RESUMEN
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.
RESUMEN
PURPOSE: First rib resection is a key component of the treatment of Thoracic Outlet Syndrome (TOS). We report our experience with, and technique for, robotic first rib resection. METHODS: Patients diagnosed with TOS underwent robotic first rib resection of the offending portion of the first rib with disarticulation of the costo-sternal joint. Definitive diagnosis of TOS was made by Magnetic Resonance Angiography (MRA) with maneuvers. RESULTS: A total of 67 patients underwent robotic first rib resection. Neurogenic TOS: 39 patients underwent robotic resection for Neurologic Symptoms of the upper extremity (Neurogenic TOS). There were 14 men and 25 women, with a mean age of 34 ± 9.5 years. Paget-Schroetter Syndrome (PSS) or Venous TOS: 28 patients underwent transthoracic robotic first rib resection for PSS. There were 16 men and 12 women, with a mean age of 24 ± 8.5 years. Operative time was 87.6 ± 10.8 minutes. There were no intraoperative complications. Hospital stay ranged from 2 to 4 days with a median hospitalization of 3 days. There were no neurovascular complications. There was no mortality. In patients with Neurogenic TOS, QuickDASH Scores (mean ± SEM) decreased from 60.3 ± 2.1 preoperatively to 5 ± 2.3 in the immediate postoperative period and to 3.5 ± 1.1 at 6 months (p<0001). Immediate relief of symptoms was seen in 35/39 patients (91%). Persistent paresthesia was seen in 4/39 (9%) immediately postop, and in 2/39 (2.5%) at 6 months. Thirty-seven of 39 (97.5%) patients reported complete relief of symptoms. Among patients with PSS or Venous TOS, 9/28 (32%) required endovascular venoplasty to completely open the subclavian vein after the relief of extrinsic compression. At a median follow-up of 24 months, all patients with PSS had an open subclavian vein, for a patency rate of 100%. CONCLUSIONS: Robotic transthoracic first rib resection allows for minimally invasive resection of the first rib in patients with TOS, with excellent relief of symptoms and no neurovascular complications.
