1. Transmanubrial Osteomuscular Sparing Approach for Apical Chest Tumors
Dominique Grunenwald, MD, Lorenzo Spaggiari, MD 
The Annals of Thoracic Surgery 
Volume 63, Issue 2, Pages (February 1997)
DOI: /S (96)

2. Fig. 1 L-shaped cervicotomy.
The Annals of Thoracic Surgery  , DOI: ( /S (96) )

3. Fig. 2
After the dissection of the sternomastoid muscle, the internal jugular vein is exposed. The major pectoral muscle is spared, and this permits isolation of the first cartilage and the internal thoracic vessels that will be subsequently divided. The figure shows the L-shaped incision on the manubrium and the limit of the first cartilage section.
The Annals of Thoracic Surgery  , DOI: ( /S (96) )

4. Fig. 3
After the L-shaped resection of the manubrium and the first cartilage section, the flap is progressively retracted; the dissection follows the posterior part of the clavicle, leaving on the subclavian vessels part of the subclavian muscle, which becomes an optimal dissection plane.
The Annals of Thoracic Surgery  , DOI: ( /S (96) )

5. Fig. 4
Exposure obtained through the transmanubrial osteomuscular sparing approach. A lace around the manubrial edge is used to elevate the flap. Starting from the venous confluent, the subclavian vein is mobilized; subsequently, the scalene muscle is sectioned and the subclavian artery and related branches are progressively controlled. At this point, all thoracic structures can be safely controlled and, when necessary, resected.
The Annals of Thoracic Surgery  , DOI: ( /S (96) )

6. Fig. 5
Patient at discharge. No postoperative alterations in the shoulder mobility were observed. This patient was operated on for lung cancer. He underwent transmanubrial approach with first and second rib resections, posterolateral thoracotomy with pneumonectomy, and laparotomy for omentoplasty.
The Annals of Thoracic Surgery  , DOI: ( /S (96) )