This study was conducted in accordance with Declaration of Helsinki and local clinical ethics committee (2018/09).
1. Physical Examination
NOTE: The provocative tests for diagnosis of the TOS are depicted in Figure 1.
<ol>
	<li>For the Adson test (scalene test, Figure 1A), bring the patient&#8217;s shoulder to external rotation with slight abduction and a little bit of extension and palpate the radial pulse. Extend the patient&#8217;s head backward and rotate toward the tested shoulder. Ask the patient to breathe in and hold their breath.
	<ol>
		<li>Consider the test positive in cases where reproduction of symptoms or abolition of the radial pulse occurs while symptoms resolve with rotating of the head to the controlateral side.</li>
	</ol>
	</li>
	<li>For the costoclavicular brace test (Figure 1B), bring the patient&#8217;s arm to the back, depress and retract over the patients&#39; scapula on the ipsilateral side. Check the pulse. If the radial pulse disappears or symptoms are reproduced, the test is deemed positive.</li>
	<li>For the hyperabduction test (Figure 1C), slightly extend the patient&#8217;s arm and palpate the radial artery. Abduct the arm 90-180&#176;. A positive test is a decrease in the pulse of the radial artery from baseline to the new position.</li>
	<li>For the Roos (East) test (Figure 1D), perform the test in either a sitting or standing position. Take the patient&#8217;s shoulders to 90&#176; abduction, externally rotate, and flex elbows to 90&#176;. The elbows should be slightly behind the frontal plane. Have the patient open and close his/her hands for 3 minutes.
	<ol>
		<li>Consider the test positive if the patient experiences heaviness, ischemic pain or weakness of the arms or numbness and tingling of the hands. Discoloration of the hands is also meaningful for the test. 
		NOTE: Surgical treatment is the first option in VTOS cases, whereas surgical treatment is performed in NTOS cases after 3 months of conservative therapy without any improvement in their daily life, work life, and sleep quality.</li>
	</ol>
	</li>
</ol>
2. Preoperative clinical and electrodiagnostic assessment
<ol>
	<li>For evaluation of the clinical improvement with surgical treatment, make clinical findings in the physical examination, EMG findings, and the QuickDASH (Disability of Arm, Shoulder, and Hand: <a href="https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf">https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf</a>) questionnaire related to symptoms of daily activities and social and psychological preoperative periods.</li>
	<li>Determine the preoperative EMGs by measuring the compound motor action potential (CMAP), sensory nerve action potential (SNAP), and nerve conduction velocity (NCV) and F-wave latency. Make recordings using a commercial EMG/NCV/EP measuring system (e.g.,&#160;Nihon&#160;Kohden&#160;Neuropack 2).</li>
</ol>
3. Transaxillary first rib resection in a stepwise manner
<ol>
	<li>Perform anesthesia using a standard anesthetic induction protocol which includes 0.6 mg/kg rocuronium bromide, 0.05 mg/kg midazolam and 1-2 &#181;g/kg fentanyl.</li>
	<li>Administer tiopenthal sodium at 6 mg/kg for maintenance.</li>
</ol>
4. Patient position (Figure 2)
<ol>
	<li>After placing the patient in the lateral decubitus position, wrap the arm, elevate and hang in a 90&#176; abduction position. If needed, reduce traction every 3-5 minutes to prevent postoperative complication.</li>
	<li>Use a solution of 10% sterile povidone-iodine for topical sterilization. Drape the arm, axilla and chest. Use sterile sheets on to rest of the body to prevent contamination.</li>
</ol>
5. Reaching the first rib
<ol>
	<li>Use the surgical instruments are shown in Figure 3 and the Table of Materials.</li>
	<li>Make an incision in a transverse fashion below the axillary hairline extending from the pectoralis muscle anteriorly and the latissimus dorsi muscle posteriorly at a length of 5-7 cm.</li>
	<li>Cross the skin, subcutaneous tissue, and fascia to reach the anterior chest wall.</li>
	<li>Use blunt dissection to reach the first rib.</li>
</ol>
6. Releasing the first rib from muscles and fascia
<ol>
	<li>Pierce the fascia overlying the first rib and dissect away the periosteum overlying the superior part of the rib. Bluntly dissect the inferior edge of the rib from surrounding muscles using monopolar cautery and rib raspatory.</li>
	<li>Split the intercostal muscles until the costoclavicular ligament at the sternocostal junction and the angular costa in the posterior costovertebral junction.</li>
	<li>In the superior edge of the first rib, expose the anterior scalene muscle anteriorly and medius scalene muscle posteriorly. Place the curved forceps under the anterior and middle scalene muscles to cut the muscles at the level of their insertion over the first rib, where they are farthest from the neurovascular bundle.</li>
</ol>
7. Removal of the first rib or the cervical rib
<ol>
	<li>Start the resection of the first rib at the sternocostal junction anteriorly. First, turn from its superior edge and then the inferior edge to resect it using a rib cutter from the sternum. Ensure that the neurovascular structures are preserved.</li>
	<li>Afterwards, resect the posterior portion of the rib, and disarticulate the part located distally to the angle of rib; hence complete the rib resection.</li>
	<li>After totally freeing the cervical rib from surrounding tissue, resect and disarticulate the rib until the articular surface of the transverse process is seen.</li>
</ol>
8. Postoperative Period
<ol>
	<li>In postoperative period, perform a chest X-ray to rule out complications, such as pnomothorax.</li>
	<li>Remove the thorax drain on postoperative day 1 in uneventful cases.</li>
	<li>Use nonsteroidal anti-inflammatory drugs, narcotic analgesics, and a muscle relaxant for postoperative pain.</li>
	<li>In the early postoperative period, examine movement of the arm in the operated side. Continue physical therapy for the first two post-operative months.</li>
	<li>Advise the patient not to perform any exhausting activity with the operated side.</li>
</ol>
9. Postoperative clinical and electrodiagnostic assessment
<ol>
	<li>For evaluation of the clinical improvement with surgical treatment, compare clinical findings in the physical examination, EMG findings, and the QuickDASH (Disability of Arm, Shoulder, and Hand: <a href="https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf">https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf</a>) questionnaire related to symptoms of daily activities and social and psychological preoperative and postoperative (3 months) periods.</li>
	<li>Compare the preoperative and postoperative EMGs by measuring the compound motor action potential (CMAP), sensory nerve action potential (SNAP), and nerve conduction velocity (NCV) and F-wave latency. Make recordings using a commercial EMG/NCV/EP measuring system (e.g.,&#160;Nihon&#160;Kohden&#160;Neuropack 2).</li>
	<li>Perform the physical examination postoperatively to evaluate the pain and paresthesia.</li>
</ol>

