Name: transaxillary first rib resection for treatment of the thoracic outlet syndrome
Uploaded: 2020-09-13T13:00:00
Description: Watch this Scientific Journal Video about Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome at JoVE.com

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 pul...

<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 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&#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

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 &#177; 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 sa...

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

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 ...

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