Abstract Aims To evaluate the outcomes of patients who underwent first rib resection (FRR) for Thoracic Outlet Syndrome (TOS) over a period of 17 years at a single District General Hospital (DGH). Methods Retrospective review of patient notes of individuals treated with FRR from August 2004 to August 2021. Results Sixty patients underwent 65 subclavian approach FRR for indications neurogenic (n=45 (69%)), venous (n=6 (9%)), arterial (n=14 (22%)) TOS. Forty-four female patients underwent FRR (68%) and mean age at time of surgery 34 years (range 27 to 64 years). Five patients (7.6%) had bilateral FRR and seven patients (10.6%) diagnosed with cervical rib. Mean length of time from initial symptoms to diagnosis 24 months (range 2 to 60 months). Forty patients (62%) underwent a failed trial of conservative management with physiotherapy before proceeding to surgical management. Fifty-two patients (80%) reported complete resolution of symptoms at follow up. Complications included wound infections 2(3%), pneumothorax 4(6%), haemothorax 1(1.5%), phrenic nerve complications 3(4.6%) and chronic pain 1(1.5%). One patient with phrenic nerve injury underwent diaphragmatic plication procedure with resultant resolution of symptoms. Mean length of stay 1.6 days. Conclusions This series presents the difficulty of diagnosis and management of TOS with the majority of patients enduring symptoms for a prolonged period of time before referral and definitive management. Phrenic nerve complications are an underreported complication of subclavian approach FRR, it is essential to counsel patients accordingly before proceeding to surgery. FRR for TOS can be performed safely and effectively in a DGH environment.