<ol>
	<li>Peet, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+evaluation+of+a+therapeutic+exercise+program.">Thoracic outlet syndrome: evaluation of a therapeutic exercise program.</a> InProc Mayo Clinic. 31, 281-287 (1956).</li><li>Han, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+approach+in+thoracic+outlet+syndrome:+the+importance+of+resection+of+the+first-rib.">Transaxillary approach in thoracic outlet syndrome: the importance of resection of the first-rib.</a> European Journal of Cardio-Thoracic Surgery. 24 (3), 428-433 (2003).</li><li>Yavuzer, &. #. 3. 5. 0. ;., Atinkaya, C., Tokat, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+predictors+of+surgical+outcome+in+patients+with+thoracic+outlet+syndrome+operated+on+via+transaxillary+approach.">Clinical predictors of surgical outcome in patients with thoracic outlet syndrome operated on via transaxillary approach.</a> European Journal of Cardio-Thoracic Surgery. 25 (2), 173-178 (2004).</li><li>Roos, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+approach+for+first+rib+resection+to+relieve+thoracic+outlet+syndrome.">Transaxillary approach for first rib resection to relieve thoracic outlet syndrome.</a> Annals of Surgery. 163 (3), 354 (1966).</li><li>Jubbal, K. T., Zavlin, D., Harris, J. D., Liberman, S. R., Echo, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Morbidity+of+First+Rib+Resection+in+the+Surgical+Repair+of+Thoracic+Outlet+Syndrome.">Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome.</a> Hand. , 1558944718760037 (2018).</li><li>Likes, K. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lessons+learned+in+the+surgical+treatment+of+neurogenic+thoracic+outlet+syndrome+over+10+years.">Lessons learned in the surgical treatment of neurogenic thoracic outlet syndrome over 10 years.</a> Vascular and Endovascular Surgery. 49 (1-2), 8-11 (2015).</li><li>Akku&#351;, M., Ya&#287;murlu, K., &#214;zarslan, M., Kalani, M. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+outcomes+of+neurogenic+thoracic+outlet+syndrome+based+on+electrodiagnostic+tests+and+QuickDASH+scores.">Surgical outcomes of neurogenic thoracic outlet syndrome based on electrodiagnostic tests and QuickDASH scores.</a> Journal of Clinical Neuroscience. 58, 75-78 (2018).</li><li>Peek, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7 (2018).</li><li>Sanders, R. J., Annest, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique+of+supraclavicular+decompression+for+neurogenic+thoracic+outlet+syndrome.">Technique of supraclavicular decompression for neurogenic thoracic outlet syndrome.</a> Journal of Vascular Surgery. 61 (3), 821-825 (2015).</li><li>Sanders, R. J., Hammond, S. L., Rao, N. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+a+review.">Thoracic outlet syndrome: a review.</a> The Neurologist. 14 (6), 365-373 (2008).</li><li>Vos, C. G., &#220;nl&#252;, &. #. 1. 9. 9. ;., Vo&#251;te, M. T., van de Mortel, R. H., de Vries, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+First+rib+resection.">Thoracic outlet syndrome: First rib resection.</a> Shanghai Chest. 1 (1), (2017).</li><li>Desai, S. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcomes+of+surgical+paraclavicular+thoracic+outlet+decompression.">Outcomes of surgical paraclavicular thoracic outlet decompression.</a> Annals of vascular surgery. 28 (2), 457-464 (2014).</li><li>Peek, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7 (2018).</li><li>Urschel, H. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+first+rib+resection+for+thoracic+outlet+syndrome.">Transaxillary first rib resection for thoracic outlet syndrome.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 10 (4), 313-317 (2005).</li><li>Sheth, R. N., Campbell, J. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+thoracic+outlet+syndrome:+a+randomized+trial+comparing+two+operations.">Surgical treatment of thoracic outlet syndrome: a randomized trial comparing two operations.</a> Journal of Neurosurgery: Spine. 3 (5), 355-363 (2005).</li><li>Urschel, H. C., Razzuk, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neurovascular+compression+in+the+thoracic+outlet:+changing+management+over+50+years.">Neurovascular compression in the thoracic outlet: changing management over 50 years.</a> Annals of Surgery. 228 (4), 609 (1998).</li><li>Povlsen, B., Hansson, T., Povlsen, S. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+for+thoracic+outlet+syndrome.">Treatment for thoracic outlet syndrome.</a> Cochrane Database of Systematic Reviews. 11, (2014).</li><li>George, R. S., Milton, R., Chaudhuri, N., Kefaloyannis, E., Papagiannopoulos, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Totally+endoscopic+(VATS)+first+rib+resection+for+thoracic+outlet+syndrome.">Totally endoscopic (VATS) first rib resection for thoracic outlet syndrome.</a> The Annals of Thoracic Surgery. 103 (1), 241-245 (2017).</li><li>Strother, E., Margolis, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+first+rib+resection.">Robotic first rib resection.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 20 (2), 176-188 (2015).</li></ol>

