The limits of surgical intervention on the regional lymphatic apparatus, which are most grounded in oncology, include the removal of groups of lymph nodes of the stage following the tumor metastasis. At the same time, regularities of lymphatic outflow from the lungs and in the mediastinum are taken into account.
Determining the indications for removal of supraclavicular lymph nodes, it is assumed that there are stable extensive connections between them and mediastinal lymphatic collectors, and with the ascending current a significant part of the lymph from the lungs enters this area.
The need to remove supraclavicular lymph nodes on the right or left, as studies performed in our clinic have shown , occurs when metastasis of lung cancer is affected by mediastinal lymph nodes located in the most upper mediastinum. For the right lung, these are the upper paratracheal or preventive, for the left lung, the upper para-archeal or pre-orthocrotic.
Removal of supraclavicular lymph nodes, i.e. supraclavicular
lymphadenectomy, in order to increase the radicalism of the intervention in the regional lung lymphatic apparatus in patients with advanced cancer stages, is performed either immediately after the completion of the extended resection, or – as a separate step, 10– days later. The reason for the division of the operation into two stages is the need to reliably ascertain the extent of the defeat by metastases of mediastinal lymphatic collectors when this is impossible by conducting an urgent histological examination and requires more complex methods.
The supraclavicular cellular tissue space is opened in the position of the patient on the back with his head turned to the right or to the left, respectively, by a cut above the collarbone .
Here are the deep lymphatic collectors of the neck, including the group of lymph nodes of the final stage of drainage of the lymph from the lungs before it enters the venous system.
Allocate and retract the scapular-hyoid muscle. Cross the outer leg of the sternocleidomastoid muscle. Consistently, within the anatomical boundaries and shells that form the supraclavicular space, cellulose tissue with lymph nodes located in it is prepared. At the same time, first they are guided by the internal jugular vein and neurovascular bundle to the place of formation of the shoulder-head vein . Then the preparation is carried out along the wall of the subclavian vein and in the upward direction to the trapezoid muscle. A fiber block thus isolated includes the lymph nodes of several groups: 1) the deep jugular chain (upper, middle, lower); 2) located along the transverse artery of the neck; 3) located along the accessory nerve.
When dissecting the fiber of the supraclavicular area behind, the intersection of the fascial bridges that run between the scalene muscles, one should try not to injure the nerves of the brachial plexus . In the case of the formation of the so-called “venous angle” – the place where the subclavian and deep jugular veins merge, it is usually possible to reach the upper part of the mediastinum. Here, the tissue with lymph nodes is already removed during mediastinal lymphadenectomy with advanced lung resection.
The removal of cellulose from the lymph nodes of the supraclavicular region completes with drainage of this space and layer-by-layer suturing of the wound.