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JTCVS Deep Dive - An Interview With Dr Bryan Burt: "Safety of Robotic First Rib Resection for Thoracic Outlet Syndrome"

Wednesday, March 24, 2021

Mitzman B, Burt B. JTCVS Deep Dive - An Interview With Dr Bryan Burt: "Safety of Robotic First Rib Resection for Thoracic Outlet Syndrome". March 2021. doi:10.25373/ctsnet.14270405

In this CTSNet Deep-Dive, Dr Brian Mitzman of the University of Utah in Salt Lake City, UT, interviews thoracic outlet syndrome expert Dr Bryan Burt of the Baylor College of Medicine. They discuss Dr Burt's latest publication currently in-press with the Journal of Thoracic and Cardiovascular Surgery, entitled "Safety of Robotic First Rib Resection for Thoracic Outlet Syndrome."

Dr Burt and team analyzed 123 first rib resections for venous and neurogenic thoracic outlet syndrome over a 5-year period. Approximately 2 years into this cohort, Dr Burt made a complete switch from supraclavicular to trans-thoracic robotic approach. The analysis centers on perioperative outcomes of each approach, with a specific focus on complications and postoperative pain control.

After discussing his paper, Dr Burt takes us through a full robotic first rib resection case, providing the tips and tricks he has learned from his experience with over 150 of these operations.

"Safety of Robotic First Rib Resection for Thoracic Outlet Syndrome"
Bryan M Burt MD, Nihanth Palivela BS, Davut Cekmecelioglu MD, Paul Paily MD, Bijan Najafi PhD, Hyun-Sung Lee MD PhD, Miguel Montero MD
Available at:


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).

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.

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).

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


Burt BM, Palivela N, Cekmecelioglu D, et al. Safety of robotic first rib resection for thoracic outlet syndrome. J Thorac Cardiovasc Surg. 2021; In Press.


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The review does not mention indications for operation, or if referrals were made to physical therapy before operative intervention. In the early 1980's, we were doing about 10 first rib resections a year for thoracic outlet syndrome. An article appeared, perhaps in NEJM or JAMA, suggesting physical therapy before operative intervention. We discussed the situation with the local therapists. They were on board. It is often a posture thing. Once we started referring to physical therapy, we never did another first rib resection. Perhaps those patients experienced resolution of symptoms, or perhaps they were referred elsewhere for an operation. I did miss doing the operation, the first few were terrifying, after that they were a nice technical experience.

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