TFRR is the most used surgical technique for treatment of TOS9,10,11. The advantage of the TFRR is that it provides a better cosmetic result with a hidden incision in the axilla without requirement of cutting the muscles to reach the surgical field. Its disadvantage is the relatively narrow and deep working space. The supraclavicular approach, which is preferred for arterial TOS treatment, puts the subclavian artery at less risk of damage12. The subclavian vein is followed in the infraclavicular approach commonly used for venous TOS treatment, and the posterolateral FRR is mostly used for the treatment of the recurrent TOS13,14.
A randomized study of the supraclavicular neoplasty of the brachial plexus by Sheeth et al. noted that TFRR provides a better surgical outcome than other surgical techniques15. Another study compared the NTOS cases treated with TFRR, the cases treated with the supraclavicular FRR+scalenectomy, and the cases treated only with scalenectomy, which resulted in clinical improvement rates of 60-92%, 64-86%, and 63-80%, respectively. Although there has not been a significant difference between surgical outcome, lower recurrence rates have been noted in cases treated with TFRR10,16,17,18,19.
The retractor should be used carefully and in an anterior-posterior direction to avoid damage to the neurovascular structures in the narrow field. The scalene triangle has anterior and middle scalene muscles on both side and has the first rib in its basal side. The subclavian artery and brachial plexus passes through the scalene triangle, and scalene vein passes anterior to the anterior scalene muscle, not through the scalene triangle. The first rib is retracted downward, and the middle scalene muscle is cut at its attachment point to the first rib. After the anterior and middle scalene muscles are cut, the fascia and soft tissues along the superior edge of the first rib are freed from the sternum anteriorly to the vertebral body posteriorly. Although not required for this illustrative case, anterior costoclavicular ligament and subclavian muscle division might be needed in some cases. The retraction should be avoided toward the apex of the scalene triangle, where neurovascular structures reside. Intraoperative nerve injury may cause severe disabilities, such as the diaphragm eventration caused by the phrenic nerve injury, winging of the scapula caused by the long thoracic nerve injury, and numbness in the arm caused by the intercostobrachial nerve injury. The inferior edge of the first rib is freed from pleura gently. In case of unintended pleura opening, a chest tube should be placed to prevent the hemothorax or pneumothorax. Since the most common cause of recurrence is leaving a piece of the posterior part of the rib, the first rib should be completely removed. During this procedure, especially posteriorly, there is a risk of injury to the intercostal vein. Oozing from the intercostal veins is stopped by tamponade rather than using the electrocautery, which may damage the brachial plexus causing postoperative causalgia.
Since the surgical corridor in TFRR technique is narrow, hemostasis is crucial to make the working area clean and to prevent postoperative hematoma. During the closure, a hemovac drain can be placed.
In conclusion among surgical treatment modalities used for cases of TOS, the TFRR technique is a unique modality with excellent surgical outcomes and lower recurrence rates. The major limitation of this procedure is that it provides restricted vascular reconstruction options in VTOS cases.

