Diese Studie wurde in Übereinstimmung mit der Deklaration von Helsinki und der lokalen klinischen Ethikkommission (2018/09) durchgeführt.
1. Körperliche Untersuchung
HINWEIS: Die provokativen Tests für die Diagnose des TOS sind in Abbildung 1 dargestellt.
<ol><li>Für den Adson-Test (Scalene-Test, Abbildung 1A) wird die Schulter des Patienten mit leichter Abduktion und etwas Streckung in eine Außenrotation gebracht und der radiale Puls abgetastet. Strecken Sie den Kopf des Patienten nach hinten und drehen Sie ihn in Richtung der getesteten Schulter. Bitten Sie den Patienten, einzuatmen und den Atem anzuhalten.<ol><li>Betrachten Sie den Test als positiv in Fällen, in denen die Reproduktion der Symptome oder die Aufhebung des radialen Pulses auftritt, während die Symptome durch Drehung des Kopfes auf die kontroverse Seite verschwinden.</li>
	</ol></li>
	<li>Für den Costoclavicular-Orthesentest (Abbildung 1B) wird der Arm des Patienten nach hinten gebracht, auf der ipsilateralen Seite über das Schulterblatt des Patienten gedrückt und zurückgezogen. Prüfen Sie den Puls. Wenn der radiale Puls verschwindet oder Symptome auftreten, gilt der Test als positiv.</li>
	<li>Für den Hyperabduktionstest (Abbildung 1C) wird der Arm des Patienten leicht gestreckt und die Arteria radialis abgetastet. Den Arm um 90-180° abziehen. Ein positiver Test ist eine Abnahme des Pulses der Arteria radialis vom Ausgangswert bis zur neuen Position.</li>
	<li>Für den Roos-Test (Ost) (Abbildung 1D) wird der Test entweder im Sitzen oder im Stehen durchgeführt. Nehmen Sie die Schultern des Patienten auf 90° Abduktion, drehen Sie sie nach außen und beugen Sie die Ellbogen bis zu 90°. Die Ellbogen sollten sich leicht hinter der Frontalebene befinden. Lassen Sie den Patienten seine Hände 3 Minuten lang öffnen und schließen.<ol><li>Betrachten Sie den Test als positiv, wenn der Patient Schweregefühl, ischämische Schmerzen oder Schwäche der Arme oder Taubheitsgefühl und Kribbeln in den Händen verspürt. Auch Verfärbungen der Hände sind für den Test aussagekräftig. HINWEIS: Die chirurgische Behandlung ist die erste Option in VTOS-Fällen, während die chirurgische Behandlung in NTOS-Fällen nach 3 Monaten konservativer Therapie ohne Verbesserung des täglichen Lebens, des Arbeitslebens und der Schlafqualität durchgeführt wird.</li>
	</ol></li>
</ol>2. Präoperative klinische und elektrodiagnostische Beurteilung
<ol><li>Um die klinische Verbesserung durch die chirurgische Behandlung zu bewerten, machen Sie klinische Befunde in der körperlichen Untersuchung, EMG-Befunde und den QuickDASH-Fragebogen (Behinderung von Arm, Schulter und 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>) in Bezug auf die Symptome der täglichen Aktivitäten und der sozialen und psychologischen präoperativen Phasen.</li>
	<li>Bestimmen Sie die präoperativen EMGs, indem Sie das zusammengesetzte motorische Aktionspotenzial (CMAP), das sensorische Nervenaktionspotenzial (SNAP) und die Nervenleitgeschwindigkeit (NCV) sowie die F-Wellen-Latenz messen. Machen Sie Aufnahmen mit einem handelsüblichen EMG/NCV/EP-Messsystem (z. B. Nihon Kohden Neuropack 2).</li>
</ol>3. Schrittweise transaxilläre erste Rippenresektion
<ol><li>Führen Sie die Anästhesie mit einem Standard-Anästhesie-Induktionsprotokoll durch, das 0,6 mg/kg Rocuroniumbromid, 0,05 mg/kg Midazolam und 1-2 μg/kg Fentanyl enthält.</li>
	<li>Verabreichen Sie Tiopenthal-Natrium in einer Dosis von 6 mg/kg zur Erhaltung.</li>
</ol>4. Patientenposition (Abbildung 2)
<ol><li>Nachdem der Patient in die seitliche Dekubitusposition gebracht wurde, wird der Arm umwickelt, angehoben und in einer 90°-Abduktionsposition aufgehängt. Reduzieren Sie bei Bedarf die Traktion alle 3-5 Minuten, um postoperative Komplikationen zu vermeiden.</li>
	<li>Verwenden Sie eine Lösung aus 10% sterilem Povidon-Jod für die topische Sterilisation. Arm, Achselhöhle und Brust drapieren. Verwenden Sie sterile Laken auf dem Rest des Körpers, um eine Kontamination zu vermeiden.</li>
</ol>5. Das Erreichen der ersten Rippe
<ol><li>Verwendung Die chirurgischen Instrumente sind in Abbildung 3 und in der Materialtabelle dargestellt.</li>
	<li>Unterhalb des axillären Haaransatzes wird ein Schnitt in Querrichtung gemacht, der sich vom Musculus pectoralis anterior und dem Musculus latissimus dorsi posterior mit einer Länge von 5-7 cm erstreckt.</li>
	<li>Durchqueren Sie die Haut, das Unterhautgewebe und die Faszien, um die vordere Brustwand zu erreichen.</li>
	<li>Verwende eine stumpfe Dissektion, um die erste Rippe zu erreichen.</li>
</ol>6. Lösen der ersten Rippe von Muskeln und Faszien
<ol><li>Durchstechen Sie die Faszie, die über der ersten Rippe liegt, und trennen Sie das Periost über dem oberen Teil der Rippe weg. Sezieren Sie stumpf den unteren Rand der Rippe von den umgebenden Muskeln mit monopolarem Kauter und Rippenraspel.</li>
	<li>Spalten Sie die Interkostalmuskeln bis zum Costoclavicularband am Sternokostalübergang und der Angulara am hinteren Rippenobertebralübergang.</li>
	<li>Am oberen Rand der ersten Rippe wird der Musculus scalene anterior und der Musculus scalene mediaus posterior freigelegt. Platzieren Sie die gekrümmte Pinzette unter den vorderen und mittleren Skalenmuskeln, um die Muskeln auf Höhe ihres Ansatzes über der ersten Rippe zu schneiden, wo sie am weitesten vom neurovaskulären Bündel entfernt sind.</li>
</ol>7. Entfernung der ersten Rippe oder der Halsrippe
<ol><li>Beginnen Sie mit der Resektion der ersten Rippe am sternocostalen Übergang anterior. Drehen Sie sich zuerst von der oberen Kante und dann von der unteren Kante, um sie mit einem Rippenschneider vom Brustbein aus zu resezieren. Stellen Sie sicher, dass die neurovaskulären Strukturen erhalten bleiben.</li>
	<li>Danach resezieren Sie den hinteren Teil der Rippe und disartikulieren den Teil, der sich distal zum Rippenwinkel befindet; Beenden Sie daher die Rippenresektion.</li>
	<li>Nachdem Sie die Halsrippe vollständig vom umgebenden Gewebe befreit haben, resezieren und disartikulieren Sie die Rippe, bis die Gelenkfläche des Querfortsatzes sichtbar ist.</li>
</ol>8. Postoperative Phase
<ol><li>Führen Sie in der postoperativen Phase eine Röntgenaufnahme des Brustkorbs durch, um Komplikationen wie einen Pnomothorax auszuschließen.</li>
	<li>Entfernen Sie die Thoraxdrainage am postoperativen Tag 1 in ereignislosen Fällen.</li>
	<li>Verwenden Sie nichtsteroidale Antirheumatika, narkotische Analgetika und ein Muskelrelaxans gegen postoperative Schmerzen.</li>
	<li>In der frühen postoperativen Phase ist die Bewegung des Arms auf der operierten Seite zu untersuchen. Setzen Sie die Physiotherapie in den ersten beiden postoperativen Monaten fort.</li>
	<li>Weisen Sie den Patienten darauf hin, keine anstrengenden Aktivitäten mit der operierten Seite auszuführen.</li>
</ol>9. Postoperative klinische und elektrodiagnostische Beurteilung
<ol><li>Um die klinische Verbesserung durch die chirurgische Behandlung zu bewerten, vergleichen Sie die klinischen Befunde der körperlichen Untersuchung, die EMG-Befunde und den QuickDASH-Fragebogen (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>) in Bezug auf die Symptome der täglichen Aktivitäten und die sozialen und psychologischen prä- und postoperativen (3 Monate) Perioden.</li>
	<li>Vergleichen Sie die präoperativen und postoperativen EMGs, indem Sie das zusammengesetzte motorische Aktionspotenzial (CMAP), das sensorische Nervenaktionspotenzial (SNAP) und die Nervenleitgeschwindigkeit (NCV) und die F-Wellen-Latenz messen. Machen Sie Aufnahmen mit einem handelsüblichen EMG/NCV/EP-Messsystem (z. B. Nihon Kohden Neuropack 2).</li>
	<li>Führen Sie die körperliche Untersuchung postoperativ durch, um die Schmerzen und Parästhesien zu beurteilen.</li>
</ol>

