First report of robot-assisted surgical resection of the first rib via a posterior approach for the treatment of thoracic outlet syndrome

Background: In thoracic outlet syndrome (TOS), the resection of the first rib in case of costoclavicular pinch with neurological/venous/arterial symptoms is a widely performed surgery using a direct approach (cervical or axillary approach). A minimally invasive anterior approach assisted by robotics has been reported, but nothing is known about the feasibility of a posterior approach. We present a minimally invasive, robot-assisted posterior approach and report the preliminary results of this technique. Methods: From July 2023 to December 2024, we prospectively collected data on patients who underwent first rib resection (for TOS resistant to physiotherapy treatment) using robotic assistance at the University Hospital of Rennes, France. Clinical and surgical results are reported. Results: Eighteen (83%women) patients underwent the minimally invasive approach. The median age was 40.5 [interquartile range (IQR), 33.3-45.8] years old. Symptoms were arterial for two patients, venous for five, and neurological for 11. The median surgery time was 117.5 (IQR, 95.5-126.0) minutes, with a median hospital length of stay of 2 (IQR, 2-3) days. There were no perioperative complications, neurovascular injuries, or perioperative mortality. We had one postoperative complication that resolved without sequelae. Symptoms had disappeared or significantly decreased within the month following the surgery. Persistent but decreasing paresthesia was observed in one patient out of 18 at 1 month after surgery. Ten patients experienced postoperative neuropathic pain, with six receiving gabapentin. Conclusions: This minimally invasive posterior approach technique appears to be feasible and safe for the first rib resection in patients with TOS. The appropriate identification of the "culprit" part of the first rib allows for excellent results with enhanced three-dimensional (3D) vision and a reduction in perioperative neurovascular complications.