The compression of the brachial plexus, subclavian artery or vein in the scalene triangle is clinically known as thoracic outlet syndrome (TOS), first described by Peet et al.1. Thoracic outlet syndrome is subdivided into neurogenic (NTOS), arterial TOS, and venous TOS based on the underlying etiology1. Patients with NTOS (93-95% of TOS cases) present with pain, numbness, and ipsilateral weakness. Patients with venous TOS (3-5%) present with venous thrombosis, and patients with arterial TOS (1-2%) present with arterial thromboembolic event and ischemia. Conservative management of TOS includes medications and physiotherapy and is the first choice for TOS cases. The surgical treatment modalities include decompression procedures and are performed after conservative management has failed2. Decompression techniques include the transaxillary first rib resection (TFRR), supraclavicular first rib resection scalenectomy (SFRRS), scalenectomy (without first rib resection via supraclavicular or transaxillary), and posterior approach first rib resection (PA-FRR)3. The transaxillary first rib resection, a technique described by Roos et al. in 1966, is an effective method for treatment of TOS4,5. The main goal of TFRR is to completely remove the last cervical and first thoracic ribs and to decompress the underlying neurovascular bundle.
Vascular TOS (VTOS) are diagnosed with CT angiography, color duplex USG, and arteriography or venography, whereas the NTOS is diagnosed with X-ray, electrodiagnostic studies (needle electromyelography), color duplex Doppler USG, and cervical MRI. Physiotherapist and psychiatrist consultations should be obtained to exclude other disorders preoperatively.The symptom relief with lidocaine injection to the anterior scalene muscle is also a good indicator for diagnosis and predictor of surgical benefit in NTOS patients6.

<table><tbody><tr><td>Ag Debakey vascular forceps 24 cm, 3.5 mm</td><td>Lawton medizintechnik</td><td>30-0032</td><td>Check the hemorrhage</td></tr><tr><td>Bone chisels curved 13x9.1/2&#039;&#039;</td><td>Aesculap Inc.</td><td>MB-992R</td><td>Dissect the periost of the first rib</td></tr><tr><td>Doyen-stille retractor 24 cm</td><td>Lawton medizintechnik</td><td>20-0650</td><td>Skin- muscle retraction</td></tr><tr><td>Foerster sponge forceps straight</td><td>Lawton medizintechnik</td><td>07-0156</td><td>For swabbing</td></tr><tr><td>Luer stille bone rongeur curved 27 cm</td><td>Lawton medizintechnik</td><td>38-0703</td><td>Bone punches</td></tr><tr><td>Luer stille rongeur straight 22 cm</td><td>Lawton medizintechnik</td><td>38-0400</td><td>Rib cutter</td></tr><tr><td>Mayo hegar needle holder 20.5 cm</td><td>Lawton medizintechnik</td><td>08-0184</td><td>Suturing</td></tr><tr><td>Metzenbaum scissors curved delicate 23 cm</td><td>Lawton medizintechnik</td><td>05-0665</td><td>Dissection</td></tr><tr><td>Overholt curved forceps delicate 30.5 cm</td><td>Lawton medizintechnik</td><td>06-0807</td><td>Split the scalen muscles from the rib</td></tr><tr><td>Roberts art forceps straight 24 cm</td><td>Lawton medizintechnik</td><td>06-0370</td><td>For sponge and remove remain bone</td></tr><tr><td>Roux retractor medium size 15.5 cm</td><td>Lawton medizintechnik</td><td>20-0402</td><td>Wound retraction</td></tr><tr><td>Semb rasparotry 22,5 cm, 12mm</td><td>Lawton medizintechnik</td><td>39-0252</td><td>Dissect the muscle of the first rib</td></tr><tr><td>Smith peterson model curved osteotome 13x205 mm</td><td>Lawton medizintechnik</td><td>46-0783</td><td>Dissect the muscle of the first rib</td></tr><tr><td>Stille -giertz rib shears 27 cm</td><td>Lawton medizintechnik</td><td>38-0200</td><td>First rib cutting</td></tr><tr><td>Stille osteotome 8x205 mm</td><td>Lawton medizintechnik</td><td>46-0248</td><td>Dissect the periost of the first rib</td></tr><tr><td>Wagner rongeur 5.5x210 mm</td><td>Lawton medizintechnik</td><td>53-0703</td><td>Punches</td></tr></tbody></table>

transaxillary first rib resection for treatment of the thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol has been used for the decompression of trapped neurovascular structures in the TOS. Among the other surgical procedures, the advantage of the TFRR is that it has the smallest rate of recurrence and better cosmetic outcomes. The disadvantage of TFRR is that it provides a narrow, and deep working corridor that makes obtaining vascular control challenging.

