The supraclavicular approach to scalenectomy and first rib resection: Description of technique  Richard J. Sanders, M.D., Susan Raymer  Journal of Vascular Surgery  Volume 2, Issue 5, Pages 751-756 (September 1985) DOI: 10.1016/0741-5214(85)90052-7 Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

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 far as possible. C, Lateral edge of sternocleidomastoid (SCM) muscle is mobilized for 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. F, 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. Journal of Vascular Surgery 1985 2, 751-756DOI: (10.1016/0741-5214(85)90052-7) Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

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 from phrenic nerve. H, Anterior scalene muscle is divided at its insertion on first rib, which exposes subclavian artery. I, 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 freed 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. Journal of Vascular Surgery 1985 2, 751-756DOI: (10.1016/0741-5214(85)90052-7) Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

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 artery 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, if possible. 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. Journal of Vascular Surgery 1985 2, 751-756DOI: (10.1016/0741-5214(85)90052-7) Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions