Is a paradigm shift from conventional to robotic approaches necessary in first rib resection for thoracic outlet syndrome?

Thoracic outlet syndrome (TOS) is a group of disorders caused by compression of the neurovascular bundle as it exits the thoracic outlet. The treatment involves first rib resection (FRR) via open surgery or minimally invasive surgery. This study compares the surgical outcomes of the supraclavicular approach and robotic-assisted thoracic surgery (RATS). We retrospectively reviewed the clinicopathological and perioperative data of patients with TOS who underwent surgery between October 2005 and July 2024. A total of 23 operations were performed on 21 patients (median age, 28 years; range, 21-68 years), with 8 (38.1%) being female. The median body mass index (BMI) was 23.7 kg/m2 (range, 20.5-42.5 kg/m2), and 15 patients had neurogenic TOS (nTOS). Among the 23 cases, robotic FRR was performed in 13 cases. The median operation time was 96 min (range, 63-211 min), and the median highest pain score on the numeric rating scale (NRS) was 3 (range, 1-7). One patient (4.3%) experienced subclavian artery injury which was successfully repaired without sequelae. Based on the Derkash classification, clinical outcomes were categorized as "excellent", which was the most prevalent category, in 19 patients (82.6%). The median subjective improvement was 95% (range, 60-100%). Postoperative peak NRS scores were better with robotic FRR compared to the supraclavicular approach (3 vs. 4.5; P=0.02). In appropriately selected patients, both supraclavicular and robotic FRR yield excellent surgical outcomes. However, given its various advantages, robotic FRR should be considered the new gold standard when a robotic system is available at the institution.