{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,1]],"date-time":"2026-02-01T08:59:17Z","timestamp":1769936357130,"version":"3.49.0"},"reference-count":31,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2021,8,31]],"date-time":"2021-08-31T00:00:00Z","timestamp":1630368000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>In thoracic outlet syndrome (TOS) the narrowing between bony and muscular structures in the region of the thoracic outlet\/inlet results in compression of the neurovascular bundle to the upper extremity. Venous compression, resulting in TOS (vTOS) is much more common than a stenosis of the subclavian artery (aTOS) with or without an aneurysm. Traditional open surgical approaches to remove the first rib usually lack good exposure of the entire rib and the neurovascular bundle. Between January 2015 and July 2021, 24 consecutive first rib resections for venous or arterial TOS were performed in 23 patients at our institutions. For our completely portal approach we used two 8mm working ports and one 12\/8 mm camera port. Preoperatively, pressurized catheter-based thrombolysis (AngioJet\u00ae) was successfully performed in 13 patients with vTOS. Operative time ranged from 71\u2013270 min (median 128.5 min, SD +\/\u2212 43.2 min) with no related complications. The chest tube was removed on Day 1 in all patients and the hospital stay after surgery ranged from 1 to 7 days (median 2 days, SD +\/\u2212 2.1 days). Stent grafting was performed 5\u201335 days (mean 14.8 days, SD +\/\u2212 11.1) postoperatively in 6 patients. The robotic approach to first rib resection described here allows perfect exposure of the entire rib as well as the neurovascular bundle and is one of the least invasive surgical approaches to date. It helps improve patient outcomes by reducing perioperative morbidity and is a procedure that can be easily adopted by trained robotic thoracic surgeons. In particular, patients with a\/vTOS may benefit from careful and meticulous preparation and removal of scar tissue around the vessels.<\/jats:p>","DOI":"10.3390\/jcm10173952","type":"journal-article","created":{"date-parts":[[2021,8,31]],"date-time":"2021-08-31T21:59:45Z","timestamp":1630447185000},"page":"3952","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Robotic-Assisted Thoracoscopic Resection of the First Rib for Vascular Thoracic Outlet Syndrome: The New Gold Standard of Treatment?"],"prefix":"10.3390","volume":"10","author":[{"given":"Adrian","family":"Zehnder","sequence":"first","affiliation":[{"name":"Department of Surgery, Cantonal Hospital of Winterthur, 8401 Winterthur, Switzerland"},{"name":"Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6622-6924","authenticated-orcid":false,"given":"Jon","family":"Lutz","sequence":"additional","affiliation":[{"name":"Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patrick","family":"Dorn","sequence":"additional","affiliation":[{"name":"Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3595-7307","authenticated-orcid":false,"given":"Fabrizio","family":"Minervini","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, Kantonsspital Luzern, 6004 Lucerne, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter","family":"Kestenholz","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, Kantonsspital Luzern, 6004 Lucerne, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hans","family":"Gelpke","sequence":"additional","affiliation":[{"name":"Department of Surgery, Cantonal Hospital of Winterthur, 8401 Winterthur, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0699-079X","authenticated-orcid":false,"given":"Ralph A.","family":"Schmid","sequence":"additional","affiliation":[{"name":"Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6531-2919","authenticated-orcid":false,"given":"Gregor J.","family":"Kocher","sequence":"additional","affiliation":[{"name":"Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,8,31]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Ahn, S.S., Conley, M., and Ahn, J.S. (2011). Axillosubclavian Vein Thrombectomy, Thrombolysis, and Angioplasty, Elsevier. [4th ed.].","DOI":"10.1016\/B978-1-4160-6208-0.10065-5"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"3250","DOI":"10.1007\/s00268-018-4636-4","article-title":"First Rib Resection for Thoracic Outlet Syndrome: The Robotic Approach","volume":"42","author":"Kocher","year":"2018","journal-title":"World J. Surg."},{"key":"ref_3","first-page":"371","article-title":"Vascular thoracic outlet syndrome","volume":"28","author":"Hussain","year":"2017","journal-title":"Endovasc. Open Vasc. Reconstr. A Pract. Approach"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"839","DOI":"10.1016\/j.jvsv.2019.05.012","article-title":"Evolving strategies for the management of venous thoracic outlet syndrome","volume":"7","author":"Madden","year":"2019","journal-title":"J. Vasc. Surg. Venous Lymphat. Disord."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"840","DOI":"10.1016\/S0039-6060(05)80274-0","article-title":"Long-term outcome after transaxillary approach for thoracic outlet syndrome","volume":"118","author":"Mingoli","year":"1995","journal-title":"Surgery"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1258\/rsmvasc.13.6.327","article-title":"Computer-assisted instrumentation during endoscopic transaxillary first rib resection for thoracic outlet syndrome: A safe alternate approach","volume":"13","author":"Martinez","year":"2005","journal-title":"Vascular"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1016\/j.arbres.2011.01.008","article-title":"Extirpacion de la primera costilla por videotoracoscopia para el tratamiento del sindrome del estrecho toracico","volume":"47","author":"Loscertales","year":"2011","journal-title":"Arch. Bronconeumol."},{"key":"ref_8","first-page":"39","article-title":"Robotic en bloc first-rib resection for Paget-Schroetter disease, a form of thoracic outlet syndrome: Technique and initial results","volume":"7","author":"Gharagozloo","year":"2012","journal-title":"Innovations"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1177\/1538574411434164","article-title":"Supraclavicular scalenectomy for thoracic outlet syndrome--functional outcomes assessed using the DASH scoring system","volume":"46","author":"Glynn","year":"2012","journal-title":"Vasc. Endovasc. