Transmanubrial approach (Spaggiari-Grunewald), is normally used for the anterior apical chest tumors. Through a manubrial L-shaped transection and first costal cartilage resection, this approach allows the retraction of an osteomuscular flap, sparing the clavicle and all its muscular insertions and affords excellent access to the subclavicular region.
This patient was affected by giant antero-posterior mediastinal goiter; she was already undergone to total thyroidectomy for goiter in 2014 but at the time giant cervico-mediastinal goiter was not resected.
The goiter developed behind the innominate artery and right carotid and it straddled the artery and jugular-innominate vein; then it descended into the posterior mediastinum, close to the esophagus and tracheal carina, stretching azygous vein.
Apical portion of the goiter was dissected via transmanubrial approach, because of impossibility of dissection via cervicotomy, due to tenacious adhesions of the first intervention; then it was dissected from esophagus, trachea and mediastinal structuers, and resected via axillary thoracotomy.