Combined Surgical Treatment of Thoracic Outlet

7/15/2019 Combined Surgical Treatment of Thoracic Outlet

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Combined surgical treatment of thoracic outlet

syndrome: transaxillary first rib resection and

transcervical scalenectomy

Erdog an Atasoy, MDDepartment of Surgery, University of Louisville School of Medicine, Louisville, KY

Kleinert, Kutz and Associates Hand Care Center, PLLC, Suite 700, 225 Abraham Flexner Way,

Louisville, KY 40202, USA

Surgical procedures performed to relieve tho-

racic outlet syndrome (TOS) have changed

dramatically since 1861 when cervical rib resection

was introduced [1]. Table 1 describes the evolution

of these procedures.

Presently, transaxillary first rib resection and

transcervical anterior and middle scalenectomy

are the most popular and standard procedures forthe surgical treatment of TOS. First rib resection

is recommended for lower-level TOS (involving

the C8T1 roots). Scalenectomy usually is the

preferred treatment for upper-level TOS (involv-

ing the C5, C6, and C7 roots), or following

whiplash injury and recurrent TOS after a pre-

viously performed first rib resection. Markedly

obese and big or excessively muscular patients

also are considered candidates for scalenectomy,

because complete resection of the first rib can be

difficult and carries a higher risk for these

patients.

In the early 1980s, some surgeons believed that

combining these two procedures was the answer

to complete TOS relief. They performed the

scalenectomy first and then followed with a trans-

axillary first rib resection [2,3]. Since 1989 the

author has combined these two surgeries but has

performed the transaxillary first rib resection first

and then followed immediately with a transcervical

anterior and medial scalenectomy [4]. By perform-

ing these two procedures in this order the author

has accomplished total decompression of the

thoracic outlet area.

Following a complete first rib resection, the

anterior and middle scalenectomy can be per-

formed easily, because all of the distal insertions of

these muscles have been released from the first rib.

During anterior scalenectomy, the distal in-sertion of the anterior scalene muscle (which was

cut at the time of the first rib resection) and the

subclavian artery are clearly visible when the

intact sheath of the scalene muscle is exposed and

pierced with a scissor. The integrity of the artery is

protected easily. During middle scalenectomy the

previously divided distal end of the middle scalene

muscle and the long thoracic nerve can be exposed

easily once the sheath of the middle scalene muscle

is cut.

Nearly 80% of the anterior scalene muscle and

40%50% of the middle scalene muscle can be

removed during the scalenectomy while ensuring

the complete integrity of the phrenic and long

thoracic nerves. During the scalenectomy, the

surgeon can see the intact sheaths of both scalene

muscles and remaining muscle fibers of the

anterior scalene muscle (which may appear

attached to the subclavian artery). If these muscle

sheaths and fibers are left intact, they may cause

the scalene muscles to become attached to the bed

of the resected first rib. Therefore, they must be

cut during the scalenectomy to decrease the risk ofrecurrent symptoms.E-mail address: [email protected]

0749-0712/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.

doi:10.1016/S0749-0712(03)00077-5

Hand Clin 20 (2004) 7182
mailto:[email protected]:[email protected]:[email protected]


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The technique of transaxillary first rib resection

Although several approaches have been de-

scribed in the literature (ie, supraclavicular, ante-

rior, infraclavicular, and posterior), the author has

found the transaxillary approach to be the most

effective.

With the patient under general anesthesia,

a Foley catheter is inserted into the patients

bladder and the patient is positioned in the lateral

position. The patients chest is turned approxi-mately 4550 posteriorly. A towel-covered 4-

inch thick foam roll is placed under the opposite

axilla. One pillow is placed on the table under the

patients leg that is touching the table, and

another pillow is placed between the patients

semiflexed legs. A padded chest brace is applied to

the edge of the table to support the patients chest,

and a rolled 3- to 4-foot wide sheath is placed

between the patients back, buttock, and the chest

brace. A wide tape is applied on the hip to help

stabilize the patient, and an extra strap is placed

on the mid thigh for further support.Surgical preparation and draping are done on

the entire upper extremity, the shoulder, the axilla,

and the anterior and posterior chest walls on the

surgical side. Two-layer stockinet is applied over

the full length of the extremity up to the axilla.

