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Robotic First Rib Resection for the Treatment of Thoracic Outlet Syndrome: Redefining Diagnosis and Treatment
M. Meyer, M. Meyer, D. Nguyen, M. Moslemi, B. Rawashdeh, B. Tempesta, K. Maas, R. Poston, F. Gharagozloo.
The University of Arizona Medical Center, Tucson, AZ, USA.

Objective: Thoracic outlet syndrome (TOS) is a highly underdiagnosed disease process that has poor medical and surgical results due to poor understanding of the disease process. Despite the majority of patients being diagnosed with neurogenic symptoms, we hypothesize that the majority of neurogenic symptoms are the result of subclavian artery (SCA) compression and neural ischemia from a tubercle in the medial aspect of an abnormally developed first rib. We present our experience in diagnosing and treating thoracic outlet syndrome with robotic first rib resection.
Methods: In a retrospective analysis of prospectively accrued data, patients referred for thoracic outlet syndrome and underwent robotic first rib resection were evaluated for diagnostic and clinical history, operative data, complications, symptomatic relief, and follow-up diagnostic and interventional imaging if needed. The medial portion of the first rib ipsilateral to clinical symptoms and radiographic findings was resected with robotic assistance.
Results: 48 patients (27 men, 24 women, mean age 35) underwent robotic first rib resection between 2009 and 2014. 21/48 patients presented with neurogenic symptoms. 8 had magnetic resonance arteriography showing compression of the SCA on abduction along with CT 3D reconstruction of the first rib showing a compressive tubercle. 18 has angiography. These patients underwent successful first rib resection with symptomatic improvement on follow up. 27/48 patients presented with arm swelling and were diagnosed with Pagett Schrotterís Disease. All 27 patients had robotic first rib resection and following surgery and had a patent subclavian vein at 3 and 6 month follow up. Mean operative time was 163 +/- 39 minutes. Median hospitalization was 3 days. There were not surgical complications and no mortality.
Conclusion: Neurogenic TOS is mainly caused by compression of the subclavian artery from a congenital tubercle of the first rib. Both dynamic MRA and 3D CT reconstruction of the first rib are essential to accurate diagnosis of thoracic outlet syndrome. Robotic transthoracic first rib resection is feasible and safe, allowing for removal of the offending portion of the first rib, and symptomatic relief of a previously poorly understood disease process.

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