Name: Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome (Video) | JoVE Journal
Uploaded: 2020-09-13T13:00:00.000+00:00
Duration: 6 min 57 s
Description: Learn transaxillary first rib resection for treating thoracic outlet syndrome caused by neurovascular compression. This surgical protocol demonstrates improved outcomes and lower recurrence rates compared to traditional approaches.

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This study was conducted in accordance with Declaration of Helsinki and local clinical ethics committee (2018/09).
1. Physical Examination
NOTE: The provocative tests for diagnosis of the TOS are depicted in Figure 1.
<ol>
	<li>For the Adson test (scalene test, Figure 1A), bring the patient&#8217;s shoulder to external rotation with slight abduction and a little bit of extension and palpate the radial pulse. Extend the patient&#8217;s head backward and rotate toward the tested shoulder. Ask the patient to breathe in and hold their breath.
	<ol>
		<li>Consider the test positive in cases where reproduction of symptoms or abolition of the radial pulse occurs while symptoms resolve with rotating of the head to the controlateral side.</li>
	</ol>
	</li>
	<li>For the costoclavicular brace test (Figure 1B), bring the patient&#8217;s arm to the back, depress and retract over the patients&#39; scapula on the ipsilateral side. Check the pulse. If the radial pulse disappears or symptoms are reproduced, the test is deemed positive.</li>
	<li>For the hyperabduction test (Figure 1C), slightly extend the patient&#8217;s arm and palpate the radial artery. Abduct the arm 90-180&#176;. A positive test is a decrease in the pulse of the radial artery from baseline to the new position.</li>
	<li>For the Roos (East) test (Figure 1D), perform the test in either a sitting or standing position. Take the patient&#8217;s shoulders to 90&#176; abduction, externally rotate, and flex elbows to 90&#176;. The elbows should be slightly behind the frontal plane. Have the patient open and close his/her hands for 3 minutes.
	<ol>
		<li>Consider the test positive if the patient experiences heaviness, ischemic pain or weakness of the arms or numbness and tingling of the hands. Discoloration of the hands is also meaningful for the test. 
		NOTE: Surgical treatment is the first option in VTOS cases, whereas surgical treatment is performed in NTOS cases after 3 months of conservative therapy without any improvement in their daily life, work life, and sleep quality.</li>
	</ol>
	</li>
</ol>
2. Preoperative clinical and electrodiagnostic assessment
<ol>
	<li>For evaluation of the clinical improvement with surgical treatment, make clinical findings in the physical examination, EMG findings, and the QuickDASH (Disability of Arm, Shoulder, and Hand: <a href="https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf">https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf</a>) questionnaire related to symptoms of daily activities and social and psychological preoperative periods.</li>
	<li>Determine the preoperative EMGs by measuring the compound motor action potential (CMAP), sensory nerve action potential (SNAP), and nerve conduction velocity (NCV) and F-wave latency. Make recordings using a commercial EMG/NCV/EP measuring system (e.g.,&#160;Nihon&#160;Kohden&#160;Neuropack 2).</li>
</ol>
3. Transaxillary first rib resection in a stepwise manner
<ol>
	<li>Perform anesthesia using a standard anesthetic induction protocol which includes 0.6 mg/kg rocuronium bromide, 0.05 mg/kg midazolam and 1-2 &#181;g/kg fentanyl.</li>
	<li>Administer tiopenthal sodium at 6 mg/kg for maintenance.</li>
</ol>
4. Patient position (Figure 2)
<ol>
	<li>After placing the patient in the lateral decubitus position, wrap the arm, elevate and hang in a 90&#176; abduction position. If needed, reduce traction every 3-5 minutes to prevent postoperative complication.</li>
	<li>Use a solution of 10% sterile povidone-iodine for topical sterilization. Drape the arm, axilla and chest. Use sterile sheets on to rest of the body to prevent contamination.</li>
</ol>
5. Reaching the first rib
<ol>
	<li>Use the surgical instruments are shown in Figure 3 and the Table of Materials.</li>
	<li>Make an incision in a transverse fashion below the axillary hairline extending from the pectoralis muscle anteriorly and the latissimus dorsi muscle posteriorly at a length of 5-7 cm.</li>
	<li>Cross the skin, subcutaneous tissue, and fascia to reach the anterior chest wall.</li>
	<li>Use blunt dissection to reach the first rib.</li>
</ol>
6. Releasing the first rib from muscles and fascia
<ol>
	<li>Pierce the fascia overlying the first rib and dissect away the periosteum overlying the superior part of the rib. Bluntly dissect the inferior edge of the rib from surrounding muscles using monopolar cautery and rib raspatory.</li>
	<li>Split the intercostal muscles until the costoclavicular ligament at the sternocostal junction and the angular costa in the posterior costovertebral junction.</li>
	<li>In the superior edge of the first rib, expose the anterior scalene muscle anteriorly and medius scalene muscle posteriorly. Place the curved forceps under the anterior and middle scalene muscles to cut the muscles at the level of their insertion over the first rib, where they are farthest from the neurovascular bundle.</li>
</ol>
7. Removal of the first rib or the cervical rib
<ol>
	<li>Start the resection of the first rib at the sternocostal junction anteriorly. First, turn from its superior edge and then the inferior edge to resect it using a rib cutter from the sternum. Ensure that the neurovascular structures are preserved.</li>
	<li>Afterwards, resect the posterior portion of the rib, and disarticulate the part located distally to the angle of rib; hence complete the rib resection.</li>
	<li>After totally freeing the cervical rib from surrounding tissue, resect and disarticulate the rib until the articular surface of the transverse process is seen.</li>
</ol>
8. Postoperative Period
<ol>
	<li>In postoperative period, perform a chest X-ray to rule out complications, such as pnomothorax.</li>
	<li>Remove the thorax drain on postoperative day 1 in uneventful cases.</li>
	<li>Use nonsteroidal anti-inflammatory drugs, narcotic analgesics, and a muscle relaxant for postoperative pain.</li>
	<li>In the early postoperative period, examine movement of the arm in the operated side. Continue physical therapy for the first two post-operative months.</li>
	<li>Advise the patient not to perform any exhausting activity with the operated side.</li>
</ol>
9. Postoperative clinical and electrodiagnostic assessment
<ol>
	<li>For evaluation of the clinical improvement with surgical treatment, compare clinical findings in the physical examination, EMG findings, and the QuickDASH (Disability of Arm, Shoulder, and Hand: <a href="https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf">https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf</a>) questionnaire related to symptoms of daily activities and social and psychological preoperative and postoperative (3 months) periods.</li>
	<li>Compare the preoperative and postoperative EMGs by measuring the compound motor action potential (CMAP), sensory nerve action potential (SNAP), and nerve conduction velocity (NCV) and F-wave latency. Make recordings using a commercial EMG/NCV/EP measuring system (e.g.,&#160;Nihon&#160;Kohden&#160;Neuropack 2).</li>
	<li>Perform the physical examination postoperatively to evaluate the pain and paresthesia.</li>
</ol>

