Sanders Richard J, Annest Stephen J
Department of Surgery, Presbyterian St. Lukes Hospital, and Vascular Institute of the Rockies, Denver, Colo; University of Colorado Health Science Center, Aurora, Colo.
Department of Surgery, Presbyterian St. Lukes Hospital, and Vascular Institute of the Rockies, Denver, Colo; University of Colorado Health Science Center, Aurora, Colo.
J Vasc Surg. 2015 Mar;61(3):821-5. doi: 10.1016/j.jvs.2014.11.047. Epub 2015 Jan 16.
The supraclavicular approach to scalenectomy and first rib resection has been modified since the original description in 1985. The incision is 1 to 2 cm above the clavicle, 1 cm lateral to the midline, and 5 to 7 cm long. Subplatysmal skin flaps are created. The sternocleidomastoid muscle is mobilized on its lateral edge and retracted but not divided. The scalene fat pad is split vertically, the omohyoid muscle excised, and the C5 nerve root dissected free. The accessory phrenic nerve is identified, if present, arising medially from C5, and preserved. The rest of the plexus is dissected free, muscular and connective tissue removed from all nerve roots and trunks, and the subclavian artery identified. The phrenic nerve is identified on the medial edge of the anterior scalene muscle (ASM). The ASM is divided on the first rib. The ASM is elevated, freed, and divided as high as possible and free of C5. The middle scalene muscle is dissected. C5 and C6 branches of the long thoracic nerve are identified and protected as the portion of middle scalene muscle adjacent to the nerves of the plexus is excised. The decision on whether the first rib is to be removed is determined by whether the lower trunk of the plexus is touching the first rib. If the rib is removed, its posterior end is freed, divided, and 1 cm excised. The rest of the rib is freed from the intercostal muscles with a periosteal elevator or harmonic scalpel, the pleura is separated from the inner surface of the rib, and the anterior end divided with an infraclavicular rib cutter. The operation has been made safer by identifying and dissecting the C5 nerve root before looking for the phrenic nerve.
自1985年首次描述以来，锁骨上入路的斜角肌切除术和第一肋骨切除术已有所改进。切口位于锁骨上方1至2厘米、中线外侧1厘米处，长5至7厘米。制作皮下皮瓣。在胸锁乳突肌外侧缘游离并牵开该肌，但不切断。垂直劈开斜角肌脂肪垫，切除肩胛舌骨肌，游离出C5神经根。如有副膈神经，确认其从C5内侧发出并予以保留。游离其余臂丛神经，从所有神经根和神经干上清除肌肉和结缔组织，辨认出锁骨下动脉。在前斜角肌内侧缘辨认出膈神经。在前斜角肌在第一肋骨处切断。尽可能在远离C5的位置将前斜角肌向上提起、游离并切断。解剖中斜角肌。辨认并保护胸长神经的C5和C6分支，同时切除中斜角肌与臂丛神经相邻的部分。是否切除第一肋骨取决于臂丛神经下干是否与第一肋骨接触。若切除肋骨，将其后端游离、切断并切除1厘米。用骨膜剥离子或超声刀将肋骨其余部分与肋间肌分离，将胸膜从肋骨内表面分离，用锁骨下肋骨切断器切断肋骨前端。通过在寻找膈神经之前先辨认并解剖C5神经根，使该手术更加安全。
