18611 Gharagozloo.mp4 (1.09 GB)

Technique of Robotic First Rib Resection—Tips and Pitfalls

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posted on 2022-08-24, 20:02 authored by Farid Gharagozloo

Robotic resection of the first rib (R-FRR) in patients with thoracic outlet syndrome (TOS) was described in 2012 by Gharagozloo et al. (1). This group has published the results of their experience in the decade since the original description (2–8). Their most recent report included 162 patients—eighty-three for venous thoracic outlet syndrome (VTOS) and seventy-nine for neurogenic thoracic outlet syndrome (NTOS)—with a median hospital stay of three days (range: 2–4) for NTOS and a median stay of four days in patients with Paget-Schroetter syndrome. 

In patients with NTOS, the QuickDASH scores were reduced significantly in the immediate postoperative period (5 ± 2.3) and at six months (3.5 ± 1.1) compared to the mean preoperative values of 50.3 ± 2.1 (p < 0.0001). Seventy-one out of seventy-nine (91%) of the NTOS patients reported that their symptoms were completely resolved in the immediate postoperative period and only three out of seventy-nine (3.8%) of them continued to have symptoms at six months. The entirety of patients with Paget-Schroetter syndrome had a patent subclavian vein in dynamic MRA—even two years postoperatively. These favorable findings were reproduced by other investigators who also showed reduced incidence of morbidity, zero mortality, and significant improvement of symptoms in NTOS and rates of subclavian vein patency (9–16).

The results derive from, one, a better understanding of the pathogenesis of TOS and, two, the technical advantages of the robotic platform.

This video presents the state-of-the-art understanding of TOS, narrates the technique of robotic first rib resection with tips and pitfalls, and presents the data from the therapeutic application of this technique to patients with TOS.


1) Gharagozloo F. et. Al. Robotic Thoracoscopic First Rib Resection and scalenectomy for the treatment of Thoracic Outlet Syndrome. Innov. 6:3, 2011

2) Gharagozloo F, Meyer M, Tempesta B, Werden S. Robotic First Rib Resection for Thoracic Outlet Syndrome. Surg Technol Int. (2020) 36:239–44.

3) Gharagozloo F, Atiquzzaman N, Meyer M, Tempesta B, Werden S. Robotic first rib resection for thoracic outlet syndrome. J Thorac Dis. (2021) 13:6141–54.

4) Gharagozloo F, Meyer M, Tempesta B, Gruessner S. Robotic transthoracic first-rib resection for Paget-Schroetter syndrome. Eur J Cardiothorac Surg. (2019) 55:434–9.

5) Gharagozloo F, Meyer M. Robotic Transthoracic First Rib Resection for Neurogenic Thoracic Outlet Syndrome. World J Cardiovasc Surg 2022; Vol.12 No.1, DOI: 10.4236/wjcs.2022.121001

6) Gharagozloo F, Werden S, Meyer M, Bouri A, Hallman-Quirk H, Ware A, Atiquzzaman N, Gruessner S. Historic Basis for the New Developments in the Diagnosis and Treatment of Thoracic Outlet Syndrome (TOS). Clin Surg J. 2022; 3:1–16.

7) Gharagozloo F, Atiquzzaman N, Meyer M, Werden S. Technique of Robotic First Rib Resection. MIS Journal. 2021; 5:39.

8) Gharagozloo, F. Reevaluating the Pathogenesis and Classification of Thoracic Outlet Syndrome. Academia Letters, Article 5408. 2022. https://doi.org/10.20935/AL5408

9) Burt BM, Palivela N, Cekmecelioglu D, Paily P, Najafi B, Lee HS, et al. Safety of robotic first rib resection for thoracic outlet syndrome. J Thorac Cardiovasc Surg. (2021) 162:1297–305.

10) Yogeswaran S, Hendriks J. Robotic first rib resection for venous thoracic outlet syndrome. Multimed Man Cardiothorac Surg. (2020) 4.

11) Zehnder A, Lutz J, Dorn P, Minervini F, Kestenholz P, Gelpke H, et al. Robotic-assisted thoracoscopic resection of the first rib for vascular thoracic outlet syndrome: the new gold standard of treatment? J Clin Med. (2021) 10:3952.

12) Kocher GJ, Zehnder A, Lutz JA, Schmidli J, Schmid RA. First rib resection for thoracic outlet syndrome: the robotic approach. World J Surg. (2018) 42:3250–5.

13) Palivela N, Lee HS, Jang HJ, Paily P, Montero M, Najafi B, et al. Improvement of disability in neurogenic thoracic outlet syndrome by robotic first rib resection. Ann Thorac Surg. (2021).https://doi.org/10.1016/j.athoracsur.2021.07.052

14) Burt BM, Palivela N, Goodman MB. Transthoracic robotic first rib resection: technique crystallized. Ann Thorac Surg. (2020) 110:e71 3.doi:10.1016/j.athoracsur.2019.12.086

15) Zehnder A, Dorn P, Lutz J, Minervini F, Kestenholz P, Gelpke H, et al. Completely thoracoscopic 3-port robotic first rib resection for thoracic outletsyndrome. Ann Thorac Surg. (2021). doi: 10.1016/j.athoracsur.2021.08.053.

16) Pupovac SS, Lee PC, Zeltsman D, Jurado J, Hyman K, Singh V. Robotic-assisted first rib resection: our experience and review of the literature. Semin Thorac Cardiovasc Surg. (2020) 32:1115–20.\

17) Gkikas A, Lampridis S, Patrini D, Kestenholz PB, Azenha LF, Kocher GJ, Scarci M and Minervini F (2022) Thoracic Outlet Syndrome: Single Center Experience on Robotic Assisted First Rib Resection and Literature Review. Front. Surg. 9:848972. doi: 10.3389/fsurg.2022.848972


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