Morbidity and validity of the hemiclamshell approach for thoracic surgery

Hemi-Clamshell Approach for Fetal Lung Interstitial Tumor Resection in a Neonate: A Case Report

Fetal lung interstitial tumor (FLIT) is a rare primary lung mass in neonates. Classical incisions, such as posterolateral thoracotomy or median sternotomy, do not provide optimal exposure of the operative field for the resection of pediatric thoracic giant tumors. Herein, we report a rare case of a FLIT in a full-term male neonate, with complete resection achieved using a hemi-clamshell approach, which provided the required visualization of the operative field. The neonate was transferred to our hospital because of mild respiratory distress, which developed 18-hour after normal vaginal delivery. A mass in his right chest, without a midline shift, was observed on chest radiographs. Computed tomography showed a well-circumscribed solid anterior cervicothoracic mass, with a uniform density and no apparent cysts, diagnosed as a primary thoracic giant tumor. Once the patient was clinically stabilized, we proceeded with right upper lobectomy, using a hemi-clamshell approach, full sternotomy, and anterolateral thoracotomy, on postnatal day 22.

Histopathologic examination revealed an 8.5 × 6.5 × 4.0 cm solid mass within the right upper lobe, which was diagnosed as a FLIT. His postoperative recovery was uneventful. The patient was followed up for 1 year, with no complaints or symptoms and no postoperative shoulder dysfunction. Gross total resection of primary thoracic giant tumors can be accomplished in neonates with optimal exposure of the chest cavity using a hemi-clamshell approach.

[Partial cervicosternotomy for resection of non-bronchogenic tumors of the thoracic outlet]

OBJECTIVE

To improve the results of surgical treatment of cervico-mediastinal tumors by using of partial upper cervicosternotomy.

MATERIAL AND METHODS

A retrospective analysis included 24 patients who underwent resection of cervico-mediastinal tumors via partial upper cervicosternotomy for the period from January 2002 to December 2019. Immediate and intermediate postoperative outcomes were analyzed.

RESULTS

Mean surgery time was 282.7 min, intraoperative blood loss - 325.0 ml. Duration of pleural cavity (mediastinum) drainage was 3 days, hospital-stay - 14 days. Major postoperative complications developed in 3 (12.5%) patients. No 90-day mortality was observed. No local relapses were detected throughout the follow-up period (median 36.1 months).

CONCLUSION

Partial cervicosternotomy is a safe and effective approach ensuring adequate visualization and reliable control of great vessels of the upper mediastinum and neck. This access is valuable for en-bloc resection of cervico-mediastinal tumors located in anterior and posterior parts of the thoracic inlet.

Lifesaving surgery for a ruptured invasive thymoma using the hemi-clamshell approach: a case report

Background

Among anterior mediastinal tumors, a teratoma is known to rupture with growth, but there have been few previous reports about thymoma rupture. We here report a rare case of an invasive thymoma with intrapulmonary and intrathoracic rupture requiring emergency life-saving surgery. To our knowledge, this is the first such case in the literature.

Case presentation

A 56-year-old woman suddenly experienced right precordial pain and hemoptysis. Enhanced computed tomography revealed a large mediastinal tumor pressing against the pulmonary hilar vascularity, with extravasation of blood into the right lung. Tumor rupture into the lungs was suspected. Given the deterioration of her respiratory status and hemodynamics, thymomectomy with removal of the involved tissues was urgently performed using the hemi-clamshell approach and intrapericardial dissection, with veno-arterial extracorporeal membrane oxygenation on standby. She survived, and no recurrence has been noted for 2 years postoperatively.

Conclusions

A large thymoma can suddenly rupture into the thorax, similar to the rupture of a teratoma. Additionally, in cases with hemoptysis, an appropriate procedure should be selected to reach both the pulmonary hilum and thorax for complete resection, as hemoptysis might suggest tumor invasion into the lungs.

Left Single Lung Transplantation Through Left Anterolateral Thoracotomy With Longitudinal Partial Sternotomy (Hemiclamshell): An Innovative Surgical Resource

INTRODUCTION

Pulmonary fibrosis (PF) is one of the main indications for lung transplantation among end-stage respiratory diseases. PF represents a surgical challenge due to the pulmonary retraction, reduction of pleural space, and limitation for access of the lung hilum by elevation, specifically on the left lung. Unilateral sternothoracotomy, or hemiclamshell (HCS) approach, is the anterolateral thoracotomy with longitudinal partial sternotomy with possibility of cervical extension. This was initially described as a surgical approach for resection of lung apex tumors and of the cervicothoracic region, excision of mediastinal and thoracic wall tumors, and as an urgent incision for the repair of mediastinal and cervicothoracic vascular lesions. HCS is not usually described for liver transplantation.

CASE

A 62-year-old man who was a nonsmoker was diagnosed with idiopathic PF. After 3 years of medical management and follow-up, the patient was referred to us for a pretransplantation study. He presented with dyspnea grade III according to the Medical Research Council. In the radiograph of the chest and computed tomography of the thorax showed signs of pulmonary fibrosis predominantly left-lung associated with loss of volume and alteration of respiratory function tests. We performed left single lung transplantation through a left HCS approach. During implantation we converted the superior pulmonary vein into "neo-atrium" for the atrial anastomosis. The patient presented excellent evolution and was discharged from the hospital at 26 days.

