Is a paradigm shift from conventional to robotic approaches necessary in first rib resection for thoracic outlet syndrome?

Introduction

The thoracic outlet is an anatomical area extending from the cervical spine and upper border of the mediastinum to the lateral aspect of the pectoralis minor muscle. Thoracic outlet syndrome (TOS) is characterized by a group of disorders resulting from the compression of the neurovascular bundle as it exits the thoracic outlet. This bundle includes the brachial plexus, the subclavian vein, and the subclavian artery. Compression can occur at various points of the thoracic outlet; however, it predominantly occurs in the scalene triangle (anterior scalene muscle anteriorly, middle scalene muscle posteriorly, and first rib inferiorly), costoclavicular space (between the clavicle and first rib), and retropectoralis minor space (between the pectoralis minor and subscapularis muscles) (1,2). In a recent study that analyzed prospectively collected data from the USA, the estimated annual TOS incidence was 2–4 cases per 100,000 people (3). However, owing to inconsistent reporting standards and the lack of objective criteria for reporting, the prevalence is likely to be underestimated. Furthermore, no definitive diagnostic test exists, and the accuracy of various diagnostic modalities is limited (1).

TOS is categorized into three main types based on the neurovascular bundle compression, neurogenic TOS (nTOS), venous TOS (vTOS), and arterial TOS (aTOS) (1,2). Accounting for >90% of cases, nTOS is caused by brachial plexus compression, leading to paresthesia, pain, and weakness. The second most common type is vTOS. The compression of the subclavian vein typically occurs in the costoclavicular space. It is characterized by swelling, heaviness, occasional cyanosis, and deep pain in the upper extremities (4). Accounting for <3% of all TOS cases, aTOS is caused by subclavian artery compression and manifests as pain, pallor, and coldness in the affected upper extremity.

First rib resection (FRR) is a surgical treatment for TOS and is conventionally performed using the supraclavicular, infraclavicular, and transaxillary approaches (5-8). However, these conventional approaches have limited surgical field due to the surrounding anatomical structures, which can result in incomplete resection of rib or damage to the neurovascular bundle. These challenges are particularly evident in patients with a short, thick neck, high body mass index (BMI), or well-developed surrounding musculature. With notable advancements in minimally invasive surgery, FRR via video-assisted thoracoscopic surgery (VATS) or robot-assisted thoracic surgery (RATS) has gained popularity (4,9-19). At our institution, we have performed FRR in patients with TOS for a long time, initially using the supraclavicular approach. More recently, we have transitioned to performing FRR via RATS. This study compares the surgical outcomes of FRR in patients with TOS via the supraclavicular approach and RATS. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-363/rc).

Methods

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of Asan Medical Center (approval No. 2024-0955). Due to the retrospective nature of the study and the anonymization of the data used in the analysis, obtaining patient consent was waived.

Patients

Patients with TOS who underwent surgery via the supraclavicular approach or RATS at the Asan Medical Center between October 2005 and July 2024 were included in this study. From 2005 to 2021, FRR was performed via the supraclavicular approach, whereas RATS has been performed since 2022. All surgeries were performed by Y.H.K. Patients with TOS typically presented to the outpatient clinic with neurologic symptoms, such as paresthesia, tingling sensation, pain, and weakness, or vascular symptoms, such as color change, coldness, swelling, heaviness, and fatigue in the upper extremity. Upon clinical suspicion of TOS, a comprehensive evaluation was conducted, including assessment of demographic characteristics, occupational and activity history, and any prior trauma. Following the initial evaluation, physical examination maneuvers, such as the Roos and the Wright tests, were performed to support the diagnosis. In the Roos test, the patient was instructed to abduct both shoulders to 90°, flex the elbows to 90°, and externally rotate the shoulders. While maintaining this position, the patient was asked to repeatedly open and close both hands. The test was considered positive if it reproduced neurologic symptoms. The Wright test was performed with the patient in a seated position. The examiner passively hyperabducted the affected arm while palpating the radial pulse. A diminished or absent pulse, or reproduction of symptoms, was indicative of a positive result. For nTOS, electromyography and nerve conduction velocity (EMG/NCV) tests, and brachial magnetic resonance imaging (MRI) were performed. In cases of suspected vascular TOS, enhanced computed tomography (CT) or magnetic resonance angiography (MRA) was performed. Imaging studies were conducted in both neutral and provocation positions, with the arms abducted and externally rotated. Imaging findings that may support the diagnosis include anatomical abnormalities such as cervical ribs, hypertrophy of the scalene muscles, broad bony structures, vascular narrowing upon arm abduction, intravascular thrombus formation, and the development of collateral circulation. For nTOS, initial management included non-surgical treatment for a minimum of 3 months, including physical therapy, postural correction, and activity modification. Surgical intervention was considered for patients who do not respond to conservative measures. However, in patients presenting with marked upper limb weakness or muscle atrophy, early surgical decompression was indicated. For vascular TOS, surgical intervention was performed when there was a lesion demonstrating hemodynamic compromise that correlates with the patient’s symptoms. In the presence of an intravenous thrombus, interventional thrombolysis was performed, followed by surgical treatment. To assess postoperative vascular patency in patients with vascular TOS, angiography was performed within 2 weeks after surgery. Clinicopathological and perioperative data of the enrolled patients were obtained from electronic medical records in a prospective database.

