Endoscopic Transaxillary First Rib Resection for Thoracic Outlet
The purpose of this article is to discuss the feasibility of using computer-enhanced instrumentation to improve visualization and therefore patient safety during transaxillary first rib resection.

From November 1998 to July 2005, 105 patients who had failed conservative treatment underwent 131 procedures for thoracic outlet decompression. Eighty-nine endoscopic transaxillary first rib resections were completed using Aesop/Hermes integrated voice control instrumentation (Computer Motion, Goleta, CA). Since February 2003, dissection in 42 procedures was performed using the daVinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA).

The surgical findings with cervical bands correlated with the preoperative symptoms. One hundred percent of patients with a combination of neurogenic and arterial thoracic outlet syndrome (TOS) requiring cervical rib resection had Roos type I and/or II bands. Additional surgical findings included the following: combination of neurogenic and arterial TOS without cervical ribs or neurogenic TOS alone had type III, IV, or V bands, and patients with venous compression (100%) had type VII bands. No mortalities or permanent neurovascular injuries occurred. There was a 6.1% postoperative complication rate. Persistent myofibrositis was found in 34% of patients with ongoing symptoms.

Conclusion: The daVinci three-dimensional optical imaging system enhances visualization, thereby promoting telemanipulation of soft tissue structures in a relatively inaccessible working space. Endoscopic computerized instrumentation in transaxillary first rib resection decreases the risk of neurovascular injury, promotes complete decompression, and therefore provides a safe alternative to standard first rib resections.

Roos, in 1966, first described the transaxillary first rib resection (TAFRR) for surgical treatment of thoracic outlet syndrome. This approach was designed to offer a less invasive alternative to the supraclavicular and posterior approaches described by Clagett in the early 1960s. In 1976, Roos wrote, "The bands are...the key to the whole problem of [thoracic outlet syndrome]." Through his extensive experience using the transaxillary approach, Roos identified the significance of surgical bands in the pathogenesis of neurovascular compression ( Table 1 and Figure 1 to 3).



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Anatomic location of a type I cervical band.







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Anatomic location of type II cervical bands.







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Cervical bands, types III through VII, as they relate to anatomic structures.





In 1982, the late Dr. Andrew Dale, reporting iatrogenic neurovascular injuries, questioned the safety of the transaxillary approach for thoracic outlet syndrome. Partial or complete postoperative brachial plexus injuries were reported in 273 patients; 52 failed to achieve complete recovery. Clearly, the procedure that Roos described 20 years earlier was hampered by a lack of accessibility to the surgical area.

In 1985, we reported a series of 64 patients, which presented a logical response to this issue. An endoscopy-assisted video technique during the transaxillary approach allowed direct visualization of anatomic structures and cervical anomalies, allowing safer surgical execution. During the next 10 years, the procedure evolved with the discovery and implementation of new endolaparoscopic instrumentation. In 1996, we reported an additional series of 213 patients providing not only data on the safety of the procedure but also the ability to complete the necessary delicate tissue manipulation under full endoscopic visualization.

This article presents a next step in the evolution of endoscopic transaxillary first rib resection: the adaptation of computer-enhanced instrumentation for enhanced patient safety.