We describe a modification of this procedure that includes an initial thoractomy for intraoperative staging and a median sternotomy incision that avoids individual division of the anterior ribs and clavicle. The skin incision is fashioned to widely encompass the tumor and biopsy site. The incision must allow for an exploratory thoracotomy and an assessment of tumor spread along the thoracic inlet.
Skin flaps are initially fashioned to provide coverage for the resultant defect.
After the chest is entered through the fifth or sixth intercostal space, the pulmonary parenchyma, pleural surface of the chest wall, and the hilum of the lung are evaluated for metastatic tumor spread. If the tumor seems operable, the back muscles are divided, the intercostal bundles are secured posteriorly, and the ribs e divided. The anterior portion of the specimen may be detached by performing a median sternotomy and resecting one half of the sternum along with the attached ribs. Following division of the strap muscles, the innominate vein, subclavian artery, and brachial plexus nerve roots are dissected free and divided. Division of the anterior, medial, and posterior scalene Muscles allows removal of the specimen.