<ol><li>Peet, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Thoracic+outlet+syndrome%3A+evaluation+of+a+therapeutic+exercise+program%5BTitle%5D)+AND+%22InProc+Mayo+Clinic%22%5BJournal%5D)">Thoracic outlet syndrome: evaluation of a therapeutic exercise program.</a> InProc Mayo Clinic. 31, 281-287 (1956).</li>
<li>Han, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transaxillary+approach+in+thoracic+outlet+syndrome%3A+the+importance+of+resection+of+the+first-rib%5BTitle%5D)+AND+%22European+Journal+of+Cardio-Thoracic+Surgery%22%5BJournal%5D)">Transaxillary approach in thoracic outlet syndrome: the importance of resection of the first-rib.</a> European Journal of Cardio-Thoracic Surgery. 24 (3), 428-433 (2003).</li>
<li>Yavuzer, Ş, Atinkaya, C., Tokat, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+predictors+of+surgical+outcome+in+patients+with+thoracic+outlet+syndrome+operated+on+via+transaxillary+approach%5BTitle%5D)+AND+%22European+Journal+of+Cardio-Thoracic+Surgery%22%5BJournal%5D)">Clinical predictors of surgical outcome in patients with thoracic outlet syndrome operated on via transaxillary approach.</a> European Journal of Cardio-Thoracic Surgery. 25 (2), 173-178 (2004).</li>
<li>Roos, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transaxillary+approach+for+first+rib+resection+to+relieve+thoracic+outlet+syndrome%5BTitle%5D)+AND+%22Annals+of+Surgery%22%5BJournal%5D)">Transaxillary approach for first rib resection to relieve thoracic outlet syndrome.</a> Annals of Surgery. 163 (3), 354(1966).</li>
<li>Jubbal, K. T., Zavlin, D., Harris, J. D., Liberman, S. R., Echo, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Morbidity+of+First+Rib+Resection+in+the+Surgical+Repair+of+Thoracic+Outlet+Syndrome%5BTitle%5D)+AND+%22Hand%22%5BJournal%5D)">Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome.</a> Hand. , 1558944718760037(2018).</li>
<li>Likes, K. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Lessons+learned+in+the+surgical+treatment+of+neurogenic+thoracic+outlet+syndrome+over+10+years%5BTitle%5D)+AND+%22Vascular+and+Endovascular+Surgery%22%5BJournal%5D)">Lessons learned in the surgical treatment of neurogenic thoracic outlet syndrome over 10 years.</a> Vascular and Endovascular Surgery. 49 (1-2), 8-11 (2015).</li>
<li>Akkuş, M., Yağmurlu, K., Özarslan, M., Kalani, M. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Surgical+outcomes+of+neurogenic+thoracic+outlet+syndrome+based+on+electrodiagnostic+tests+and+QuickDASH+scores%5BTitle%5D)+AND+%22Journal+of+Clinical+Neuroscience%22%5BJournal%5D)">Surgical outcomes of neurogenic thoracic outlet syndrome based on electrodiagnostic tests and QuickDASH scores.</a> Journal of Clinical Neuroscience. 58, 75-78 (2018).</li>
<li>Peek, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome%5BTitle%5D)+AND+%22Diagnostics%22%5BJournal%5D)">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7(2018).</li>
<li>Sanders, R. J., Annest, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Technique+of+supraclavicular+decompression+for+neurogenic+thoracic+outlet+syndrome%5BTitle%5D)+AND+%22Journal+of+Vascular+Surgery%22%5BJournal%5D)">Technique of supraclavicular decompression for neurogenic thoracic outlet syndrome.</a> Journal of Vascular Surgery. 61 (3), 821-825 (2015).</li>