<ol>
	<li>Peet, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+evaluation+of+a+therapeutic+exercise+program.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+approach+in+thoracic+outlet+syndrome:+the+importance+of+resection+of+the+first-rib.">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, &. #. 3. 5. 0. ;., Atinkaya, C., Tokat, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+predictors+of+surgical+outcome+in+patients+with+thoracic+outlet+syndrome+operated+on+via+transaxillary+approach.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+approach+for+first+rib+resection+to+relieve+thoracic+outlet+syndrome.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Morbidity+of+First+Rib+Resection+in+the+Surgical+Repair+of+Thoracic+Outlet+Syndrome.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lessons+learned+in+the+surgical+treatment+of+neurogenic+thoracic+outlet+syndrome+over+10+years.">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>Akku&#351;, M., Ya&#287;murlu, K., &#214;zarslan, M., Kalani, M. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+outcomes+of+neurogenic+thoracic+outlet+syndrome+based+on+electrodiagnostic+tests+and+QuickDASH+scores.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique+of+supraclavicular+decompression+for+neurogenic+thoracic+outlet+syndrome.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+a+review.">Thoracic outlet syndrome: a review.</a> The Neurologist. 14 (6), 365-373 (2008).</li><li>Vos, C. G., &#220;nl&#252;, &. #. 1. 9. 9. ;., Vo&#251;te, M. T., van de Mortel, R. H., de Vries, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+First+rib+resection.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcomes+of+surgical+paraclavicular+thoracic+outlet+decompression.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+first+rib+resection+for+thoracic+outlet+syndrome.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+thoracic+outlet+syndrome:+a+randomized+trial+comparing+two+operations.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neurovascular+compression+in+the+thoracic+outlet:+changing+management+over+50+years.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+for+thoracic+outlet+syndrome.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Totally+endoscopic+(VATS)+first+rib+resection+for+thoracic+outlet+syndrome.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+first+rib+resection.">Robotic first rib resection.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 20 (2), 176-188 (2015).</li></ol>

