| Background and ObjectivePrimary bone tumors in the ribs account for about 5%-7% of all bone tumors.Although primary malignant tumors in the first rib are rare in clinical work,patients with clinical symptoms caused by local metastasis of the lung tip malignant tumor to the first rib region are often found.Due to the continuous oppression of tumor tissue,conventional radiotherapy and chemotherapy often can not effectively solve the problem.Due to the special location of the first rib and the complexity of the surrounding anatomy,and the malignant tumor requires extensive resection,which greatly increases the difficulty of the operation,and the lack of cutting edge will lead to a high tumor recurrence rate.Therefore,the tumor of the first rib becomes the relative contraindication of rib tumor resection.Although there are many common surgical methods for the first rib resection,such as subaxillary approach,cervical-thoracic approach,supraclavicular approach and so on,each approach has its own advantages and disadvantages.Because this kind of case is rare,there is no exploration and review literature to deeply interpret and systematically summarize the surgical methods of extended resection of malignant tumors in this region,so that the operation can not be standardized.How to choose the surgical approach in this area is a problem to be solved in the surgical treatment of bone and soft tissue tumors.This study will be carried out in three parts:anterior surgical approach(including supraclavicular approach and cervicothoracic approach),axillary surgical approach and posterior surgical approach.Through anatomical practice,the injury and resection ranges of these commonly used surgical approaches are systematically summarized in order to provide some reference for the selection of approaches for clinical treatment of the disease.Part I: Anatomical study on resection of the first rib through anterior approach Methods1.Five formalin fixed cadaveric specimens,including 3 males and 2 females,were used to dissect and separate the important tissues such as subclavian artery and vein,anterior and middle scalenus muscle and brachial plexus nerve.The first rib was dissociated forward and posterior,and the distance of the farthest exposure point of the first rib from the medial edge of the anterior scalenus muscle and the anterior edge of the middle scalenus muscle was measured;2.Longitudinal split sternum was performed by cervical-thoracic approach,and important tissues such as internal thoracic artery,vein,aortic arch,recurrent laryngeal nerve and sympathetic trunk were dissected and measured;3.Combined with the knowledge of statistics,the above data were statistically analyzed,and the exposure range and resection range of the approach were analyzed combined with the location of important tissues.Results1.The distance between the upper edge of the first sternocostal joint and the bilateral subclavian vein is: left: 50.27 ± 3.850(44.02～54.34mm),right: 50.22 ± 3.743(44.18～53.98mm);the distance between the upper edge of the first sternocostal joint and the medial edge of the bilateral anterior scalenus muscle stop is: left: 60.73 ± 3.497(55.14～64.68mm),right: 60.65 ±3.699(54.98～64.38mm).The distances between the upper edge of the first sternocostal joint and the medial edge of the bilateral brachial plexus are65.60 ±3.539(60.22～69.06mm)and 65.71 ±3.731(60.02～69.44mm),respectively,and the distances between the upper edge of the first sternocostal joint and the bilateral subclavian artery are: left: 66.70 ±3.323(61.68～70.14mm),right: 66.333.698(60.96～70.68mm).The distances between the upper edge of the first sternocostal joint and the anterior edge of the bilateral middle scalenus muscle are: left: 76.81 ± 3.565(71.48～80.64mm),right: 50.22 ±3.743(71.72～80.52mm);the distance between the outer edge of the sternum of the first sternal costal joint and the internal sternal artery is: left: 3.63±0.518(2.98～4.36mm),right:3.67±0.487(3.02～4.28mm).The distance between the outer edge of the sternum of the first sternal rib joint and the internal thoracic vein is: left: 6.77±0.304(6.48～7.30mm),right: 6.65± 0.530(5.92～7.50mm).According to the above data and the distance between the sympathetic trunk and the costal head of the T1-T3 segment,there was no statistical difference between the left and right sides.When performing the left approach,attention should be paid to the influence of the aortic arch on the operative area,and attention should be paid to the starting point of the recurrent laryngeal nerve on the right side(which is higher than that on the left side);2.During the supraclavicular approach,the distance