Clinical Outcomes 
A total of 15 patients were included in this study. Three patients (20%) were male and 12 of patients (80%) were female. The mean age of patients was 30.6 ± 8.98 years. All male participants and 5 of female participants were manual laborers. The most common complaint of the NTOS group was arm-forearm pain and numbness weakness of grip and hypothenar atrophy. In the postoperative clinical follow-up, patients were questioned about their paresthesia and pain severity, overall satisfaction, their activity and work status. QuickDASH scores and EMG value were evaluated preoperatively and in the postoperative period. Comparison of preoperative and postoperative EMG measurements are presented in Table 1, Table 2, Figure 4, Figure 5 and Figure 6. We found a remarkable clinical improvement between preop- and postoperative QuickDASH7.
The postoperative exam at six months was evaluated for recurrence or surgical failure. The recurrence rate has been noted to be between 6-54% in different case series8. In the study here, recurrence was observed in 6% of patients (n=1) at the operative side after six months of operation while 20% of patients (n=3) reported TOS symptoms at the controlateral side in follow-up (4 to12 years).
All patients were discharged between postoperative days 2-5. The morbidity rates have been noted to be between 5-40% and include pneumothorax, infection, nerve injury (long thoracic nerve, cervical sympathetic chain, roots of the brachial plexus), hemothorax, hematoma in the surgical field, and lymphatic fluid leakage. These complications are often temporary and resolve within a few days. Deficits lasting longer may require surgical intervention.
Electrodiagnostic outcomes 
The latency of the median F-wave was remarkably prolonged on the affected side compared to the unaffected side preoperatively. There was no significant difference in the latency of ulnar F-waves between sides. Compound motor action potential (medial antebrachial cutaneous), sensory nerve action potential (ulnar), and nerve conduction velocity (median motor amplitude) values increased significantly postoperatively. EMG findings are correlated with postoperative clinical improvement7.
<img alt="Anatomical drawing showing shoulder joint ranges of motion; muscles and arm positions labeled A-D." class="xfigimg" src="/files/ftp_upload/59659/59659fig01.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1: Provocative tests for thoracic outlet syndrome. (A) The Adson test. (B) The Costoclavicular brace test. (C) Hyperabduction test. (D) Roos (East test. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59659/59659fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical incision with drainage tube on patient's shoulder, post-operation setup in hospital." class="xfigimg" src="/files/ftp_upload/59659/59659fig02.jpg" data-altupdatedat="1747911167000" data-alt="Figure 2"> 
Figure 2: Operative position used for patient positioning. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59659/59659fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical instrument set, labeled and arranged, various clamps, scalpels, forceps, and retractors." class="xfigimg" src="/files/ftp_upload/59659/59659fig03.jpg" data-altupdatedat="1747911167000" data-alt="Figure 3"> 
Figure 3: Surgical instruments used for the procedure. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59659/59659fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Nerve conduction graph showing MAC nerve action potentials vs. number of patients, comparison chart." class="xfigimg" src="/files/ftp_upload/59659/59659fig04.jpg" data-altupdatedat="1747911167000" data-alt="Figure 4"> 
Figure 4: Comparison of preoperative and postoperative values of the medial antebrachial cutaneous (MAC) nerve action potantials on each patient. Blue: preoperative data; Red: postoperative data. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59659/59659fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Ulnar nerve action potentials chart; comparison of sensory potentials in 15 patients." class="xfigimg" src="/files/ftp_upload/59659/59659fig05.jpg" data-altupdatedat="1747911167000" data-alt="Figure 5"> 
Figure 5: Comparison of preoperative and postoperative values of the ulnar nerve sensory responses on each patient. Blue: preoperative data; Red: postoperative data. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59659/59659fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Bar chart of median motor actions (mV) across 15 patients; displays patient response variability." class="xfigimg" src="/files/ftp_upload/59659/59659fig06.jpg" data-altupdatedat="1747911167000" data-alt="Figure 6"> 
Figure 6: Comparison of preoperative and postoperative values of the median motor actions amplitude responses on each patient. Blue: preoperative data; Red: postoperative data. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59659/59659fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Unaffected Side</td>
			<td>Affected Side</td>
			<td>p value</td>
		</tr>
		<tr>
			<td>Median F Response(ms)</td>
			<td>22.94±1.79</td>
			<td>23.98±2.05</td>
			<td>0.015</td>
		</tr>
		<tr>
			<td>Ulnar F Response(ms)</td>
			<td>23.57±1.97</td>
			<td>24.01±2.49</td>
			<td>0.246</td>
		</tr>
		<tr>
			<td colspan="4">This table has been modified from [7].</td>
		</tr>
	</tbody>
</table>
Table 1: Comparison of the median nerve F response and ulnar nerve F response of upper extremities preoperatively.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Preoperative</td>
			<td>Postoperative</td>
			<td>p value</td>
		</tr>
		<tr>
			<td>MAC(m/s)</td>
			<td>55.1 ± 6.36</td>
			<td>62.15 ± 3.08</td>
			<td>0.0001</td>
		</tr>
		<tr>
			<td>U-SNAP (µV)</td>
			<td>51.35 ± 8.95</td>
			<td>58.66 ± 6.8</td>
			<td>0.003</td>
		</tr>
		<tr>
			<td>MMA(mV)</td>
			<td>12.43 ± 2.32</td>
			<td>15.2 ± 2.82</td>
			<td>0.0001</td>
		</tr>
		<tr>
			<td colspan="4">MAC: medial antebrachial cutaneous, U-SNAP: ulnar sensory neural action potential,</td>
		</tr>
		<tr>
			<td colspan="4">MMA: median motor amplitude</td>
		</tr>
		<tr>
			<td colspan="4">This table has been modified from [7].</td>
		</tr>
	</tbody>
</table>
Table 2: Preoperative and postoperative comparisons of the electrophysiological measures.
Video: Transaxillary first rib resection in a stepwise manner. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59659/TOSvideo.mp4" target="_blank">Please click here to download this video.</a>

