Transpleural Infraclavicular Approach

Abstract

This lesser known approach is also used for treatment of the neurogenic-arterial thoracic outlet syndrome. The technique was published by Nelson and Jenson in 1970 [1], and further modified by Murphy et al. in 1980 [2]. The patient must be placed in the lateral decubitus position at 45°. The incision is made in a subclavicular transverse fashion and after separating the fibers of the pectoralis major muscle the first rib is approached immediately beneath. The inferior border of the first rib is then dissected. In order to accomplish visualization and dissection of that rib, the procedure now becomes an intrapleural one (i.e., a limited thoracotomy). The costosternal junction is divided with a rib cutter. Once the anterior end of the first rib is isolated it can be held with a Kocher forceps or a bone holder to facilitate circumferential dissection. By displacement of the rib downward, the anterior scalene muscle is exposed and can be divided at the point of its insertion onto the rib. Further downward displacement of the rib exposes the scalene medius muscle insertion which is also divided. The subclavian vessels are retracted superiorly, while the greater and the lesser curvature of the first rib are now exposed and further dissected until the junction with the transverse process is reached posteriorly. The rib is divided at that level and removed. In the published descriptions of this operation, the posterior end of the rib is best divided using a Sauerbruch rib shear because it is sufficiently narrow to be positioned far posteriorly on the rib very close to its junction with the transverse process.