between the anterior edge of the middle scalenus muscle stop and the upper edge of the farthest point of the first rib exposure was on the left side: 12.85 ±2.739(7.74～15.86mm),and on the right side: 13.17 ±2.623(8.82～16.28mm).There was no statistical significance in bilateral data analysis,while in the combined cervical-thoracic approach,a total of 16 sides of 8 specimens could expose the full length of the first rib and the posterior first thoracic vertebra.Part 2: Anatomical study on resection of the first rib through subaxillary approach Methods1.Five formalin fixed cadaveric specimens,including 3 males and 2 females,were used to dissect and separate the important tissues such as subclavian artery and vein,anterior and middle scalenus muscle and brachial plexus nerve.The first rib was dissociated forward and posterior,and the distance of the farthest exposure point of the first rib from the medial edge of the anterior scalenus muscle and the anterior edge of the middle scalenus muscle was measured;2.Combined with the knowledge of statistics,the above data were statistically analyzed,and the exposure range and resection range of the approach were analyzed combined with the location of important tissues.ResultsThe distance between the furthest exposure point of the front end of the first rib and the inner edge of the scalenus muscle stop is: left: 39.42 ±3.045(34.30～42.48mm),right: 39.56±3.067(34.42～42.26mm);the distance between the furthest exposure point of the first rib and the leading edge of the middle scalenus stop is: the left: 19.49 ±1.470(17.76～21.28mm),the right: 19.54 ±1.452(17.84～21.32mm).There was no statistical difference between the left and right sides of the above data.Part III: Anatomical study on resection of the first rib through posterior approach Methods1.In the same part as the second part,the posterior approach was performed on both sides of the specimen,the shoulder and the muscular layer of the head and neck involved were dissected and dissected,and the first rib was dissociated forward.The distance of the farthest exposure point of the first rib from the medial edge of the anterior scalenus muscle and the anterior edge of the middle scalenus muscle was measured.2.Combined with the knowledge of statistics,the above data were statistically analyzed to analyze the injury of the muscular layer of the head and neck and the exposure range and resection range of the first rib area under this approach.Results1.The distance between the farthest exposure point of the front end of the first rib and the leading edge of the middle scalenus muscle stop is: left: 17.54 ±1.590(15.24～19.16mm),right: 17.62 ±1.401(15.38～18.66mm).There was no statistical difference between the left and right sides of the data;2.During the implementation of this approach,trapezius muscle and rhomboid muscle can be separated along the muscle fiber,but there is some damage to the inferior head clamp muscle,cervical clip muscle and head hemispinx muscle,and the reconstruction is relatively difficult;Conclusion1.The supraclavicular approach and the subaxillary approach can effectively remove the tumor in the anterior middle of the first rib and the tumor in the middle of the first rib,respectively: the supraclavicular approach is more fully exposed to the first anterior rib and the starting point of the anterior and middle scalenus muscle.and it can operate under direct vision,but the exposure range of the tumor in the middle and posterior part of the first rib is not enough,in order to ensure the sufficient cutting edge,the posterior range of the tumor can not invade the middle scalenus muscle.The injury of the axillary approach is relatively small,but the scope of resection is limited: the posterior can not exceed the middle scalenus muscle stop,and the anterior can not exceed the 2cm of the medial edge of the anterior scalenus muscle;2.The combined cervicothoracic approach has a resection range that can not be achieved by other approaches: it can remove the whole first rib under direct vision,including lesions involving the sternocostal joint,costal joint and even part of the vertebral body,but the injury is large and should be carefully selected;3.Resection of the first rib through the posterior approach can well expose the root structure of the brachial plexus and is more convenient for neurolysis.However,the resection scope of this approach is limited,which is limited to the tumor occurring at the back of the first rib,and this approach has great damage to the head and neck muscle,so it is difficult to reconstruct the muscle after operation. |
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