Surgical techniques

Supraclavicular approach

The patient is positioned supine with the head rotated opposite the incision. A 5 cm horizontal incision from the lateral border of the sternocleidomastoid muscle is made 1–2 cm above the clavicle. The subcutaneous layer and platysma are divided, and the scalene fat pad is separated from the sternocleidomastoid muscle. The omohyoid muscle is divided, deeper dissection exposes the anterior scalene muscle and phrenic nerve. After isolating the phrenic nerve, it is retracted gently. The anterior scalene muscle is separated from the first rib and the subclavian artery and brachial plexus are identified. With the subclavian artery and brachial plexus retracted, the middle scalene muscle is divided. The first rib is resected with a rib cutter and rongeur at the T1 transverse process level posteriorly and costal cartilage anteriorly. After drain system insertion, wound closure is performed.

RATS

The patient is placed in the lateral decubitus position with a double-lumen endotracheal tube. The operating table is bent at the level of the xiphoid process. Three 8-mm ports [4^th intercostal space (ICS) in the anterior axillary line, 5^th ICS in the posterior axillary line, and 6^th ICS in the midaxillary line for the camera] and one 10 mm assistant port (5^th or 6^th ICS in the anterior axillary line) are inserted (Figure 1A,1B). Carbon dioxide insufflation is performed at a pressure of 6–10 mmHg to provide a clear view of the surgical field. The Da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA, USA) is docked with Prograsp forceps and a permanent cautery hook. After thorough exploration of the intrathoracic anatomy, the parietal pleura below the first rib is opened. The intercostal muscle and remnant pleura are dissected along the upper and lower border of the first rib. After sufficient dissection of the first rib, two gauze balls are packed behind the division site of the first rib, and the robotic system is de-docked. The gauze balls prevent injury to the surrounding soft tissues during the resection. In VATS, a Midas Rex MR8 high-speed drill system (Medtronic, Minneapolis, MN, USA) is used to grind the cortex to approximately half of the bone thickness of the first rib (Figure 1C). The remaining portion of the rib is resected using a 6-mm thoracoscopic Kerrison bone cutter (Depuy Inc., Raynham, MA, USA) or a 10-mm Dennis rib cutter (Scanlan International, Inc., Saint Paul, MN, USA) (Figure 1D,1E). The first rib is resected anteriorly at the costal cartilage level and posteriorly at the transverse process level. After re-docking the robotic system, the remnant muscles attached to the first rib, including the anterior and middle scalene and the subclavius muscles, are divided (Figure 2A-2C). Once the first rib is freed from the soft tissue, it is removed through an assistant port (Figure 2D). To ensure adequate decompression of the neurovascular bundle, anterior and middle scalenectomy is performed, along with fibrous soft tissue resection around the neurovascular bundle. A Baro-Vac drainage device (Sewoon Medical Co., Chungnam, South Korea) is placed after hemostasis. The surgical procedure is presented in Video 1.

Figure 1 Ports placement and instruments in robotic surgery. (A,B) Placement of ports in robotic surgery; (C) Midas Rex MR8 high-speed drill system; (D) a 6-mm thoracoscopic Kerrison bone cutter; (E) a 10-mm Dennis rib cutter.

