Robotic-Assisted Thoracoscopic Resection of the First Rib for Vascular Thoracic Outlet Syndrome: The New Gold Standard of Treatment?

Abstract

In thoracic outlet syndrome (TOS) the narrowing between bony and muscular structures in the region of the thoracic outlet/inlet results in compression of the neurovascular bundle to the upper extremity. Venous compression, resulting in TOS (vTOS) is much more common than a stenosis of the subclavian artery (aTOS) with or without an aneurysm. Traditional open surgical approaches to remove the first rib usually lack good exposure of the entire rib and the neurovascular bundle. Between January 2015 and July 2021, 24 consecutive first rib resections for venous or arterial TOS were performed in 23 patients at our institutions. For our completely portal approach we used two 8mm working ports and one 12/8 mm camera port. Preoperatively, pressurized catheter-based thrombolysis (AngioJet®) was successfully performed in 13 patients with vTOS. Operative time ranged from 71–270 min (median 128.5 min, SD +/− 43.2 min) with no related complications. The chest tube was removed on Day 1 in all patients and the hospital stay after surgery ranged from 1 to 7 days (median 2 days, SD +/− 2.1 days). Stent grafting was performed 5–35 days (mean 14.8 days, SD +/− 11.1) postoperatively in 6 patients. The robotic approach to first rib resection described here allows perfect exposure of the entire rib as well as the neurovascular bundle and is one of the least invasive surgical approaches to date. It helps improve patient outcomes by reducing perioperative morbidity and is a procedure that can be easily adopted by trained robotic thoracic surgeons. In particular, patients with a/vTOS may benefit from careful and meticulous preparation and removal of scar tissue around the vessels.

Thoracic Outlet Syndrome: Single Center Experience on Robotic Assisted First Rib Resection and Literature Review

“…These favorable findings led to more wide use of R-FRR for TOS as this is mirrored by the increasing number of relevant publications over the last 5 years ( 12 , 42 , 43 , 50 – 52 , 62 , 73 – 76 ). The available evidence suggests that the results from Gharagozloo et al were reproducible in other departments leading in reduced incidence of morbidity, zero mortality and significant improvement of symptoms in NTOS and rates of subclavian vein patency ( Table 2 ).…”

“…This is better performed with collaboration among different medical specialties due to the diverse pathology which surrounds TOS. This team is frequently comprised of neurologists, psychiatrists, radiologists, spine, hand, vascular and thoracic surgeons ( 12 , 43 ). For patients with NTOS initial treatment is almost always conservative ( 44 ).…”

“…Similarly to many other aspects of TOS, there is no universally accepted surgical approach for excising the first rib. These can be categorized to open (10,(57)(58)(59)(60)(61), video-assisted (62)(63)(64)(65)(66)(67)(68)(69) and robotic-assisted procedures (12,26,(41)(42)(43)(70)(71)(72)(73)(74)(75)(76)(77). The traditional procedures for the treatment of FRR have been performed via open surgery using posterior thoracotomy (58,59), transaxillary (10), supra-or infra-clavicular approaches (61).…”

Videothoracoscopic First Rib Resection for Neurogenic Thoracic Outlet Syndrome: Results of 13 Patients

“… 7) VATS is accepted as a minimally invasive procedure in thoracic surgery, and it has been called as a beneficial technique over the open approaches in the resection of the first rib. 15) VATS increases the view along the full length of the rib with definite identification of all the neurovacular bundle, and since there is no 6 to 10 cm incision along the throacic wall, it avoids injury to intercostobrachial cutaneous nerve. 8) Therefore, since its first presentation in 1999 by Ohtsuka et al, 5) endoscopic approaches to the first rib resection, including VATS and robotic-assisted thoracic surgery, have been used in cases of all kinds of TOS, and even for Paget-Schroetter Disease.…”

“… 8) Therefore, since its first presentation in 1999 by Ohtsuka et al, 5) endoscopic approaches to the first rib resection, including VATS and robotic-assisted thoracic surgery, have been used in cases of all kinds of TOS, and even for Paget-Schroetter Disease. 6 – 11 , 14 , 15) …”