The alternative of an anterior transmanubrial approach with resection of the first or second rib as needed provides wide access to an obstructed passage for open dissection and controlled resection. In benign tumors, preserving the sternoclavicular joint as proposed by Grunenwald leaves no bony defect in contrast to the original technique of Dartevelle with resection of the medial third of the clavicle. The incision rarely leads to complications; even radiated (>56 gray) wounds heal without delay, and postoperative pain associated with posterior incisions far exceeds the anterior discomfort.
For tumors in this location, preoperative angiography frequently offers important diagnostic information. Neurogenic tumors typically derive their blood supply from intercostal arteries. These in turn sometimes possess collaterals to the anterior and posterior spinal arteries, not only at the level of the artery of Adamkiewicz. Preoperative recognition of spinal artery collaterals should give pause to plans for resection. As an added advantage, controlled preoperative embolization of larger arteries supplying neurogenic tumors or the occasional hemangioma as noted in this series reduce intraoperative bleeding and permit the surgeon to operate in a bloodless field.
The study describes the advantages of a minimal invasive approach, but caution is advised in elevating the short-term goal of recovery above the real risk of long-term nerve dysfunction.