1. Twenty-Five Years' Experience With a Trap-Door Thoracotomy Modified With Disconnection of the First Rib for Tumors Invading the Anterior Superior Sulcus 
Hiroaki Nomori, MD, Masaru Abe, MD, Hiroshi Sugimura, MD, Akihiko Takeshi, MD 
The Annals of Thoracic Surgery 
Volume 97, Issue 6, Pages (June 2014)
DOI: /j.athoracsur
Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Schema of modified trap-door thoracotomy. (A) Incision. The modification is the disconnection of the first rib (gray zone) from inside the thorax. (B) The first rib is disconnected from the inside the thorax using a bone rongeur at the anterior site. (C) The brachiocephalic and subclavian vessels can be directly visualized and are readily under control. Sufficient exposure is obtained by a modified trap-door thoracotomy combined with further dissection of the peripheral first rib. (D) The vessel is resected with tumor.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
(A) A 71-year-old woman with left Pancoast type lung cancer. The tumor extended beyond the thoracic outlet. The arrow indicates the occlusion of left brachiocephalic vein by the tumor. The tumor was treated with preoperative chemoradiation therapy followed by surgery. (B) Intraoperative finding of modified trap-door thoracotomy at the fourth intercostal space. The first rib is being cut by a bone rongeur. (C) The chest wall is well opened like a trap door. (D) The operative view after left upper lobectomy with resection of the left brachiocephalic vein. The arrows indicate the dorsal and frontal cross sections of the first rib. The pulmonary artery is encircled with a tape.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions