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Page 2 of 10 Gharagozloo et al. Mini-invasive Surg 2021;5:39 https://dx.doi.org/10.20517/2574-1225.2021.74

Over the years, due to the lack of objective findings in the majority of patients with NTOS, NTOS has been
further classified as True NTOS and Disputed (NTOS). The majority of patients with TOS have NTOS, and
the majority of patients with NTOS are in the “Disputed” category (DNTOS). Patients with DNTOS have
neurologic symptoms such as pain and paresthesia in the upper extremity, neck and shoulder with a normal
neurologic exam and nerve conduction studies. Historically, it has been thought that TOS results from the
compression of the neurovascular structures in the upper chest and the neck. The first rib has been the
common denominator in this hypothesis.

[3,4]
Recently Gharagozloo et al. have described a congenital malformation at the costo-sternal joint of the
first rib as the “offending” pathologic entity in patients with PSS and DTNOS [Figures 1-4]. Using dynamic
Magnetic Resonance Imaging and 3-D computerized tomography reconstruction, these authors have shown
that with the elevation of the upper extremity and activity, the subclavian vein is compressed between the
costo-sternal joint and the clavicle. They have hypothesized that in patients with DNTOS, neurologic
symptoms may manifest nerve pain that results from venous compression and the resultant venous
ischemia of the nerves in the upper extremity. This hypothesis is based on the fact that the upper extremity
is fed by a single artery and vein as an “end organ”. Venous congestion may be an essential factor
precipitating circulatory disturbance in nerve roots and inducing neurogenic intermittent claudication.
[5]
Venous congestion has been shown to break the blood-nerve barrier and result in relative ischemia . As a
proof of concept, these authors have demonstrated that in patients with persistent neurologic symptoms
following first rib resection, the disarticulation of the costo-sternal joint, which was previously described as
[6-8]
the costoclavicular ligament, has resulted in excellent relief of symptoms . Therefore, it is crucial to
disarticulate the costo-sternal joint as part of first rib resection in patients with TOS. Also, these authors
have shown that PSS is simply the manifestation of the same pathologic entity, which results in thrombosis
with prolonged compression of the subclavian vein.

The most common first rib resection is performed using a transaxillary or supraclavicular approach.
However, these approaches are associated with neurovascular complications, incomplete decompression of
the subclavian vein and the medial aspect of the thoracic outlet, and difficulty in disarticulating the costo-
sternal joint from outside the chest cavity.

The robotic surgical systems have the advantages of 3D visualization and precise instrument
maneuverability in a confined space. The surgical robot has facilitated a precise, minimally invasive
transthoracic approach to disarticulating of the costo-sternal joint and resection of the first rib. This
approach has been associated with the best-reported results in patients with PSS and NTOS.

This communication outlines the technique of robotic first rib resection with disarticulation of the costo-
sternal joint for patients with TOS.

TECHNIQUE OF ROBOTIC RESECTION OF THE MEDIAL ASPECT OF THE FIRST RIB AND
DISARTICULATION OF THE COSTO-STERNAL JOINT
A video of the procedure is available at: https://www.youtube.com/watch?v=2mCKcgAAjb8

Patients are placed in the lateral decubitus position with the affected side up with single lung ventilation of
the ipsilateral side. The procedure is performed in 5 steps.