TFRR ist die am häufigsten verwendete Operationstechnik zur Behandlung von TOS 9,10,11. Der Vorteil der TFRR besteht darin, dass sie ein besseres kosmetisches Ergebnis mit einem versteckten Schnitt in der Achselhöhle liefert, ohne dass die Muskeln durchtrennt werden müssen, um das Operationsfeld zu erreichen. Sein Nachteil ist der relativ schmale und tiefe Arbeitsraum. Der supraklavikuläre Zugang, der für die arterielle TOS...

Die Kompression des Plexus brachialis, der Arteria subclavia oder der Vene im Skalendreieck wird klinisch als Thoracic Outlet Syndrom (TOS) bezeichnet, das erstmals von Peet et al.1 beschrieben wurde. Das Thoracic Outlet Syndrom wird basierend auf der zugrunde liegenden Ätiologie in neurogene (NTOS), arterielle TOS und venöse TOS unterteilt1. Patienten mit NTOS (93-95% der TOS-Fälle) stellen sich mit Schmerzen, Taubheitsgefühl und ipsilateraler Schwäche vor. Patienten mit venösem TOS (3-5 %) stellen sich mit venöser Thrombose und Patienten mit arteriellem TOS (1-2 %) mit arteriellem thromboembolischem Ereignis und Ischämie vor. Die konservative Behandlung des TOS umfasst Medikamente und Physiotherapie und ist die erste Wahl bei TOS-Fällen. Die chirurgischen Behandlungsmodalitäten umfassen Dekompressionsverfahren und werden nach Versagen der konservativen Therapie durchgeführt2. Zu den Dekompressionstechniken gehören die transaxilläre erste Rippenresektion (TFRR), die supraklavikuläre erste Rippenresektion Scalenektomie (SFRRS), die Skalenektomie (ohne erste Rippenresektion supraklavikulär oder transaxillär) und die posteriore erste Rippenresektion (PA-FRR)3. Die transaxilläre erste Rippenresektion, eine Technik, die 1966 von Roos et al. beschrieben wurde, ist eine effektive Methode zur Behandlung des TOS 4,5. Das Hauptziel der TFRR ist es, die letzten Hals- und ersten Brustrippen vollständig zu entfernen und das darunter liegende neurovaskuläre Bündel zu dekomprimieren.
Vaskuläre TOS (VTOS) werden mit CT-Angiographie, Farbduplex-USG und Arteriographie oder Venographie diagnostiziert, während das NTOS mit Röntgen, elektrodiagnostischen Untersuchungen (Nadelelektromyelographie), Farbduplex-Doppler-USG und zervikaler MRT diagnostiziert wird. Physiotherapeuten und Psychiater sollten konsultiert werden, um andere Erkrankungen präoperativ auszuschließen. Die Symptomlinderung mit Lidocain-Injektion in den vorderen Skalenmuskel ist ebenfalls ein guter Indikator für die Diagnose und Prädiktor für den chirurgischen Nutzen bei NTOS-Patienten6.

