Safety of robotic first rib resection for thoracic outlet syndrome

Trans-axillary thoracic outlet decompression

Thoracic outlet syndrome (TOS) is a group of conditions thought to be caused by the compression of neurovascular structures going to the upper extremity. TOS is a difficult disease to diagnose, and surgical treatment remains challenging. Many different surgical techniques for the treatment of TOS have been described in the literature and many reasonable to good outcomes have been reported, which makes it hard for surgeons to determine which techniques should be used. Our aim was to describe the rationale, techniques, and outcomes associated with the surgical treatment of TOS. Most patients in our center are treated primarily through a trans-axillary approach. We will elaborate on the technical details of performing trans-axillary thoracic outlet decompression. The essential steps during surgery are illustrated with videos. We focused on the idea behind performing a trans-axillary thoracic outlet decompression in primary cases. Institutional data on the outcomes of this surgical approach are described briefly.

Video-assisted thoracic surgery and robotic-assisted first-rib excision and thoracic outlet syndrome decompression

Multiple surgical approaches have been used in the management of thoracic outlet syndrome. These approaches have traditionally been "open" approaches and have been associated with the inherent morbidities of an open approach, including a risk of injury to the neurovascular structures due to traction and trauma while resecting the first rib. In addition, there has been concern that recurrence of symptoms may be related to incomplete resection of the rib with conventional open techniques. With the advent of minimally invasive thoracic surgery, surgeons began to explore first-rib resection via a thoracoscopic approach. Unfortunately, the existing video-assisted thoracic surgery technology and equipment was not well suited to working in the apex of the chest. With the introduction and subsequent progress in robotic surgery and instrumentation, this dissection can be performed with all the advantages of robotics, but also with minimal traction and trauma to the neurovascular structures, and incorporates almost complete resection of the rib with minimal residual stump. Robotics has developed as a reliable, safe, and less invasive approach to first-rib resection, yielding excellent results while limiting the morbidity of the procedure.

Robotic First Rib Resection in Thoracic Outlet Syndrome: A Systematic Review of Current Literature

Thoracic outlet syndrome (TOS) involves the compression of neurovascular structures in the thoracic outlet. TOS subtypes, including neurogenic (nTOS), venous (vTOS), and arterial (aTOS) are characterized by distinct clinical presentations and diagnostic considerations. This review explores the incidence, diagnostic challenges, and management of TOS with a focus on the innovative approach of Robotic First Rib Resection (R-FRR). Traditional management of TOS includes conservative measures and surgical interventions, with various open surgical approaches carrying risks of complications. R-FRR, a minimally invasive technique, offers advantages such as improved exposure, reduced injury risk to neurovascular structures, and shorter hospital stays. A comprehensive literature review was conducted to assess the outcomes of R-FRR for TOS. Data from 12 selected studies involving 397 patients with nTOS, vTOS, and aTOS were reviewed. The results indicate that R-FRR is associated with favorable intraoperative outcomes including minimal blood loss and low conversion rates to traditional approaches. Postoperatively, patients experienced decreased pain, improved function, and low complication rates. These findings support R-FRR as a safe and effective option for medically refractory TOS.

Technical Aspects of Robotic First Rib Resection

Robot-assisted thoracoscopic surgery for the treatment of thoracic outlet syndrome is a novel approach that continues to increase in popularity due to advantages compared with traditional open first rib resection. Following publication of the Society of Vascular Surgeons expert statement in 2016, the diagnosis and management of thoracic outlet syndrome is favorably evolving. Technical mastery of the operation requires precise knowledge of anatomy, comfort with robotic surgical platforms, and understanding of the disease.

Transthoracic Robotic First and Cervical Rib Resection for Thoracic Outlet Syndrome

INTRODUCTION

Neurogenic thoracic outlet syndrome (TOS) is a musculoskeletal condition in which the brachial plexus is dynamically compressed within the scalene triangle, an anatomic space bordered by the anterior and middle scalene muscles and the first rib. In some cases, an offending cervical rib is present. Traditional surgical approaches to first rib resection and scalenectomy are limited by exposure, require retraction of neurovascular structures, and result in morbidity.

METHODS

We describe a novel transthoracic robotic approach to first/cervical rib resection that overcomes these limitations, and we review its early clinical outcomes.

RESULTS

Robotic first rib resection (FRR) is crystallized into 12 distinct steps, each with detailed video commentary, and nuances specific to neurogenic and venous TOS cases are provided. Published data supports decreased surgical morbidity of robotic FRR compared with open cases.

CONCLUSIONS

Robotic FRR offers advantages over traditional operative approaches including improved exposure and elimination of retraction of neurovascular structures, which result in improved safety.

Thoracic Outlet Syndrome: Single Center Experience on Robotic Assisted First Rib Resection and Literature Review

Background

Thoracic outlet syndrome (TOS) is a pathological condition caused by a narrowing between the clavicle and first rib leading to a compression of the neurovascular bundle to the upper extremity. The incidence of TOS is probably nowadays underestimated because the diagnosis could be very challenging without a thorough clinical examination along with appropriate clinical testing. Beside traditional supra-, infraclavicular or transaxillary approaches, the robotic assisted first rib resection has been gaining importance in the last few years.