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1155","DOI":"10.1016\/j.jvs.2012.10.089","article-title":"High-definition video-assisted transaxillary first rib resection for thoracic outlet syndrome","volume":"57","author":"Chan","year":"2013","journal-title":"J. Vasc. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1016\/j.avsg.2013.02.029","article-title":"Outcomes of surgical paraclavicular thoracic outlet decompression","volume":"28","author":"Desai","year":"2014","journal-title":"Ann. Vasc. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1016\/j.athoracsur.2016.06.075","article-title":"Totally Endoscopic (VATS) First Rib Resection for Thoracic Outlet Syndrome","volume":"103","author":"George","year":"2017","journal-title":"Ann. Thorac. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e253","DOI":"10.1016\/j.athoracsur.2018.04.016","article-title":"Robotically Assisted Transthoracic Cervical Rib Resection","volume":"106","author":"Wybaillie","year":"2018","journal-title":"Ann. Thorac. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1308\/rcsann.2017.0154","article-title":"The infraclavicular approach for Paget-Schroetter syndrome","volume":"100","author":"Samoila","year":"2018","journal-title":"Ann. R. Coll. Surg. Engl."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1093\/ejcts\/ezy275","article-title":"Robotic transthoracic first-rib resection for Paget-Schroetter syndrome","volume":"55","author":"Gharagozloo","year":"2019","journal-title":"Eur. J. Cardio-Thorac. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"354","DOI":"10.1097\/00000658-196603000-00005","article-title":"Transaxillary approach first rib resection for thoracic outlet syndrome","volume":"163","author":"Roos","year":"1966","journal-title":"Ann. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"934","DOI":"10.1016\/j.jamcollsurg.2014.12.046","article-title":"A decade of excellent outcomes after surgical intervention in 538 patients with thoracic outlet syndrome","volume":"220","author":"Orlando","year":"2015","journal-title":"J. Am. Coll. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"60","DOI":"10.1378\/chest.102.1.60","article-title":"Imaged thoracoscopic lung biopsy","volume":"102","author":"Lewis","year":"1992","journal-title":"Chest"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1482","DOI":"10.1007\/s00464-018-6430-7","article-title":"Robot-assisted versus laparoscopic single-incision cholecystectomy: Results of a randomized controlled trial","volume":"33","author":"Grochola","year":"2019","journal-title":"Surg. Endosc."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e71","DOI":"10.1016\/j.athoracsur.2019.12.086","article-title":"Transthoracic Robotic First Rib Resection: Technique Crystallized","volume":"110","author":"Burt","year":"2020","journal-title":"Ann. Thorac. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Burt, B.M., Palivela, N., Cekmecelioglu, D., Paily, P., Najafi, B., Lee, H.S., and Montero, M. (2020). Safety of robotic first rib resection for thoracic outlet syndrome. J. Thorac. Cardiovasc. Surg., in press.","DOI":"10.1016\/j.jtcvs.2020.08.107"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1016\/j.xjtc.2020.01.005","article-title":"Transthoracic robotic first rib resection: Twelve steps","volume":"1","author":"Burt","year":"2020","journal-title":"JTCVS Tech."},{"key":"ref_23","unstructured":"Yogeswaran, S., and Hendriks, J. (2020). Robotic first rib resection for venous thoracic outlet syndrome. Multimed. Man. Cardio-Thorac. Surg., 2020."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Hoexum, F., Jongkind, V., Coveliers, H.M.E., Yeung, K.K., and Wisselink, W. (2021). Robot-assisted transthoracic first rib resection for venous thoracic outlet syndrome. Vascular, 1708538121997332.","DOI":"10.1177\/1708538121997332"},{"key":"ref_25","first-page":"89","article-title":"Venous obstruction in the upper extremity; Paget-Schroetter\u2019s syndrome; a review of 320 cases","volume":"88","author":"Hughes","year":"1949","journal-title":"Surg. Gynecol. Obs."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Paget, J. (1875). Clinical Lectures and Essays. Am. J. Med. Sci.","DOI":"10.1097\/00000441-187510000-00034"},{"key":"ref_27","unstructured":"Von Schroetter, L. (1884). Erkrankungen der Gefossl. Nathnogel: Handbuch der Pathologie und Therapie, Holder."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1007\/s00276-000-0111-6","article-title":"The subclavius posticus muscle: A factor in arterial, venous or brachial plexus compression?","volume":"22","author":"Akita","year":"2000","journal-title":"Surg. Radiol. Anat."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1007\/s11552-014-9652-8","article-title":"Subclavius posticus: An anomalous muscle in association with suprascapular nerve compression in an athlete","volume":"10","author":"Cogar","year":"2015","journal-title":"Hand"},{"key":"ref_30","unstructured":"Moore, W.S., and Ahn, S.S. (2010). Endovascular Surgery, Elsevier. [4th ed.]."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"485","DOI":"10.1016\/j.jvsv.2016.01.004","article-title":"Diagnosis and treatment of effort-induced thrombosis of the axillary subclavian vein due to venous thoracic outlet syndrome","volume":"4","author":"Vemuri","year":"2016","journal-title":"J. Vasc. Surg. Venous Lymphat. Disord."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/17\/3952\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:53:35Z","timestamp":1760165615000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/17\/3952"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,8,31]]},"references-count":31,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2021,9]]}},"alternative-id":["jcm10173952"],"URL":"https:\/\/doi.org\/10.3390\/jcm10173952","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,8,31]]}}}