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.

Related

Atlas of Minimally Invasive Thoracic Surgery (Vats)