First Rib Resection for Thoracic Outlet Syndrome—Video 29-1

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CHAPTER 29 First Rib Resection for Thoracic Outlet Syndrome—Video 29-1

Randall Kevin Wolf, Robert J. McKenna, Jr.

Introduction

There are several surgical approaches for thoracic outlet syndrome (TOS). The video-assisted thoracic surgical (VATS) approach has several advantages. The shoulder does not have to be lifted and held for an extended time, the exposure is very good, and cutaneous nerves in the axilla are not disturbed.

Treatment of TOS requires resection of the first rib. TOS refers to compression of the subclavian vessels or the brachial plexus, or both, by the first rib and adjacent structures at the superior aperture of the chest.¹ Sir James Paget in 1875 in London and von Schroetter in 1884 in Vienna reported thrombosis of the subclavian vein caused by TOS. This vascular form of TOS is known as Paget–von Schroetter syndrome. However, the most common symptoms are neurologic and are related to compression of the brachial plexus in the distribution of the ulnar nerve.

Approach to Video-Assisted First Rib Resection

Order of Operative Steps

The order of the steps for video-assisted first rib resection is as follows: lateral decubitus position with the arm elevated on an airplane support, complete mobilization of the rib, excision of a 1-cm piece of the rib in the mid-clavicular line, and removal of the anterior and posterior pieces of the rib.³

Key Points

♦ Count and visualize the ribs carefully. On thoracoscopic examination, the first rib can be easily identified in the “roof” of the thorax. It can be palpated indirectly using an endokittner and can be clearly visualized.

♦ On the left, the subclavian artery is easily visualized on the thoracoscopic examination.

♦ Mobilize the entire rib before opening the pleura, because the carbon dioxide decompression of the lung is lost after opening the pleura, and the operative field is ecchymotic after the pleura is opened.

♦ When the rib has been mobilized as much as possible, excise a 1-cm piece of the rib in the mid-axillary line. This allows caudal displacement of the rib to complete the mobilization to the sternum anteriorly and to the vertebral bodies posteriorly.

♦ The ribs can be disarticulated or cut, but cutting seems to cause less pain.

♦ Care must be taken in developing the plane of dissection, and dissecting anterior to the vein initially is recommended.

♦ Care should be taken to observe and preserve the internal mammary artery anteriorly and the sympathetic chain posteriorly to the borders of the first rib.

♦ Port sites are best placed at some distance from the target to allow adequate manipulation of the instruments in a comfortable arc.

Video-Assisted First Rib Resection (Video 29-1)

Step 1. Patient Positioning

♦ Place the patient in the lateral decubitus position.

♦ Support the arm with an airplane splint (Figure 29-1).

Figure 29-1 A and B, Positioning of the patient for video-assisted first rib resection.

(Modified from Wolf RK, Crawford AH, Hahn B: Thoracoscopic first rib resection for thoracic outlet syndrome. In Yim APC, Hazelrigg SR, Izzat MB, et al (eds): Minimal access cardiothoracic surgery, Philadelphia, Saunders, 2000, pp. 330-331, Figs. 41-2 and 41-3.)

Step 2. Incisions

♦ Incision 1: Place a 5-mm trocar and 30-degree thoracoscope through the fifth or sixth intercostal space in the mid-axillary line (Figure 29-2).

♦ Incision 2: Make a 2-cm incision over the third rib in the mid-axillary line.

Figure 29-2 A and B, Incisions for video-assisted first rib resection.

Step 3. Identification of the First Rib

♦ Exposure: Decompresses the lung with carbon dioxide insufflation.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed apically.

♦ Identify the first rib (Figure 29-3). The vessels can be seen in the cupola above the first rib.

♦ Dissect the parietal pleura and intercostal muscles from the costal edge of the first rib using the Harmonic scalpel (Ethicon Endosurgery, Cincinnati, Ohio) (Figure 29-4).

♦ The Harmonic scalpel, which operates with ultrasonic energy and produces less smoke and lower heat than regular electrocautery, is used to facilitate endoscopic dissection of the first rib.²

♦ Bluntly dissect to the surface of the ribs and then caudally to the first rib, which is identified by feeling the flat, unique conformation of the rib.

♦ Confirm identification of the first rib visually with the thoracoscope. The subclavian artery can be seen on the superior aspect of the rib.

Figure 29-3 Identification of the first rib.

Figure 29-4 Harmonic scalpel mobilization of pleura and muscles for the first rib resection.

Step 4. Dissection of the First Rib

♦ Exposure: Use carbon dioxide insufflation.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed apically.

♦ Bluntly dissect the lateral surface of the first rib with a periosteal elevator.

♦ Bluntly dissect the superior surface of the first rib with a periosteal elevator.

♦ Pass a right-angle clamp over the top of the first rib.

♦ The subclavian vein, subclavian artery, and brachial plexus, lying from anterior to posterior and draped over the first rib, are bluntly freed using an endoscopic Cobb elevator and endoscopic curettes.

♦ Cautious dissection with a transverse process elevator frees the rib circumferentially.

♦ Protect the neurovascular bundle with the index finger that goes through the incision and parallel to the elevator. Keep the finger between the elevator and the neurovascular bundle to minimize the chance of damaging those structures.

♦ Bluntly dissect the inferior surface of the first rib with a periosteal elevator. Stay extrapleurally because the carbon dioxide decompression of the lung is lost after opening the pleura, and the operative field is ecchymotic after the pleura is opened.

♦ Pass a right-angle clamp around the superior aspect of the rib (Figure 29-5).

♦ Remove a 1-cm piece of the first rib in the mid-axillary line (Figure 29-6). This allows the surgeon to push the rib caudally to complete the mobilization to the sternum (anteriorly) and the vertebral bodies (posteriorly).

♦ Cut the rib with a rib cutter (Figure 29-7).

♦ After transection of the rib, any additional muscle attachments, such as the scalenus anticus or medius, can be divided under direct vision.

♦ Remove the pieces of the rib. The rib can be delivered easily through one of the port sites after removing the port.

♦ After complete thoracoscopic first rib excision, the contents of the neurovascular bundle drape gently across the apex of the pleural cavity. The extent of rib resection and its immediate effect on the structures of the thoracic outlet are clearly visualized (Figure 29-8).

Figure 29-5 Rib cutter (Sofamor Danek, Nashville, TN).

(Modified from Wolf RK, Crawford AH, Hahn B: Thoracoscopic first rib resection for thoracic outlet syndrome. Yim APC, Hazelrigg SR, Izzat MB, et al (eds): Minimal access cardiothoracic surgery, Philadelphia, Saunders, 2000, p. 333.)

Figure 29-6 Right-angle clamp around the top of the first rib.

Figure 29-7 Cutting the rib by the vertebral body.

Figure 29-8 Chest radiograph after resection of the left first rib.

(From Wolf RK, Crawford AH, Hahn B: Thoracoscopic first rib resection for thoracic outlet syndrome. In Yim APC, Hazelrigg SR, Izzat MB, et al (eds): Minimal access cardiothoracic surgery, Philadelphia, Saunders, 2000, p. 334.)

References

1 Poole G.V., Thomae K.R. Thoracic outlet syndrome reconsidered. Am Surg. 1996;62:287-291.

2 Ohtsuka T., Wolf R.K., Dunsker S.B. Port-access first-rib resection. Surg Endosc. 1999;13:940-942.

3 Yim A.P.C., Hazelrigg S.R., Izzat M.B., et al. Minimal access cardiothoracic surgery. Pheladelphia: Saunders, 2000.