Thoracic Outlet Syndrome: Single Center Experience on Robotic Assisted First Rib Resection and Literature Review

Robotic-assisted costectomy using a Gigli saw for fibrous dysplasia

BACKGROUND

Fibrous dysplasia (FD) is the most common benign tumor of the ribs, with surgical resection being the preferred treatment modality for rib FD, leading to enhanced quality of life and favorable outcomes. The complexity of surgical intervention varies depending on the location of costal FD, presenting challenges for both open surgical and thoracoscopic approaches. In this study, we present a novel technique for three-port robotic-assisted costectomy utilizing a Gigli saw, detailing our initial findings and outcomes.

METHODS

We reviewed five patients with benign rib tumors who underwent three-port robotic-assisted rib resection using a Gigli saw between May 2021 and December 2022. Data on patient characteristics, relevant short-term surgical outcomes and clinical long-term treatment effects were collected.

RESULTS

The surgery was successful in all five patients without any need for an additional port and emergency conversion to open surgery. Median operative time was 76.8 min (range, 73-116 min), and the median intraoperative blood loss volumes was 75 ml (range, 40- 105 mL). On average, chest tubes were removed 1.2 days postoperatively (range, 1-2 days), with a mean drainage volume of 93 ml on postoperative day 1 (range, 70-135 ml). Patients were discharged between the 2nd and 4th postoperative day. During 1-year follow-up period, no recurrence was observed in either patient.

CONCLUSIONS

The utilization of a three-port robotic-assisted costectomy in conjunction with a Gigli saw represents a viable, secure, and efficient approach for treating isolated benign rib lesions. Our aim is to provide clinical guidance on this technique and promote its broader application.

Arterial thoracic outlet syndrome caused by a cervical rib: a combined thoracoscopic and supraclavicular approach for 'en bloc'-resection

A cervical rib is the cause of ∼5% of thoracic outlet syndromes (TOS). We report the case of a patient with arterial TOS due to the presence of a cervical rib, managed by combined thoracoscopic and supraclavicular approach. An 18-year-old female patient presented with symptoms of arterial TOS. Magnetic resonance imaging and computed tomography angiography scans showed a tortuous subclavian artery due to a fused cervical and 1st rib. Three-port thoracoscopy was performed, which allowed to mobilize the ventral part of the 1st rib. Supraclavicular access allowed mobilization as well as central division of the ribs. After removal of the ribs, the subclavian artery presented a normal calibre and aspect. In recent years, there has been a trend towards minimally invasive approach to TOS, either by thoracoscopy or by robotic-assisted surgery. The advantages of this approach are the 'enbloc'-resection of both ribs and the possibility to evaluate the subclavian artery during the same procedure and perform repair if necessary.

Robotic-assisted thoracoscopic surgery first rib resection-surgical technique

Thoracic outlet syndrome (TOS) is a rare condition resulting from the compression of the brachial plexus and/or the subclavian vessels in the thoracic outlet (TO). Neurogenic TOS (NTOS) is the most common form in up to 95% of the cases, while venous TOS (VTOS) occurs in 3-5% and arterial TOS (ATOS) in 1-2% of the cases. Patients may suffer from the pathologic coexistence of arterio-venous compression in the TO called arterio-venous TOS (AVTOS) with an overlap of clinical symptoms. While imaging studies such as computed tomography (CT)-angiography, magnetic resonance imaging (MRI)-angiography and duplex sonography are helpful to detect the underlying condition in vascular pathologies, electrodiagnostic testing is necessary to distinguish NTOS from other peripheral neuropathies. Subclavian vein (SV)-compression in the TO can result in venous thrombosis, called Paget-Schroetter syndrome (PSS), named after the discoverers of the disease. Besides oral anticoagulation in cases with venous upper extremity thrombosis and multimodal conservative treatment in the management of NTOS, surgical decompression is the current standard of care for TOS. Surgical decompression aims to remove structures compressing the brachial plexus or the subclavian vasculature in the TO. In NTOS, when conservative management has failed, surgical resection of the 1st or a cervical rib is often combined with scalenectomy and brachial plexus neurolysis. Minimally invasive techniques have replaced traditionally open supra-, infraclavicular or transaxillary approaches with excellent results and minimal morbidity. Video-assisted thoracoscopic surgery (VATS) was described to offer better visualization, shorter length of stay (LOS) and less neurovascular injuries attributable to less traction applied. Robotic-assisted thoracoscopic surgery (RATS) moreover, further improved magnification, angulation of the surgical instruments in narrow anatomical spaces and the comfort for the operating surgeon. Uniportal RATS (uRATS) has lately been applied for 1st rib resection. The aim of this surgical technique manual is to describe and illustrate a RATS 1st rib resection with its advantages over traditionally open approaches step by step.

