Robotic transthoracic first rib resection for thoracic outlet syndrome: a narrative review

Introduction

Thoracic outlet syndrome (TOS) has been recognized for centuries (1). TOS results from compression of the brachial plexus, subclavian artery (SCA), and/or subclavian vein (SCV) at the superior thoracic outlet. This results in a combination of pain, paresthesia, swelling, among other symptoms depending on which structures are compressed and comprises the different subtypes of TOS (neurogenic, venous, and arterial). Over time, an increased understanding of the underlying anatomy and its pathological variants guided the development of surgical interventions for TOS. Dating back to the early 20^th century, initial surgical approaches began with costal resections and extensive division of surrounding musculature. Over time, supraclavicular and transaxillary approaches became the favored approaches for TOS with key components being resection of the first rib on the affected side, scalenectomy and lysis of adhesions to the subclavian vessels and brachial plexus (2,3). Nevertheless, surgical management of TOS has continued to evolve, particularly in recent years with the application of video assisted thoracoscopic surgery (VATS).

By the 1990s, thoracoscopic surgery emerged as a viable technique for other intrathoracic pathologies. Applications to surgical interventions for TOS soon followed (4). This initially manifested as endoscopic-assisted transaxillary resections, which demonstrated improved visualization of critical structures (5).

Neville et al. and Gharagozoloo et al. reported the first robotic assisted transthoracic approach in 2011 and 2012, respectively, in patients with Paget-Schroetter syndrome (PSS) (3).

In subsequent years, the frequency and size of studies reporting the utilization of this approach increased. Prior to 2020, only 5 case series were reported which included 126 resections. After 2020, the number of studies increased almost 3-fold (13 articles) and 540 resections were reported. As expected, given the novelty of this approach, there has been much variability as to the nuances of this approach including port placement, instrument use, post operative management, and outcomes (6,7). Previous studies have providing superficial review of literature surrounding robotic first rib resections for TOS; however, a comprehensive review of early as well as contemporary data on this technique is lacking. The purpose of this review is to review and summarize data as well as techniques for robotic first rib resection from the technique’s inception to its more recent developments. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-61/rc).

Methods

PubMed, Medline, Emboss, Cochrane Review, Scopus, Google Scholar were searched using the key terms provided in Table 1 from January 1, 2010, to October 1, 2025. Articles were reviewed for inclusion and exclusion criteria provided in Table 1. All the included studies were retrospective reviews. While some studies included patients who did not receive a robotic-assisted approach, all studies must have included a robotic cohort for analysis in this review of the robotic approach to TOS.

The authors abstracted the number of resections performed, the etiology of TOS, intraoperative and postoperative complications, as well as measures of treatment efficacy as reported in individual studies. In the reported outcomes in Table 2, safety outcomes are defined as intraoperative or postoperative complications. Efficacy outcomes were defined as measures assessing vein patency, pain/disability scores [i.e., visual analog scale (VAS), Disabilities of the Arm, Shoulder, Hand (DASH) or Quick DASH scores, and Derkash class], re-intervention rates related to the intended therapeutic effect. Outcomes of each study are reported in Table 2 using median or means for continuous variables and proportions as reported in each respective publication. Cumulative outcomes for continuous variables are reported as ranges. Overall incidences of complications are reported using individual counts from each study. Given that the response rate of patient reported outcomes for symptomatic improvement was not collected, proportion of patients with symptomatic improvement is reported as a range. Techniques for robotic resections were reviewed and summarized.

Results

A total of 18 studies met the above-mentioned inclusion criteria and were reviewed (Table 2). Included studies were published from 2011 to 2025, with cohort sizes ranging from 5 to 162 procedures analyzed (7-24). A total of 666 first rib resections were reported, of which 565 (85%) were performed robotically. Three studies directly compared the supraclavicular approach to robotic resections (13,18,23). Three hundred and eleven resections (46%) were performed for neurogenic TOS (nTOS), of which 223 (72%), were performed robotically. A total of 267 (40%) resections were performed for venous TOS (vTOS), of which 254 (95%) were performed robotically.

Safety

As it pertains to clinical outcomes, of highest importance was the demonstration of the safety of this approach. Eighty-three percent (15/18) of studies included perioperative complications in their reported outcomes (541 resections for which perioperative complications were reported, of which 487 were robotic resections). There were no reports of perioperative mortality. Furthermore, there were very few intraoperative complications. Only one study reported a single arterial injury that did not require reconstruction and one study reported conversion to trans-axillary approach intraoperatively in 3/15 cases. Complication rates for each included study are included in Table 2. The most common complications in robotic resections included pneumothorax (5/487), temporary nerve palsies (3/487), and pleural effusions (2/487). No complications from post-operative venous stent placement or balloon angioplasty were reported.

