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Aghayev K. Safety and Efficacy of Posterior Upper Rib Excision and Decompression Technique for Surgical Treatment of Neurogenic Thoracic Outlet Syndrome. World Neurosurg 2023; 180:e739-e748. [PMID: 37813334 DOI: 10.1016/j.wneu.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND There are several approaches used for surgical treatment of neurogenic thoracic outlet syndrome (n-TOS). The posterior upper rib excision and decompression technique is a novel technique that was developed and used by the author for the past 8 years. The purpose of this paper is to report clinical outcomes of patients treated with this approach. METHODS All patients with n-TOS operated by single surgeon from 2015 to 2023 were retrospectively analyzed. Demographic, clinical, radiologic, surgical, and postoperative data were collected and reported with emphasis on efficacy and complications. The surgical success was evaluated subjectively as excellent, good, fair, poor, and bad. Radiologic data were analyzed to assess the extent of accessory/first rib removal. RESULTS Eighty procedures were performed in 61 patients with a mean follow-up of 1153 (87-3048) days. The majority (60.7%) of patients were women, with 39.3% being men. In 11 cases (18%) causative factor was bone abnormality. Two patients were previously operated at another centers (3.3%). Total mean subjective improvement rate was 91.5%. More than half (55) of the patients reported "excellent" (>75%) and 6 "good" improvements (50%-75%); no fair, poor, and worse outcomes were reported. Patients reporting "good" outcome had statistically significant shorter follow-ups than the "excellent" group (P < 0.001). Complications included pleural opening, Horner syndrome, and apical hematoma, none of which were permanent. CONCLUSIONS The posterior upper rib excision and decompression approach provides excellent clinical outcomes in patients with n-TOS. It allows better intraoperative visualization and removal of the first rib and full decompression of the neurovascular bundle.
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Affiliation(s)
- Kamran Aghayev
- Department of Neurosurgery, Esencan Hospital, Baglarcesme Mahallesi, Istanbul, Turkey.
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Oh WT, Kim SH, Koh IH, Koh YW, Choi YR. Robot-Assisted Retroauricular Anterior Scalenectomy for Neurogenic Thoracic Outlet Syndrome. Clin Orthop Surg 2023; 15:637-642. [PMID: 37529194 PMCID: PMC10375822 DOI: 10.4055/cios22296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 08/03/2023] Open
Abstract
Background This study described the surgical technique of a robot-assisted retroauricular anterior scalenectomy and assessed clinical outcomes and complications for patients with neurogenic thoracic outlet syndrome (nTOS). Methods Between February 2014 and August 2016, 5 patients underwent robot-assisted retroauricular anterior scalenectomy using the da Vinci Xi system for nTOS. For clinical assessment, visual analog scale (VAS) symptom score, pinch and grip strength, and disabilities of arm, shoulder and hand (DASH) score were assessed to compare preoperative and postoperative outcomes. Postoperative complications were also reviewed. Results The VAS symptom, pinch and grip strength, and DASH scores improved 1 year after the operation. All patients were satisfied with the surgical scars. Temporary postoperative complications, which spontaneously resolved within 3 months, were noticed in 2 patients: one with vocal cord palsy and the other with upper brachial plexus palsy. Conclusions The robot-assisted retroauricular anterior scalenectomy for patients with nTOS seems feasible and safe, providing satisfactory cosmetic results.
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Affiliation(s)
- Won-Taek Oh
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sang-Hee Kim
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Il-Hyun Koh
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Woo Koh
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Yun-Rak Choi
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
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Current Concepts in the Management of Neurogenic Thoracic Outlet Syndrome: A Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4829. [PMID: 36875924 PMCID: PMC9984160 DOI: 10.1097/gox.0000000000004829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/04/2023] [Indexed: 03/06/2023]
Abstract
Thoracic outlet syndrome is a constellation of signs and symptoms due to compression of the neurovascular bundle of the upper limb. In particular, neurogenic thoracic outlet syndrome can present with a wide constellation of clinical manifestations ranging from pain to paresthesia of the upper extremity, resulting in a challenge to correctly diagnose this syndrome. Treatment options range from nonoperative treatment, such as rehabilitation and physical therapy, to surgical correction, such as decompression of the neurovascular bundle. Methods Following a systematic review of the literature, we describe the need for a thorough patient history, physical examination, and radiologic images which have been reported to correctly diagnose neurogenic thoracic outlet syndrome. Additionally, we review the various surgical techniques recommended to treat this syndrome. Results Postoperative functional outcomes have been shown to be more favorable in arterial and venous thoracic outlet syndrome (TOS) patients when compared with neurogenic TOS patients, likely due to the ability to completely remove the site of compression in cases of vascular TOS as compared with incomplete decompression in neurogenic TOS. Conclusions In this review article, we provide an overview of the anatomy, etiology, diagnostic modalities, and current treatment options of correcting neurogenic TOS. Additionally, we offer a detailed step-by-step technique of the supraclavicular approach to the brachial plexus, a preferred approach for decompressing neurogenic TOS.
