Transclavicular approach for delivery of intrathoracic giant goiter. An alternative surgical option

To remove the immerse portion of a cervical goitre it is necessary to treat preventively the cervical thyroid arteries. In most cases it is afterwards it is easy the blunt finger dissection of the mediastinal bulk following the correct cleavage plane and its dislodging in the cervical area. But in very rare instances, according also to the personal experience, remains some difficulty for the passage of a too bulky and hard mediastinal mass through the rigid limits of the upper thoracic outlet, or the immerse struma is too fragile for pulling it by transfixion threads. Therefore, traditionally arises the opportunity of an additional surgical access, through the breastbone or through the thoracic wall, according to the circumstances. Our experience, completely occasional but extremely positive of two of such cases, induces us to advance a proved alternative surgical proposal. When the difficulty of the removal of the immerse portion of the goitre comes only from the incongruence of the immerse volume and the rigid limits of the upper thoracic outlet, our proposal is that to obtain an amplification of the narrow passage breaking the continuity of the clavicle, by its section beneath the periostium near the breastbone and removing this sternal stump from the joint. The result is that of an widening of the upper thoracic outlet, no more rigid, and making easy the transit of the immerse portion from anterior mediastinum so dislodged in the neck. The rationale of this choice is that all is requested in such cases is only to overcome the obstacle of the incongruence among volume and bulk of the immerse portion and the bone limits fixed from the narrow upper thoracic outlet. Both the traditional sternotomy and the thoracotomy seems disproportional for this purpose, moreover with additional problems during the operation. The true advantage of these classical solutions is in treating under direct vision the anomalous arteries of the mediastinal goitre in cases of ectopic localization. But this is not the case of an immerse cervical goitre. It is therefore essential to note that this proposal applies only to the migrated goitre and not to the ectopic ones. The recovery is extremely simple, and both the aesthetics and the static of the scapular joint are not substantially compromised.