[The transmanubrial approach for tumors of the superior thoracic aperture]

A considerable difficulty in surgical management of apical chest tumors is represented by the potential involvement of the thoracic outlet anatomic structures (i.e.: vertebral body, subclavian vessels, first rib). Among the various techniques proposed, the anterior trans-cervical approach popularized by Dartevelle significantly improved the radical treatment of these tumors. This approach offers a wide access to the thoracic outlet with satisfactory control of subclavian vessels, safe dissection of brachial plexus and upper part of the mediastinum, permitting a radical treatment. However, this approach is associated invariably with aesthetic deformity, severe impairment in shoulder mobility (due to medial half clavicle sacrifice) and respiratory failure in case of chest wall resection. The authors present their experience with an alternative approach, the trans-manubrial osteomuscular sparing approach to anteriorly situated apical chest tumors recently standardized by Grunenwald and Spaggiari. From June 1996 to June 1997 5 patients were operated on through this approach: 3 non-small-cell lung cancer, 1 pseudotumor, 1 desmoid tumor of the first rib. In 2 cases the resection was extended respectively to the vertebral body (D1-2-3 hemivertebrectomy) and to the subclavian vessels. This patient died on 10-postoperative day for massive pulmonary ernbolism, whereas no other complications were recorded. This technique compared to the approach popularized by Dartavelle presents the same oncological radicality, with a better surgical exposure and with the complete sparing of osteomuscular components that allow the maintainance of shoulder girdle movements associated excellent functional and cosmetic results.