Open Cervical and Robotic First Rib Resections for Neurogenic Thoracic Outlet Syndrome

This is the winning video in the 9th Annual Resident Video Competition.

There are three types of thoracic outlet syndrome (TOS): neurogenic (the majority of cases), arterial, and venous. Neurogenic TOS requires extensive workup prior to surgery, and Botox injections into the scalene muscles can both treat and diagnose the condition. There are multiple surgical approaches including supra- and infraclavicular, transaxillary, and robotic.

This video presents a unique case of a patient with neurogenic TOS who was treated with both an open supraclavicular cervical rib resection and a robotic first rib resection.



The patient is a twenty-seven-year-old woman with a history of a prior open right first rib resection in 2012 for neurogenic thoracic outlet syndrome who presented with three weeks of pain in the left shoulder radiating down her arm with intermittent numbness that was exacerbated with activity. She also had occasional coolness and swelling of the hand.

The patient’s workup included physical exam maneuvers, physical therapy, a CT scan with IV contrast, an MRI of the neck and chest, vascular duplex, and a Botox injection in the anterior and middle scalene muscles.

For the Adson’s test, the patient’s arm was externally rotated, slightly abducted, and slightly extended while palpating the radial pulse. The patient extended and turned her head, then inhaled and held her breath. For the Roos test, the patient adbucted her arms 90 degrees with external rotation and flexed her elbows. The patient then opened and closed her hands for three minutes.

The Botox injection improved the patient’s symptoms, which helped confirm the diagnosis. A CT scan of the chest with IV contrast showed an incomplete left cervical rib but otherwise normal anatomy. After making the diagnosis, the team proceeded to the operating room. Prior to starting, they set up somatosensory evoke potential monitoring.

To begin, the surgeons completed a supraclavicular incision, divided the platysma, and exposed the sternocleidomastoid and omohyoid muscles. The omohyoid was then divided and the SCM was medially rotated to expose the anterior scalene. The phrenic nerve was identified on the anterior medial border of the anterior scalene.

Next, surgeons dissected between the anterior and middle scalenes to expose the brachial plexus. They then exposed the cervical rib lateral to the scalenes and divided it at its proximal joint. After closing the neck incision the patient was placed in right lateral decubitus. Surgeons marked the scapula as a landmark for entry.

Next, the seventh intercostal space was entered, and two additional incisions were made at the fifth intercostal space posterior to the scapula tip and the fourth intercostal space at the anterior axillary line. To ensure  a safe method for entering the thorax, a blunt-tip Kelly forceps was used to spread down to the pleura. After entering the cavity, the Kelly was rotated 180 degrees before entering further and spreading.

After placing the first port, the robot was positioned at  the patient’s side and the laser-line was driven to that port. To dock the arm, the angle was first adjusted at the top. Then, surgeons simultaneously push the bottom button and bottom lever to bring the arm to the port and make a connection. They installed the camera and targeted the robot and visual entry of the other two ports.

Before starting the operation, surgeons noticed remnants of the prior neck dissection. They started by incising the pleura between the phrenic nerve and the superior edge of the first rib, then carried the dissection along the phrenic nerve to expose the sternocostal joint. The incision was then continued along the inferior portion of the rib.

After incising the pleura and exposing the rib, the intercostal muscles were removed using bipolar cautery. Surgeons took special care to stay on the rib and not bury the tip of the instrument. The same technique was used on the superior aspect of the rib. The phrenic nerve was gently retracted to avoid injury.

Next, surgeons attempted to traverse the sternocostal cartilage to gain leverage for the rest of the dissection. They approached the cartilage from many angles, but the cartilage was tenacious. Attention was then turned to the posterior aspect of the rib. The team started with a 20 cm long-necked drill with a 2 mm matchstick bit to drill through the rib. They finished coming through the rib with a rongeur.

After transecting the rib, the team was able to put downward traction on it to expose the remaining attachments and pull the rib away from the critical structures of the thoracic outlet. This allowed surgeons to get behind the sternocostal cartilage and safely remove the final attachments.

At this point, the rib was completely free. It was removed from the field using a bag. The chest was suctioned, a chest tube placed, and the lung was re-expanded. The ports were closed and the case concluded. Postoperatively, the patient recovered well without issues and was discharged home.

References

1. Burt BM, Palivela N, Karimian A, Goodman MB. Transthoracic robotic first rib resection: Twelve steps. JTCVS Tech. 2020 Jan 18;1:104-109. doi: 10.1016/j.xjtc.2020.01.005. PMID: 34317727; PMCID: PMC8288632.

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