Efficacy

As it pertains to efficacy in treating TOS, median operative time ranged from 88 to 188 minutes with a notable trend to shorter operative times in more recent years, while median length of stay ranged from 1 to 4 days with many studies reporting length of stay between 2–3 days (Figure 1). Efficacy measures were reported at follow up durations ranging from 2 weeks to 1 year in the majority of studies with few studies reporting patient outcomes up to 2 and 3 years (10,12,17). Complete symptomatic response rates ranged from 74% to 100% (Table 2). Quantitative tools including VAS and DASH scores postoperatively demonstrated improvement after robotic first rib resection (15). Only one study utilized the Derkash classification for symptomatic evaluation, which again demonstrated excellent results using this tool (23).

Figure 1 Median operative times for robotic first rib resections by publication year.

For patients undergoing first rib resection for vTOS, rates of vein re-interventions ranged from 50% in smaller cohorts to 20% in larger cohorts (Table 2). Several cohorts achieved 100% vein patency at follow up times up to 24 months postoperatively. Of note, 116 (43%) of the operations performed for vTOS were specified as Paget Schroetter syndrome and one cohort specifically analyzed first rib resections in patients with chronic Paget Schroetter syndrome (average duration of approximately 6 months prior to surgical intervention) and demonstrated a particularly high re-intervention rate in this subgroup (60%, 9/15) (21). While the data shows that vein patency rates may be higher with an infraclavicular approach, a substantial venolysis can be performed with robotic assistance and the available data is underpowered to provide a direct comparison at this time.

Technique and technical considerations

We report here our technique for robotic transthoracic first rib resection, based heavily on the previous reports by Dr. Burt and colleagues (25).

Patients are positioned in the lateral decubitus position with the operative side up and a slight reverse trendelenberg to allow the lung to fall away from the apex. Three 8 mm robotic ports and one 12 mm assist ports are used. Of critical importance is proper positioning of the subscapular port site as this will be the port site through which the drill will be introduced and thus adequate reach to the posterior aspect of the first rib must be ensured. This is generally just inferior to the tip of the scapula. The camera port is at approximately the 7^th intercostal space and the mid axillary line. The anterior working port is placed in approximately the 4^th intercostal space, usually directly across from the posterior port. The accessory port will be placed caudal on the chest wall between the camera port and the anterior working port. A 30 degree thoracoscope will be utilized. It is important to assess the drill’s trajectory by using a laparoscopic instrument through the posterior port to ensure appropriate port placement.

Figure 2 shows the initial intraoperative view before dissection begins. The SCA, SCV, and brachial plexus are identified on the inferior aspect of the rib. Initial dissection begins along the superior aspect of the first rib using hook cautery and a caudiere grasper. The parietal pleura and intercostal muscles are opened in layers. This starts with the pleura, followed by the internal intercostal muscles, and lastly the external intercostal muscles. It is easy to differentiate the plane between the intercostal muscles as the fibers change direction. This dissection should be performed from the mammary vessels anteriorly all the way posterior to the T1 nerve root. By opening the pleura just above the root, the nerve drops away from the rib slightly allowing more room for eventual drilling.

Figure 2 Intraoperative view of right first rib and surrounding anatomical landmarks.

Anteriorly, the costochondral cartilage is identified just above the mammary vein. This can often be transected with careful use of monopolar cautery, but occasionally there may be an osseous bridge requiring drilling. Once complete, all pleura and soft tissue is stripped off the pleural surface of the first rib in order to clearly identify the inferior edge.

Once the anterior and superior aspects of the rib have been mobilized, the hook cautery should be exchanged for a bipolar instrument to allow for more precise energy transmission. The pleura along the underside of the rib is then opened, being careful to stay superficial and not injure the underlying neurovascular structures. The inferior surface of the posterior superior aspect is freed from muscle fibers and care must be taken to avoid injury to the brachial plexus. A posterior point of division of the rib is identified. All surrounding soft tissue must be cleared from this area, as it will interfere with the functioning of the handheld drill. During dissection, we prefer to use a flexible remotely operation suction irrigation (ROSI) system (Vascular Technology Inc., Nashua, NH, USA), which is placed through the assist port and used as needed to allow additional autonomy to the operating surgeon.

The posterior rib is now ready to be divided (Figure 3). The posterior robotic port is undocked and removed from the subscapular site and a handheld Midas Rex MR8™ drill (Medtronic, Minneapolis, MN, USA) is introduced to the division line. A rigid suction/irrigator tip is used through the assist port to irrigate bone shavings away during cutting (Figure 4). The rib is then divided carefully, and hemostatic agents used to control any oozing from the transected bone. The robot is then redocked once hemostasis is achieved.

Figure 3 First rib with pleura dissected, intercostal muscles and anterior cartilage divide.

