Right Thoracoscopic First Rib Resection for Arterial Thoracic Outlet Syndrome
A twenty-three-year-old male patient presented with symptoms of bilateral arm pain and swelling. He was investigated with magnetic resonance (MR) angiography and found to have bilateral subclavian artery compression on arm abduction. After discussion at the vascular surgery multidisciplinary team meeting, the decision was made to proceed with bilateral staged thoracoscopic first rib resections.
The procedure was performed through a right posterior uniportal VATS approach. The right first rib was identified, and the pleura and overlying connective tissue were divided and dissected off. A passage was then created above the rib, and a nylon tape was passed above the rib. This tape allowed retraction of the first rib, exposing the scalene anterior, scalene medius, and subclavius muscles, which were then divided and dissected off the rib. Once a safe margin from the subclavian vessels had been established, the rib was divided proximally and distally with thoracoscopic rib cutters and a Kerrison Bone Nibbler.
The patient was fitted with a surveillance chest drain, which was removed on postoperative day one. There were no inpatient complications, and the patient was discharged home on postoperative day two. At his follow-up clinic four weeks later, he had excellent resolution of right-sided symptoms with a QuickDASH (1) score of 11.4. A QuickDASH score of 15 or less is graded as good to excellent resolution of symptoms. He was very keen to proceed with his left-sided procedure, which was scheduled in four weeks.
1) Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord 2006;7:44. https://doi.org/10.1186/1471-2474-7-44