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First Rib Resection For Thoracic Outlet Syndrome - The Robotic Approach
Adrian Zehnder1, Gregor J. Kocher2, Juerg Schmidli2, Ralph A. Schmid2
1Cantonal Hospital Winterthur, Winterthur, Switzerland, 2University Hospital Bern, Bern, Switzerland
Background: Thoracic outlet syndrome (TOS) designates the symptomatic compression of the neurovascular structures as they traverse the thoracic outlet. In case of a triggerable vascular insufficiency or progressive neurologic dysfunction despite conservative treatment, surgical decompression of the space between the clavicle and the first rib is indicated. Herein we present our experience in 22 cases with this robotic assisted minimally invasive approach. Methods: Between January 2015 and May 2019, 22 consecutive first rib resections were performed in 19 patients (left: n=7; right: n=15) at our institutions. The etiologies were: venous (vTOS, n=10), arterial (aTOS, n=2), neurogenic (nTOS, n=3) and nonspecific (nsTOS, n=7). The patients with vTOS have been referred by vascular surgeons or angiologists with a history of recurrent thrombosis in the subclavian vein or documented stenosis, mostly after interventional thrombolysis. One patient has been referred with stent in situ. They were offered surgery within 2-4 weeks after thrombolysis. The first rib was removed using a 3 access ports for the robotic camera and two working channels with an additional axillary incision in the first 7 cases for extraction of the rib. Postoperatively, anticoagulation was maintained for three to six months. Results: Operative time ranged from 88-150 min (median 116.5 min). Mean postoperative hospital stay was two days (range 1 - 4 ). Postoperative courses were uneventful in all patients and all showed partial (n=8) or complete relief (n=11) of their symptoms 3 months after surgery.In vTOS, four patients needed stent placement postoperatively due to scarring and stenosis. In the other patients one re-thrombosis occurred due to low-flow which resolved under anticoagulation. One patient presented with transient dysesthesia of the medial upper arm. In the follow-up examination after one year all veins showed full patency. Conclusion A well developed minimally invasive robotic assisted technique for first rib resection in thoracic outlet syndrome is presented. Excellent postoperative results were achieved and no postoperative complications were noted. The success of this treatment, however, needs an interdisciplinary approach with angiologists and vascular surgeons.
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