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Robotic Thoracoscopic First Rib Resection for Paget-Schroetter Disease: A Case Series of the Early Experience
Mark Meyer, Barbara Tempesta, Marc Margolis, Srini Tummala, Richard Neville, Farid Gharagozloo.
Washington Institute of Thoracic and Cardiovascular Surgery at The GW University Medical Center, Washington, DC, USA.
BACKGROUND: First rib resection is the most effective treatment for Paget-Schroetter Disease. Previously described techniques have been associated with incomplete rib resection and neurovascular complications. We report a minimally-invasive robotic transthoracic approach for resection of the first rib.
METHODS: Over a 24 month period, 14 robotic first rib resections were performed in 9 patients. Pre-operative assessment included physical exam and bilateral venous angiography. On a thoracoscopic platform using 3, 2cm incisions, the robot was used to dissect the first rib and divide the scalene muscles. Success of the first rib resection was assessed by postoperative venous angiography.
RESULTS: There were 14 total procedures. 5 patients had staged bilateral resections. There were 6 men and 3 women. Mean age was 35.7 +/- 8.1 years. All patients had an occluded subclavian vein, were diagnosed with Paget-Schroetter Disease, and underwent thrombolysis and anticoagulation prior to referral for first rib resection. Operative time was 180.5 +/- 25.7 minutes. There were no complications and no mortality. All patients (100%) were found to have a bony tuberosity at the site of the subclavian vein groove that compressed the subclavian vein with resultant thrombosis. Patients with a normal and patent subclavian vein on the postoperative venogram were anticoagulated with warfarin for 3 months. Patients with a stenotic or occluded subclavian vein underwent angioplasty and stent placement. These patients received antiplatelet therapy for 3 months. On a venogram three months after first rib resection, the vein was open in all patients (100%). At a median clinical follow-up of 12 months, all patients had normal arm function, no swelling, and had returned to their normal daily activities.
CONCLUSION: Robotic transthoracic first rib resection is feasible. This technique allows for a minimally-invasive en bloc resection of the offending portion of the first rib, while minimizing neurovascular complications. While greater experience is necessary, this new approach to first rib resection may allow for a more aggressive treatment to patients with Paget-Schroetter Disease.
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