Article 8: Surgical Approaches for TOS

Intro:

• What is the cause of TOS?

• What are the 4 main types of TOS?

• Cause:

  • Entrapment of the neurovascular bundle in the interscalene, costoclavicular, or subpectoral minor space 

• 4:

  • Arterial TOS (ATOS)

  • Neurogenic TOS (NTOS)

  • Venous TOS (VTOS)

  • Pectoralis Minor Syndrome

Intro:

• Arterial and Neurogenic TOS is caused by the compression of….

• Venous TOS is caused by the compression at the…

  • What 4 structures are included here?

• ATOS/NTOS:

  • Interscalene/costoclavicular space by the anterior and middle scalene muscles or the first rib

• VTOS

  • Anterior Costoclavicular Space

    • Anterior Scalene Muscles

    • First Rib

    • Costocoracoid Lig

    • Subclavius Tendon

Intro:

• Pectoralis Minor Syndrome:

  • _ compression in the _ _ space

• Infraclavicular Compression in the Subpectoral Minor Space

Intro:

• What 2 approaches are COMMONLY USED for the resection of the FIRST RIB AND SCALENE MUSCLES?

• Introduction of what 2 advanced technology procedures addressed the limitations of traditional approaches to TOS Tx?

• Transaxillary and Supraclavicular Approaches

• 2:

  • Endoscopic or Robot Assisted First Rib Resection

  • Arthroscopic Pec Minor Release

Purpose:

• The purpose of this study was to:

  • Summarize and update info on reported ___ approaches for TOS tx, including the hx of the approach, surgical procedures, advantages and disadvantages, clinical outcomes, and complications.

• Surgical

Significant Findings: Main Principles of Surgical Tx of TOS

• What is the MAIN PRINCIPLE?

• Relieve compression of the neurovascular structures in the thoracic outlet 

Significant Findings: Main Principles of Surgical Tx of TOS

• Treatment procedure for NTOS includes what 4 procedures?

• Excision of anomalous anatomical structures

• Excision of anterior and middle scalene

• Neurolysis of brachial plexus

• Resection of first rib id compressing the brachial plexus

Significant Findings: Main Principles of Surgical Tx of TOS

• Sometimes necessary for first rib and scalene muscle ___ ___ for ATOS with Aneurysm or Mural Thrombus

• VTOS ts requires resection of what 4 structures?

• ATOS:

  • Vascular Reconstruction

• VTOS:

  • Subclavian Muscles

  • Anterior Aspect of the First Rib

  • Anterior Scalene Muscle

  • Constoclaviuclar Lig

What are the 7 main surgical approaches to surgically treating TOS?

• Transaxillary

• Infraclaviuclar

• Posterior

• Combined Transaxillary and Supraclavicular

• Combines Supra and Infraclavicular Approach (Paraclavicular Approach)

• Endoscopic Assisted Transaxillary Approach

• Video Assisted Thoracoscopic Surgery (VATS)

Transaxillary Approach:

• Intended for…

• Incision is made where?

  • This allows for rapid and easy exposure of _ _ and _ _ without muscle dissection

• Performed in __ position and arm stabilized by what?

• First Rib Resection

• Between Pec Major and Lats

  • First Rib and Scalene

• Lateral Position; Arm Holder

Transacillary Approach:

• What are the 2 main DISADVANTAGES?

• Neurological complications >> nerve traction injury 

• Increases risk of pneumothorax d/t first rib resection 

Infraclavicular Approach:

• Intended for…

• Used to treat what 2 types of TOS?

• Incision made 1-2 cm below ____ >> __ __ is spared or released from clavicle to expose __ muscle (excised)

• Removal of First Rib

• VTOS and Pec Minor Sydrome

• Clavicle » Pec Major; Subclavian

Infraclavicular Approach:

• Allows for resection of what 4 muscles?

• Reduces risk of brachial plexus, phrenic nerve, and supraclavicular nerve injuries compared to what approach?

• Cosmetically better compared to ____ incision (HOWEVER, ____ is the better) 

• 4:

  • Subclavian Muscle

  • Anterior Aspect of First Rib

  • Costoclavicular Lig

  • Anterior Scalene Muscle (Which compresses Subclavian Vein)

• Subclavian

• Supraclavicular; Transaxillary

Infraclavicular Approach:

• What are the 3 main DISADVANTAGES?

• Difficult to access posterior aspect of first rib and middle scalene muscle 

• Not easily applicable to NTOS tx 

• Limited to tx of VTOS and Pec Minor syndrome

Posterior Approach:

• Intended for…

• Longitudinal Periscapular Incision between what 2 structures?

• What 2 muscles are separated » exposing the first rib?