This enables full mobility of the upper extremity,

which is important.

Under the instruction and direction of the

operating surgeon, the surgical assistant applies

intermittent controlled traction on the patients

arm. This is an important part of the surgerybecause controlled arm traction and proper

wound edge retraction enable the surgeon to see

the deep part of the operative field, the full length

of the first rib, and all vital structures. The

assistant places his forearm under the forearm of

the patient on the same side. He grips the patients

wrist with his opposite hand and then grips his

own wrist with his other hand (Fig. 1A). Roos [5]

described this as the wristlock holding technique.

This method enables the assistant to hold the

patients arm without putting any pressure on

the patients forearm nerves. It also decreases

the effort required by the surgical assistant andminimizes his discomfort. Mechanical arm hold-

ing devices are not satisfactory for this purpose,

because controlled, intermittent, precise arm

traction that allows for an instantaneous change

of direction and degree is important during the

surgery, and only a human assistant can achieve

this.

With the patients arm fully abducted by the

surgical assistant, a 5- to 6-in long smile-shaped

incision is marked slightly below the axillary

hairline where the axilla and chest wall meet. Thismarking is located near the level of the third rib

(Fig. 1B). The incision is performed along the

marked line, deepened through subcutaneous

tissue, and then continued through the axillary

fascia. During the incision, a few arterial and

venous branches from the lateral axillary vessels

and sometimes one or two smaller nerve branches

(branches of the third intercostobrachial cutane-

ous nerve) can be seen. If possible these vessels are

preserved, and during wound edge retraction they

help to protect the nerve branches. Retraction

of the skin flaps with small rake-like retractorsis helpful. After further deepening the dissec-

tion through the axillary fascia, which can be

Table 1

Evolution of thoracic outlet syndrome surgery

Name of operation

Year first

performed

Surgeon who

introduced it

Cervical rib resection 1861 Coote [1]

First rib resection 1908 Murphy [6]

Scalenotomy 1927 Adson and Coffey [7]

First rib resection - posterior approach 1961 Clagett [10]

First rib resection - supra and infra clavicular approach 1960s Various surgeons

First rib resection - transaxillary approach 1966 Roos [11]

Scalenectomy 1938 Adson

Refined scalenectomy 1979 Sanders [12]

Combined approach (transaxillary

first rib resection followed

immediately by transcervical

anterior and medial scalenectomy)

1989 Atasoy [4]

72 E. Atasoy/ Hand Clin 20 (2004) 7182


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distinctive in some patients, the axillary fat pad is

exposed. The axillary fatty tissue has a different

appearance than the subcutaneous fat. The

dissection is deepened directly down to the chest

wall until the areolar tissue on the chest cage

becomes visible. It is important to go straightdown to the chest wall without disturbing the

axillary lymph nodes that are present in the

axillary fat pad, otherwise the axillary fat pad

may be cut, the lymph nodes, and lymphatic

drainage may be disturbed, and the surgeon may

get lost in the operative field.

During this stage the longer ends of the

Richardson retractor are used to perform wound

retraction. The branches of the second and

sometimes the smaller third intercostobrachial

cutaneous nerves can be seen at the mid to lateralside of the operative field, and they should be

protected. These nerves innervate the posterior

portion of the axilla and medial posterior upper

arm skin.