Watch this Scientific Journal Video about Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome at JoVE.com

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Here, we present a protocol of the transaxillary resection of the first rib for treatment of thoracic outlet syndrome caused by compression of the brachial plexus, subclavian vein and artery.

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...

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Nanyang Technological University

Research

JoVE Journal

Medicine

2.8K Views.  Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital. Hier presenteren we een protocol van de transaxillaire resectie van de eerste rib voor de behandeling van het thoracic outlet-syndroom veroorzaakt door compressie van de plexus brachialis, de ader subclavia en de slagader.

Video: Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

The goal of this protocol is to describe in detail the technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy and central aortic cannulation. This technique can potentially enhance patients&#39; comfort and, by reducing post-operative morbidity, promote lowering the length of stay and global costs.

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The ...

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains controversial. A transthoracic approach may improve lymph node dissection, but it has considerable morbidity and respiratory complications. Transhiatal access has been demonstrated as an efficient means of minimizing post-operative complications. Minimally invasive transhiatal esophagectomy may reduce operative trauma and morbidity as well as enhance postoperative recovery with no compromise in cancer recurrence or survival. Nevertheless, it has a technical limitation in terms of cervical esophagus dissection. Thus, a low-cost single-port device was developed to complete upper mediastinal dissection by a transcervical approach during minimally invasive transhiatal esophagectomy. This device uses a nasogastric tube, a number-eight sterile glove, a sterile sponge, and 3 permanent 5-mm trocars. The step-by-step process of transhiatal esophagectomy and the development of this device are described. This technique allows for the dissection of the upper mediastinum, as well as the esophagus over the aortic arch and behind the superior portion of the trachea. The harvesting of lymph nodes along the left recurrent laryngeal nerve and paratracheals was improved.

Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Here, we describe a step-by-step description of transhiatal esophagectomy and the development of a low-cost single-port device for a transcervical approach in a minimally invasive transhiatal esophagectomy.

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains ...

Laminectomy for the Removal of Thoracic Ossification of the Ligamentum Flavum (TOLF) Using Ultrasonic and Conventional Osteotomes

Thoracic ossification of the ligamentum flavum (TOLF) is a common cause of progressive thoracic myelopathy. TOLF is typically treated with surgical decompression. A variety of surgical techniques, including laminoplasty, laminectomy, and lamina fenestration, are used for the effective treatment of TOLF. However, traditional methods are associated with a substantial risk of perioperative complications, including dural laceration and/or iatrogenic spinal cord injury. Therefore, it is important to develop an efficient and secure surgical technique for TOLF. Herein, we describe a method for laminectomyperformed at the thoracic spine using an ultrasonic osteotome combined with a conventional osteotome. This technique can reduce intraoperative complications. This is a relatively safe and easy-to-learn method that should be recommended for the treatment of TOLF.

