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

Adrian Zehnder,Ralph A Schmid,Jon Lutz,Hans Gelpke,Patrick Dorn,Peter Kestenholz,Gregor J Kocher,Fabrizio Minervini

doi:10.3390/jcm10173952

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.

Highlights

Thoracic outlet syndrome (TOS) involves three different structures that may contribute to the symptomatology to varying degrees
Since we used thrombolysis via pressure catheter in the preoperative phase of vTOS, this procedure led to acute renal failure in one case, which resulted in a delay of the surgery by four weeks until renal function was fully restored
In patients with venous TOS and recent thrombosis, the therapeutic treatment with oral or subcutaneous anticoagulants was initiated on the first postoperative day and routinely continued up to 3 months postoperatively, depending on whether impaired venous return or residual thrombus was detected on the postoperative venous duplex scan [3,4]

Summary

Introduction

Thoracic outlet syndrome (TOS) involves three different structures that may contribute to the symptomatology to varying degrees. The subclavian vein lies most anteriorly and is bounded by the subclavius muscle anteriorly and by the anterior scalene muscle posteriorly. The anterior and middle scalene muscles encompass the subclavian artery and the brachial plexus. They insert on the postero-lateral aspect of the first rib. Some patients suffer from congenital bands and fibrous slips interdigitating with neurovascular structures. This fact elucidates why mechanical compression is the principal cause of symptoms [1].

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Conclusion