When the ceiling of the axilla is reached, the

subclavian vein may become visible. The thin

membrane that covers the top of the first rib, the

subclavian vessels, and the lower trunk is pushed

gently upward with a sponge stick. This action

exposes the subclavian vein, the insertion of

the anterior scalene muscle to the first rib, the

subclavian artery, and the lower trunk of thebrachial plexus (see Fig. 1B). Using the curved or

sharp ends of the Overholt rib stripper (Fig. 1C)

to continue the anterior dissection, the subclavius

tendon and the costocoracoid ligament and their

insertions are exposed. The dissection continues

posteriorly to expose the middle scalene muscle

and its wide insertion to the first rib, and finally

the T1 root of the lower trunk posteriorly. If the

highest thoracic artery that is present in 30%

40% of cases is encountered, it is ligated, divided,

or cauterized, depending on its size.Sometimes the first two digitations of the

serratus anterior muscle to the first and second

rib are prominent and prevent good visualization

of the posterior part of the first rib. Dividing or

stripping these digitations from the first and

second ribs can resolve this problem.

Evaluating the tautness of the T1 and lower

trunk when the wide end of the long finger forceps

touches them can determine the tension caused by

the surgical assistant holding the patients arm in

traction. If the surgeon notices any excessive

tautness when touching the T1 and lower trunk,the assistant is asked to relax the arm. Intermit-

tent traction and relaxation prevents ischemic and

traction injury to the brachial plexus and gives the

surgical assistant a chance to rest his arms.

When the first rib is exposed anteriorly from

the costochondral junction posteriorly to its neck,

the important structures that are visible include the

costocoracoid ligament, subclavius tendon, sub-clavian vein, lower portion and insertion of the

anterior scalene muscle to the first rib, subclavian

artery, scalene minimus (if present), the T1 root

Fig. 1. Right transaxillary first rib resection. (A)

Marking of the incision and holding of the arm in the

wristlock position. (B ) (i) Location of skin incision. (ii)

Exposure of first rib, scalene muscles, subclavian artery

and vein. The dotted lines show the intended cut on thescalene muscles. (C) Complete assortment of instru-

ments used during a first rib resection. Overholt rib

strippers (elevators) are in top center of photograph, and

to their right are Cameron Haight strippers (elevators).

Rib cutters are in top left, Sauerbach first rib rongeurs

are in lower center, and large and small Richardson

retractors are in upper right. (D) Schematic axillary view

of right thoracic outlet anatomy with right arm fully

abducted. (E) Subperiosteal dissection of first rib with

a Cameron Haight elevator, and levering of first rib with

the handle of long finger pick-up. (F) Cutting of first rib

in the dissected area. (G ) Removal of the anterior por-

tion of the first rib. (H) Removal of the posterior

portion of the first rib. (I) View following a 90%95%

resection of the first rib.

73E. Atasoy/ Hand Clin 20 (2004) 7182


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Fig. 1 (continued)



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Fig. 1 (continued)



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(which emerges from under the very back portion

of the first rib and extends and joins to the C8 to

form the lower trunk), and finally, the wide

insertion of the middle scalene muscle to the first

rib (Fig. 1D). If the scalenus minimus muscle is

present, which occurs in 30%50% of TOS cases[6,7], it usually inserts on the first rib between the

subclavian artery and T1 root of the lower trunk.

Generally the dissection and mobilization of

the first rib is performed from the anterior to

posterior direction. The most anterior structures,

the costocoracoid ligament and the subclavius

tendon insertion on the first rib, are divided either

by the sharp curved end of the Overholt stripper or

by a long-handled knife, using extreme caution

around the subclavian vein. Next the anterior

scalene muscle is dissected carefully from thesubclavian artery and vein using the blunt wide

end of a long finger forceps, the unopened tip of

a long dissection scissor, or even a fingertip, if the

area can be reached easily. The next step is to

divide the anterior scalene muscle, which can be

done either by gently passing a right-angle clamp

behind a portion of the muscle, pulling anteriorly,

and then making a few attempts to cut it near its

insertion or cutting it with a smaller bite with

a long scissor. The remaining few intact fibers are

close to the subclavian vein and artery and they

can be left alone and divided later during theremoval of the first rib. After dividing the anterior

scalene muscle, attention is focused on the middle

scalene muscle. Using the wide end of the long

finger forceps, the subclavian artery and T1 branch

of the plexus are pushed gently, achieving full

exposure of the portion of the middle scalene

muscle near its insertion to the first rib. The

middle scalene muscle insertion to the first rib is

cut either with a long scissor or by gently inserting

a right-angle clamp under a portion of the muscle

and gently pulling it off and tearing it from the firstrib. The remaining undivided, high-positioned

muscle fibers are pushed away from the first rib

with an Overholt or a long rib stripper.

