Transthoracic robotic first rib resection: Twelve steps

Management of thoracic outlet syndrome in patients with hemodialysis access

Patients with threatened arteriovenous access are often found to have central venous stenoses at the ipsilateral costoclavicular junction, which may be resistant to endovascular intervention. Stenoses in this location may not resolve unless surgical decompression of thoracic outlet is performed to relieve the extrinsic compression on the subclavian vein. The authors reviewed the management of dialysis patients with central venous lesions at the thoracic outlet, as well as the role of surgical decompression with first-rib resection or claviculectomy for salvage of threatened, ipsilateral dialysis access.

Robotic chest wall resection for primary benign chest wall tumors and locally advanced lung cancer: an institutional case series and national report

Background

Limited data exists for robotic chest wall resection; we report institutional and national experience of robotic chest wall resection.

Methods

In this comparative retrospective case series we describe patients who underwent robotic chest wall resection at our institution and enrich this case series with data from the National Cancer Database (NCDB). We describe our preoperative workup, operative technique, and postoperative care. Outcomes included conversion to open, length of stay, readmissions, and 30- and 90-day mortality. The results are descriptively reported and compared.

Results

We describe 6 patients institutionally and 96 NCDB patients. At our institution 66.7% were males, median age was 70.0 (range, 39-91) years, and 50% were primary chest wall tumors. Median tumor size was 5.25 (range, 2.3-8.3) cm. Outcomes were as follows: no open conversions, median length of stay 3 (range, 1-6) days, no unplanned 30-day readmissions or 90-day mortality. In the NCDB, 55.2% were males with median age of 68.5 (range, 30-89) years. Median tumor size was 3.90 (range, 2.4-6.0) cm. NCDB outcomes were as follows: 18.8% open conversion, median length of stay 7 (range, 5-10) days, 3.1% unplanned 30-day readmission, and 8.3% 90-day mortality. Our institutional case series had 18.0 months median follow-up (range, 6-54 months) with no functional deficits. Median survival in NCDB was 49.6 months.

Conclusions

Robotic chest wall resection is feasible and is performed nationally with acceptable short- and long-term outcomes. Our institutional experience reports our technique, resultant short hospital stay, and excellent functional outcomes.

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.

Venous thoracic outlet syndrome and hemodialysis

Central venous stenotic disease is reported in 7%-40% of patients needing a central venous catheter for dialysis and in 19%-41% of hemodialysis patients who have had a prior central venous catheter. Half of these patients will be asymptomatic. Venous Thoracic Outlet syndrome in hemodialysis (hdTOS) is part of this spectrum of disease. The extrinsic mechanical compression of the subclavian vein at the costoclavicular triangle between the clavicle and 1st rib results in an area of external compression with a predisposition to intrinsic mural disease in the vein. The enhanced flow induced by the presence of a distal arteriovenous access in all patients exacerbates the subclavian vein's response to ongoing extrinsic and intrinsic injury. Repeated endovascular interventions during the maintenance of vascular access accelerates chronic untreatable occlusion of the subclavian vein in the long term. Similar to patients with central venous stenosis, patients with hdTOS can present immediately after access formation with ipsilateral edema or longitudinally with episodes of access dysfunction. hdTOS can be treated in an escalating manner with arteriovenous access flow reduction to <1,500 ml/min, endovascular management, surgical decompression by first rib resection in healthy patients and medial clavicle resection in less healthy patients followed by secondary venous interventions, or finally, a venous bypass. hdTOS represents a complex and evolving therapeutic conundrum for the dialysis community, and additional clinical investigations to establish robust algorithms are required.

A case report of robotic-assisted resection of large fibrous benign tumor of second rib

BACKGROUND

Surgical resection is the most effective curative management of benign rib tumors and carries an excellent prognosis. Due to complex anatomy and narrow field, higher rib resection is technically demanding and requires extensive dissection.

CASE PRESENTATION

We report a case of second rib tumor resection performed transthoracic under Da Vinci robot assistance. A 32-year-old male complained about increasing pain in the left anterior chest wall. After 3D reconstruction of CT, it showed a well-circumscribed fusiform lesion with a multi-component structure. Measured 17 × 6 × 4 cm and extended into the chest cavity to the depth below the pectoralis minor muscle. The patient underwent robotic-assisted trans-thoracic second rib resection. At four weeks of outpatient follow-up, the patient reported no pain and uncomplicated wound healing.

CONCLUSION

This minimally invasive approach offers optimal visualization and tissue manipulation while dramatically decreasing the possibility of collateral damage, hence ensuring fast function recovery. To the best of our knowledge, these kinds of procedures are rarely reported in detail.

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.