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The cervical incision is made first to determine whether the lesion can be removed and reconstruction accomplished. The initial incision is transverse and follows the line of the clavicles at the base of the neck (Figure 34-1). If resection is to be performed, the incision is extended laterally and turned downward slightly at either end as the shoulder is reached in order to allow the flap to be moved caudad and into the mediastinum more easily. The upper skin flap is elevated superiorly, with platysma attached to a point above the hyoid bone. If skin must be removed with the specimen due to invasion by tumor, this area is outlined during initial elevation of the flaps and remains with the specimen. In such case, the incision will require individual planning. Inferiorly, the skin flap is initially raised to the sternal notch. The mode of exploration will necessarily vary with the lesion. Strap muscles are usually left attached to a bulky tumor in the case of thyroid carcinoma. If not involved, the strap muscles are separated in the midline, elevated, and eventually divided inferiorly at the sternal level. Often, to determine resectability, it is necessary to develop the plane medial to the sternocleidomastoid muscles and to the internal jugular veins and carotid arteries to discover whether tumor has invaded these vessels. If there is no involvement of the thyroid gland on one side or both, the isthmus is divided in the midline and the lobes turned laterally, with the superior thyroid blood supply intact. This will permit continued thyroid and parathyroid function, if not already destroyed by irradiation.

figure 34-1 Incisions for cervicomediastinal exenteration and mediastinal tracheostomy. The neck and mediastinum are explored through the upper horizontal incision. The lower parallel horizontal incision is made later when the decision has been made to proceed with resection. The upper midline laparotomy incision provides for mobilization and transfer of the pedicled omental flap and esophageal substitute, if the procedure is to be completed.

figure 34-1 Incisions for cervicomediastinal exenteration and mediastinal tracheostomy. The neck and mediastinum are explored through the upper horizontal incision. The lower parallel horizontal incision is made later when the decision has been made to proceed with resection. The upper midline laparotomy incision provides for mobilization and transfer of the pedicled omental flap and esophageal substitute, if the procedure is to be completed.

However, if tumor invades the thyroid gland, it is removed en bloc with the specimen. No irrevocable moves, such as division of functioning recurrent laryngeal nerves, are made until a final decision has been made that the lesion is indeed removable either for satisfactory palliation or possible cure. I have been willing to sacrifice one internal jugular vein, if necessary, but have generally preferred not to add carotid artery replacement to this extensive oncologic procedure, unless the problem is uniquely promising.

The inferior extent of a tumor and its possible invasion of mediastinal structures must be assessed to determine resectability. The inferior skin flap is elevated from the pectoral fascia with cautery, raising it from medial to lateral in order to follow the natural lines of the pectoral muscle fibers. The flap is retracted and elevation carried broadly to a point below the second interspace over the sternum. The sternoclei-

domastoid muscles are detached from the sternum and clavicles bilaterally (Figure 34-2A). The pectoral muscles are elevated on either side from the midline of sternum to expose the cartilages of the first and second ribs and medial portions of the first and second intercostal muscles (see Figure 34-2A). Most of this dissection is done with cautery. In baring the heads of the clavicles, which are likely to be resected later, the periosteum is left on the bone. If periosteum remains in the tissues, bone spurs are likely to form. The margins of the sternum in the second interspace are developed bilaterally, below the angle of Louis, with care taken to avoid the internal mammary vessels. The mediastinum is dissected bluntly away from the under-surface of the bone. The sternum is divided transversely, using either a Gigli saw, a Lebsche knife, or a sternal saw. The undersurface of the sternum is bluntly dissected from the sternal notch, and the proximal sternum is divided from the notch to the transverse sternal division (see Figure 34-2A). The margins of the divided sternum are spread with a sternal retractor, permitting definitive assessment of the extent of medi-astinal tumor. This access also facilitates later removal of the anterior chest wall segments.

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