New Surgical Innovations
Each of the surgical approaches described above has advantages and disadvantages. However, surgery of the thoracic outlet should always be considered a major procedure. Thus, there are excellent surgeons around the country working on new and innovative approaches to the thoracic outlet. New surgical techniques aim to reduce operative time, increase safety margins, produce better results, reduce side effects, and decrease recovery time. Not every one of these goals can be accomplished with each innovation. However, surgeons continue to strive towards these goals.
We believe that we are on the cusp of one of the most exciting innovations in thoracic outlet surgery. A number of pioneering specialists are applying modern robotic surgery techniques to the challenges of thoracic outlet syndrome.
The Da Vinci Surgical System provides capabilities that no human hand can achieve. The system utilizes tiny laparoscopes, so the surgeon can see within tiny areas of the human body without requiring a large incision. The system also includes tools of various sizes, some of which are far smaller than a surgeon’s fingers. Not only can these tools reach areas that are inaccessible to the human hand, but they provide a range of motion no human can accomplish. Finally, the computer-assisted robot enables the surgeon with amazing precision and control.
Surgeons who are experienced with robotic surgery have found considerable success in shortening operative time, minimizing surgical complications, and improving outcomes, in addition to shortened recovery times.
Several recognized centers are pursuing the use of these tools in thoracic outlet syndrome:
We have been privileged to hold many discussions with Dr. Farid Gharagozloo at the Global Robotics Institute. Dr. Gharagozloo is a pioneer in the use of robotic surgery of the thoracic outlet. We have been able to observe this surgery, and the procedure is eye-opening. Through a radical approach from beneath the first rib, Dr. Gharagozloo was able to remove nearly all of the rib. His technique protected the brachial plexus and phrenic nerve, yet completely mobilized the floor of the thoracic outlet. This results in an excellent decompression, allowing the brachial plexus and subclavian artery and vein to flow freely through the thoracic outlet.
Dr. Gharagozloo believes that our old concepts of thoracic outlet syndrome should be considered in a new light. Specifically, compression of blood vessels in the thoracic outlet, even in the absence of aneurysm or blood clot, causes persistent, low-grade swelling and reduction in oxygen to the soft tissues. In combination with relatively milder compression or tension of the brachial plexus, symptoms can result. Here is an excellent video introducing Dr. Gharagozloo’s ideas and technique. We are happy to work with Dr. Gharagozloo on imaging these patients, as well as moving the field of thoracic outlet syndrome forward with new concepts and understanding.
Microdissection without First Rib Resection
Most traditional surgical approaches to thoracic outlet syndrome focus on removal of a segment of the first rib. However, some surgeons are applying a different paradigm to the treatment of thoracic outlet syndrome. These surgeons believe that thoracic outlet syndrome represents a group of distinct diseases, with different mechanisms causing compression or tension of the brachial plexus within the thoracic outlet. In particular, these surgeons find some TOS patients with the traditional mechanism of brachial plexus compression between the first rib and clavicle. On the other hand, these surgeons also find patients without this traditional compression, but with compression or tension caused by fibrous bands, scalene anomalies, or brachial plexus anomalies. In these patients, surgeons perform careful soft tissue dissection and release of abnormal soft tissues. These patients do not require first rib resection. Specifically, this approach decreases the surgical complications, shortens the time in the operating room, and leaves the first rib in place as a structural strut.
Detailed MRI examination can provide exceptionally useful information prior to surgery in this group of patients. All of the pertinent soft tissues can be assessed in detail. Additionally, the absence of compression between rib and clavicle can be documented.
Modified Infraclavicular Approach
Most TOS surgeons are well aware of the limitations of the infraclavicular approach to thoracic outlet syndrome. Specifically, the infraclavicular approach limits access to the lateral aspect of the first rib, and to the scalene muscles and brachial plexus. However, one highly-experienced TOS surgeon has turned this conventional knowledge on its head. Dr. James Avery, in San Francisco, currently utilizes the infraclavicular approach in nearly all patients he treats for thoracic outlet syndrome. Dr. Avery has extensive experience performing the supraclavicular approach for decades. While the infraclavicular approach limits the surgeon’s approach to the scalene muscles, Dr. Avery has found this to be an advantage, rather than a limitation. He begins at the most anterior aspect of the first rib, then marches back along the rib. In this process, he frees up the subclavian vein, then the subclavian artery, and finally the brachial plexus, in sequence. When the brachial plexus is decompressed, Dr. Avery has hit his landmark.
Dr. Avery has found that procedure times are significantly shortened, recovery time in-hospital has been shortened, and patients undergoing this procedure experience the same results as those who previously underwent supraclavicular thoracic outlet decompression. These results create excitement in the TOS community.
Decompression of the thoracic outlet is a major surgical procedure. There are many vital structures coursing through a very small area, and the anatomy is quite complex. Additionally, many patients have unexpected variations of anatomy. Importantly, the first rib is quite stout and strong, so removing it requires significant effort. Finally, once the first rib is removed, a structural strut is no longer present.
Given these points, surgery of the thoracic outlet should always be considered a major procedure. As with any other major surgical procedure, serious complications may occur:
- Pneumothorax-An air leak around the lung, which may cause collapse of the lung.
- Chylothorax-The largest lymph vessel in the body, the thoracic duct, passes through the left thoracic outlet. Injury of the thoracic duct may cause chylothorax, and accumulation of lymph fluid around the lung.
- Infection-A risk factor of any surgical procedure.
- Bleeding-Injury to the subclavian artery or subclavian vein may cause major bleeding during surgery.
- Nerve Damage-The brachial plexus may branch and divide in complex, unpredictable ways. Thus, injury to the plexus remains a risk. Additionally, the small phrenic nerve passes anterior to each anterior scalene muscle. Even minor injury to the phrenic nerve may weaken or paralyze the diaphragm on the same side. This weakness or paralysis may significantly limit the ability to breathe. Often, this weakness or paralysis resolves by itself over several months.
- Brachial plexus inflammation or fibrosis-This is a complication that has not been well-described in the literature. However, we have seen many patients with thickening and swelling of the brachial plexus, as well as active inflammatory tissue surrounding the plexus. Since many surgeons perform neurolysis of the brachial plexus (stripping of scar tissue surrounding the plexus) during routine thoracic outlet decompression, there remains a concern that the procedure leads to this post-operative finding.