Laminectomy for the Removal of Thoracic Ossification of the Ligamentum Flavum TOLF Using Ultrasonic and Conventional Osteotomes

We present a methodology for using an ultrasonic osteotome combined with a conventional osteotome for laminectomy in thoracic ossification of the ligamentum flavum. This is a relatively safe and easy-to-learn method that avoids the perioperative complications associated with the conventional method.

Thoracic ossification of the ligamentum flavum (TOLF) is a common cause of progressive thoracic myelopathy. TOLF is typically treated with surgical ...

A Non-Intubation Protocol for Video-Assisted Thoracoscopic Surgery with Preserved Autonomic Breathing

Non-Intubated Video-Assisted Thoracoscopic Surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia 

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral vestibule approaches. Essentially, various approaches to thyroid surgery only move the traditional surgical incision to a more concealed position but still leave scars on the body surface. Among them, thyroid surgery via the oral vestibule approach can obtain the best cosmetic outcome through the shortest natural cavity. However, in the early time, thyroid surgery via the oral vestibule approach usually requires three incisions in the mouth and one axillary incision. We have introduced a robotic surgical system into thyroidectomy via the oral vestibule approach and successfully completed total thyroidectomy and bilateral central lymph node dissection. During the operation, only three incisions were made at the oral vestibule without an axillary incision. This article aims to present the unique three-port method of robotic thyroidectomy via oral vestibule for the treatment of patients with papillary thyroid cancer.

The transoral robotic total thyroidectomy and bilateral central regional lymph node dissection using three ports without axillary incision are feasible and safe for early-stage papillary thyroid carcinoma. Here we present the operative techniques of this operation.

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral ...

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to achieve favorable therapeutic outcomes while maintaining excellent cosmetic results. Among the available endoscopic procedures, the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) has gained popularity among surgeons. This is attributed to its straightforward cavity construction, spacious operating area, precise visual field exposure, and manageable learning curve. However, few studies have provided detailed descriptions of the specific surgical steps involved in GETTA. Drawing from a synthesis of existing literature and our own clinical expertise, we present a comprehensive outline of the GETTA procedure. This process can be categorized into five distinct stages: positioning and incision planning; establishment of surgical cavities; identification and protection of the recurrent laryngeal nerve, inferior parathyroid gland, and central neck dissection; localization and preservation of the superior laryngeal nerve, superior parathyroid gland, and dissection of the thyroid's superior pole; transection of the thyroid isthmus followed by en bloc resection of the thyroid gland and central neck lymph nodes. The five-step approach of GETTA is easy to learn and can be adapted for resecting both benign and malignant thyroid and parathyroid diseases.

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

This protocol presents the procedure for conducting thyroidectomy using the gasless endoscopic thyroidectomy trans-axillary approach (GETTA).

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to ...

Removal of Subcostal Specimen After Complete Portal Robotic Lobectomy

Subcostal Specimen Removal in Completely Portal Robotic Lobectomy

The Completely Portal Robotic Lobectomy (CPRL-4) technique is increasingly favored for lobectomy procedures due to its advancements over traditional robot-assisted lobectomy (RAL). CPRL-4 integrates a fourth robotic arm and CO2 insufflation, resulting in superior visualization within the intrathoracic cavity owing to enhanced lung deflation. While CPRL-4 effectively achieves pulmonary resection, extracting specimens typically necessitates an intercostal utility thoracotomy, which may pose risks. To address potential damage associated with this method, we introduced a subcostal trans-diaphragmatic access port during resection, later enlarging it for specimen removal post-lobectomy. This study evaluated the efficacy and feasibility of this subcostal trans-diaphragmatic specimen removal approach following CPRL-4 procedures for pulmonary malignancies, all performed by a single surgical team. The findings suggest that subcostal specimen removal post-CPRL-4 offers several advantages, including reduced risk of thoracotomy-related complications, making it a practical, feasible, and safe method. This innovation has the potential to improve outcomes and patient care in pulmonary malignancy surgeries significantly.

This protocol describes the removal of lung specimens following a completely portal robotic lobectomy. Determining the optimal location for specimen extraction is a pertinent question, as both intercostal and subcostal routes can serve as potential extraction paths following robotic or video-thoracoscopic lobectomy. We choose subcostal lung specimen removal over intercostal removal.

The Completely Portal Robotic Lobectomy (CPRL-4) technique is increasingly favored for lobectomy procedures due to its advancements over traditional ...