<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&#39;&#39;</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

Das Thoracic-Outlet-Syndrom (TOS) ist eine häufige Erkrankung, die zu einem erheblichen Produktivitätsverlust führt. Das Protokoll der transaxillären ersten Rippenresektion (TFRR) wurde für die Dekompression von eingeklemmten neurovaskulären Strukturen im TOS verwendet. Unter den anderen chirurgischen Verfahren besteht der Vorteil des TFRR darin, dass es die geringste Rezidivrate und bessere kosmetische Ergebnisse aufweist. Der Nachteil von TFRR besteht darin, dass es einen schmalen und tiefen Arbeitskorridor bietet, der die Gefäßkontrolle erschwert.

Klinische Ergebnisse Insgesamt wurden 15 Patienten in diese Studie eingeschlossen. Drei Patienten (20%) waren männlich und 12 der Patienten (80%) weiblich. Das Durchschnittsalter der Patienten betrug 30,6 ± 8,98 Jahre. Alle männlichen Teilnehmer und 5 der weiblichen Teilnehmer waren Handarbeiter. Die häufigste Beschwerde der NTOS-Gruppe waren Arm-Unterarm-Schmerzen und Taubheitsgefühle, Griffschwäche und hypothenare Atrophie. In der postoperativen klinischen Nachsorge wurden die Patienten zu ihr...

Watch this Scientific Journal Video about Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome at JoVE.com

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Hier präsentieren wir ein Protokoll der transaxillären Resektion der ersten Rippe zur Behandlung des Thorax-Outlet-Syndroms, das durch Kompression des Plexus brachialis, der Vena subclavia und der Arterie verursacht wird.

Transaxilläre erste Rippenresektion zur Behandlung des Thoracic-Outlet-Syndroms

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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JoVE Journal

Medicine

2.7K Aufrufe.  Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital. Hier präsentieren wir ein Protokoll der transaxillären Resektion der ersten Rippe zur Behandlung des Thorax-Outlet-Syndroms, das durch Kompression des Plexus brachialis, der Vena subclavia und der Arterie verursacht wird.

Serie: Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Isolated Hepatic Perfusion as a Treatment for Liver Metastases of Uveal Melanoma

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic agent melphalan. Briefly, the procedure starts with the setup of a percutaneous veno-venous bypass from the femoral vein to the external jugular vein. Via a laparotomy, catheters are then inserted into the proper hepatic artery and the caval vein. The portal vein and the caval vein, both supra- and infrahepatically, are then clamped. The arterial and venous catheters are connected to a heart lung machine and the liver is perfused with melphalan (1 mg/kg body weight) for 60 min. This way it is possible to locally perfuse the liver with a high dose of a chemotherapeutic agent, without leakage to the systemic circulation.
In previous studies including patients with isolated liver metastases of uveal melanoma, an overall response rate of 33-100% and a median survival between 9 and 13 months, have been reported. The aim of this protocol is to give a clear description of how to perform the procedure and to discuss IHP as a treatment option for liver metastases of uveal melanoma.

Here, we present a protocol how to perform an isolated liver perfusion (IHP) with melphalan and we also discuss IHP as a treatment option for liver metastases of uveal melanoma.

Isolierte Leberperfusion als Behandlung für Lebermetastasen von Aderhautmelanom

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic ...

