The hemiclamshell approach to bulky cervico-mediastinal lesions: how to do it

Abstract

The hemiclamshell incision is a combination of partial median sternotomy and anterolateral thoracotomy, allowing excellent exposure of mediastinum, one pleural cavity and the neck. It can be used for superior sulcus tumors with mediastinal involvement or to resect bulky mediastinal lesions or lesions requiring cervical, mediastinal and pleural exposition. Although the vast majority of mediastinal lesions can now be approached by minimally invasive techniques, the hemiclamshell incision still plays a pivotal role in the case of bulky lesions involving cervical, mediastinal and pleural cavities. In the case of cardiac or great vessel involvement, the procedure should be performed in experienced high-volume centers with the availability of cardio-pulmonary bypass, extra-corporeal membrane oxygenator or venous shunts. Although the vast majority of mediastinal lesions can now be approached by minimally invasive techniques, the hemiclamshell incision still plays a pivotal role in the case of bulky lesions involving cervical, mediastinal and pleural cavities. It consists of a combination of subtotal median vertical sternotomy and antero-lateral thoracotomy in the 4^th intercostal space, providing excellent exposure of the neck, mediastinum and one pleural cavity. The objective of this paper is to describe the standard steps for performing a hemiclamshell incision by using modern devices and technology which contribute to make this procedure easier, faster and safer.

Keywords: Hemiclamshell; mediastinum; sternotomy; thoracotomy; thymoma.

Figure 1

The hemiclamshell consists of a median vertical sternotomy from the jugulum to the 4^th costo-chondral joint and an anterior thoracotomy with mammary vessel ligation and sectioning.

Figure 2

The sternocostal flap is easily retracted and then pushed upwards to expose the pleuro-mediastinal cavity. Some soft adhesions are usually found between the pericardial fat and the posterior aspect of the sternocostal flap and should be carefully coagulated and dissected to maximize proper flap mobilization and cavity exposure.

Figure 3

A Finochietto retractor is placed with the upper branch under the tip of the sternocostal flap and the lower one above the 5^th chondro-sternal joint.

Figure 4

The left jugulo-subclavian vein confluence and the innominate vein are isolated (orange and blue vessel slings); the phrenic nerve is isolated (blue and double yellow vessel slings).

Figure 5

Fully recovered hemiclamshell 1 month after surgery.