Position the patient supine. Slightly hyperextend the neck, rotated away from the side of the approach. Use the inflatable cervical pillow for support; a small roll under the shoulder often helps to extend the neck. Location of the thoracic duct and recurrent laryngeal nerve becomes even more important at this level. Approaches from the left for C6 through T2 are directly in the vicinity of the thoracic duct. Identify the thoracic duct when possible and protect it. A large fatty meal the day before surgery will help. If the thoracic duct is inadvertently divided, double ligate both ends well. The approach to the right should definitely identify the recurrent laryngeal nerve and protect it. We recommend the right supraclavicular approach with identification of the recurrent laryngeal nerve.
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