Video-Assisted Thoracoscopic First Rib Resection With Craniotome: A Novel Approach to Venous Thoracic Outlet Syndrome

Paget-Schroetter syndrome, also known as effort thrombosis, is a condition in which a thrombus forms in the subclavian vein due to an obstruction along its course, resulting in venous thoracic outlet syndrome (TOS). This obstruction is most commonly caused by a supernumerary rib but may also occur in athletes due to hypertrophy of the neck muscles. Physical therapy is the first-line treatment for most patients, and oral anticoagulant therapy may offer some benefits as a noninvasive strategy. The decision to pursue surgical treatment is made on an individual basis, typically reserved for cases where nonsurgical measures have failed and symptoms are disabling (1). 

Currently, there is no consensus on the optimal surgical approach for thoracic outlet decompression, with common access routes including transaxillary, supraclavicular, and infraclavicular approaches (2). 

The purpose of this video is to illustrate the technical aspects of first rib resection (FRR) via video-assisted thoracoscopic surgery (VATS) for thoracic outlet syndrome, using a specialized neurosurgical instrument—a craniotome. This device allows for precise and rapid bone sectioning, proving especially useful in thoracoscopic rib resections. 

This video presents the case of a 28-year-old male with no comorbidities, who had previously played water polo. He experienced a pulmonary embolism secondary to subtotal deep vein thrombosis of the right subclavian and axillary veins. Physiotherapy yielded no significant improvement. 

Electromyography revealed normal motor and sensory conduction in the right upper limb. MRI performed with the right arm elevated demonstrated stenosis of the right subclavian vein and compression of the right brachial plexus within the thoracic outlet. After a multidisciplinary evaluation involving angiology, anesthesia, neurology, and orthopedic surgery, VATS first rib resection was scheduled. 

The procedure was performed under general anesthesia using a left-sided double-lumen endotracheal tube, with the patient placed in the left lateral decubitus position. A hook monopolar cautery was used for dissection and hemostasis. The thoracoscope was inserted through the sixth intercostal space in the axillary line. A utility port was created in the fourth intercostal space anteriorly, and two additional ports were placed in the fourth and fifth intercostal spaces along the posterior axillary line. 

The parietal pleura was incised above the first rib, and dissection began at the inferior and medial aspect of the rib to fully skeletonize it. The medial cutting point was identified just lateral to the chondrosternal joint, and the cartilage was transected using electrocautery. The subclavian muscle was then identified and transected. The lateral cutting point was located just lateral to the anterior and middle scalene muscles. The rib was then transected using the craniotome. The anterior and middle scalene muscles were isolated through blunt dissection and subsequently transected. 

The total surgical time was 90 minutes, and the postoperative course was uneventful. The chest drain was removed on postoperative day three, and the patient was discharged on postoperative day four. He remains asymptomatic and has resumed normal physical activity. 

Compared to open procedures, thoracoscopic first rib resection via VATS offers excellent visualization of the entire first rib and eliminates the need for retraction of the brachial plexus or subclavian vessels. The use of dedicated instruments is critical for the safe execution of this technique. In certain cases, adapting instruments from other surgical specialties, such as the craniotome from neurosurgery, can be particularly advantageous. 

Some anatomical factors may make thoracoscopic FRR more technically challenging. For instance, in muscular patients, subluxating the rib into the thoracic cavity can be more time-consuming due to the development of the scalene muscles. 

The use of a craniotome for thoracoscopic first rib resection is a feasible and effective approach that facilitates precise and efficient bone transection, especially in complex thoracic outlet syndrome cases. 

References

1. Zehnder A, Dorn P, Lutz J, Minervini F, Kestenholz P, Gelpke H, Schmid RA, Kocher GJ. Completely Thoracoscopic 3-Port Robotic First Rib Resection for Thoracic Outlet Syndrome. Ann Thorac Surg. 2022 Oct;114(4):1238-1244. doi: 10.1016/j.athoracsur.2021.08.053. Epub 2021 Sep 27. PMID: 34592270.
2. Nuutinen H, Riekkinen T, Aittola V, Mäkinen K, Kärkkäinen JM. Thoracoscopic Versus Transaxillary Approach to First Rib Resection in Thoracic Outlet Syndrome. Ann Thorac Surg. 2018 Mar;105(3):937-942. doi: 10.1016/j.athoracsur.2017.10.004. Epub 2017 Dec 28. PMID: 29289365.

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