Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.
J Thorac Cardiovasc Surg. 2012 Jul;144(1):72-80. doi: 10.1016/j.jtcvs.2012.03.049. Epub 2012 Apr 13.
Several surgical approaches have been described to access apical thoracic malignancies extending into the thoracic inlet. However, most publications have focused on a specific approach and considered the thoracic inlet as 1 entity. In the present analysis, we divided the thoracic inlet into 5 different zones requiring specific surgical considerations to identify the best approach for each zone.
A review of 22 consecutive patients undergoing surgery for apical thoracic malignancies extending into the thoracic inlet from January 2005 to November 2011 was performed.
Different surgical approaches were used for each zone. The first (anterolateral) zone required a subclavicular approach to open the costoclavicular space and expose the subclavian vein with or without elevating or removing the clavicle (n = 4). The second (anterocentral) zone required a transverse supraclavicular approach with or without extension to a partial (trapdoor) or full sternotomy (n = 10). The third (posterosuperior) zone located between the top of the subclavian artery and the T1 vertebra along the posterior superior border of the first rib was the most difficult area to access (n = 5). The transclavicular approach was ideally suited to expose this zone in our experience. The fourth (posteroinferior) zone and fifth (inferolateral) zone located posteriorly and laterally along the inferior border of the first rib were accessed using a posterolateral and posterotransaxillary approach, respectively (n = 3).
The thoracic inlet could be divided into 5 zones requiring specific surgical considerations and different approaches. Division of the thoracic inlet into these zones could provide more clarity and guidance for thoracic surgeons to select the correct surgical approach.
已有多种手术入路被用于处理延伸至胸廓入口的胸顶部恶性肿瘤。然而，大多数文献仅聚焦于某一特定入路，并将胸廓入口视为一个整体。在本分析中，我们将胸廓入口划分为 5 个不同区域，每个区域需要特定的手术考虑，以明确每个区域的最佳入路。
回顾了 2005 年 1 月至 2011 年 11 月期间连续 22 例接受手术治疗的延伸至胸廓入口的胸顶部恶性肿瘤患者的资料。
不同的手术入路适用于每个区域。第 1 （前外侧）区需要经锁骨下入路打开肋锁间隙，显露锁骨下静脉，必要时可抬高或切除锁骨（n = 4）。第 2 （前中央）区需要行锁骨上横切口，必要时可向部分（活瓣式）或全胸骨切开术（n = 10）扩展。第 3 （后上）区位于锁骨下动脉顶端和第 1 肋椎关节之间，沿第 1 肋后上缘，是最难进入的区域（n = 5）。在我们的经验中，经锁骨入路最适合暴露该区域。第 4 （后下）区和第 5 （后外侧）区位于第 1 肋后缘和外侧缘，分别采用后外侧和后外侧经胸廓入路（n = 3）。
胸廓入口可分为 5 个需要特定手术考虑和不同入路的区域。将胸廓入口分为这些区域可为胸外科医生选择正确的手术入路提供更清晰的指导。