<li>Sanders, R. J., Hammond, S. L., Rao, N. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Thoracic+outlet+syndrome%3A+a+review%5BTitle%5D)+AND+%22The+Neurologist%22%5BJournal%5D)">Thoracic outlet syndrome: a review.</a> The Neurologist. 14 (6), 365-373 (2008).</li>
<li>Vos, C. G., Ünlü, Ç, Voûte, M. T., van de Mortel, R. H., de Vries, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Thoracic+outlet+syndrome%3A+First+rib+resection%5BTitle%5D)+AND+%22Shanghai+Chest%22%5BJournal%5D)">Thoracic outlet syndrome: First rib resection.</a> Shanghai Chest. 1 (1), (2017).</li>
<li>Desai, S. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Outcomes+of+surgical+paraclavicular+thoracic+outlet+decompression%5BTitle%5D)+AND+%22Annals+of+vascular+surgery%22%5BJournal%5D)">Outcomes of surgical paraclavicular thoracic outlet decompression.</a> Annals of vascular surgery. 28 (2), 457-464 (2014).</li>
<li>Peek, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome%5BTitle%5D)+AND+%22Diagnostics%22%5BJournal%5D)">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7(2018).</li>
<li>Urschel, H. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transaxillary+first+rib+resection+for+thoracic+outlet+syndrome%5BTitle%5D)+AND+%22Operative+Techniques+in+Thoracic+and+Cardiovascular+Surgery%22%5BJournal%5D)">Transaxillary first rib resection for thoracic outlet syndrome.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 10 (4), 313-317 (2005).</li>
<li>Sheth, R. N., Campbell, J. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Surgical+treatment+of+thoracic+outlet+syndrome%3A+a+randomized+trial+comparing+two+operations%5BTitle%5D)+AND+%22Journal+of+Neurosurgery%3A+Spine%22%5BJournal%5D)">Surgical treatment of thoracic outlet syndrome: a randomized trial comparing two operations.</a> Journal of Neurosurgery: Spine. 3 (5), 355-363 (2005).</li>
<li>Urschel, H. C., Razzuk, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Neurovascular+compression+in+the+thoracic+outlet%3A+changing+management+over+50+years%5BTitle%5D)+AND+%22Annals+of+Surgery%22%5BJournal%5D)">Neurovascular compression in the thoracic outlet: changing management over 50 years.</a> Annals of Surgery. 228 (4), 609(1998).</li>
<li>Povlsen, B., Hansson, T., Povlsen, S. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Treatment+for+thoracic+outlet+syndrome%5BTitle%5D)+AND+%22Cochrane+Database+of+Systematic+Reviews%22%5BJournal%5D)">Treatment for thoracic outlet syndrome.</a> Cochrane Database of Systematic Reviews. 11, (2014).</li>
<li>George, R. S., Milton, R., Chaudhuri, N., Kefaloyannis, E., Papagiannopoulos, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Totally+endoscopic+%28VATS%29+first+rib+resection+for+thoracic+outlet+syndrome%5BTitle%5D)+AND+%22The+Annals+of+Thoracic+Surgery%22%5BJournal%5D)">Totally endoscopic (VATS) first rib resection for thoracic outlet syndrome.</a> The Annals of Thoracic Surgery. 103 (1), 241-245 (2017).</li>
<li>Strother, E., Margolis, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Robotic+first+rib+resection%5BTitle%5D)+AND+%22Operative+Techniques+in+Thoracic+and+Cardiovascular+Surgery%22%5BJournal%5D)">Robotic first rib resection.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 20 (2), 176-188 (2015).</li>
</ol>