Figure 4 Positioning of rigid suction and drill immediately prior to division of posterior aspect of rib.

The remainder of the rib is mobilized. A Prograsp forceps is utilized in the non-dominant hand as it allows for better manipulation of the rib as it becomes more mobile. The anterior and posterior sides of the rib may be approached in either order. Anteriorly the subclavius muscle and costochondral ligament are divided with bipolar cautery. Posteriorly the middle scalene is divided (Figure 5). The neurovascular structures are gently pushed away from the rib. Lastly, the anterior scalene is divided taking at least 1 cm of the muscle with the rib to debulk the outlet (Figure 6). The rib is then set aside and attention is turned to lysis of adhesions surrounding the SCV, SCA and brachial plexus. In our practice, we perform as much adhesiolysis of the neurovascular bundle as safely feasible to achieve adequate decompression, based on the patient’s preoperative symptoms and likely type of TOS. Visually improved mobility of these structures is seen following lysis (Figure 7). Indocyanine green (ICG) may be administered intravenously to assess flow through the SCV if there are any concerns about adequate lysis. Care is taken during this step to identify lymphatic channels and clip when identified. Once adequate lysis is performed and hemostasis is achieved, the rib is grasped using a laparoscopic tenaculum forcep through the assistant port. Robotic instruments are removed and the robot is undocked. The specimen is removed. Figure 8 shows that the majority of the first rib has been removed, rather than just a small section, which is paramount no matter which surgical approach is chosen. A single chest tube introduced through the camera port site using a single running absorbable Stratafix suture which allows for the incision to be closed at the time of chest tube removal. Prior to reinflating the lung, reversal agent of nerve paralytics are given and the diaphragm is visualized to ensure no inadvertent phrenic nerve trauma and appropriate diaphragm contraction.

Figure 5 Caudal retraction of divided rib demonstrating neurovascular bundle between middle and anterior scalene muscle bundles.

Figure 6 Caudal retraction of rib with isolated anterior scalene and neurovascular bundle exposed.

Figure 7 SCV, SCA, brachial plexus and T1 nerve root decompressed following adhesiolysis. SCA, subclavian artery; SCV, subclavian vein.

Figure 8 First rib specimen after extraction.

Pitfalls

Several important pitfalls are to be kept in mind during this approach. First, the use of the handheld drill is a critical component of the procedure. The subscapular port must be placed in a location such that there is adequate reach to the posterior aspect of the rib so as to not require excessive force and increase the risk of injury during drilling, especially to the artery and plexus. More broadly, proper triangulation of ports is necessary to ensure adequate length of instruments to not compromise fine movements during dissection.

Careful dissection near neurovascular bundle is also of utmost importance. The larger fibers of the brachial plexus are easily identified, but also important is visualization of the T1 nerve root which is in closest proximity to the drill during division. Furthermore, lymphatic channels may arise near the SCV and may not always be clearly visualized during lysis, however the presence of clear fluid accumulation in this space may indicated lymphatic leak that can be identified in the operating room and controlled with clips or ligation.

Variations in technique

Various techniques for robotic first rib resections have been described in the literature. Variability arises in the number of incisions used, port positioning, and methods for both suction and disarticulation of the first rib. We provide below a non-exhaustive description of variation in techniques that have been reported in the literature. The majority of included studies described their preferred surgical approach.

In general, three 8 mm ports are placed triangulating the apex of the thoracic cavity. The most posterior ports are most often positioned posterior or inferior to the scapula. In some centers, the procedure is completed with only 3 ports. In other instances, an additional assist port is placed inferior to the camera port. Suction and instruments for division of the first ribs can be introduced via the assist port as well as a site for specimen removal and chest tube placement at the termination of the case. We find the use of the ROSI device and specimen/sponge removal through the assist port to increase the efficiency of the procedure. A combination of Cadiere or Prograsp forceps as well as either hook or bipolar cautery are used for dissection of the pleura and musculature.

The area of most variability in robotic first rib resections occur in methods of use to disarticulate the first rib. Owing to the fact that there are currently no robotic instruments capable of dividing bones, a number of methods have been used to accomplish this critical component of the operation. Both sharp and electrocautery have been described to divide the cartilaginous medial aspect of the rib. Most commonly this was completed using Kerrigan rongeurs, while others prefer to use monopolar hook as division can performed safely and decreases the amount of time with the robotic system undocked (9,12-14,18,20). Division of the posterior aspect of the rib can again be completed with Kerrigan rongeurs although Burr drills and Midas Rex drills have also been used (23,25). Great care must be taken to avoid injury to the T1 nerve root during this step. In our experience we find that utilizing a rigid suction-irrigator allows for gentle traction of the T1 nerve root away from the drill while simultaneously allowing for suction of debris to improve visualization during division.