CONCLUSION

We present a case of left single lung transplantation by PF through an HCS approach as novel and effective resource for this type of procedure.

The use of the trapdoor incision for access to thoracic inlet pathology in children

Lesions at the thoracic inlet are difficult to access via a thoracic or cervical approach. The use of the anterior cervico-thoracic trapdoor incision has been reported to give good exposure to the anterior superior mediastinum in adults. We report our experience of four cases where a trapdoor incision was used to gain excellent access and exposure to thoracic inlet pathology in children.

A hemiclamshell incision for a giant solitary fibrous tumor of the right hemithorax

A 41-year-old female was admitted with respiratory distress. Chest radiographs showed opacity in the right hemithorax with mediastinal shift. Computed tomography (CT) scan showed a pleural mass with a 22 cm diameter occupying the whole right hemithorax and causing atelectasis. Magnetic resonance imaging (MRI) showed lower position of the right hemidiaphragm and the liver. Superior vena cava and heart were shifted to left. Presence of infiltration to the adjacent tissues could not be clearly evaluated because of pressure effect. Transthoracic needle biopsy specimen was reported to be benign. Because of the size and location of the mass, a hemiclamshell incision was chosen, which allowed excellent visualization and complete dissection of the giant tumor. The histopathology of the resected specimen confirmed solitary fibrous tumor. The patient was stabilized by careful observation and treatment. No complication except pneumonia in the postoperative first month occurred during the 22-month follow-up period.

The surgical approach for cervicothoracic masses in children

BACKGROUND

The surgical approach to masses located in the cervicothoracic juncton represents a challenge for surgeons. Many techniques have been described with good results.

METHODS

We analyzed and compared the results obtained in 2 Italian pediatric surgery centers using 2 different techniques in patients with tumors of the thoracic inlet: center 1, using anterior cervical transsternal approach on 7 patients, and center 2, applying "trap-door" technique on 5 patients.

RESULTS

Excision was incomplete in 5 patients and complete in 7 patients. Histologic examination revealed 5 patients with neuroblastoma; 3, ganglioneuroblastoma; 1, mixoid liposarcoma; 1, desmoid fibromatosis; 1, Castleman disease; and 1, Schwann cell tumor. The median duration of the procedure was 345 minutes in center 1 and 245 minutes in center 2. The median blood loss was 200 mL in both centers. The median hospital stay was 11 days in center 1 and 9 days in center 2. Globally, 5 patients developed postoperative complications. No significant differences were encountered comparing the main surgical outcome parameters between the 2 approaches.

CONCLUSIONS

Both techniques resulted in valid options to achieve a safe excision of thoracic inlet masses with a manageable complication rate and acceptable hospital stay. Surgical risk factors should be carefully investigated preoperatively. Postoperative pain control is important to guarantee early recovery.

The hemiclamshell approach in thoracic surgery: indications and associated morbidity in 50 patients

This retrospective study was carried out to evaluate the indications for and outcomes of the hemiclamshell (HCS) approach (longitudinal partial sternotomy with antero-lateral thoracotomy) in patients undergoing mass resection in thoracic surgery. All patients (50) who underwent a HCS procedure in our department, between July 1996 and July 2005, were studied retrospectively, analyzing the indications, morbidity and outcome (pain, neurological or shoulder defects, mortality) at one month and one year. The main indications were apical tumours (38%), tumours of the cervicothoracic junction (46%) and chest wall (10%), and 'bulky' tumours (6%). One-month mortality was 6%. Two patients suffered from a chylothorax and one from phrenic paralysis. The postoperative analgesic requirements were similar to those after other thoracic surgery approaches. Twelve percent of patients suffered pain at one month and 6% at one year. Shoulder dysfunction was observed in 10% of patients at one month and 6% at one year. In conclusion, the HCS surgical approach was associated with an uncomplicated postoperative course. This anterior approach is suitable for apical tumours, tumours of the cervicothoracic junction and 'bulky' lung tumours, providing good access for control of the large vessels and radical mediastinal clearance.

Cardial gunshot injury: treatment in a trauma hospital without a cardiac unit

Gunshot injuries to the chest often require urgent admission to the nearest hospital, because of the cardiorespiratory status, transfer to a hospital without a cardiothoracic unit might be unsafe. In this case, a male patient was transferred to the nearest hospital on being shot through the heart. On admission, he was in shock, and immediate surgery was performed. We report our treatment regime for thoracic injuries and the specific management of this patient. We conclude that every hospital with an accident and emergency department has to be prepared for such an injury and that operative management is possible without cardiopulmonary bypass.

Clamshell and hemiclamshell incisions

Sternotomy is one of the most frequent accesses in cardio-thoracic surgery. Transverse sternotomy with bilateral thoracotomy and combined approaches are developed. Surgical techniques, indications and pitfalls of these incisions are described.

Large thoracic duct cyst - a case report and review of the literature

Large thoracic duct cysts are rare and standard lateral thoracotomy is usually used for resection. In the reported case the combination of an antero-lateral thoracotomy with a partial longitudinal median sternotomy (hemiclamshell approach) allowed an excellent visualization and dissection of a large thoracic duct cyst expanding in the anterior cervico-thoracic junction, and was associated with an uncomplicated recovery.