• First Rib Resection

• Between Spinous Process or Medial Border to Scap

• TRap and Rhomboid Minor

Posterior Approach:

• Useful for pts with history of surgery trough what 2 approaches that require reoperation?

• Rarely use for _ _ » LIMITED to _ ONLY

• Anterior or Transaxillary Approach

• Initial Operations » Reoperations

Posterior Approach: Disadvantages

• What 2 things is difficult to do using this approach?

• Potential complications include what 6 things?

• 2:

  • Visualization of anterior structures

  • Arterial reconstruction

• 6:

  • Scapular Winging

  • C/S Instability

  • Pleural Tears

  • Pneumothorax

  • Hemothorax

  • Phrenic Nerve Palsy

Combined Transaxillary and Supraclavicular Approach:

• Compensates for ___ for each approach

• Different OR Same incisions and procedures?

  • Transaxillary:

  • Supraclavicular:

• Provides secure resection of the structures around the neurovascular bundle thru ____ incision 

• Disadvantages

• SAME

  • T: First Rib Resection

  • S: Anterior and Middle Scalene Resection

• Double

Combined Transaxillary and Supraclavicular Approach: Disadvantages

• Double Incision » Increased risk for what associated with each approach.

• Is this approach indicated for INITIAL surgery?

  • When is this approach used?

• Nerve Injury

• NAUR

  • FAILED initial sx or recurrent TOS

Combined Supra and Infraclavicular Approach (Paraclavicular Approach):

• Used to treat what type of TOS?

• What type of incisions are made?

• Provides sufficient exposure for effective ____ of all neurovascular structures and performance of potential interventions 

• VTOS

• 2 Transverse Incisions above and below clavicle

• Decompression

Combined Supra and Infraclavicular Approach (Paraclavicular Approach): Disadvanatges

• Greater _____ and less _____ ____ d/t double incision around clavicle 

• 3-19% of patients who undergo this approach require _____ management (drainage, reoperation d/t hematoma/bleeding)

• Invasiveness; cosmetic appeal

• Postoperative

Endoscopic- Assisted Transaxillary Approach:

• Indicated for…

• Introduced to overcome limitations of what approach?

• Endoscopic Assistance:

  • What 2 muscles are dissected free from their origins at the first rib?

  • What technique do they use to do this?

• First Rib Resection

• Transaxillary Approach

• EA:

  • Anterior and Middle Scalenes

  • Electrocautery

Endoscopic- Assisted Transaxillary Approach:

• Excellent visualization of what structure?

  • Especially the ____ aspect of first rib and middle scalene muscle?

• Potentially ____ complications that occurs during surgery in a deeper and narrower field 

• Thoracic Outlet

  • Posterior

• Minimizes

Endoscopic- Assisted Transaxillary Approach:

• What are the 2 main disadvantages of this approach?

• Demanding 

• Special instruments (endoscopic device) required 

Video- Assisted Thoracoscopic surgery (VATS):

• What type of resection is this approach?

• Thoracoscope inserted into WHERE?

  • First rib is visible thru ____ 
    

• Minimally invasive first rib resection

• 5th intercostal space at mid axillary line

  • pleura

Video- Assisted Thoracoscopic surgery (VATS): Disadvantages

• D/t opening in the pleura, what is necessary to place?

• T/F: Highly demanding and requires special equipment 

• T/F: Can only be performed by well trained thoracic surgeon

• Pleural Drain

• True

• True

Conclusion:

• Inadequate release of compressed structure leads to what 2 things?

• Complication rate =

• Failed or recurrent outcomes

• 13-26%

Surgical approach should be selected based on what 6 things?

• Surgeons skills

• Surgeon preferences

• Surgical invasiveness

• Cosmetic appearance

• Presence of special equipment

• Advantages/disadvantages of each approach 

Quiz Question:

T/F: Endoscopic-assisted transaxillary first-rib resection was introduced as a result of the variety of risk factors and complications associated with the transaxillary approach.

TRUE

Quiz Question:

1. Which surgical approach has the best Clinical Outcomes?

   1.  Combined transaxillary and supraclavicular 

   2.  Supraclavicular scalenectomy with first-rib excision 

   3.  Combined supraclavicular and infraclavicular 

   4.  Video-assisted thoracoscopic 

1.  Combined transaxillary and supraclavicular 

Quiz Question:

1. What is the “gold standard” for treatment of TOS?

   1. There is no gold standard because most studies are case series or retrospective case-control studies 

   2. Surgical resection of 1st rib and scalene musculature 

   3. Surgical resection of all involved structures 

   4.  There is no gold standard because it depends on the patient’s presentation 

1. There is no gold standard because most studies are case series or retrospective case-control studies