An incision is made parallel to the clavicle approximately 1–1½ in. below this level. The incision should extend from the lateral border of the sternum towards the deltopectoral groove (Fig. 19.1). After entering the subcutaneous tissue, the fibers of the pectoralis major are encountered. Usually a groove or natural separation of the fibers of the pectoralis major muscle exists, one group going to the clavicle and the other group towards the sternum. The incision is continued in that groove by splitting the muscle fibers bluntly without cutting or dividing them. This allows the surgeon to reach the retropectoral space exactly on top of the first rib. The adipose tissue is dissected and reflected laterally in order to expose the rib cage (Fig. 19.2). In severe cases of venous obstruction, it is necessary to inspect for the presence of dilated lymphatic channels which may be seen reaching the subclavian vein. These must be divided and tied securely in order to prevent post operative lymphatic drainage.
KeywordsCage Heparin Assure Warfarin Dextran