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.

Management of Paget-Schroetter Syndrome: a Systematic Review and Meta-Analysis

OBJECTIVE

Currently, there is no consensus on the optimal management of Paget-Schroetter syndrome (PSS). The objective was to summarise the current evidence for management of PSS with explicit attention to the clinical outcomes of different management strategies.

DATA SOURCES

The Cochrane, PubMed, and Embase databases were searched for reports published between January 1990 and December 2021.

REVIEW METHODS

A systematic review and meta-analysis was conducted following PRISMA 2020 guidelines. The primary endpoint was the proportion of symptom free patients at last follow up. Secondary outcomes were success of initial treatment, recurrence of thrombosis or persistent occlusion, and patency at last follow up. Meta-analyses of the primary endpoint were performed for non-comparative and comparative reports. The quality of evidence was assessed using the GRADE approach.

RESULTS

Sixty reports were included (2 653 patients), with overall moderate quality. The proportions of symptom free patients in non-comparative analysis were: anticoagulation (AC), 0.54; catheter directed thrombolysis (CDT) + AC, 0.71; AC + first rib resection (FRR), 0.80; and CDT + FRR, 0.96. Pooled analysis of comparative reports confirmed the superiority of CDT + FRR compared with AC (OR 13.89, 95% CI 1.08 - 179.04; p = .040, I2 87%, very low certainty of evidence), AC + FRR (OR 2.29, 95% CI 1.21 - 4.35; p = .010, I2 0%, very low certainty of evidence), and CDT + AC (OR 8.44, 95% CI 1.12 - 59.53; p = .030, I2 63%, very low certainty of evidence). Secondary endpoints were in favour of CDT + FRR.

CONCLUSION

Non-operative management of PSS with AC alone results in persistent symptoms in 46% of patients, while 96% of patients managed with CDT + FFR were symptom free at end of follow up. Superiority of CDT + FRR compared with AC, CDT + AC, and AC + FRR was confirmed by meta-analysis. The overall quality of included reports was moderate, and the level of certainty was very low.

Congenital, Acquired, and Trauma-Related Risk Factors for Thoracic Outlet Syndrome-Review of the Literature

Thoracic outlet syndrome is a group of disorders that affect the upper extremity and neck, resulting in compression of the neurovascular bundle that exits the thoracic outlet. Depending on the type of compressed structure, the arterial, venous, and neurogenic forms of TOS are distinguished. In some populations, e.g., in certain groups of athletes, some sources report incidence rates as high as about 80 cases per 1000 people, while in the general population, it is equal to 2-4 per 1000. Although the pathogenesis of this condition appears relatively simple, there are a very large number of overlapping risk factors that drive such a high incidence in certain risk groups. Undoubtedly, a thorough knowledge of them and their etiology is essential to estimate the risk of TOS or make a quick and accurate diagnosis.

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 (TROTS) registry: A study protocol for the primary upper extremity deep venous thrombosis section

INTRODUCTION

There is a lack of comprehensive and uniform data on primary upper extremity deep venous thrombosis (pUEDVT). pUEDVT includes venous thoracic outlet syndrome related upper extremity deep venous thrombosis (UEDVT) and idiopathic UEDVT. Research on these conditions has been hampered by their rarity, lack of uniform diagnostic criteria, and heterogeneity in therapeutic strategies. To improve current research data collection using input of all various pUEDVT treating medical specialists, we initiated the ThoRacic OuTlet Syndrome (TROTS) registry. The aim of the TROTS registry is to a) collect extensive data on all pUEDVT patients through a predefined protocol, b) give insight in the long term outcome using patient reported outcome measures, c) create guidance in the diagnostic and clinical management of these conditions, and thereby d) help provide content for future research.

METHODS AND ANALYSIS

The TROTS registry was designed as an international prospective longitudinal observational registry for data collection on pUEDVT patients. All pUEDVT patients, regardless of treatment received, can be included in the registry after informed consent is obtained. All relevant data regarding the initial presentation, diagnostics, treatment, and follow-up will be collected prospectively in an electronic case report form. In addition, a survey containing general questions, a Health-related Quality of Life questionnaire (EQ-5D-5L), and Functional Disability questionnaire (Quick-DASH) will be sent periodically (at the time of inclusion, one and two years after inclusion, and every five years after inclusion) to the participant. The registry protocol was approved by the Medical Ethical Review Board and registered in the Netherlands Trial Register under Trial-ID NL9680. The data generated by the registry will be used for future research on pUEDVT and published in peer reviewed journals.

CONCLUSION

TROTS registry data will be used to further establish the optimal management of pUEDVT and lay the foundation for future research and guidelines.

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.