Forschung

Medizin

Surgical Models of Gastroesophageal Reflux with Mice

Multiple surgical procedures have been reported to induce gastroesophageal reflux in animals. Herein, we report three surgical models with mice aiming to induce reflux of gastric contents, duodenal contents or mixed contents. Surgical procedures and general principles have been described in detail. A researcher with surgical experience should be able to grasp the technique after a short period of practice. After surgery, most mice can survive and develop reflux esophagitis similar to that in humans. However, it should be noted that histological differences between mouse and human esophagus are the inherent limitations of these surgical models. If used for research on Barrett&#8217;s esophagus and adenocarcinoma, these procedures may need to be combined with genetic modifications.

This article demonstrates surgical procedures of gastroesophageal reflux with mice. These models are useful tools for research on mechanisms and treatment of gastroesophageal reflux disease and potentially Barrett&#8217;s esophagus and esophageal adenocarcinoma.

Chirurgische Modelle aus gastroösophagealen Reflux mit Mäusen

Multiple surgical procedures have been reported to induce gastroesophageal reflux in animals. Herein, we report three surgical models with mice aiming to ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Netzwerkanalyse von Foramen Ovale Elektrode Recordings in Resistente Temporallappen Epilepsie-Patienten

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this approach makes an innovative improvement in the treatment of G-GISTs that are less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to combine endoscopic and laparoscopic surgeries, fully realizing their respective advantages and avoiding their drawbacks. The main steps are as follows. First, gastroscopy and laparoscopy are combined to confirm the location and boundary of the tumor. Tumor resection is carried out laparoscopically, guided by a gastroscope. The specimen is removed orally and the gastric wound closed laparoscopically. Then, gastroscopy and laparoscopy are combined to determine whether there is wound bleeding, if the suture is satisfactory, and if the gastric cavity is deformed.
LECS has natural advantages in the treatment of G-GISTs that are less than 5 cm in size. The accurate estimation of tumor location and boundary greatly improves the complete resection rate of tumors. The risk of tumor rupture is substantially reduced, and the long-term prognosis of patients is significantly improved. The process allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient's postoperative rehabilitation is greatly accelerated, and oral feeding can resume on the day of the operation. The specimen is taken out through the mouth to avoid the need for an extended abdominal incision. This greatly reduces the patient's postoperative pain and scarring. The method greatly shortens the postoperative hospital stay (i.e., discharge is possible on the day after the operation), increasing the turnover of hospital beds.

Laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors less than 5 cm in size. It can achieve the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

Laparoskopie-Endoskopie Kooperative Chirurgie zur Behandlung von Magen-Darm-Stromatumoren

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this ...

Laparoscopic Oocyte Retrieval and Cryopreservation during Vaginoplasty for Treatment of Mayer-Rokitansky-Kuster-Hauser Syndrome

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, we propose that a concomitant laparoscopic oocyte retrieval for cryopreservation is performed. Oocyte retrieval is pursued at the beginning of the laparoscopy. Right and left 5 mm trocars are positioned, through which a 17 G ovum aspiration needle is used for puncture of the right and left ovaries, respectively. To facilitate exposure of the follicles, the ovaries are mobilized and held with laparoscopic forceps.
When aspirating multiple follicles near each other, the needle tip is retained in the ovary to reduce the number of times that the ovarian cortex is transfixed and due to the inherent risk of bleeding. Subsequent steps are unchanged compared to the Davydov laparoscopic modified technique for vaginoplasty. Prior to surgery, controlled ovarian stimulation is performed with a gonadotropin hormone-releasing hormone (Gn-RH) antagonist protocol, and the concomitant procedure of oocyte retrieval and vaginoplasty is scheduled 36 h after the final follicular maturation trigger. Follicular fluid is collected in the same 10 mL sterile tubes used during transvaginal oocyte retrieval and transferred in a warming block (37 &#176;C) to the assisted reproduction laboratory, where mature (metaphase II) oocytes are vitrified.
In this case, a series of 23 women with MRKH, oocytes were successfully retrieved and cryopreserved in all patients; vaginoplasty was subsequently conducted without modifications, and the inpatient and outpatient postoperative care (day of urinary catheter removal, day of hospital discharge, dilator use, and comfort at follow-up) remained unaffected. One postoperative complication occurred in one patient (fever developing on day 5 post surgery and intraperitoneal fluid detection on transabdominal ultrasound) and resolved after conservative treatment. Rather than performing surgical vaginoplasty and delaying oocyte retrieval in MRKH patients, this approach combines both procedures in a single laparoscopy, thereby minimizing surgical invasiveness and anesthesiologic risks.

