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 1^st 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 1^st rib resection. The aim of this surgical technique manual is to describe and illustrate a RATS 1^st rib resection with its advantages over traditionally open approaches step by step.