Robotic first rib resection for thoracic outlet syndrome

Robotic resection of the “offending portion” of the first rib in patients with thoracic outlet syndrome (TOS) has been associated with excellent results. The results have been due to (I) a better understanding of the pathogenesis of TOS, and (II) the technical advantages of the robotic platform. This article outlines the recent understanding of the pathogenesis of TOS, and reports the experience with robotic resection of the “offending portion” of the first rib in patients with neurogenic and venous TOS. Patients diagnosed with TOS underwent robotic first rib resection. Diagnosis of TOS was made by magnetic resonance angiography (MRA). On a thoracoscopic platform, the robot was used to dissect the “offending portion” of the first rib. A total of 162 patients underwent robotic first rib resection. Eighty-three patients underwent robotic first rib resection for Paget-Schroetter syndrome (PSS) (venous TOS). There were 49 men and 34 women. Mean age was 24±8.5 years. Operative time was 127.6±20.8 minutes. Median hospitalization was 4 days. There were no surgical complications, neurovascular injuries, or mortality. At a median follow-up of 24 months, all patients had an open subclavian vein (SV) for a patency rate of 100%. Seventy-nine patients underwent robotic first rib resection for neurologic symptoms of the upper extremity (neurogenic TOS). There were 29 men and 50 women. Mean age was 34±9.5 years. Operative time was 87.6±10.8 minutes. There were no intraoperative complications. Hospital stay ranged from 2–4 days with a median hospitalization of 3 days. There were no neurovascular complications. There was no mortality. In patients with neurogenic symptoms, Quick DASH Scores (mean ± SEM) decreased from 60.3±2.1 preoperatively to 5±2.3 in the immediate postoperative period, and 3.5±1.1 at 6 months (P<0.0001). Immediate relief of symptoms was seen in 71/79 (91%) patients. Persistent paresthesia was seen in 9/79 (9%) immediately postop and 3/79 (3.8%) patients at 6 months. Following the appropriate identification of the “offending portion” of the first rib which results in compression of the SV at its junction with the innominate vein by MRA, robotic resection of the “offending portion” of the first rib allows is associated with excellent results.

Beyond the learning curve: a review of complex cases in robotic thoracic surgery

The number of thoracic surgery cases performed on the robotic platform has increased steadily over the last two decades. An increasing number of surgeons are training on the robotic system, which like any new technique or technology, has a progressive learning curve. Central to establishing a successful robotic program is the development of a dedicated thoracic robotic team that involves anesthesiologists, nurses, and bed-side assistants. With an additional surgeon console, the robot is an excellent platform for teaching. Compared to current methods of video-assisted thoracoscopic surgery (VATS), the robot offers improved wristed motion, a magnified, high definition three-dimensional vision, and greater surgeon control of the operation. These advantages are paired with integrated adjunctive technology such as infrared imaging. For pulmonary resection, these advantages of the robotic platform have translated into several clinical benefits, such as fewer overall complications, reduced pain, shorter length of stay, better postoperative pulmonary function, lower operative blood loss, and a lower 30-day mortality rate compared to open thoracotomy. With increased experience, cases of greater complexity are being performed. This review article details the process of becoming an experienced robotic thoracic surgeon and discusses a series of challenging cases in robotic thoracic surgery that a surgeon may encounter “beyond the learning curve”. Nearly all thoracic surgery can now be approached robotically, including sleeve lobectomy, pneumonectomy, resection of large pulmonary and mediastinal masses, decortication, thoracic duct ligation, rib resection, and pulmonary resection after prior chest surgery and/or chemoradiation.

Evaluation and Management of Neurogenic Thoracic Outlet Syndrome with an Overview of Surgical Approaches: A Comprehensive Review

Neurogenic thoracic outlet syndrome (NTOS) represents a disorder believed to involve compression of one or more neurovascular elements as they exit the thoracic outlet. This comprehensive literature review will focus on the occurrence, classification, etiology, clinical presentation, diagnostic measures, and both nonoperative and operative therapies for NTOS. NTOS represents the most common subtype of thoracic outlet syndrome and can significantly impair quality of life. Botulinum toxin injection into the anterior scalene muscle, or even the middle scalene or pectoralis minor muscles, can reduce the symptoms of this syndrome. The best available evidence for botulinum toxin therapy to the cervicothoracic muscles supports the value of this treatment for reducing pain in the affected extremity, and for an approximate duration of 2 months or more. Surgical approaches and newer minimally invasive surgical approaches offer high rates of improvement in select centers.

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.

