Robotic-Assisted Left First Rib Resection

The authors present a robotic-assisted approach for first rib resection. Traditionally, first rib resection is performed through conventional open surgery, often using either a supraclavicular or transaxillary approach, each with its own advantages and disadvantages. A minimally invasive approach can solve many shortcomings of the conventional open approach, and in expert centers, proved superior in terms of dissection, visualization, and postoperative recovery. 

The case the author's present was performed at CHU Rouen by Pr. Jean-Marc Baste and his team. This patient was a 60-year-old women who was diagnosed with venous thoracic outlet syndrome. This pathology can either be venous, arterial, or neurogenic. 

The patient was placed in right lateral decubitus. Four 8 mm ports were placed, followed by the addition of a 12 mm assistant port. Port placement was done anteriorly in the 5th intercoastal space, with the posterior ports in the 6th intercoastal space. The assisting port was positioned in the 7th intercoastal space between the anterior port and the camera port. The DaVinci X System was used. Once the robot was docked cranially, the left pleural cavity and lung were visualized, the instruments were introduced, and dissection began. In this part of the video, the authors showcase the importance of proper port placement for instruments. The correct trajectory allows for optimal angling of each instrument toward the target, in this case, the narrow apical thoracic outlet. 

These cases can often present diagnosis and treatment challenges. The patient in this case underwent thorough investigations and tests, including a Doppler ultrasound, chest X-ray, CT scan, and MRI. After specific clinical assessment, a diagnosis of venous TOS was made. There was no cervical rib or thrombosis identified on the preoperative work up. 

A robotic-assisted surgery approach was proposed and consented to by the patient. A thorough review of both the CT scan and intraoperative anatomy was paramount. The first rib was identified, and the inventory of neurovascular elements was clearly visualized. 

The rib resection began anteriorly, following the edge of the rib after incising the pleura. Careful dissection was performed, and the unparalleled view offered by the robotic platform ensured an all-time visualization of nearby anatomy. The extreme maneuverability of the robotic instruments, with their seven degrees of movement, enhanced the efficiency of dissection while minimizing traction of the neurovascular elements. A bipolar instrument, in this case a Maryland dissector, was used for dissection and denuding the edge of the rib. After completion of detaching the intercostal muscle from the rib, the anterior pole of the rib was prepped for drilling. 

A supplementary port was created posteriorly for drill access. The mini drill could be introduced through a posterior port in the 3rd or 4th intercostal space or an anterior port in the 3rd intercostal space, depending on the orientation of the first rib. The drill was introduced and controlled either by the rescrubbed lead surgeon or the first assistant surgeon. The drilling of the anterior pole of the rib was performed while the assistant intermittently irrigated the dissection site. After completely disconnecting the rib anteriorly, the same process was repeated posteriorly. As the main goal of the surgery was decompression of the vein, thorough dissection was mandatory; the muscles were disconnected from the rib, and the posterior pole of the rib was drilled and disconnected as well. At this point, the rib could be mobilized and tilted. Completion of the rib resection was achieved after sequential dissection of the subclavicular muscle, costoclavicular ligament, and the middle scalene, followed lastly by the anterior scalene muscle. The rib was then completely excised. ultrasound Doppler 

The dissection site was inspected, and hemostasis was thoroughly done respecting the surrounding structures. If necessary, a thorough dissection of any remaining tissue around the subclavian vein is performed. A TachoSil was placed to reinforce the hemostasis. The rib was removed from the chest cavity through the utility port, and a 20-gauge drain was placed, allowing the lung to be inflated. Standard closure of the ports followed. A postoperative chest X-ray showed normal appearances, and the chest drain was removed on the first postoperative day. The patient had an uneventful recovery. 

As more procedures are reimagined and adapted for minimally invasive surgery, standardization is key to maintaining safety and improving outcomes, therefore, more data is necessary to establish the superiority of one method over another. The safety of transthoracic robotic-assisted first rib resection was studied by Burt et al. with positive outcomes in favor of the robotic approach (1). 

When transitioning from open surgery to minimally invasive surgery, certain steps of the surgery are adapted and tried to fit the new approach. For instance, an alternative for the supplemental port is anteriorly placing the drill port placement as shown in the video. Although encircling the rib for traction allowed for disconnection of the rib, the authors find that this method made controlling the instrument and the angle of drilling unnecessarily challenging. 

As with any other surgical procedure, potential complications can be stratified and may range from operative to anesthetic or other adverse effects. It is important to note that, given the robotic-assisted approach, the most cited complications in conventional open surgery —such as phrenic nerve injury, thoracic duct injury or vascular injury —are theoretically less likely to occur due to the continuous excellent visualization and almost no necessary traction gestures of the neurovascular structures (2). 

The authors found the method to be safe, feasible, and reproducible when performed in a step-by step standardized manner, which matches other centers’ experience (3). In addition to the advantages illustrated here, the authors emphasis the structured and trainable advantage of this approach. 

References

1. Burt BM, Palivela N, Cekmecelioglu D, Paily P, Najafi B, Lee H-S, et al. Safety of robotic first rib resection for thoracic outlet syndrome. J Thorac Cardiovasc Surg. 2021;162:1297-305.e1.
2. Gharagozloo F, Atiquzzaman N, Meyer M, Tempesta B, Werden S. Robotic first rib resection for thoracic outlet syndrome. J Thorac Dis. 2021 Oct;13(10):6141-6154. doi: 10.21037/jtd-2019-rts-04. PMID: 34795965; PMCID: PMC8575845.
3. Burt BM, Palivela N, Karimian A, Goodman MB. Transthoracic robotic first rib resection: Twelve steps. JTCVS Tech. 2020 Jan 18;1:104-109. doi: 10.1016/j.xjtc.2020.01.005. PMID: 34317727; PMCID: PMC8288632.

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