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Lassner F, Becker M, Prescher A. Relevance of Costovertebral Exarticulation of the First Rib in Neurogenic Thoracic Outlet Syndrome: A Retrospective Clinical Study. J Pers Med 2023; 13:jpm13010144. [PMID: 36675805 PMCID: PMC9861701 DOI: 10.3390/jpm13010144] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023] Open
Abstract
Purpose: The failure rate for operative decompression in neurogenic thoracic outlet syndrome (NTOS) is high compared to more distal nerve compression syndromes, such as cubital or carpal tunnel syndrome. Herein, we aimed to determine if a more radical approach, namely costovertebral exarticulation of the first rib, may improve the postoperative results in patients with NTOS. Methods: From October 2002 to December 2020, 105 operative decompressions in 95 patients were evaluated; in 10 cases, decompressions were performed bilaterally. We presented the clinical outcomes of 59 exarticulations compared to those of 46 conventional resections. Evaluation was performed at a minimum of one year post-operation using the DASH questionnaire. Results: The exarticulation group presented with significantly better clinical outcomes (two-sample t-test assuming unequal variances, p < 0.001). Conclusions: This study showed that significantly better results were obtained when exarticulation of the first rib was performed in patients with NTOS. This finding supports the hypothesis that, in certain cases, the proximal portion of the first rib plays a pivotal role in the pathogenesis of NTOS.
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Affiliation(s)
- Franz Lassner
- Pauwelsklinik, Boxgraben 56, 52064 Aachen, Germany
- Correspondence: ; Tel.: +49-241-900-8630; Fax: +49-241-900-8595
| | | | - Andreas Prescher
- Institute für Molecular und Cellular Anatomy, Aachen University, Pauwelsstr. 30, 52074 Aachen, Germany
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Hemp J, McGriff E, Kern J, Olazagasti J, Cherry K, Hanley M. Thoracic Outlet Syndrome: Review of Surgical Approaches and Radiographic Complications. APPLIED RADIOLOGY 2022. [DOI: 10.37549/ar2855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Factors Associated with 30-Day Adverse Events After Brachial Plexus Neurolysis. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:332-336. [DOI: 10.1016/j.jhsg.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
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Hoexum F, Jongkind V, Coveliers HM, Yeung KK, Wisselink W. Robot-assisted transthoracic first rib resection for venous thoracic outlet syndrome. Vascular 2021; 30:217-224. [PMID: 33832359 DOI: 10.1177/1708538121997332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Venous thoracic outlet syndrome (vTOS) is caused by external compression of the subclavian vein at the costoclavicular junction. It can be subdivided in McCleery Syndrome and Paget-Schroetter Syndrome (PSS). To improve the venous outflow of the arm and to prevent recurrent thrombosis, first rib resection with venolysis of the subclavian vein can be performed. Open transaxillary, supraclavicular, infraclavicular or combined paraclavicular approaches are well known, but more recent robot-assisted techniques are introduced. We report our short- and long-term results of a minimal invasive transthoracic approach for resection of the anteromedial part of the first rib using the DaVinci surgical robot, performed through three trocars. METHODS We analyzed all patients with vTOS who were scheduled to undergo robot-assisted transthoracic first rib resection in the period July 2012 to May 2016. Outcomes were: technical success, operation time, blood loss, hospital stay, 30-day complications and patency. Functional outcomes were assessed using the "Disability of the Arm, Shoulder and Hand" (DASH) questionnaire. RESULTS Fifteen patients (8 male, 7 female; mean age 32.9 years, range 20-54 years) underwent robot-assisted transthoracic first rib resection. Conversion to transaxillary resection was necessary in three patients. Average operation time was 147.9 min (range 88-320 min) with a mean blood loss of 79.5 cc (range 10-550 cc). Mean hospital stay was 3.5 days (range 2-9). In three patients, complications were reported (Clavien-Dindo grade 2-3a). Patency was 91% at 15.5 months' follow-up. DASH scores at one and three years showed excellent functional outcomes (7.1 (SD= 6.9, range 0-20.8) and 6.0 (SD= 6.4, range 0-25)) and are comparable to the scores of the normative general population. CONCLUSION Robot-assisted transthoracic first rib resection with only three trocars is a feasible minimal invasive approach for first rib resection in the management of vTOS. This technique enables the surgeon to perform venolysis under direct 3D vision with good patency and long-term functional outcome. Studies with larger cohort size are needed to compare the outcomes of this robot-assisted technique with other more established approaches.
