Robotic First Rib Resection

Thoracic outlet syndrome is a complex disease, presenting with multiple symptoms arising from a possible combination of subclavian vein, subclavian artery, or brachial plexus compression. Multiple techniques have been used for first rib resection, some of which are no longer used. Current common techniques use a supraclavicular, transaxillary, or infraclavicular approach, each of which has its limitations. Minimally invasive transthoracic approaches have been slow to gain popularity owing to limitations in current video-assisted thoracoscopic surgery instrumentation and technology. We describe a minimally invasive and successful transthoracic approach utilizing the da Vinci robotic system with excellent results and minimal morbidity. The described approach incorporates first rib resection and division of the scalene muscles with removal of the rib in a nonpiecemeal fashion, with clear visualization of the entire rib and the need for minimal dissection around the subclavian vessels and brachial plexus.