Thoracic outlet syndrome: first rib resection by video-thoracoscopy using two ports

Thoracic outlet syndrome (TOS) is defined as the set of signs and symptoms due to compression of the neural and vascular structures that cross the opening of the upper thorax. It can involve the brachial plexus, subclavian artery and vein. Treatment can be medical or surgical. The latter is indicated when conservative management fails and is based on decompression of the compromised structures by resection of the first rib, scalenotomy and resection of the cervical rib, if present. Open extrathoracic approaches have been used over time. Ohtsuka et al. described the first endoscopic approach for resection of the first rib and since then the videothoracoscopic technique has been optimized, finding several fully endoscopic approaches in the literature. We present our video-assisted surgical technique with 2 ports. We have been performing this technique for several years and each patient who will undergo surgery is evaluated in a multidisciplinary way, with neurologists, vascular doctors and orthopedists. The main advantages of this technique have been in the illumination and the magnified view from the video-camera. Visualization of the full length of the first rib and the neurovascular bundle is excellent and there is no need to retract any of the elements of the neurovascular bundle, therefore eliminating the risk of brachial plexus injury. In this approach body mass index also becomes a less important factor. This technique can achieve significant advantages in a shorter overall operative time, a lower postoperative morbidity rate, and a milder impact on the inflammatory system. All of this leads to better patient satisfaction, a shorter hospital stay, and a lower financial costs. Clinical success is obtained in the majority of patients, with slightly more variable results for the neurogenic TOS.