Robotic-assisted first and supernumerary rib resection: case series

Background: A constriction between bony and muscular structures in the costoclavicular space may lead to compression of the neurovascular bundle to the upper extremity, resulting in thoracic outlet syndrome (TOS). In very few patients suffering from TOS, an additional cervical or supernumerary rib is present. To overcome constraints associated with conventional techniques we implemented now our previously described robotic approach for resection. Case Description: Between March 2019 and November 2022, in our series of 67 patients undergoing first rib resection, 6 consecutive patients presented with a cervical rib and a resulting TOS. They have been treated using our 3-port robotic approach, where we used two 8-mm working ports and one 8-mm camera port. According to our experience in first rib resection, we extended the procedure to the additional cervical structures. The total surgery time including vascular replacement in two cases was between 75 and 365 min [median 170.5 min; interquartile range (IQR), 90-232 min] without any major complications. Chest tube was removed on postoperative day 1 in all patients and hospital stay after surgery was a median of 3 days (IQR, 3-8 days). In one case an additional arterial graft and neurolysis were performed according to the patients findings. Beside one incisional hematoma in that particular case, no relevant intra- or postoperative complications were observed and complete or subtotal resolution of symptoms was achieved in all patients. Conclusions: The robotic technique has proven to be a safe approach even in these demanding cases. The good exposure of the entire field of resection in the thoracic outlet region and the possibility of meticulous dissection prevented both intra- and postoperative complications. Therefore, the robotic technique is also suitable for concomitant resection of the first rib as well as supernumerary cervical rib if needed. It is safe and one of the most minimally invasive approaches to date.