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Affiliation(s)
- Frank Hoexum
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | - Vincent Jongkind
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | | | - Kak K Yeung
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | - Willem Wisselink
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
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Maqbool T, Novak CB, Jackson T, Baltzer HL. Thirty-Day Outcomes Following Surgical Decompression of Thoracic Outlet Syndrome. Hand (N Y) 2019; 14:107-113. [PMID: 30182746 PMCID: PMC6346360 DOI: 10.1177/1558944718798834] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Surgical thoracic outlet syndrome (TOS) management involves decompression of the neurovascular structures by releasing the anterior and/or middle scalene muscles, resection of the first and/or cervical ribs, or a combination. Various surgical approaches (transaxillary, supraclavicular, infraclavicular, and transthoracic) have been used with varying rates of complications. The purpose of this study was to evaluate early postoperative outcomes following surgical decompression for TOS. We hypothesized that first and/or cervical rib resection would be associated with increased 30-day complications and health care utilization. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all TOS cases of brachial plexus surgical decompression in the region of the thoracic inlet from 2005 to 2013. RESULTS There were 225 patients (68% females; mean age: 36.4 years ± 12.1; 26% body mass index [BMI] ⩾ 30). There were 205 (91%) patients who underwent first and/or cervical rib resection (±scalenectomy), and 20 (9%) underwent rib-sparing scalenectomy. Compared with rib-sparing scalenectomy, rib resection was associated with longer operative time and hospital stays ( P < .001). In the 30 days postoperatively, 8 patients developed complications (rib-scalenectomy, n = 7). Only patients with rib resection returned to the operating room (n = 10) or were readmitted (n = 9). CONCLUSIONS Early postoperative complications are infrequent after TOS decompression. Rib resection is associated with longer surgical times and hospital stays. Future studies are needed to assess the association between early and long-term outcomes, surgical procedure, and health care utilization to determine the cost-effectiveness of the various surgical interventions for TOS.
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Affiliation(s)
- Talha Maqbool
- Faculty of Medicine, University of Toronto, ON, Canada
| | - Christine B. Novak
- Toronto Western Hospital Hand Program, Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Toronto, ON, Canada
| | - Timothy Jackson
- Division of General Surgery, Department of Surgery, University of Toronto, ON, Canada
| | - Heather L. Baltzer
- Toronto Western Hospital Hand Program, Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Toronto, ON, Canada,Heather L. Baltzer, Toronto Western Hospital Hand Program, Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Toronto, 399 Bathurst Street, 2EW, Toronto, ON, Canada M5T 2S8.
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Morjaria JB, Aslam I, Johnson B, Greenstone MA, Kastelik JA. Bilateral chylothorax: an unusual complication of cervical rib resection. Ther Adv Chronic Dis 2015; 6:29-33. [PMID: 25553240 DOI: 10.1177/2040622314552072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Bilateral chylothorax is a rare cause of pleural effusions. Here we report an unusual acute presentation of bilateral chylothorax following thoracic outlet surgery. Unique to this case was the disparate characteristics of pleural fluid analyses with an exudate on the left and a transudate on the right. This report describes the recognition and management of bilateral chylothoraces, an uncommon but potentially serious complication of this frequently performed surgical procedure.