Chest tubes are placed through a variety of port sites. Intercostal nerve injection of local anesthetics are often performed during port placement. Some centers have utilized OnQ systems for continuous local anesthetic to incision sites; however, this is less common.

Discussion

In summary, this narrative review found that the utilization of robotic transthoracic approaches for first rib resection in TOS has become increasingly common since 2010. Included studies were predominantly single intuitional and all retrospective in nature with the largest single cohort being 162 resections. As previously demonstrated, intraoperative complications are exceedingly rare, and postoperative complication rates remain low, offering an excellent safety profile for patients using this technique. As expected, there is moderate variability in surgical technique, especially as it is related to disarticulation of the first rib, with multiple safe methods having been described. Complete symptomatic resolution occurred in a large proportion of patients with both nTOS and vTOS, while adjunctive invasive vascular intervention for residual venous stenosis or thrombosis was not uncommon.

Achievement of low perioperative to the robotic platforms’ enhanced visualization, improved instrument dexterity, making dissection critical structures more precise (12). However, adequate cross comparison of complication rates between robotic to open approaches remains challenging. This is in part due to a paucity of studies that have directly compared the two approaches. Additionally, patient selection bias and eligibility for less invasive approaches are institution dependent and not yet standardized, as such specific subsets of patients for which this approach is safe have yet to be established (e.g., previous thoracic radiation, prior subclavian stent placement, etc.). As more centers adopt robotic resections and patient selection criteria is standardized, a body of high-quality comparative data will continue to grow (26,27).

Given that patients with TOS seek medical attention for lifestyle limiting symptoms, achieving satisfactory symptomatic improvement is of critical importance, indeed surgical interventions for TOS remain a common source of malpractice suits against surgeons (28). Variability in achievement of symptomatic improvement in the reported studies may be due to several factors including patient selection, duration of follow up and TOS subtype. Of these factors, rigorous pre-operative evaluation is critical. Pre-operative evaluation including physical therapy, multimodal pain control regimens including muscle or nerve blocks are useful to identify patients who will most likely achieve improvement of symptoms after resection (12). Furthermore, this review found little standardization of objective tools used to evaluation pain and functional outcomes in patients before and after surgery and only one study utilized the TOS specific Derkash classification to evaluate postoperative functional outcomes (23). Overall, further evaluation and protocolization of what constitutes reasonable patient expectations and definition of successful symptomatic relief after robotic first rib resection is prudent.

Within the subgroup of patients undergoing resection for vTOS, invasive re-intervention for residual stenosis was approximately 20%. While some studies specified if patients with vTOS had previously been diagnosed with Paget Schroetter syndrome, others did not. As one study found, the chronicity and preoperative management of SCV thrombosis may directly impact the likelihood of achieving vein patency postoperatively, thus the role of post operative venography continues to be explored (21).

Future directions may include multi-institutional retrospective data pooling or prospective registries to investigate differences in short-term outcomes, long-term durability across TOS subtypes, and cost-benefit between robotic and open approaches. These approaches would come with their own set of potentially confounding variables including surgeon experience and preference, patients’ selection criteria, and postoperative management protocols that can be highly variable between institutions. As access to the da Vinci systems continues to grow, theoretically more centers would be able to adopt this approach under the proper guidance and training as institutions build familiarity with this approach. More widespread adoption of this approach would be needed to continue building larger registries and longer follow-up to assess outcomes and costs.

This review has various limitations. First, this narrative review aimed to provide a broad overview of robotic first rib resections and was not subjected to the same degree of standardization as a systematic review. Additionally, the entirety of the studies included were retrospective, single center studies as such were subject to selection bias, institutional preference to certain surgical approaches and differing postoperative management protocols. Furthermore, definitions for reporting complications and postoperative outcomes were not homogenous across studies thus limiting the utility of study cross comparisons. Ove Some of the articles included had yet other be published in manuscript form at the time of this review and as such data available from abstracts were used which resulted in lack of detail provided for some data points that were more readily available in articles with full manuscripts. Nevertheless, this review was able to successfully summarize contemporary perioperative outcomes and techniques used for robotic first rib resections.

Conclusions

In conclusion, robotic first rib resection is a safe and efficacious method of first rib resection in both neurogenic and vTOS with good durable short and mid-term results thus far. Where expertise and resources exist, it can reasonably be considered a preferred approach for selected patients with TOS. Multiple safe techniques have been described to this approach. More widespread adoption of this technique and higher-level evidence is needed in the future to further validate these findings.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-61/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-61/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-61/coif). B.M. reports the consulting fees from Intuitive Surgical, Vascular Technology Inc, Navigation Sciences Inc, and the payment or honoraria for lectures from Intuitive Surgical. The other 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.

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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