Robotic first rib resection: Paget-Schroetter syndrome

Effort-induced thrombosis of the upper extremity is a relatively rare condition and one aspect of thoracic outlet syndrome. It accounts for 10% of all deep venous thromboses. In the vast majority of cases the etiology is repetitive motion of the upper extremity resulting in trauma to the axillo-subclavian vein as it passes through the thoracic outlet resulting in injury to the venous intima and the surrounding supportive tissue. A secondary cause is catheter-induced injury from central venous instrumentation. Patients usually present with swelling of the affected upper extremity and complaints of heaviness and pain. Diagnosis is confirmed by duplex ultrasonography and/or contrast venography. Computed tomogram and magnetic resonance imaging are complimentary. Treatment usually involves a combination of anticoagulation, thrombolysis, and surgical decompression. Of the different techniques to surgically decompress the axillo-subclavian vein, robotic technology offers an opportunity to precisely resect the first rib and a portion of the anterior scalene muscle along with the division of the costoclavicular ligament and surrounding venous scar. The details of the technique are described with a description of the outcomes.