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Affiliation(s)
- Jaymin B Morjaria
- Department of Respiratory Medicine, Hull & East Yorkshire Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Imran Aslam
- Department of Respiratory Medicine, Hull & East Yorkshire Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Brian Johnson
- Department of Vascular Surgery, Hull & East Yorkshire Hospitals NHS Trust, Hull Royal Infirmary, Hull, UK
| | - Michael A Greenstone
- Department of Respiratory Medicine, Hull & East Yorkshire Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Jack A Kastelik
- Department of Respiratory Medicine, Hull & East Yorkshire Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
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Fried SM, Nazarian LN. Dynamic neuromusculoskeletal ultrasound documentation of brachial plexus/thoracic outlet compression during elevated arm stress testing. Hand (N Y) 2013; 8:358-65. [PMID: 24426950 PMCID: PMC3745249 DOI: 10.1007/s11552-013-9523-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The diagnosis and validation of thoracic outlet syndrome/brachial plexopathy (TOS) remains a difficult challenge for surgeons, neurologists, and radiologists. This is due to the fact that the responses of standard elevated arm stress tests can be considered somewhat subjective and can vary. Therefore, non-vascular TOS cases are presently diagnosed clinically, and any objective diagnosis has been controversial. METHODS This is a technique paper describing the use of dynamic neuromusculoskeletal ultrasound to assist in the diagnosis of thoracic outlet/brachial plexus pathology. We propose a new way to observe the brachial plexus dynamically, so that physical verification of nerve compression between the anterior and middle scalene muscles can be clearly made at the onset of clinical symptoms. This gives a way to objectively identify clinically significant brachial plexus compression. RESULTS Dynamic testing can add objective analysis to tests such as the elevated arm stress tests and can correlate the onset of symptoms with plexus compression between the anterior and middle scalene muscles. With this, the area of pathologic compression can be identified and viewed while performing the dynamic testing. If compression is seen and the onset of symptoms ensues, this is a positive confirmatory test for the presence of TOS and a clinically significant disease. CONCLUSIONS This paper offers a simple, objective, and visual diagnostic test that can validate the presence or absence of brachial plexus compression during arm elevation in patients with brachial plexus injury and thoracic outlet syndrome.
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Affiliation(s)
| | - Levon N. Nazarian
- />Department of Radiology, Division of Diagnostic Ultrasound, Thomas Jefferson University Hospital, 7th Floor, Main Building, Philadelphia, PA USA
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Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS. Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management. J Man Manip Ther 2011; 18:132-8. [PMID: 21886423 DOI: 10.1179/106698110x12640740712338] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Proper management of thoracic outlet syndrome (TOS) requires an understanding of the underlying causes of the disorder. A comprehensive examination process, as described in Part 1 of this review, can reveal the bony and soft tissue abnormalities and mechanical dysfunctions contributing to an individual's TOS symptoms. OBJECTIVE Part 2 of this review focuses on management of TOS. CONCLUSION The clinician uses clinical examination results to design a rehabilitation program that focuses on correcting specific problems that were previously identified. Disputed neurogenic TOS is best managed with a trial of conservative therapy before surgical treatment options are considered. Cases that are resistant to conservative treatment may require surgical intervention. True neurogenic TOS may require surgical intervention to relieve compression of the neural structures in the thoracic outlet. Surgical management is required for cases of vascular TOS because of the potentially serious complications that may arise from venous or arterial compromise. Post-operative rehabilitation is recommended after surgical decompression to address factors that could lead to a reoccurrence of the patient's symptoms.
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Affiliation(s)
- Troy L Hooper
- Center for Rehabilitation Research, School of Allied Health Sciences, Texas Tech University Health Science Center, USA
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Araujo LFL, Moreschi AH, Macedo GBD, Moschetti L, Machado EL, Saueressig MG. Fístula linfática após tratamento cirúrgico de síndrome do desfiladeiro torácico à direita. J Bras Pneumol 2009; 35:388-91. [PMID: 19466278 DOI: 10.1590/s1806-37132009000400014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Accepted: 07/16/2008] [Indexed: 11/22/2022] Open
Abstract
A fístula linfática como complicação de correção de síndrome do desfiladeiro torácico é um evento muito raro. Relatamos um caso de fístula linfática à direita e apresentamos uma breve revisão do tratamento de quilotórax pós-cirúrgico.