Figure 2 Surgical view and gross finding RATS for FRR. (A) Operative field before FRR; (B) operative field after FRR; (C) exposed subclavian vein, subclavian artery, and brachial plexus following FRR; and (D) gross finding of resected first rib. Dashed line, remnant costal cartilage of the first rib. BP, brachial plexus; FRR, first rib resection; RATS, robot-assisted thoracic surgery; SA, subclavian artery; SV, subclavian vein.

Definition of variables

Postoperative pain was assessed at 8-hour intervals using the numerical rating scale (NRS) (20), and the highest pain score until discharge was recorded. The operation time was defined as the interval from skin incision to closure. All patients underwent outpatient follow-up at 2 and 10 weeks after discharge. Further outpatient follow-up was determined based on the existing symptoms. Clinical outcomes were evaluated using the Derkash classification and the patient’s subjective degree of improvement, assessed at each outpatient visit (21). Derkash classification comprises the following four categories: excellent (no pain and easy return to preoperative professional and leisure activities), good (intermittent well-tolerated pain and potential return to preoperative activities), fair (intermittent pain with poor tolerance and difficulty in preoperative professional and leisure activities), and poor (no improvement or aggravated symptoms). The patients’ subjective degree of improvement was assessed through an outpatient clinic or telephonic interview, ranging from 0% to 100%. The most recent follow-up was performed in November 2024. To analyze the relationship between symptom duration and improvement duration, early recovery was defined as “excellent” or “good” improvement according to the Derkash classification during the second outpatient visit.

Statistical analysis

Categorical data are expressed as frequencies and percentages and are compared using the Chi-squared or Fisher’s exact tests. Continuous data are presented as medians and ranges and are compared using Student’s t-test or the Wilcoxon rank-sum test. Statistical analyses were performed using R, version 4.4.1 (The R Foundation for Statistical Computing, Vienna, Austria). Statistical significance was set at P values <0.05.

Results

Between October 2005 and July 2024, 23 FRRs were performed for 21 patients. Table 1 presents the baseline characteristics of enrolled patients. The median age was 28 years (range, 21–68 years), with 8 (38.1%) female patients. The median BMI was 23.7 kg/m² (range, 20.5–42.5 kg/m²), and 10 (47.6%) patients had right-sided TOS. Five (23.8%) patients had bilateral TOS, and two of them underwent staged operations conducted several months apart. The median preoperative symptom duration was 16 months (range, 1–78 months), and 17 (81.0%) patients received treatment at multiple hospitals because of inaccurate diagnoses. Among them, three patients were misdiagnosed with carpal tunnel syndrome and underwent surgery. Twelve (57.1%) patients were non-office workers, whereas the remaining were office workers or students. Five (23.8%) patients had a trauma history, and 5 (23.8%) were engaged in repetitive tasks. Most patients were diagnosed with nTOS (15/21, 71.4%) and the predominant symptoms were paresthesia (93.3%), pain (80.0%), and weakness (53.3%). All patients with vTOS complained of swelling, and three of the five patients experienced color changes. A patient with aTOS reported color change and pain. Symptoms were typically exacerbated by Roos or Wright tests. In patients with nTOS, abnormal findings were detected in 12 (80.0%) patients by MRI and in only 3 (20.0%) patients by the EMG/NCV test. The most common MRI finding was extrinsic compression of the neurovascular bundle. Asymmetric anatomical abnormalities, including cervical spine, fibrotic bands, costoclavicular narrowing, vascular injuries, and fractures, were also observed. In 20% of patients who underwent surgical treatment for nTOS, MRI findings were unremarkable. However, surgery was performed based on strong clinical suspicion following comprehensive history-taking and physical examination, with informed consent obtained after thorough counseling regarding diagnostic uncertainty and imaging limitations. Most of the patients (13/17, 76.5%) with nTOS in this study received preoperative physical therapy, and the median duration of physical therapy was 4 months (range, 3–8 months). However, because their symptoms did not improve with non-surgical treatment, surgery was subsequently performed. Among the 23 FRR cases, 13 underwent RATS. The median operation time was 96 min (range, 63–211 min) [supraclavicular approach, 80 min (range, 63–90 min); RATS, 105 min (range, 70–211 min); P=0.14]. The median highest NRS pain score was 3 (range, 1–7). Injury to the subclavian artery during RATS was reported in one case, which was successfully repaired without further complications. One patient included in this study demonstrated fusion of the first and second ribs on preoperative imaging. As only the second rib was resected during the initial surgery, the patient’s symptoms persisted, necessitating an additional procedure. The median duration of drainage and hospital stay was 1.6 days (range, 0.5–5.0 days) and 2.0 days (range, 2.0–7.0 days), respectively. Based on the Derkash classification, clinical outcomes were categorized as “excellent” in 19 patients (82.6%). The median subjective degree of improvement was 95% (range, 60–100%) (Table 2). A comparison of perioperative characteristics revealed a substantial difference only in the postoperative peak NRS pain score between the supraclavicular approach and RATS (4.5 vs. 3; P=0.02). When patients were categorized based on the median duration of symptoms, a shorter duration was associated with early recovery (P=0.02 for all TOS cases; P=0.08 for nTOS cases) (Table 3).