Robot-assisted transthoracic first rib resection for venous thoracic outlet syndrome

BACKGROUND

Venous thoracic outlet syndrome (vTOS) is caused by external compression of the subclavian vein at the costoclavicular junction. It can be subdivided in McCleery Syndrome and Paget-Schroetter Syndrome (PSS). To improve the venous outflow of the arm and to prevent recurrent thrombosis, first rib resection with venolysis of the subclavian vein can be performed. Open transaxillary, supraclavicular, infraclavicular or combined paraclavicular approaches are well known, but more recent robot-assisted techniques are introduced. We report our short- and long-term results of a minimal invasive transthoracic approach for resection of the anteromedial part of the first rib using the DaVinci surgical robot, performed through three trocars.

METHODS

We analyzed all patients with vTOS who were scheduled to undergo robot-assisted transthoracic first rib resection in the period July 2012 to May 2016. Outcomes were: technical success, operation time, blood loss, hospital stay, 30-day complications and patency. Functional outcomes were assessed using the "Disability of the Arm, Shoulder and Hand" (DASH) questionnaire.

RESULTS

Fifteen patients (8 male, 7 female; mean age 32.9 years, range 20-54 years) underwent robot-assisted transthoracic first rib resection. Conversion to transaxillary resection was necessary in three patients. Average operation time was 147.9 min (range 88-320 min) with a mean blood loss of 79.5 cc (range 10-550 cc). Mean hospital stay was 3.5 days (range 2-9). In three patients, complications were reported (Clavien-Dindo grade 2-3a). Patency was 91% at 15.5 months' follow-up. DASH scores at one and three years showed excellent functional outcomes (7.1 (SD= 6.9, range 0-20.8) and 6.0 (SD= 6.4, range 0-25)) and are comparable to the scores of the normative general population.

CONCLUSION

Robot-assisted transthoracic first rib resection with only three trocars is a feasible minimal invasive approach for first rib resection in the management of vTOS. This technique enables the surgeon to perform venolysis under direct 3D vision with good patency and long-term functional outcome. Studies with larger cohort size are needed to compare the outcomes of this robot-assisted technique with other more established approaches.

Surgical Technique: Minimally Invasive First-Rib Resection

Minimally invasive surgical approaches to the treatment of thoracic outlet syndrome (TOS) will become increasingly common as more surgeons gain experience in thoracoscopic and robotic technique. Robotic surgery may be more technically advantageous because of improved visualization and maneuverability of wristed instruments. Longer-term outcome data are necessary to definitively establish the equivalency or superiority of minimally invasive TOS compared with open surgery in the treatment of TOS.

Safety of robotic first rib resection for thoracic outlet syndrome

OBJECTIVES

Robotic first rib resection (R-FRR) is an emerging approach in the field of thoracic outlet syndrome (TOS) that has technical advantages over traditional open approaches, including superior exposure of the first rib and freedom from retracting neurovascular structures. We set out to define the safety of R-FRR and compare it with that of the conventional supraclavicular approach (SC-FRR).

METHODS

We queried a prospectively maintained, single-surgeon, single-institution database for all FRR operations performed for neurogenic TOS and venous TOS. Preoperative, intraoperative, and complications were compared between approaches.

RESULTS

Seventy-two R-FRRs and 51 SC-FRRs were performed in 66 and 50 patients, respectively. These groups were not significantly different in age, body mass index, sex, type of TOS, or preoperative use of opioids. Length of procedure and hospital stay were not different between groups. Postoperative inpatient self-reported pain (visual analog scale score 4.7 vs 5.2; P = .049) and administered morphine milligram equivalents (37.5 vs 81.1 MME, P < .001) were significantly lower in R-FRR than SC-FRR. Brachial plexus palsy was less frequent after R-FRR than SC-FRR (1% vs 18%, P = .002) and resolved by 4 months in call cases. All cases were sensory palsies with the exception of 2 motor palsies, which were both in the SC-FRR group. In multivariable analyses, R-FRR was independently associated with less frequent total complications than SC-FRR (P = .002; odds ratio, 0.08; 95% confidence interval, 0.02-0.39).

CONCLUSIONS

R-FRR provides outstanding exposure of the first rib and eliminates retraction of the brachial plexus and its consequences.

Paget-Schroetter syndrome in pregnancy: A case report and discussion of management options

Paget-Schroetter syndrome is a form of primary venous thoracic outlet syndrome whereby thrombosis of the subclavian vein is instigated by repeated and vigorous overhead activity of the arm. We describe a 35-year-old pregnant white woman at 8 weeks' gestation, a competitive swimmer by profession, who was diagnosed with a left upper extremity thrombus. First rib resection through an infraclavicular approach was performed 1 week after percutaneous pharmacomechanical thrombectomy. Repeated venography demonstrated residual thrombus requiring percutaneous pharmacomechanical thrombectomy with balloon venoplasty. We present a challenging case with focus on the unique diagnostic evaluation and management of pregnant patients with this condition.