A dedicated team can offer Mayer-Rokitansky-Kuster-Hauser patients the option to perform controlled ovarian stimulation and oocyte cryopreservation at the time of laparoscopic vaginoplasty.

Laparoskopische Eizellentnahme und Kryokonservierung während der Vaginoplastik zur Behandlung des Mayer-Rokitansky-Kuster-Hauser-Syndroms

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may cause severe thoracolumbar kyphotic deformity, often accompanied by intractable low back pain or compression of the spinal cord, leading to severe neurological symptoms or even paralysis. If conservative treatment cannot relieve the symptoms or correct the deformities, surgical treatment is usually needed. For severe kyphotic deformity, reconstruction of the physiological curvature and rigid fixation determine the prognosis of the patients. Osteotomy and orthopedics are the standard procedure for deformities with severe compression of the front and middle column, but the trauma to the patients is high, with a long operation time and massive blood loss. To avoid these disadvantages, we have developed a modified technique to remove the diseased vertebra unilaterally. In this technique, we use a modified trephine to resect the vertebral columns like in the pedicle screw technique by adding a locking instrument that can restrict the trephine to lower the risk of osteotomy and shorten the surgery time and blood loss.

We describe a modified technique for resecting the posterior vertebral column unilaterally based on a modified trephine for patients with thoracolumbar kyphotic deformity.

Modifizierte posteriore Wirbelsäulenresektion bei Patienten mit thorakolumbaler kyphotischer Deformität

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with achalasia. Endoscopists, especially trainees during the learning phase, commonly face difficulty in tissue plane dissection and selective myotomy while working near the esophagogastric junction, with increased risks of inadvertent injury, unexpected bleeding, and inadequate myotomy. To minimize the technical difficulty and improve the safety of POEM, we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis. The standard techniques used with the scissor-type knife involve grasping the target tissue, and then dissection or coagulation. The confirmation of the cutting line after grasping improves the accuracy and reliability of dissection, which is particularly useful for the selective myotomy of the internal circular muscle. Meanwhile, the scissor-type knife provides enhanced hemostatic capability and enables hemostasis and pre-coagulation without the device exchange for hemostatic forceps. Evaluation of the clinical outcomes in three patients who successfully received POEM using the scissor-type knife revealed no perioperative adverse events. At the 3-month follow-up, all patients achieved clinical success with postoperative Eckardt scores ranging from 0 to 1. In conclusion, the use of a scissor-type knife could minimize the technical difficulty and improve the safety of the POEM procedures, which may be suitable for trainees during the learning phase.

To minimize the technical difficulty and improve the safety of peroral endoscopic myotomy (POEM), we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis.

Verwendung des Scherenmessers während der peroralen Endoskopie Myotomie zur Behandlung von Achalasie

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Klinische Anwendung der laparoskopischen Resektion mit einem Chirurgen und drei Anschlüssen bei Darmkrebs mit natürlicher Probenextraktion

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative asoedema, hematoma, sustaining pain, and seminal tract obstruction in patients who have undertaken nonmicroscopic epididymal cyst resection or epididymal resection. Nonmicroscopic epididymal cyst surgery is suggested for patients with childbirth plans as a precaution. The treatment of male epididymal cysts via microtechnology is obviously a beneficial option; we took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled &#34;microscopic epididymal exploration and cystectomy&#34;. The postoperative follow-up lasted for 3-50 months. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. Bleeding during the operation was significantly reduced (2-3 mL) and wound drainage was not required. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention. Besides, preliminary experience and reflection suggest that microscopic epididymal exploration and cystectomy provide efficient preservation of the epididymal patency through refined treatment, while a better prognosis can be achieved. We recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause the complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Mikroskopische Zystenresektion zur Behandlung von Patienten mit Nebenhodenzyste

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative ...

Ein Nicht-Intubationsprotokoll für die videoassistierte thorakoskopische Chirurgie mit erhaltener autonomer Atmung

Non-Intubated Video-Assisted Thoracoscopic Surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Autor im Rampenlicht: Eine nicht-intubierte videoassistierte thorakoskopische Chirurgie mit multimodaler Analgesie und Sevofluran-Inhalationsanästhesie 

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Nicht-intubierte videoassistierte Thorakoskopie

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...