Robotic-assisted First Rib Resection Safe and Effective in Alleviating Thoracic Outlet Syndrome

A novel treatment for patients with thoracic outlet syndrome (TOS) may be safer, more effective, and more aesthetically pleasing than conventional surgical techniques, according to authors of a new study presented at the 65th Annual Meeting & Exhibition of the Southern Thoracic Surgical Association.

“Thoracic outlet syndrome comprises a constellation of signs and symptoms that arise from neurological and vascular compression of the brachial plexus and subclavian vasculature, respectively,” said study author Stevan Pupovac. Pupovac, a third-year resident at Northwell Health in Astoria, N.Y., presented his team’s findings.

“When non-surgical treatment fails to appropriately alleviate TOS, surgical decompression of the neurovascular structures is indicated,” he said.

Study researchers reviewed single-center data on 18 robotic-assisted first rib resection patients between July 2014 and January 2018. Mean patient age was 45 years, and there were ten women. Nine patients had venous TOS (vTOS), eight had neurogenic TOS (nTOS), and one had a non-healing, traumatic rib fracture. No complications or conversions to open surgery occurred. At a mean short-term follow-up of 10.3 days, postoperative venogram showed patent vasculature, and the whole vTOS cohort remained asymptomatic. After two and six months, patients still had no symptoms.

Average intraoperative blood loss was 30.0 mL, and mean operation time was 111.6 minutes. Mean length of stay was 1.7 days. Resected rib length was a mean 5.8 cm. The vTOS cohort received Xarelto for a mean of 5.1 months. Three patients required a chest tube for a mean 1.3 days.

“The most important thing to talk about with thoracic outlet syndrome is not the procedure itself, but rather who should be operated on,” Pupovac said.

Often, Pupovac explain, vTOS patients already have their diagnosis made when they are diagnosed using clinical history, physical examination, and imaging, Pupovac said. After diagnosis, the team performs a venous duplex, and a positive duplex scan is followed by definitive imaging, usually catheter-based venography with the intention of treating if necessary. CT and MR venography have also been used in previous cases. Three to six months of anticoagulation is initiated. Surgical decompression generally takes place two weeks after venography, and after surgery, additional follow-up is conducted with intervention if needed.

In nTOS patients, a diagnosis is made based on thorough clinical history, physical examination, imaging, and neurological testing. Other diagnoses, Pupovac noted, must be ruled out, and ulnar nerve testing is performed.

“The most important thing is to make sure they get rehab,” Pupovac emphasized. “If that doesn’t alleviate the symptoms, have a frank discussion with the patients” and make them aware of the risks and benefits associated with the surgery.

Pupovac’s team had no injuries, but it could happen in a larger cohort, which makes complication management vital, he said.

According to Pupovac, the new technique has a minimal learning curve. Four different surgeons performed the procedure for the study. Surgeons with competence completing level II and level III operations from Linsky and Wei’s classification of “operations for thoracic surgeons” with previous robotic experience were comfortable doing the procedure, he said.

The study had several limitations, including its single-center retrospective design, which leaves room for selection bias. While it is one of the largest studies present in the literature, it had a relatively small sample size. Pupovac said a multicenter prospective study would be “ideal.”

“We offer a superior, magnified, and well-visualized view of the thoracic inlet [that] avoids limitations of neurovascular complications often associated with conventional approaches,” said Pupovac. “I think it’s an aesthetically pleasing, safe, and effective technique that should be added to the armamentarium of thoracic surgeons.”