If the scalenus minimus muscle and any

recognizable bands are present, they are cut at

their insertion to the first rib and a portion of

them is removed.

Next, the first rib is freed from the intercostal

muscles along the inferior border with the sharp,

flat-notched end of the Overholt rib stripper. The

middle part of the first rib is dissected approxi-

mately 2 inches along the posterior surface. Usingeither the flat end of the Overholt stripper or

preferably the wide flat end of the long finger

pick-up, the first rib is leveraged on the second rib.

Then, using the flat, thinner end of the Cameron

Haight rib elevator, subperiosteal dissection of the

first rib is performed (Fig. 1E). The curved end of

the Overholt stripper is used to continue the

periosteal stripping.Next, the curved end of the most suitable

Overholt stripper is passed gently under the

dissected portion of the first rib between the

periosteum and the first rib. To separate the first

rib from the soft tissue, the tip of the stripper is

pushed gently upward, carefully staying close to

the first rib at the concave border. When the tip of

the stripper is visible at the upper border of the

first rib, the area is scraped gently, both anteriorly

and posteriorly, to make enough room to pass the

rib cutter through the space. The wide end of thelong finger pick-up can be used to push the lower

plexus and subclavian artery gently upward.

Then, using a straight rib cutter, the first rib is

divided (Fig. 1F). The anterior portion of the rib

is grasped with a Kocher clamp, lifted up gently,

pulled outward and dissected from the posterior

periosteum. The few remaining fibers of the

anterior scalene muscle attached to the upper

border of the first rib are divided carefully.

Dissection of the anterior portion of the first rib

is continued at least 1 cm beyond the costochon-

dral junction. The subclavian vein is close to theupper edge of this portion of the rib and it should

be protected. The costochondral junction is

scored with an Overholt strippers longer, curved

end. Then an attempt is made to avulse the

anterior portion of the first rib at the costochon-

dral junction. If dissection has not been extended

beyond the costochondral junction, the avulsion

can tear the pleura, causing pneumothorax. If

avulsion does not occur, the anterior portion of

the first rib is cut and removed (Fig. 1G). Then

the sharp tips are rongeured up to the costochon-dral junction.

Next, using a Kocher clamp or a long finger

pick-up interchangeably, the posterior portion of

the first rib is lifted up, pulled outward, and dis-

sected from the posterior periosteum and from the

soft tissues along the upper and lower borders up

to the transverse process of T1 vertebra. Maximum

care should be given to avoid injury to the sub-

clavian vessels and the lower portion of the

brachial plexus, especially T1, which has a close

relationship with the posterior portion of the

first rib.This portion of the first rib is cut with Roos

right-angle rib cutter or a straight rub cutter as far



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back as possible (Fig. 1H). A large Sauerbruchs

first rib rongeur and then a smaller size of the

same rongeur are used to remove the remaining

posterior portion of the rib up to the transverse

process, if possible. If the transverse process of T1

cannot be reached because of the difficulty inperforming the dissection, no more than 1 cm of

the first rib can be left in this area.

After removing the first rib, the loose ends of

both scalene muscles are trimmed as high as safety

permits (Fig. 1I).

Occasionally arterial bleeding may occur in the

middle scalene muscle from the deep transverse

cervical artery (dorsal scapular artery) or from

one of its branches. Smaller bleeding can be

controlled easily by applying pressure with

a sponge stick or using a silver vascular clip.If the bleeding is excessive and not accessible

through the axilla, an immediate scalenectomy is

necessary. The bleeding can be located easily at

the middle scalenectomy site and controlled

quickly.

