Minimally invasive surgical approaches to the treatment of thoracic outlet syndrome (TOS) will become increasingly common as more surgeons gain experience in thoracoscopic and robotic technique. Robotic surgery may be more technically advantageous because of improved visualization and maneuverability of wristed instruments. Longer-term outcome data are necessary to definitively establish the equivalency or superiority of minimally invasive TOS compared with open surgery in the treatment of TOS.
Key points
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In the hands of experienced surgeons, thoracoscopic and robotic surgery for thoracic outlet syndrome (TOS) is safe and effective. However, randomized trials and long-term outcome data are needed to establish equivalency to traditional approaches.
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Minimally invasive techniques, including thoracoscopic and robotic surgery, have a minimum learning curve required to achieve proficiency.
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Robotic surgery provides clear advantages with improved visualization and maneuverability of instruments.
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Patients well selected for minimally invasive thoracic outlet surgery may experience decreased iatrogenic morbidity compared with open surgery.
Introduction
Thoracic outlet syndrome (TOS) can be subclassified into 3 subtypes, arterial (aTOS), venous (vTOS), and neurogenic (nTOS), defined by the compression of neurovascular structures within the triangular space between the first rib, the clavicle, and the scalene muscles. Neurogenic (NTOS) comprises 95% of cases. Involvement of the subclavian artery (aTOS) or subclavian vein (vTOS) is an indication for surgical intervention, while conservative management, including physical therapy and pharmacologic therapy, is the mainstay of initial treatment of nTOS. Refractory symptomatic cases are evaluated for surgical treatment.
Transaxillary or supraclavicular surgical approaches to the thoracic outlet have historically been the most commonly described techniques, which are based on the foundation of decompression of the neurovascular structures. Importantly, this is achieved through resection of the first rib as well as a scalenectomy, or cervical rib resection, if present. For cases of vTOS, additional venolysis is necessary to liberate the subclavian vein from a reactive fibrous capsule that has formed. In order to achieve adequate anatomic visualization and decompression via these traditional approaches, there is requisite manipulation of the brachial plexus and subclavian vessels. Limited exposure in a confined space can lead to iatrogenic injury related to stretching or retraction of neurovascular structures during the resection. Furthermore, long-term outcomes suggest that inadequate symptomatic relief, or early recurrence of symptoms, is related to incomplete resection of the first rib. Incomplete resection of the first rib, specifically posteriorly, can be attributed to technique as well as challenge with adequate exposure.
With the expansion of minimally invasive approaches across all surgical specialties, application of thoracoscopic or robotic-assisted management of TOS is being evaluated. As compared with traditional techniques, advantages to minimally invasive approaches include improved visualization of anatomic structures, safer dissections owing to maneuverability of instruments to gain exposure, and reduction of complications with the potential for improved long-term outcomes. , Importantly, minimally invasive approaches allow for these advantages regardless of body habitus.
Patient Diagnostic Considerations
Patients are offered surgery when refractory symptoms of TOS are disabling. For nTOS, conservative management is the mainstay of initial treatment; however, in the cases of aTOS or vTOS, endovascular intervention can be necessary before surgical decompression, such as thrombolysis. Recent diagnostic criteria have been proposed to better identify cases of TOS by standardizing the variability of symptomatic presentation. Ultimately, this will allow for better comparison of treatment pathways, more uniform outcome metrics, and comparison of surgical approaches. In cases of nTOS, studies have demonstrated that symptomatic improvement after scalene botulinum injection is useful as a proxy for whether patients will improve with surgical decompression. , Furthermore, distinction of neurogenic pectoralis minor syndrome as compression of the brachial plexus in the retropectoral space must be accurately recognized and should rather be treated with the simplicity of outpatient tenotomy. Given a variety of subspecialists treat TOS, most of which are vascular surgeons, minimally invasive TOS is the growing domain of thoracic surgeons given their training set in thoracoscopic and robotic surgery.
