Cadaveric analysis of a safe trail for surgical exposure of the anterior cervico-thoracic junction

BACKGROUND: Surgical access to the cervico-thoracic junction in pediatric tumors presents substantial challenges due to complex anatomy and the proximity of critical neurovascular structures. To improve interdisciplinary training and minimize iatrogenic risks, we optimized a stepwise dissection protocol—referred to as the “Trail of Safety”—using formalin-fixed cadavers. METHODS: Sixteen bilateral cervico-thoracic dissections were conducted on eight formalin-fixed adult cadavers by a team of vascular and pediatric surgeons. A structured protocol involving supraclavicular incision, median sternotomy, and anterolateral thoracotomy was employed to sequentially expose neurovascular structures, including the common carotid, subclavian and vertebral arteries, as well as the vagus, phrenic and recurrent laryngeal nerves. Each anatomical landmark was scored for difficulty of exposure using a four-point scale. RESULTS: All targeted neurovascular structures were successfully exposed. Supraclavicular and midline approaches provided reliable access to anterior mediastinal structures without necessitating lateral thoracotomy. The vertebral artery and recurrent laryngeal nerves were consistently the most challenging to expose. The rigid lungs of formalin-fixed cadavers impeded visualization of posterior mediastinal structures, which became accessible only after lung removal. Bidirectional dissection (from both cervical and thoracic fields) improved safety and exposure, particularly for nerves obscured beneath the clavicle. CONCLUSIONS: The formalin-fixed cadaveric model proved effective for iterative interdisciplinary training and for refining a reproducible “Trail of Safety” protocol. This approach enhances anatomical familiarity and may contribute to safer surgical strategies for rare but complex pediatric cervico-thoracic pathologies.