Improved Thoracoscopic-Assisted Surgery for the Treatment of Metastatic Thoracic Vertebral Tumors

The significant progress made in the diagnosis and treatment of malignant tumors has led to improved patient survival rates. However, the metastatic spread of these tumors to the thoracic vertebrae remains a significant challenge, often resulting in bone-related adverse events, such as pathological fractures and severe complications. To address this issue, a refined multidisciplinary approach has been explored, which utilizes thoracoscopic techniques for tumor resection and spinal interventions. Thoracoscopic techniques offer a minimally invasive alternative to traditional open surgical methods, aiming to reduce the overall trauma experienced by patients. By leveraging the advantages of thoracoscopy, clinicians can effectively resect metastatic tumors within the thoracic vertebrae while minimizing the impact on surrounding tissues and structures. This approach, combined with targeted spinal interventions, has the potential to improve patient outcomes and quality of life by mitigating the debilitating effects of pathological fractures and other complications associated with metastatic bone disease. The implementation of this multidisciplinary strategy, incorporating thoracoscopic tumor resection and spinal interventions, represents a promising avenue for the management of metastatic tumors within the thoracic vertebrae. Further research and clinical evaluation are necessary to fully elucidate the long-term benefits and establish the optimal treatment protocols for this patient population, ultimately enhancing the care and outcomes for individuals afflicted by this challenging condition.

Here, we present a protocol to demonstrate an improved thoracoscopic-assisted surgery for the treatment of metastatic thoracic vertebral tumors.

The significant progress made in the diagnosis and treatment of malignant tumors has led to improved patient survival rates. However, the metastatic ...

Minimal Invasive Resection of Large Retrosternal Thyroid Goiter

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic approach is linked to higher postoperative morbidity, reaching up to 30% when compared to the transcervical approach. Although alternative options like thoracoscopic resection have shown promising results, the morbidity of mediastinal dissection remains a concern. Thoracoscopic-assisted transcervical approach might be a feasible, less invasive alternative. This video outlines the steps and potential pitfalls of the procedure.
The patient is positioned supine with an extended neck. Initially, the endocrine surgeon mobilizes the thyroid gland through cervical access. If a transcervical resection is not feasible, the patient is mobilized into a lateral decubitus position, and a second team thoracoscopically guides the mediastinal tumor through the thoracic inlet. This allows a stepwise controlled transcervical dissection of the retrosternal mass until complete resection is achieved, thus eliminating the need for mediastinal dissection.
To demonstrate the procedure, we present the case of an 84-year-old male with lymph node-positive oncocytic thyroid carcinoma and a large retrosternal goiter extending posteriorly into the mediastinum up to the aortic arch. Thoracoscopic-assisted transcervical resection was performed. The recurrent laryngeal nerve was identified and monitored with a neurostimulation device during dissection. No palsy was noted in the postoperative evaluation. The patient had an uneventful postoperative course and was discharged on the second postoperative day.
Thoracoscopic-assisted transcervical resection of large retrosternal goiter seems a feasible alternative to mitigate risks associated with thoracotomy, sternotomy, or thoracoscopic mediastinal dissection. Potential advantages include decreased postoperative morbidity and length of stay. This technique requires thoracoscopic expertise and may be limited depending on the goiter&#39;s size and mediastinal positioning.

Here, we present a protocol for retrosternal thyroid goiter resection using a thoracoscopic-assisted transcervical approach.

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic ...

A Modified Technique for Transverse Aortic Constriction in Mice

Transverse aortic constriction (TAC) is a frequently used surgery in research regarding heart failure and cardiac hypertrophy based on the formation of pressure overload in mouse models. The main challenge of this procedure is to clearly visualize the transverse aortic arch and precisely band the target vessel. Classical approaches perform a partial thoracotomy to expose the transverse aortic arch. However, it is an open-chest model that causes a rather large surgical trauma and requires a ventilator during the surgery. To prevent unnecessary trauma and simplify the operating procedure, the aortic arch is approached via the proximal proportion of the sternum, reaching and binding the target vessel using a small self-made retractor that contains a snare. This procedure can be conducted without entering the pleura cavity and does not need a ventilator or microsurgical operation, which leaves the mice with physiological breathing patterns, simplifies the procedure, and significantly reduces operation time. Due to the less invasive approach and less operation time, mice can undergo fewer stress reactions and recover rapidly.

The present protocol describes a modified and simplified technique with a minimally invasive transverse aortic constriction (TAC) procedure using a self-made retractor. This procedure can be conducted without a ventilator or microscope and introduces pressure overload, eventually leading to cardiac hypertrophy or heart failure.

Transverse aortic constriction (TAC) is a frequently used surgery in research regarding heart failure and cardiac hypertrophy based on the formation of ...

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

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