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BILATERAL INFERIOR DEEP CERVICAL (SCALENE FAT PAD) AND PARATRACHEAL LYMPH NODE BIOPSIES
BILATERAL INFERIOR DEEP CERVICAL (SCALENE FAT P A D ) A N D PARATRACHEAL LYMPH N O D E BIOPSIES Alfred H. F. Lui, M.D.*
Wayne W. Glas, M.D.*
and
Eugene H. Lansing, M.D., Eloise, Mich.
B
of tins inferior deep cervical lymph nodes, as advocated by Daniels 1 in 1949, has proved to be a worthwhile procedure in the diagnosis of intrathoracic diseases. This operation is usually performed on one side and consists of a partial excision of the scalene fat pad with its associated inferior deep cervical lymph nodes. Steele and Marable 2 have described an excellent method of removing the paratracheal and inferior deep cervical lymph nodes on one side through an incision along the anterior border of the sternocleidomastoideus muscle. We have extended this procedure and at present it is our policy to perform bilateral inferior deep cervical and paratracheal lymph node biopsies through a single incision. IOPSY
TECHNIQIK
The patient is placed in the supine position and the neck is extended by placing a folded sheet beneath the shoulders. With the surgeon on the left side, a transverse incision is made about 3 cm. above the suprasternal notch (Fig. 1, 1). The ends of this incision should be located slightly lateral to the anterior border of each sternocleidomastoideus muscle. The incision is extended through the platysma muscle and the upper and lower flaps are undermined in the subplatysmal plane. The investing layer of the deep cervical fascia is incised verti cally in the midline avoiding the anterior jugular veins and the jugular venous arch (Fig. 1, 2). The sternohyoid and stemothyroid muscles are retracted laterally to expose the pretracheal layer of the deep cervical fascia. This fascia is incised vertically in the midline avoiding the underlying inferior thyroid veins and exposing the trachea in the superior mediastinum (Fig. 1, 3). Lymph nodes with their accompanying adipose tissue from the right and left para tracheal areas are dissected free and removed. The right scalene fat pad with its associated inferior deep cervical lymph nodes is partly excised by removing its medial and inferior portions which are adjacent to the internal jugular and subclavian veins. This is accomplished by retracting the sternocleidomastoideus muscle anteriorly and laterally after the From the Department of Surgery, Wayne County General Hospital, Eloise, Mich. Received for publication Oct. 12, 1959. ♦Instructor in Surgery, University of Michigan School of Medicine.
90
Vol. 40, No. 1 July, 1960
L Y M P H NODE B I O P S I E S
91
investing layer of the deep cervical fascia along its anterior border has been incised for a short distance. The sternohyoid and sternothyroid muscles are retracted medially. The pretracheal fascia, forming the anterior portion of the carotid sheath, is incised longitudinally exposing the internal jugular vein which is retracted medially (Fig. 1, 4). The scalene fat pad is palpated anterior to the scalenus anticus muscle in the subclavian triangle. The scalene fat pad is dissected off the prevertebral fascia covering the scalenus anticus muscle thus
Svbctovmn
vwfft·
JU u F i e · ,1·^.1' Transverse skin incision for bilateral inferior deep cervical and paratracheal lymph node biopsies. 2, Vertical midline incision through the investing layer of the deep cervical fascia. S, Vertical midline incision through the pretracheal fascia exposing the trachea. 1,, Exposure of the right scalene fat pad obtained by retracting the sternocleidomastoideus muscle anteriorly and laterally, and the internal jugular vein medially. 5, Exposure of the right scalenus anticus muscle with its overlying phrenic nerve after the scalene fat pad has been removed.
exposing the phrenic nerve (Pig. 1, 5). It is also dissected off the proximal por tions of the internal jugular and subclavian veins. The inferiomedial portion of the scalene fat pad with its associated inferior deep cervical lymph nodes is then excised. The surgeon now moves to the right side of the table and the left scalene fat pad is removed in a similar manner. Particular care is exercised to prevent injury to the thoracic duct. Lymph nodes from the four different areas of bi opsy are placed in separate specimen jars. After complete hemostasis is obtained
92
L U I , GLAS, LANSING
J. Thoracic and Cardiovas. Surg.
in all four areas of biopsy, the investing layer of the deep cervical fascia is ap proximated in the midline by interrupted sutures. The skin flaps, including the platysma muscle, are approximated with one layer of interrupted sutures placed so that the knots are buried in the subplatysmal plane. The superficial portion of these sutures is located in a subcuticular position and no skin sutures are used. A pressure dressing completes the procedure. SUMMARY
A method of biopsy in which both the right and left inferior deep cervical and paratracheal lymph nodes are removed through a single incision is de scribed. This eliminates a second biopsy through a separate incision on the op posite side. We believe that a greater number of positive diagnoses will be made when both right and left inferior deep cervical and paratracheal lymph nodes are biopsied routinely. REFERENCES
1. Daniels, A. C : Method of Biopsy Useful in Diagnosing Certain Intrathoracic Diseases, Dis. Chest 16: 360-366, 1949. 2. Steele, J . D., and Marable, S. A. : Cervical Mediastinotomy for Biopsy, J . THORACIC SDKG. 37: 621-624, 1959.
