The supraclavicular approach to scalenectomy and first rib resection: Description of technique

The supraclavicular approach to scalenectomy and first rib resection: Description of technique Richard J. Sanders, M.D., and Susan Raymer, Denver, Colo. Supraclavicular first rib resection has been performed since 1910. During the 75 years since then, improved techniques and more versatile instruments have been developed to facilitate the operation. Although a surgeon may prefer the transaxillary, infraclavicular, or the posterior approach to the rib, there will always be circumstances when the supraclavicular route will be the most desirable. The anatomy of the thoracic outlet area, as seen from above, should be a part of ever), surgeon's armamentarium. TECHNIQUE (FIG. 1) The steps of the procedure are delineated throughout Fig. 1. The patient is placed in a supine position with a rolled towel running vertically under the dorsal spine. This technique extends the neck and lowers the shoulders (Fig. 1, A). Skin flaps are elevated (Fig. 1, B). The lateral edge of the sternocleidomastoid (SCM) muscle is mobilized and retracted. Although some surgeons advocate division of the clavicular head of the SCM, the procedure to mobilize and retract it medially is more physiologic and preserves the muscle to cover the area postoperatively. The external jugular vein, found on the lateral edge of the SCM, is dissected free for 3 to 5 cm and gently retracted laterally with a vein retractor. Division of this vein should be avoided, particularly in thin women, as the ligated end may produce an undesirable prominent bulge in the neck (Fig. 1, C). The omohyoid muscle is usually, but not always, found in the fat pad and divided (Fig. 1, D). The scalene fat pad is dissected bluntly over the lateral edge of the anterior scalene muscle. If the internal jugular vein comes into view, the dissection is usually too medial (Fig. 1, E). The muscle is located by palpating a round bulge below the fat pad. The anterior scalene muscle lies exposed beneath the fat pad with the phrenic nerve on its surface, usually, but not always, on the medial edge; the nerve is freed on From the Department of Surgery, Rose Medical Center and the University of Colorado Health Science Center. Reprint requests: Richard J. Sanders, M.D., 4545 E. Ninth Ave., Suite 240, Denver, CO 80220. its lateral side only. Lifting the SCM muscle with the Richardson retractor will elevate the phrenic nerve without the necessity of touching it. No suture is placed around the nerve because this can lead to nerve injury. The nerve is never touched with a retractor because even minimal retraction can cause temporary diaphragmatic palsy. The phrenic nerve is easily spared when it lies on the medial edge of the anterior scalene muscle but is in jeopardy if it lies on the lateral edge of the muscle. In the latter case, the nerve is best left alone while the anterior scalene muscle is either carefully dissected out, medial to the nerve, or is pulled as lateral as possible with the umbilical tape (Fig. 1, F) (see also Fig. 1, G and H). Passing an umbilical tape around the anterior scalene muscle facilitates its dissection. Three or four separate passes may be needed to surround the entire muscle. This permits lateral traction and pulls the muscle away from the phrenic nerve when necessary (Fig. 1, G). The anterior scalene muscle is divided at the first rib. Dividing it here will permit better visualization of the rib when it is excised, later in thc operation. The subclavian artery lies behind the muscle, but it can lic low, near the rib, or high, 3 or 4 cm above the rib (Fig. 1, H). If significant venous bleeding occurs when dissecting below the clavicle, the subclavian vein has probably been injured. If it cannot be repaired easily, the bleeding is controlled by tamponading the vein against the clavicle with a retractor while scalenectomy and rib resection are completed. The subclavian vein is then exposed with an infraclavicular incision through which an assistant's finger can control the bleeding while the surgeon repairs the vein from the supraclavicular incision. When the upper end of the anterior scalene muscle is divided, careful dissection will avoid injury to the phrenic nerve and the C5 and C6 nerves of the brachial plexus. Sometimes it is safer to remove the muscle in pieces (Fig. 1, I). After the anterior scalene muscle is removed, the middle scalene is approached. Its medial fibers are usually found medial to C7 and superior to the subclavian artery. They are sometimes easier to remove 751