Discussion

This study retrospectively reviewed the surgical outcomes of FRR in patients with TOS. All FRR procedures were successfully performed by a single surgeon via the supraclavicular approach or RATS. Additionally, a detailed account of both techniques is described.

TOS is often underestimated because of its ambiguous symptoms and the lack of definitive diagnostic tests. This ambiguity could prolong the symptom duration and delay treatment. Furthermore, many patients are incorrectly diagnosed, leading to multiple hospital visits or unnecessary surgeries or procedures. Table 1 shows the frequency of abnormal findings of EMG/NCV and MRI in patients with nTOS. Notably, the EMG/NCV test showed abnormal results in only 20% of symptomatic nTOS patients, corroborating previous findings (2,9). Therefore, its diagnostic utility is limited to distinguishing conditions, such as carpal tunnel syndrome or ulnar nerve compression. However, brachial MRI revealed abnormal findings in 80% of symptomatic nTOS patients (Figure 3). Hardy et al. reported that MRI exhibited high specificity in diagnosing TOS when correlating MRI interpretations with intraoperative findings despite its low sensitivity. Specifically, the presence of a cervical rib showed 100% sensitivity and specificity, whereas hypertrophy of the anterior scalene, subclavius, and pectoralis minor muscles exhibited a sensitivity and specificity of >80% (22). Therefore, brachial MRI has considerable diagnostic value in suspected nTOS cases. CT and MRA are recommended for vascular TOS and play a conclusive role. They are not only effective in identifying the lesion causing symptoms but also in assessing postoperative patency (1,11).

Figure 3 Abnormal imaging findings of TOS. Presence of cervical rib observed in (A) simple chest radiography, (B) coronal view of CT, and (C) T1-weighted MRI. Fusion of the first and second ribs observed in (D) simple chest radiography, (E) coronal view of CT, and (F) T1-weighted MRI. CT, computed tomography; MRI, magnetic resonance imaging; TOS, thoracic outlet syndrome.

A recent consensus from several authors recommends conservative treatment as the initial approach for nTOS, except for vascular TOS and some nTOS cases (23). In nTOS, conservative treatments such as pain control and physiotherapy often alleviate symptoms effectively; therefore, non-surgical treatment is recommended before considering surgery. However, there are currently no clear guidelines regarding the optimal duration of conservative treatment, with reported periods ranging from 1 to over 6 months. This highlights the need for large-scale prospective studies in the future (13-15,24). At our institution, surgical intervention was considered for patients who did not experience symptom improvement after at least 3 months of conservative treatment, those who exhibited muscle hypotrophy or weakness, and those with clear anatomical abnormalities on imaging. In patients with vascular TOS, surgery was performed when symptoms were present and abnormal findings were observed on imaging. Subclavian vein thrombosis, commonly observed in vascular TOS, is referred to as Paget-Schroetter syndrome. This condition is typically caused by external vascular compression and may serve as a key diagnostic indicator. Zehnder et al. recommended performing FRR between 2 and 4 weeks after interventional thrombolysis in patients with Paget-Schroetter syndrome. They explained that this timing aims to avoid perivenous inflammation-related injury within the first 2 weeks and to reduce the risk of recurrent thrombosis if the procedure is delayed beyond 4 weeks (14).