TFRR is the most used surgical technique for treatment of TOS9,10,11. The advantage of the TFRR is that it provides a better cosmetic result with a hidden incision in the axilla without requirement of cutting the muscles to reach the surgical field. Its disadvantage is the relatively narrow and deep working space. The supraclavicular approach, which is preferred for arterial TOS treatment, puts the subclavian artery at less risk...

The compression of the brachial plexus, subclavian artery or vein in the scalene triangle is clinically known as thoracic outlet syndrome (TOS), first described by Peet et al.1. Thoracic outlet syndrome is subdivided into neurogenic (NTOS), arterial TOS, and venous TOS based on the underlying etiology1. Patients with NTOS (93-95% of TOS cases) present with pain, numbness, and ipsilateral weakness. Patients with venous TOS (3-5%) present with venous thrombosis, and patients with arterial TOS (1-2%) present with arterial thromboembolic event and ischemia. Conservative management of TOS includes medications and physiotherapy and is the first choice for TOS cases. The surgical treatment modalities include decompression procedures and are performed after conservative management has failed2. Decompression techniques include the transaxillary first rib resection (TFRR), supraclavicular first rib resection scalenectomy (SFRRS), scalenectomy (without first rib resection via supraclavicular or transaxillary), and posterior approach first rib resection (PA-FRR)3. The transaxillary first rib resection, a technique described by Roos et al. in 1966, is an effective method for treatment of TOS4,5. The main goal of TFRR is to completely remove the last cervical and first thoracic ribs and to decompress the underlying neurovascular bundle.
Vascular TOS (VTOS) are diagnosed with CT angiography, color duplex USG, and arteriography or venography, whereas the NTOS is diagnosed with X-ray, electrodiagnostic studies (needle electromyelography), color duplex Doppler USG, and cervical MRI. Physiotherapist and psychiatrist consultations should be obtained to exclude other disorders preoperatively.The symptom relief with lidocaine injection to the anterior scalene muscle is also a good indicator for diagnosis and predictor of surgical benefit in NTOS patients6.

