Transthoracic robotic first rib resection: Twelve steps

摘要

Central MessageThe transthoracic robotic approach to FRR offers unparalleled exposure of the first rib and is anticipated to minimize operative morbidity and favorably disrupt the field of TOS.See Commentaries on pages 110 and 112. The transthoracic robotic approach to FRR offers unparalleled exposure of the first rib and is anticipated to minimize operative morbidity and favorably disrupt the field of TOS. See Commentaries on pages 110 and 112. Thoracic outlet syndrome (TOS) is a trio of debilitating musculoskeletal disorders that result from compression of the neurovascular structures that serve the upper extremity, each defined by a distinct clinical presentation. The most common types of TOS are neurogenic TOS in which compression of the brachial plexus results in disabling upper-extremity pain and paresthesias, and venous TOS (vTOS), which results in subclavian vein thrombosis, upper-extremity swelling, and cyanosis secondary to subclavian vein compression.1Rinehardt E.K. Scarborough J.E. Bennett K.M. Current practice of thoracic outlet decompression surgery in the United States.J Vasc Surg. 2017; 66: 858-865Google Scholar TOS is treated surgically by first rib resection (FRR), the traditional surgical approaches of which are supraclavicular and transaxillary. An infraclavicular approach, either alone or in combination with a supraclavicular approach (paraclavicular), is often used in cases of vTOS in which it is important to resect the anterior most aspect of the first rib. Each of these approaches has at least some limitation for achieving optimal exposure of the first rib, and this is commonly amplified in patients with obese body habitus or muscular stature. Each of these approaches requires at least some degree of retraction or manipulation of central neurovascular structures that include the brachial plexus, the phrenic nerve, and the subclavian artery and vein. The emerging transthoracic robotic approach to FRR provides striking exposure of the near entirety of the first rib without any retraction. It is described in 12 steps. The technique of transthoracic robotic FRR (rFRR) is described in a series of distinct 12 steps, each with an accompanying video. The described approach uses the da Vinci Xi system (Intuitive Surgical, Sunnyvale, Calif) and a Midas Rex handheld surgical drill (Medtronic, Minneapolis, Minn). Full instrumentation is provided in the case card that is included as Figure 1. The rFRR technique is demonstrated in an 18-year-old female athlete with left Paget–Schroetter syndrome 4 weeks after successful catheter-based lysis of a subclavian vein thrombosis. Single lung isolation is achieved with a double-lumen tube or bronchial blocker, and the patient is placed in the full lateral decubitus position. An arterial line and urinary catheter are considered optional. The procedure is distilled into 12 steps:1.Port Placement (Video 1): Three 8-mm ports and one 10-mm assistant port are used. The border of the scapula is marked. The site of the posterior port is marked just inferior to or slightly posterior to the tip of the scapula. The site of the anterior port is marked at approximately the fourth interspace, just anterior to the anterior axillary line. Equidistant from and slightly inferior to these 2 working ports, the camera port is marked, generally corresponding to approximately the seventh interspace in the mid axillary line. The 8-mm camera port incision is made, and the chest is entered with a clamp. A port is placed, the camera is inserted, and insufflation is begun at 8 mm of pressure once safe pleural entry is confirmed. We used a 0-degree camera; however, a 30-degree camera can also be used. Intercostal nerve blocks are placed with 3 mL of dilute Marcaine placed in the fourth to ninth intercostal spaces posteriorly. The posterior port is placed in the fifth of sixth intercostal space, and the anterior port is placed in the fourth (but sometimes third or fifth) intercostal space. The position o