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Thoracic Outlet Syndrome: Part II. Management and Outcomes of 133 Operative Neurogenic Thoracic Outlet Syndrome Cases. ACTA ACUST UNITED AC 2007. [DOI: 10.1097/wnq.0b013e31803201a1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Loukas M, Wartmann CT, Louis RG, Tubbs RS, Salter EG, Gupta AA, Curry B. Cisterna chyli: A detailed anatomic investigation. Clin Anat 2007; 20:683-8. [PMID: 17415746 DOI: 10.1002/ca.20485] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
With recent laparoscopic advancements in retroperitoneal and thoracic surgical procedures, familiarity with major lymphatic structures, such as including the cisterna chyli (CC) and thoracic duct (TD), has proven beneficial in avoiding misdiagnosis and iatrogenic intraoperative injury. In this light, the aim of our study was to explore and delineate the topography of the CC, classify the different patterns of lymphatic tributaries, and categorize its varying location with respect to the vertebral bodies. The anatomy of the CC was examined in 120 adult human cadavers. The CC was found in 83.3% of the specimens and both the tributaries of the CC and the location, with respect to vertebral level, demonstrated wide variation. The results were classified into four types. The most common tributary configuration (type I), found in 45% specimens, was a single CC formed by the union of the left lumbar trunk (LT) and the intestinal trunk (IT). In 30% the CC was formed where the IT opened into the TD and the right lumbar trunk (RT), LT, retroaortic nodes (RN) and branches from the intercostal lymphatics (IL) joined variably (type II). In 20% the CC was formed by the junction of the RT and IT (type III), while in 5% there was a variable confluence pattern of lymphatic trunks that could not be classified (type IV). The CC was located at L1-L2 (type A) in 63%, T12-L1 (type B) in 21%, T11-T12 (type C) in 8%, T10-11 (type D) in 5%, and T9-10 (Type E) in 3%, of the specimens. The CC was found in the retrocrural space and, in 75% of the cases, to the right of the abdominal aorta. We hope that the data supplied by this study will provide useful information in the future to anatomists, radiologists and surgeons alike.
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Affiliation(s)
- Marios Loukas
- Department of Anatomical Sciences, St. George's University, School of Medicine, Grenada, West Indies.
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Morgan CJ, Lyons J, Ling BC, Maher PC, Bohinski RJ, Keller JT, Howington JA, Kuntz C. Video-assisted thoracoscopic dissection of the brachial plexus: cadaveric study and illustrative case. Neurosurgery 2006; 58:ONS-287-90; discussion ONS-290-1. [PMID: 16582652 DOI: 10.1227/01.neu.0000204657.56274.86] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Standard surgical approaches to the brachial plexus require an open operative technique with extensive soft tissue dissection. A transthoracic endoscopic approach using video-assisted thoracoscopic surgery (VATS) was studied as an alternative direct operative corridor to the proximal inferior brachial plexus. METHODS VATS was used in cadaveric dissections to study the anatomic details of the brachial plexus at the thoracic apex. After placement of standard thoracoscopic ports, the thoracic apex was systematically dissected. The limitations of the VATS approach were defined before and after removal of the first rib. The technique was applied in a 22-year-old man with neurofibromatosis who presented with a large neurofibroma of the left T1 nerve root. RESULTS The cadaveric study demonstrated that VATS allowed for a direct cephalad approach to the inferior brachial plexus. The C8 and T1 nerve roots as well as the lower trunk of the brachial plexus were safely identified and dissected. Removal of the first rib provided exposure of the entire lower trunk and proximal divisions. After the fundamental steps to the dissection were identified, the patient underwent a successful gross total resection of a left T1 neurofibroma with VATS. CONCLUSION VATS provided an alternative surgical corridor to the proximal inferior brachial plexus and obviated the need for the extensive soft tissue dissection associated with the anterior supraclavicular and posterior subscapular approaches.
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Affiliation(s)
- Chad J Morgan
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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