<table><tbody><tr><td>Ag Debakey vascular forceps 24 cm, 3.5 mm</td><td>Lawton medizintechnik</td><td>30-0032</td><td>Check the hemorrhage</td></tr><tr><td>Bone chisels curved 13x9.1/2&#039;&#039;</td><td>Aesculap Inc.</td><td>MB-992R</td><td>Dissect the periost of the first rib</td></tr><tr><td>Doyen-stille retractor 24 cm</td><td>Lawton medizintechnik</td><td>20-0650</td><td>Skin- muscle retraction</td></tr><tr><td>Foerster sponge forceps straight</td><td>Lawton medizintechnik</td><td>07-0156</td><td>For swabbing</td></tr><tr><td>Luer stille bone rongeur curved 27 cm</td><td>Lawton medizintechnik</td><td>38-0703</td><td>Bone punches</td></tr><tr><td>Luer stille rongeur straight 22 cm</td><td>Lawton medizintechnik</td><td>38-0400</td><td>Rib cutter</td></tr><tr><td>Mayo hegar needle holder 20.5 cm</td><td>Lawton medizintechnik</td><td>08-0184</td><td>Suturing</td></tr><tr><td>Metzenbaum scissors curved delicate 23 cm</td><td>Lawton medizintechnik</td><td>05-0665</td><td>Dissection</td></tr><tr><td>Overholt curved forceps delicate 30.5 cm</td><td>Lawton medizintechnik</td><td>06-0807</td><td>Split the scalen muscles from the rib</td></tr><tr><td>Roberts art forceps straight 24 cm</td><td>Lawton medizintechnik</td><td>06-0370</td><td>For sponge and remove remain bone</td></tr><tr><td>Roux retractor medium size 15.5 cm</td><td>Lawton medizintechnik</td><td>20-0402</td><td>Wound retraction</td></tr><tr><td>Semb rasparotry 22,5 cm, 12mm</td><td>Lawton medizintechnik</td><td>39-0252</td><td>Dissect the muscle of the first rib</td></tr><tr><td>Smith peterson model curved osteotome 13x205 mm</td><td>Lawton medizintechnik</td><td>46-0783</td><td>Dissect the muscle of the first rib</td></tr><tr><td>Stille -giertz rib shears 27 cm</td><td>Lawton medizintechnik</td><td>38-0200</td><td>First rib cutting</td></tr><tr><td>Stille osteotome 8x205 mm</td><td>Lawton medizintechnik</td><td>46-0248</td><td>Dissect the periost of the first rib</td></tr><tr><td>Wagner rongeur 5.5x210 mm</td><td>Lawton medizintechnik</td><td>53-0703</td><td>Punches</td></tr></tbody></table>

transaxillary first rib resection for treatment of the thoracic outlet syndrome

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol has been used for the decompression of trapped neurovascular structures in the TOS. Among the other surgical procedures, the advantage of the TFRR is that it has the smallest rate of recurrence and better cosmetic outcomes. The disadvantage of TFRR is that it provides a narrow, and deep working corridor that makes obtaining vascular control challenging.

Clinical Outcomes 
A total of 15 patients were included in this study. Three patients (20%) were male and 12 of patients (80%) were female. The mean age of patients was 30.6 ± 8.98 years. All male participants and 5 of female participants were manual laborers. The most common complaint of the NTOS group was arm-forearm pain and numbness weakness of grip and hypothenar atrophy. In the postoperative clinical follow-up, patients were questioned about their paresthesia and pain severity, overall satisfact...

Here, we present a protocol of the transaxillary resection of the first rib for treatment of thoracic outlet syndrome caused by compression of the brachial plexus, subclavian vein and artery.

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...

transaxillary-first-rib-resection-for-treatment-thoracic-outlet

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Learn transaxillary first rib resection for treating thoracic outlet syndrome caused by neurovascular compression. This surgical protocol demonstrates improved outcomes and lower recurrence rates compared to traditional approaches.

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

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