Burden of In-Hospital Admissions and Outcomes of Thoracic Outlet Compression Syndrome in the United States From 2010 to 2021

Introduction Despite advancements in medical and surgical management, thoracic outlet syndrome (TOS) remains a complex and often understudied condition with variable outcomes. This study assessed hospitalization rates and outcomes, including patient characteristics, mortality risks, and healthcare costs associated with TOS hospitalizations. Methods We analyzed elective and nonelective hospitalization data for TOS between 2010 and 2021 from the National Inpatient Sample (NIS) and National Readmission Databases (NEDS) and classified the data into neurogenic, venous, and arterial subtypes using the International Classification of Diseases (ICD) diagnostic and procedural codes. The primary endpoint of this study was hospital-related all-cause mortality. Secondary outcomes included hospitalization costs, length of hospital stay, in-hospital complications, and 30-day readmissions. The odds of primary and secondary outcomes were assessed using multivariate hierarchical logistic regression analysis. Cox proportional hazard models were used to assess predictors of 30-day readmission. Results A total of 37,174 hospitalizations for TOS were identified in the NIS datasets included in our study. Of these, 7,397 (19.9%) were for venous TOS, 3,346 (9.0%) were for arterial TOS, and 26,430 (71.1%) were for neurogenic TOS. Patients with arterial TOS were significantly older (median age: 66; interquartile range (IQR): 54-77 years) compared with venous (63 years; IQR: 50-74) or neurogenic TOS (58 years; IQR: 53-73; P < 0.001). Scalenectomy, with or without first rib resection, was performed in 18% (6,692) of TOS hospitalizations, mainly in neurogenic TOS (16.7%, 4,405 cases) compared to venous (13%, 964 cases) and arterial TOS (38.1%, 1,273 cases). The median duration of hospitalization for TOS was three days (IQR: two to six days). The mean cost of care for all TOS hospitalizations was $107,481 (standard deviation (SD): $4,158). The mean cost of hospitalization was significantly higher for vascular TOS than neurogenic TOS ($114,824 vs. $98,278; P < 0.001) and for venous TOS than arterial TOS ($119,042 vs. $110,606; P = 0.041). Overall, in-hospital mortality was 446 (1.2%). Mortality rates were significantly higher in venous TOS compared to arterial TOS (263 (59.1%) vs. 182 (40.7%); adjusted hazards ratio (AHR): 1.56; 95% confidence interval (CI): 1.26-3.56; P = 0.041). Black race (adjusted Odds ratio (aOR): 3.86, 95% CI: 8.80-16.90; P = 0.043), deep vein thrombosis (aOR: 1.68, 95% CI: 1.18-2.03; P = 0.018), previous coronary artery bypass graft (aOR: 2.37, 95% CI: 1.84-3.92; P = 0.003), pulmonary embolism (aOR: 2.63, 95% CI: 1.23-3.45; P < 0.001), and postoperative sepsis with multiorgan failure (aOR: 3.33, 95% CI: 2.13-6.40; P = 0.032) were correlated with mortality. Conclusion Hospitalization duration and mortality rates for TOS are generally low, though vascular TOS has a longer length of stay and higher mortality than neurogenic TOS. Mortality was significantly associated with Black race, deep vein thrombosis, previous coronary artery bypass grafting (CABG), pulmonary embolism, and postoperative septicemia.