752 Sanders and Ra~,mer Journal of VASCUI.AR SURGERY Incision ' t sc~ I r _ CM ~.~m o h y o id M. ~ ~ SGM "~~, calene fat pad E Fig. 1. A-F. A, Position with rolled towel running vertically under dorsal spine. Incision (7 to 8 cm) is 2 to 3 cm above clavicle. B, Upper and lower skin flaps are elevated as tar as possible. C, Lateral edge ofsternocleidomastoid (SCM) muscle is mobilized fbr 6 to 8 cm and retracted with small Richardson retractor. External jugular vein is usually at lateral edge of SCM. D, Omohyoid muscle is found and divided. E, Scalene fat pad is dissected bluntly over lateral edge of anterior scalene muscle and retracted medially with SCM. F, Anterior scalene muscle is exposed beneath fat pad. Brachial plexus lies laterally and phrenic nerve lies on its surface, usually on medial edge. Phrenic nerve is freed on its lateral side only. Lifting SCM with Richardson retractor will elevate phrenic nerve without touching it. with an approach medial to C7.* In other cases, no muscle fibers are found here, and dissection continues lateral to C5 (Fig. 1, J). The middle scalene muscle fibers, lateral to C5, that insert on the first rib, are now divided. First, the nerve trunks of C5 and C6 are mobilized along their lateral edge as extensively as possible to prevent stretching of these nerves in the next few steps. The middle scalene fibers are found just posterior and *Gersmer PL. The approach to a limited middle scalenectomy. Personal communication. lateral to these nerves. Middle scalenectomy is begun by dividing a few fibers at a time. A forceps that is heavy, smooth, and wide is used to grasp a few muscle bundles. If the shoulder jumps when the muscle is squeezed, the forceps bite probably includes a portion of the long thoracic nerve. The nerve should be isolated before that bite of muscle is cut. The C5 and C6 contributions to the long thoracic nerve usually traverse the belly of the middle scalene muscle as a single nerve fiber. Its position varies slightly, but it is usually found immediately behind the C5 nerve root. The muscle is divided all the way down to the

Voltm2t" Number 5 September 1985 Technique of scalenectomy and first rib resection 753 i SCM Phrenic N. ~, ~Phreni N. I Phrenic Ant.ScaleneM. Ant. ScaleneM. ~ ~ FirstRib Phrenic N J lane to e Scalene M Ant. Scale~ ~--~ I ~ J Subcl.Art. C5 SCM ~ ~ C5,6&7 First Rib Fig. 1. G-L. G, Umbilical tape is passed around anterior scalene muscle by dissecting plane immediately above brachial plexus. This permits lateral traction, pulling muscle away f?om phrenic nerve. H, Anterior scalene muscle is divided at its insertion on first rib, which exposes subclavian artery. L Origin of anterior scalene muscle is divided as close to transverse processes as possible. J, Entire anterior scalene muscle has been removed, exposing C5, C6, and C7 nerves, subclavian artery, and phrenic nerve. The most medial fibers of middle scalene muscle, found medial to C7 and superior to subclavian artery, are in space indicated by heavy arrow. They are removed in small bits until C8 nerve root is exposed and clean. K, After extensively mobilizing lateral edge of C5 and C6, middle scalene muscle is divided, a few fibers at a time. Long thoracic nerve is identified and spared as it runs through belly of this muscle. Muscle is removed down to first rib. If a cervical rib is present, it is encountered here and removed. L, After medial and lateral muscle attachments to posterior half of rib are f?eed with Overholt No. 1 elevator, suction tip gently retracts C5 and C6 nerves as Raney neurosurgical rongeur transects neck of first rib in several small bites. neck o f the first rib, often 2 to 3 cm below C5. As much as possible o f the bulk o f the muscle is removed. I f a cervical rib is present, it is found in the midst o f the middle scalene muscle and excised. The fibers lying behind the plexus can be removed with the aid o f a right-angle clamp, until C8 is seen. In some cases the medial portion o f the middle scalene muscle is easier to remove through the space between C6 and C7 because o f the normal variations that occur in the anatomy o f this area. It is unnecessary to remove the middle scalene fibers that lie lateral to the first rib (Fig. 1, K). At this point, anterior and middle scalenectomy is complete. I f first rib resection is not to be performed, the operation can terminate here. First rib resection is begun by an Overholt No.

