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Page 8 of 10 Gharagozloo et al. Mini-invasive Surg 2021;5:39 https://dx.doi.org/10.20517/2574-1225.2021.74

Figure 8. Intraoperative photograph during the robotic resection of the medial right first rib in a patient with Disputed Neurogenic TOS.
The abnormal boney tubercle at the costo-steral joint results in compression of the subclavian vein (SV) at its junction with the
innominate vein (IV). TOS: Thoracic outlet syndrome.

[4]
Outlet Syndrome or “Subclavian Vein Compression Syndrome”. Gharagozloo et al. have proposed that
symptoms which were previously classified as Neurogenic and Venous (PSS) TOS represent a variable
symptomatic presentation of the compression of the subclavian vein by an abnormal boney tubercle at
costo-sternal joint, which results in neurologic symptoms with mild compression (Neurogenic TOS) and
thrombosis of the vein with prolonged compression (PSS). As a proof of concept, robotic resection of the
medial aspect of the first rib and disarticulation of the costo-sternal joint has been associated with excellent
results.

The robotic resection of the first rib has a number of technical challenges. These challenges can be divided
into:

1. Anesthesia management: it is important to use hand ventilation with minimal mediastinal excursion
during the robotic dissection. It prevents injury to the phrenic nerve or the superior vena cava.

2. Rib dissection: the costo-sternal joint for the first rib is invariably abnormal. The first rib should be
identified at the costo-sternal joint and traced posteriorly. The first rib is covered with pleura and inner
intercostal muscles. It is important to delineate the edges of the first rib clearly. In addition, the subclavian
groove should be identified by tracing the suvbclavian artery from inside the chest. The Kerrison instrument
is ideal for dividing the rib at the subclavian groove, where the rib is the thinnest. The anvil of the Kerrison
instrument protects the subclavian artery while the blade divides the bone. The use of powered instruments
or a Giggly saw has been described by Strother and Margolis . However, we have found the Kerrison to be
[15]
the safest instrument for rib division.