Adoption of the Robotic Platform across Thoracic Surgeries

With the paradigm shift in minimally invasive surgery from the video-assisted thoracoscopic platform to the robotic platform, thoracic surgeons are applying the new technology through various commonly practiced thoracic surgeries, striving to improve patient outcomes and reduce morbidity and mortality. This review will discuss the updates in lung resections, lung transplantation, mediastinal surgeries with a focus on thymic resection, rib resection, tracheal resection, tracheobronchoplasty, diaphragm plication, esophagectomy, and paraesophageal hernia repair. The transition from open surgery to video-assisted thoracoscopic surgery (VATS) to now robotic video-assisted thoracic surgery (RVATS) allows complex surgeries to be completed through smaller and smaller incisions with better visualization through high-definition images and finer mobilization, accomplishing what might be unresectable before, permitting shorter hospital stay, minimizing healing time, and encompassing broader surgical candidacy. Moreover, better patient outcomes are not only achieved through what the lead surgeon could carry out during surgeries but also through the training of the next generation via accessible live video feedback and recordings. Though larger volume randomized controlled studies are pending to compare the outcomes of VATS to RVATS surgeries, published studies show non-inferiority data from RVATS performances. With progressive enhancement, such as overcoming the lack of haptic feedback, and future incorporation of artificial intelligence (AI), the robotic platform will likely be a cost-effective route once surgeons overcome the initial learning curve.

Tackling complex thoracic surgical operations with robotic solutions: a narrative review

Background and Objective

The adoption of robotic surgery for general thoracic surgery has rapidly progressed over the last two decades from its application in basic operations to complex pathologies. As such, the purpose of this narrative review is to highlight the collective experience of tackling complex thoracic surgical operations with minimally invasive robotic solutions.

Methods

Electronic searches of PubMed were conducted for each subtopic, using specific keywords and inclusion criteria. Once identified, the articles were screened through the abstract, introduction, results and conclusion for relevancy, and included based on a standard narrative review inclusion criteria.

Key Content and Findings

The role of the robotic approach has increased in thoracic outlet syndrome, chest wall resection, tracheobronchomalacia, airway and sleeve lung surgery, lobectomy after neoadjuvant therapy, complex segmentectomy, giant paraesophageal hernia repair, esophagectomy and esophageal enucleation, mediastinal masses and thymectomy and lung transplantation. Robotic surgery has several advantages when compared to video-assisted and open thoracoscopic surgery. These include better pain control and aesthetic outcome, improved handling of complex anatomy, enhanced access to lymph nodes, and faster recovery rates. Although it is associated with longer operative time, robotic surgery has comparable morbidity rates.

Conclusions

The robotic approach to complex thoracic problems is safe, effective, and associated with improved patient outcomes. To encourage wider adoption of robotic technology, increased training and expanded research efforts are essential, alongside improved worldwide access to this technology.

Histologic evidence of brachial plexus compression sites at the thoracic inlet and variations in formation of the lower trunk in cadavers

BACKGROUND

In thoracic "outlet" syndrome (TOS), pathologic evidence is well documented for vascular but not neurologic compression. We hypothesized that histologic evidence of compression would be identified at sites where the upper trunk was impacted by the anterior scalene muscle and the lower trunk by anatomic anomalies or the first rib. The purpose of this study was to investigate this hypothesis in human cadavers.

MATERIALS AND METHODS

Twenty-five cadavers' brachial plexuses were dissected and excised. Histologic and descriptive analysis was directed at juncture 1, the upper trunk and anterior scalene muscle, and juncture 2, C8 and T1 nerve roots (lower trunk) with the posterior border of the first rib. Measurements were obtained at the juncture of the T1 nerve root with the C8 nerve root in relationship to the first rib.

RESULTS

Histologic analysis demonstrated epineurial and perineurial fibrosis, myelin thinning, and Renaut bodies at junctures 1 and 2. Lower trunk formation occurred on or lateral to the first rib in 66% of specimens, with asymmetry in 32% of cadavers. A muscle of Albinus was present in 18% of cadavers. A large dorsal scapular artery coursed through 36% of plexuses with a high, arched subclavian artery.

CONCLUSIONS

We report histologic changes consistent with chronic compression of the upper and lower plexus in the thoracic inlet at hypothesized sites of brachial plexus compression that may correlate with clinical neck/shoulder (upper trunk) and "ulnar nervelike" (C8-T1/lower trunk) symptoms. Anatomic anomalies identified should alert the surgeon to variations of lower trunk formation at compression sites.