754 Sanders and Raymer Journal of VASCULAR SURGERY SC Overho~t Elevator ~rst Rib Q Fig. 1. M-R. M, Rib is transected; long thoracic nerve lies free, lateral to rib. Posterior remnant of rib is now removed up to transverse process. Transverse cervical or suprascapular arte~ and vein may lie at this level, in belly of middle scalene muscle. When seen, they are divided and ligated. N, Finger dissection of posterior rib is begun by using right-angle end of Overholt No. 1 rib elevator to lift divided end of rib if space is tight. O, Index finger dissection continues. Finger is run behind rib, freeing it from pleura. Intercostal muscles are torn laterally, with finger kept close to rib. Finger dissection proceeds as far as possible onto anterior portion of rib. P, Field of exposure is changed. Narrow Richardson retractor (5 cm in length) elevates clavicle, protecting subclavian vein and exposing anterior portion of first rib. Use of head light is helpful here as it is often difficult to see rib. Either duck-bill rongeur or Urschell first-rib rongeur is used to transect rib anteriorly. This is usually about 2 cm lateral to costochondral junction. Anterior rib remnant is rongeured smooth, ifpossible.q., Once divided, rib is removed with Kocher clamp either anteriorly, below brachial plexus, or posteriorly, lateral to brachial plexus. Posterior approach is probably safest. R, Wound closure begins by fixing fat pad over cords of plexus with one stitch if needed. Skin is closed with subcuticular absorbable suture. Closed-system suction drain is left in wound for 6 to 24 hours. 1 rib elevator freeing the medial and lateral muscle attachments to the posterior half of the rib. A suction tip gently retracts C5 and C6. A Raney neurosurgical rongeur is used to transect the neck of the first rib in several small bites (Fig. 1, L). Injury to C5, C6, and C7 is most likely to occur during this step if these nerve roots are retracted too strongly. After the rib is transected, the posterior remnant of the rib is removed until the line of rib removal is flush with the transverse process. Because the C8 and

Volume 2 Number 5 September 1985 Technique of scalenectomy and first rib resection 755 T1 nerve roots often touch the neck of the rib in this area, it is important to visualize the jaws of the rongeur during this maneuver. If visualization is poor, it is wise to leave this small bone remnant rather than risk nerve injury. An arterial bleeder is sometimes found just beneath the neck of the rib and is controlled with a metal clip. The transverse cervical or suprascapular artery and vein may lie at this level, in the belly of the middle scalene muscle. (They may also run above or below the anterior scalene muscle.) When seen, they are divided and ligated. If significant bleeding occurs as the muscle is divided, the cause is usually an injury to one of these vessels. Bleeding is controlled by finger pressure, the use of a smalltipped oral suction, and careful isolation of the bleeding vessel. Once one end is ligated, the other end should be sought and also ligated to avoid postoperative bleeding (Fig. 1,214). Dissection of the rib with an index finger is begun behind the rib, from posterior to anterior, freeing the rib from the pleura. The finger usually frees the rib below the subclavian artery (Fig. 1, N and O). If brisk bleeding occurs at this stage, a torn transverse cervical or suprascapular artery or vein is usually the cause and it is handled as described earlier (Fig. 1, M). When the rib is free of all attachments, the anterior portion is divided medial and inferior to the subclavian artery (Fig. 1, P). Because the clavicle lies anterior and superior to the front of the first rib, this step can be very difficult. Often the angled rongeur is positioned under direct vision, but the cutting tip cannot be seen. When exposure is too difficult, an infraclavicular skin incision can be made 3 cm below the clavicle and the pectoralis major muscle fibers split to visualize the anterior portion of the first rib. This is an easier approach to the front of the rib and permits its division at the costochondral junction. However, the infraclavicular incision has one major disadvantage: it frequently produces a hypertrophic scar that itches and is cosmetically poor. After 35 rib resections were performed with both supra- and infraclavicular incisions, the combined approach was abandoned for routine use because of the frequent morbidi~ caused by the infraclavicular