Based on the Derkash classification, evaluating the clinical outcomes of the surgery, most cases (95.7%) were classified as “excellent” or “good”, and the median subjective degree of improvement was 95% (range, 60–100%). Overall, FRR performed in appropriately selected patients generally yielded satisfactory outcomes. Furthermore, among the patients who underwent FRR, basketball and kendo players achieved nearly 100% functional recovery and were able to continue their sports activities postoperatively. Generally, patients with a high BMI, thick chest wall, and well-developed surrounding muscles face considerable difficulties in conventional open surgery. However, FRR via RATS offers distinct advantages in such cases by providing a clear surgical view and minimizing restrictions on the surrounding anatomical structures. One of the patients included in this study had a BMI approaching 42.5 kg/m²; however, successful robotic FRR was performed without conversion or any complications.

Conventional approaches for FRR include the supraclavicular, infraclavicular, and transaxillary approaches (5-8). With advancements in minimally invasive surgery, FRR via VATS and RATS has gained popularity (4,9-16). Burt et al. compared the surgical outcomes of 66 patients who underwent robotic FRR and 50 patients who underwent supraclavicular FRR. They reported that the former group required less postoperative analgesics (P<0.001) and had a lower incidence of brachial plexus palsy than the latter group (1% vs. 18%; P=0.002) (13). Palivela et al. reported that robotic FRR results in a lower pain score (P=0.02) and greater pain improvement (P=0.008) at the first postoperative visit (2.4 weeks) compared to supraclavicular FRR (15). Similar results were observed in this study, with the robotic FRR group showing better postoperative pain outcomes than the supraclavicular FRR group (NRS score, 4.5 vs. 3; P=0.02) (Table 2). Although scars from supraclavicular incisions may be visible when wearing everyday clothing, RATS offers cosmetic benefits by avoiding visible scars. RATS also provides clear visual information using a high-definition camera, allowing meticulous dissection and more delicate decompression of the sheath and soft tissues around the neurovascular bundle. Moreover, it reduces the risk of neurovascular bundle injury by avoiding the direct manipulation of structures compared to conventional approaches. Therefore, although the differences in surgical outcomes may not be notable, surgeons and patients may prefer the robotic surgical approach.

One patient in this study showed fusion of the first and second ribs on preoperative imaging, with symptoms persisting after initial surgery. Postoperative chest radiography revealed that only the second rib had been resected. Following additional FRR, the patient’s symptoms improved. This highlights the importance of complete resection of the anatomical structures causing compression to achieve favorable surgical outcomes. Moreover, complete resection and destruction of the periosteum are known to be crucial factors in preventing recurrence and rib regrowth (25,26). Therefore, it is important to avoid leaving a long posterior stump during the surgical resection. At our institution, the first rib was resected anteriorly at the costal cartilage level and posteriorly at the transverse process level.

No study has investigated the relationship between the duration of symptoms and improvement in patients with TOS who underwent FRR. Chang et al. reported that approximately 75% of patients returned to full-time work within 5 months postoperatively, whereas it took approximately 23 months to regain a normal quality of life and approximately 12 months to recover their mental function (27). Panda et al. compared patients whose symptoms improved after surgical treatment with those who did not and found no difference in the time from symptom onset to surgery between them (8). However, we believe that a correlation exists between the duration of symptoms and duration of improvement (Table 3). Patients with a shorter duration of symptoms experienced rapid improvement. The reason for these results remains unclear, and further research with a larger sample size is warranted to explore this correlation in detail.

This study has several limitations. This may have been subject to bias owing to its retrospective nature and relatively small sample size. Furthermore, only two different approaches were analyzed in this study, precluding comparisons with other approaches. Existing issues in TOS research, including the lack of a standardized reporting system and reliance on subjective patient symptoms as the primary measure of treatment efficacy, remain unresolved.

Conclusions

TOS is often underestimated because of its ambiguous symptoms and lack of definitive diagnostic tests, necessitating thorough examination and assessment. In appropriately selected patients with TOS, both supraclavicular and robotic FRR yield excellent surgical long-term outcomes. However, given its various advantages, robotic FRR should be considered the new gold standard when a robotic system is available at the institution.

Acknowledgments

We would like to thank Editage (https://www.editage.co.kr/) for English language editing. We also gratefully acknowledge the support provided by Sungchul Kim (Youngjin Angle Co., Ltd.) during the course of this study.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-363/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-363/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-363/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-363/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of Asan Medical Center (approval No. 2024-0955). Due to the retrospective nature of the study and the anonymization of the data used in the analysis, obtaining patient consent was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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