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Thoracoscopic Resection of the First Rib for Thoracic Outlet Syndrome: A Case Report
J Korean Soc Traumatol 2017;30(2):63-65
Published online June 30, 2017
© 2017 The Korean Society of Traumatology.

Jae Gul Kang, Soon-Ho Chon, Kilsoo Yie, Min Koo Lee1, Oh Sang Kwon1, Song Hyun Lee1, and June Raphael Chon2

Department of Thoracic and Cardiovascular Surgery, Cheju Halla Hospital, Jeju, Korea,
1Department of Trauma Surgery, Cheju Halla Hospital, Jeju, Korea,
2Student at St. Johnsbury Academy, Jeju, Korea
Correspondence to: Soon-Ho Chon, M.D., Ph.D. Department of Thoracic and Cardiovascular Surgery, Cheju Halla Hospital, 1963-2 Yeon Dong, Jeju City, Korea Tel : 82-64-740-5039, Fax : 82-64-743-3110, E-mail : sh.chon@hotmail.com
Received April 25, 2017; Revised April 28, 2017; Accepted April 28, 2017.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Standard open procedures for resection of the first rib in thoracic outlet syndrome can prove to be quite difficult with extensive incisions. A minimal invasive procedure can also be painstaking, but provides an attractive alternative to the more radical open procedures. We report the details of the technique with direct video footage of the procedure performed in a 41-year-old man with thoracic outlet syndrome done entirely by thoracoscopic methods.

Keywords : First rib resection, Thoracic outlet syndrome, Video assisted thoracoscopic surgery
I. Introduction

Minimally invasive thoracoscopic surgery has provided an option for many radical procedures. Thoracosopic surgery is evolving and becoming more tangible. We report a case of thoracic outlet syndrome occurring in a 41 yr-old young man, whom had his first rib resected by thoracoscopic surgery. Three ports were utilized and the rib removed through the axillary port. The patient was discharged on the postoperative 10th day without pain and paresthesia and is happy with the cosmesis.

II. Case Report

A 41 yr-old male had visited our clinic with symptoms of left upper extremity pain and paresthesia of 1 year onset after a traffic accident. He had sustained multiple rib fractures, left 4, 8, 9 and 10th and has had the above complaints ever since. He was diagnosed with thoracic outlet syndrome after conduction velocity testing showing delay in velocities from below his root to below his elbow and electromyographic studies that had shown abnormal paravertebral muscle done 3 and 6 months after the incident at a university hospital. His cervical-spine MRI presented traumatic c-spine injury with foraminal encroachment with suspected cervical 6 and cervical 7 nerve impingement. After failure of medication, the patient consulted our hospital for thoracoscopic resection of his first rib one year after the accident. The patient had positive hyperabduction test as seen by symptoms of ulnar division pain and paresthesia aggravated by abduction of his left arm.

The operation was scheduled and the procedure was done with double lumen intubation (Fig. 1). The patient was placed in the right down decubitus position with arm elevated and placed over an arm rest. CO2 insufflation after placing three ports was utilized. A 5 mm camera port was placed in his 6th intercostal space in his mid-axillary line, a 1 cm port in his areola margin and a 1.5 cm port in his axilla in his 3rd intercostal space at his mid-axillary line. The overlying pleura was dissected off with the help of Harmonic scalpel and readily available open instruments, a freer and periosteal elevator. The anterior portion of the first rib was cut with Kerrison bone punch. The rib was held with endoscopic cardiovascular clamp (Sonntec, Colorado, USA) and long Kelly. The posterior portion of the rib was very difficult to cut and use of an orthopedic drill (Zimmer, Microdrill, Minnesota, USA), similar to the case described by Ohtsuka et al, was used to help cut the rib.(1) The Kerrison bone punch was found to be too short to reach the posterior portions of the rib. A 24 French chest tube was inserted.

Fig. 1.

Captured shot of the procedure showing the rib cut with total thoracoscopic methods using a Kerrison bone punch.


His postoperative course was uneventful and his tube was removed on his postoperative 2nd day. At the request of the patient, he was discharged on the 10th postoperative day without complication. An immediate follow up computer tomogram has shown over 80% removal of the rib with decompression of his thoracic outlet components (Fig. 2). The patient no longer has symptoms of pain and paresthesia of his ulnar division and is happy with the results (Fig. 3).

Fig. 2.

Chest 3D Computer tomographic scan showing the removed first rib (arrows showing the extent of the resection).


Fig. 3.

Postoperative picture of the port wounds placed in his axilla, areola margin, and in his 6th intercostal space inferiorly.


III. Discussion

Compression of the neurovascular structures in the superior outlet of the thoracic cavity defines thoracic outlet syndrome. This includes symptoms due to compression of structures such as the subclavian vein, subclavian artery, or brachial plexus. Such compression is due to mechanical factors caused by pressure between the scalene muscles, between the clavicle and first rib, or in the subcoracoid tunnel.(2) Until recently, most of the corrective operative procedures have been done by open methods, supraclavicular and transaxillary approaches. Thoracoscopy allows for direct visualization and safe removal of the first rib. The first description of thoracoscopic removal of the first rib was done in 1999 and since then very few reports have been made that have utilized compete removal by thoracoscopic methods in the English literature.(1) Our procedure is similar to the case reported in Korea.(3)

Our particular case also presented similar methods of removal with readily available instruments. However, there was great difficulty in cutting the posterior portion of the rib and the use of the drill was inevitable. Until there are bone punches which are longer than the conventional open instruments, there will be some difficulty.

IV. Conclusion

Thoracic outlet syndrome can be treated by a minimally invasive procedure. It is feasible and resection of the first rib can be done by thoracoscopic methods. Using the robot as described in a couple series can be done, but are at expense of high costs in Korea.(4,5) Again, further case analyses and development of instruments that would make the procedure more simple would be necessary in the future.

References
  1. Ohtsuka T, Wolf RK, and Dunsker SB. Port-access first-rib resection. Surgical Endoscopy 1999;13:940-2.
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  2. Soukiasian HJ, Shouhed D, Serna-Gallgos D, McKenna III R, Bairamian VJ, and McKenna RJ. A video-assisted thoracoscopic approach to transaxillary first rib resection. Innovations 2015;10:21-6.
    CrossRef
  3. Kim DJ, Kang C-H, Kim Y-T, and Kiim J-H. Video-assisted first rib resection. Korean J Thorac Cardiovasc Surg 2007;40:463-6.
  4. Sanders RJ, and Pearce WH. The treatment of thoracic outlet syndrome: an analysis of 200 consecutive cases. J Vasc Surg 1992;16:534-42.
    CrossRef
  5. Martinez BD, Wiegand CS, Evans P, Gerhardinger A, and Mendez J. Computer-assisted instrumentation during endoscopic transaxillary first rib resection for thoracic outlet syndrome a safe alternate approach. Vasc 2005;13:327-35.
    CrossRef


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