Minimally Invasive First-Rib Resection
In 2007, Abdellaoui and colleagues reported a series of video-assisted transaxillary approaches to enhance visualization of relevant anatomy in the thoracic outlet. Using minimally invasive instruments, this approach still required a 6- to 7-cm transaxillary incision between the pectoralis major anteriorly and the latissimus dorsi posteriorly, where both the camera and the instruments were introduced through the same incision. However, despite the larger incision, enhanced visualization provided by the thoracoscope without the need for added retraction of the neurovascular bundle seemed to be a clear advancement to the traditional techniques. Subsequent studies continued to explore varied techniques using a video-assisted approach. Soukiasian and colleagues published the first larger series in the literature describing a video-assisted thoracoscopic (VATs) first-rib resection using a 5-mm camera port and 2- to 3-cm transaxillary port. Central to the technique remains complete removal of the first rib, and scalenectomy for decompression of the outlet, yet the limited sophistication of the thoracoscopic instruments hamper dissection of neurovascular bundle. Increasing sophistication of robotic systems, with improved maneuverability of instruments in confined spaces, allowed Gharagozloo and colleagues to introduce the first small robotic series of 5 patients with Paget-Schroetter disease. The authors describe both minimally invasive techniques here and review the available literature.
Video-Assisted Thoracoscopic First-Rib Resection
Surgical technique
Patients undergo general anesthesia with a double-lumen endotracheal tube for single-lung ventilation. They are positioned in the lateral decubitus position with the side being operated on facing up. VATs approach can vary by surgeon experience. Hwang and colleagues used 3 thoracoscopic ports, 2 × 5 mm at the third intercostal space (ICS) anterior axillary line and posterior axillary line, and one 11.5-mm port at the midaxillary line in the fifth ICS. Soukiasian and colleagues used 1 port and a second longer incision: one for a 5-mm 30° thoracoscope in the fifth ICS at the midaxillary line, and a second 3-cm incision over the third ICS in the midaxillary line. Nuutinen and colleagues use three 10-mm ports placed in the fourth or fifth ICS.
The parietal pleura of the first rib is then opened using hook electrocautery. The rib is dissected from the intercostal muscle anteriorly to the costal cartilage and posteriorly to the costovertebral junction. The medial head of the first rib is cut with a 4.5-mm Kerrison punch anteriorly and posteriorly, while a Rongeur is used to trim the residual bone edges. The rib is held in traction, and the anterior and middle scalene muscles are divided using hook-type electrocautery or ultrasonic shear probe. The rib is then removed via a port site incision with any type of thoracoscopic graspers.
Robotically Assisted Thoracoscopic First-Rib Resection
Surgical technique
Patients are positioned in the same fashion for robotic cases as a VATs approach, also using single-lung ventilation. Three 8-mm working ports and one 10-mm assistant port are placed. The first 8-mm posterior port is placed just inferior to the tip of the scapula at the seventh ICS in the posterior axillary line. This is followed by placement of an anterior port around the fourth ICS in the anterior axillary line. Importantly, ports should not be positioned too far anteriorly or posteriorly, as it can impinge movement of the robotic arm at the costosternal and costovertebral junction to resect the entire rib. Inferior to, and between these 2 working ports, the third 8-mm camera port is placed at approximately the seventh ICS in the midaxillary line. A 10-mm assistant port is then placed anteriorly and inferiorly in the ninth ICS ( Fig. 1 ). A thoracoscopic instrument should be introduced to ensure the proper working angles from the port site to enable bone cutting of the first rib. Intercostal nerve blocks are placed in the fourth to ninth ICS spaces posteriorly for pain control.
Intrathoracic visualization of the thoracic inlet provides optimal exposure to important anatomic landmarks, including the first rib, first intercostal muscle, subclavian artery, and brachial plexus ( Fig. 2 , Burt and colleagues ). Using a hook cautery, or spatula monopolar cautery, the parietal pleura is incised as the first intercostal muscle is divided from the first rib as well as the periosteum, and any residual can serve as a nidus for bone regrowth. , The dissection should then travel anteriorly to the costosternal junction with careful attention to the internal thoracic artery and vein. If not ossified, the costal cartilage of the first rib can be divided using the monopolar electrocautery or bipolar. The dissection is then extended posteriorly following the curve of the first rib toward the vertebral body. All attachments to the superior and inferior borders of the rib are divided. Posteriorly, a tunnel is created using a curved bipolar dissector to allow for the posterior first rib to be divided free of attachments, while extra attention is paid to protecting the neurovascular bundle from energy posteriorly, particularly the T1 nerve root. ,
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