Methods

We conducted a retrospective cohort analysis of all patients who underwent robotic assisted first rib resection due to TOS at Lucerne Cantonal Hospital and then we performed a narrative review of the English literature using PubMed, Cochrane Database of Systematic Reviews and Scopus.

Results

Between June 2020 and November 2021, eleven robotic assisted first rib resections were performed due to TOS at Lucerne Cantonal Hospital. Median length of stay was 2 days (Standard Deviation: +/– 0.67 days). Median surgery time was 180 min (Standard Deviation: +/– 36.5). No intra-operative complications were reported.

Conclusions

Robotic assisted first rib resection could represent a safe and feasible option in expert hands for the treatment of thoracic outlet syndrome.

Digital Biomarkers for the Objective Assessment of Disability in Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (nTOS) is a musculoskeletal disorder in which compression of the brachial plexus between the scalene muscles of the neck and the first rib results in disabling upper extremity pain and paresthesia. Currently there are no objective metrics for assessing the disability of nTOS or for monitoring response to its therapy. We aimed to develop digital biomarkers of upper extremity motor capacity that could objectively measure the disability of nTOS using an upper arm inertial sensor and a 20-s upper extremity task that provokes nTOS symptoms. We found that digital biomarkers of slowness, power, and rigidity statistically differentiated the affected extremities of patients with nTOS from their contralateral extremities (n = 16) and from the extremities of healthy controls (n = 13); speed and power had the highest effect sizes. Digital biomarkers representing slowness, power, and rigidity correlated with patient-reported outcomes collected with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the visual analog scale of pain (VAS); speed had the highest correlation. Digital biomarkers of exhaustion correlated with failure of physical therapy in treating nTOS; and digital biomarkers of slowness, power, and exhaustion correlated with favorable response to nTOS surgery. In conclusion, sensor-derived digital biomarkers can objectively assess the impairment of motor capacity resultant from nTOS, and correlate with patient-reported symptoms and response to therapy.

Completely thoracoscopic 3-port robotic first rib resection for thoracic outlet syndrome

BACKGROUND

In thoracic outlet syndrome (TOS), the constriction between bony and muscular structures leads to compression of the neurovascular bundle to the upper extremity. Traditional surgical techniques using supra-, infraclavicular or transaxillary approaches to remove the first rib do not usually allow good exposure of the entire rib and neurovascular bundle. We have therefore developed a robotic approach to overcome these limitations.

METHODS

Between January 2015 and November 2020, 38 consecutive first rib resections for neurogenic, venous or arterial TOS were performed in 34 patients at our institutions. For our completely portal approach, we used two 8mm working ports and one 12mm camera port.

RESULTS

The surgery time was between 71 to 270 min (median 133 min, SD+/-44.7 min) without any complications. Chest tube was removed on postoperative day 1 in all patients and the hospital stay after surgery ranged from 1 to 7 days (median 2 days, SD+/-2.1 days). No relevant intra- or postoperative complications were observed and complete or subtotal resolution of symptoms was seen in all patients.

CONCLUSIONS

The robotic technique described here for first rib resection has proven to be a safe and effective approach. The unsurpassed exposure of the entire first rib and possibility for a robotic-assisted meticulous surgical dissection has prevented both intra- and postoperative complications. This makes this technique unique as the safest and most minimally invasive approach to date. It helps improving patient outcomes by reducing perioperative morbidity with an easily adoptable procedure.

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

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.

Improvement of disability in neurogenic thoracic outlet syndrome by robotic first rib resection

BACKGROUND

Robotic transthoracic first rib resection (R-FRR) has advantages over traditional approaches however its impact on post-operative nTOS outcomes is unknown. Our primary objective was to determine improvement of patient-reported outcome measures (PROMs) of pain and disability following R-FRR in neurogenic thoracic outlet syndrome (nTOS). Our secondary objective was to compare improvement of patient-reported pain between R-FRR and supraclavicular FRR (SC-FRR) in nTOS.

METHODS

We queried a prospectively-maintained, single surgeon, single institution database for nTOS patients undergoing R-FRR or SC-FRR with available pre-operative and post-operative PROMs. PROMs included the Disability of the Arm, Hand, and Shoulder (DASH) questionnaire and Visual Analog Scale (VAS) for pain.

RESULTS

Cohort 1 included 37 patients undergoing 40 R-FRRs and was comprised of 32 females, aged 36 years on average. Pre-operative VAS and DASH (6.0 and 64.2, respectively) improved significantly at the first (2.8 and 35.0, P<0.001 for both) and second post-operative visits (1.4 and 30.2, P<0.01 for both) which occurred at 2.6 and 15.3 weeks, respectively. Cohort 2 included 57 R-FRR performed in 53 patients, and 35 SC-FRRs performed in 34 patients. R-FRR and SC-FRR groups did not significantly differ in sex, age, hand dominance, TOS laterality, or pre-operative VAS. At first post-operative visit (2.4 weeks), R-FRR was associated with lower VAS scores (P=0.023) and greater VAS improvement than SC-FRR (53% and 27% decrease, respectively, P=0.008).

CONCLUSIONS

R-FRR results in significant improvement in disability and pain in nTOS and may have a greater impact on patient-reported pain than SC-FRR in the early postoperative period.