incision. However, it should be used in those few cases when exposure of the anterior portion of the first rib becomes too difficult (Fig. 1, P). The final removal of the rib, following its complete detachment, is safely done by traction on the posterior end of the rib. There may be some remaining muscle attachments that can be torn or cut as the rib is delivered into the wound (Fig. 1, Q). Table I. Complications resulting from 145 operations Pleura opened No sequelae Required needle aspiration Required chest tube Temporary numbness and weakness in hand (All recovered within 4 mo) Phrenic nerve palsy (All recovered from 1-14 too) Thoracic duct leak Required reoperation, no sequelae Long thoracic nerve injury (Winging developed in one) Postoperative bleeding; reoperation required (Neither required transfusion) The wound is closed with subcutaneous and subcuticular sutures (Fig. 1, R). A small suction drain removes 30 to 150 ml of bloody fluid in the first 24 hours. A Penrose drain is not used because its use can result in a pneumothorax if the pleura is opened. A chest x-ray film, taken with the patient in a sitting position, is obtained in the recovery room. A small pneumothorax (i.e., less than 3 cm of air in the apex) can be left alone. A pneumothorax greater than 20% is evacuated with a plastic needle (14 gauge), introduced anteriorly, through the third inner space. A chest tube has never been required. In an occasional patient it is difficult or impossible to expose the neck of the first rib without excessive traction on the C5 and C6 nerve roots. In such a situation, supraclavicular rib resection is abandoned and the operation limited to scalenectomy. If the patient's hand symptoms do not improve postoperatively, at a later date, a transaxillary approach is used to remove the rib. RESULTS One hundred forty-five supraclavicular scalenectomies and rib resections were performed between 1981 and 1984. There were no deaths, no major nerve injuries, and no damage to the subclavian artery or vein. The usual blood loss was 200 to 300 ml. The complications are listed in Table I. Retraction of the brachial plexus too vigorously with a suction tip accounted for the four instances of temporary weakness and paresthesias in the hands. Three recovered within 1 month; the fourth required 4 months. Phrenic nerve palsy occurred in four patients, all as a result of the nerve lying on the lateral, instead of the medial edge of the anterior scalene muscle. Although all four patients eventually recovered, it took more than 1 year for two of them to do so. Usually, the thoracic duct is not seen during 20 4 24

756 Sanders and Raymer Journal of VASCUI,AR SURGERY Table II. Day of discharge from hospital (145 operations) Postoperative day % 1 12 2 36 3 35 4 12 5-8 5 this operation. If it is visualized and injured, even slightly, it is carefully ligated, If lymph drainage develops postoperatively, the patient undergoes reoperation and the duct is gently occluded with a metal clip. Most patients went home 2 or 3 days after operation (Table II). DISCUSSION Supraclavicular scalenectomy and first rib resection have been described in the past,~'e The method illustrated here is a modification of a technique described by Hemple et al? in 1980. The exposure, through this approach, permits complete anterior and middle scalenectomy, something that is not pos- sible via the transaxilla~ route. The advantage of the approach is that it allows complete removal of the neck of the first rib at the transverse process, under good exposure. A disadvantage is that the anterior 2 to 3 cm of the rib cannot be safely excised through this incision. However, the anterior portion of the rib is usually at least 1 cm away from the plexus and its removal is rarely necessa~. Failure to excise it has not caused problems. Whether the addition of rib resection to scalenectomy significantly improves the results is debatable. However, for those who wish to combine scalenectomy with first rib resection, it can safely be done, with low morbidity, through a supraclavicular incision. REFERENCES 1. Brickner WM. Brachial plexus pressure by the normal first rib. Ann Surg 1927; 85:858-72. 2. Adson AW. Surgical treatment tbr symptoms produced by cervical ribs and the scalenus anticus muscle. Surg Gynecol Obstet 1947; 85:687-700. 3. Hempel GK, Rusher Jr AH, Wheeler CG, Hunt DG, Bukhari HI. Supraclavicular resection of the first rib for thoracic outlet syndrome. Am J Surg 1981; 141:213-5.