Wayne W. Glas, M.D.*
and
Eugene H. Lansing, M.D., Eloise, Mich.
B
of tins inferior deep cervical lymph nodes, as advocated by Daniels 1 in 1949, has proved to be a worthwhile procedure in the diagnosis of intrathoracic diseases. This operation is usually performed on one side and consists of a partial excision of the scalene fat pad with its associated inferior deep cervical lymph nodes. Steele and Marable 2 have described an excellent method of removing the paratracheal and inferior deep cervical lymph nodes on one side through an incision along the anterior border of the sternocleidomastoideus muscle. We have extended this procedure and at present it is our policy to perform bilateral inferior deep cervical and paratracheal lymph node biopsies through a single incision. IOPSY
TECHNIQIK
The patient is placed in the supine position and the neck is extended by placing a folded sheet beneath the shoulders. With the surgeon on the left side, a transverse incision is made about 3 cm. above the suprasternal notch (Fig. 1, 1). The ends of this incision should be located slightly lateral to the anterior border of each sternocleidomastoideus muscle. The incision is extended through the platysma muscle and the upper and lower flaps are undermined in the subplatysmal plane. The investing layer of the deep cervical fascia is incised verti cally in the midline avoiding the anterior jugular veins and the jugular venous arch (Fig. 1, 2). The sternohyoid and stemothyroid muscles are retracted laterally to expose the pretracheal layer of the deep cervical fascia. This fascia is incised vertically in the midline avoiding the underlying inferior thyroid veins and exposing the trachea in the superior mediastinum (Fig. 1, 3). Lymph nodes with their accompanying adipose tissue from the right and left para tracheal areas are dissected free and removed. The right scalene fat pad with its associated inferior deep cervical lymph nodes is partly excised by removing its medial and inferior portions which are adjacent to the internal jugular and subclavian veins. This is accomplished by retracting the sternocleidomastoideus muscle anteriorly and laterally after the From the Department of Surgery, Wayne County General Hospital, Eloise, Mich. Received for publication Oct. 12, 1959. ♦Instructor in Surgery, University of Michigan School of Medicine.
90
Vol. 40, No. 1 July, 1960
L Y M P H NODE B I O P S I E S
91
investing layer of the deep cervical fascia along its anterior border has been incised for a short distance. The sternohyoid and sternothyroid muscles are retracted medially. The pretracheal fascia, forming the anterior portion of the carotid sheath, is incised longitudinally exposing the internal jugular vein which is retracted medially (Fig. 1, 4). The scalene fat pad is palpated anterior to the scalenus anticus muscle in the subclavian triangle. The scalene fat pad is dissected off the prevertebral fascia covering the scalenus anticus muscle thus
Svbctovmn
vwfft·
JU u F i e · ,1·^.1' Transverse skin incision for bilateral inferior deep cervical and paratracheal lymph node biopsies. 2, Vertical midline incision through the investing layer of the deep cervical fascia. S, Vertical midline incision through the pretracheal fascia exposing the trachea. 1,, Exposure of the right scalene fat pad obtained by retracting the sternocleidomastoideus muscle anteriorly and laterally, and the internal jugular vein medially. 5, Exposure of the right scalenus anticus muscle with its overlying phrenic nerve after the scalene fat pad has been removed.
exposing the phrenic nerve (Pig. 1, 5). It is also dissected off the proximal por tions of the internal jugular and subclavian veins. The inferiomedial portion of the scalene fat pad with its associated inferior deep cervical lymph nodes is then excised. The surgeon now moves to the right side of the table and the left scalene fat pad is removed in a similar manner. Particular care is exercised to prevent injury to the thoracic duct. Lymph nodes from the four different areas of bi opsy are placed in separate specimen jars. After complete hemostasis is obtained
92
L U I , GLAS, LANSING
J. Thoracic and Cardiovas. Surg.
in all four areas of biopsy, the investing layer of the deep cervical fascia is ap proximated in the midline by interrupted sutures. The skin flaps, including the platysma muscle, are approximated with one layer of interrupted sutures placed so that the knots are buried in the subplatysmal plane. The superficial portion of these sutures is located in a subcuticular position and no skin sutures are used. A pressure dressing completes the procedure. SUMMARY
A method of biopsy in which both the right and left inferior deep cervical and paratracheal lymph nodes are removed through a single incision is de scribed. This eliminates a second biopsy through a separate incision on the op posite side. We believe that a greater number of positive diagnoses will be made when both right and left inferior deep cervical and paratracheal lymph nodes are biopsied routinely. REFERENCES
1. Daniels, A. C : Method of Biopsy Useful in Diagnosing Certain Intrathoracic Diseases, Dis. Chest 16: 360-366, 1949. 2. Steele, J . D., and Marable, S. A. : Cervical Mediastinotomy for Biopsy, J . THORACIC SDKG. 37: 621-624, 1959.