If major bleeding from the subclavian vein or

artery occurs during the first rib resection,

immediate action must be taken. Usually a tear

in the subclavian vein is small, and because of low

venous pressure, bleeding is not severe. Finger

pressure, suctioning the operative field, and

suturing the tear with an interrupted or a contin-uous 6-0 Prolene vessel suture can control such

bleeding. The size of the tear determines the

severity of subclavian artery bleeding. To control

bleeding in the subclavian artery, immediate

pressure must be applied and then the operative

field must be suctioned, vascular clamps applied,

and the tear must be stitched with 5-0 or 6-

0 Prolene vessel sutures. During TOS surgery the

rate of major vessel injury is 1% or less.

After meticulous hemostasis is achieved, the

wound is irrigated first with lactated Ringerssolution and then bacitracin solution (50,000 U in

1000 mL Ringers solution). Then a 1-in Penrose

drain is inserted through a small stab wound just

below the posterior end of the incision, and the

end of the drain is placed in the high point in the

axillary space just behind the T1 nerve. The drain

is sutured to the skin with 5-0 nylon. Then the

axillary fascia is closed with an interrupted

5-0 polyglactin suture. Skin closure is performed

in two layers: several interrupted 5-0 polyglactin

sutures are placed in the deep layer of the dermis

including a little bit of fatty tissue below thedermis, and 5-0 polyglactin continuous sutures are

placed in the dermis. Then steri-strips are applied

to the skin. The dressing should include a 4 4

pad on the incision, three to four open layers of

ABD pads on the drain site, and long taping.

Dressing changes should be performed at least

daily and sometimes twice a day. The drain

usually is removed in 48 hours.The pneumothorax incidence is less than 10%

in the authors cases; if pneumothorax occurs,

a small chest tube (size 28) can be inserted through

the fourth or fifth intercostal space at the mid-

axillary line and connected to pleura-vactype

drainage. If the pleural tear is large enough it can

be sutured and at least partially closed. The chest

tube usually is removed the next day.

If a cervical rib is present, is 2 in or longer, and

is not articulated with the first rib, resection of

only the cervical rib is usually sufficient and firstrib resection is not needed. If the cervical rib is

articulated with the first rib, usually the cervical

and first rib are removed; generally, the fusion site

is removed, then the cervical rib is removed,

followed by the first rib. A cervical rib less than

1 cm does not need to be resected as long as the soft

tissue attachments to the cervical rib are dissected

and removed. Then a full first rib resection is

performed.

If the first rib is wide or the fusion between the

first and second ribs is wide, it may not be possible

to cut this wide area completely with the bite ofthe straight rib cutter. In such cases a wedge

resection is performed first in the wide area. Once

the area is narrowed, complete cutting can be

performed easily with a straight rib cutter.

In a muscular person who also may have

hyperabduction syndrome (especially a male),

pectoralis minor division near the coracoid should

be performed as a supplement to first rib re-

section, either before or after first rib resection

(preferably before). Through the same incision,

the pectoralis minor is dissected from the pector-alis major, keeping its nerve supply intact and

divided just below the coracoid process by using

electrocautery.

The most common complaint after transaxil-

lary first rib resection is decreased sensation

associated with some paresthesias along the upper

medial and posterior aspect of the upper arm.

This usually is caused by traction placed on the

second and third intercostobrachial cutaneous

nerves during the surgery, and most of the time

it is temporary. Permanent injury to the brachial

plexus (usually T1 and C8) has been reportedrarely. Permanent major nerve injury occurs in

less than 0.5% of cases as a result of TOS surgery.



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With long thoracic nerve injury, the patient

may have a mild to marked winging of the

scapula. If the winging of the scapula is severe

enough to disable the patients shoulder girdle

motions and does not show any improvement for

at least 1 year, then a scapulothoracic stabilizationprocedure is considered [8].

Sympathetic overactivity causing severe cold-

ness and Raynaud phenomenon-like symptoms

has been observed in some cases of TOS. In these

patients, a transaxillary first rib resection followed

with a transthoracic upper extremity sympathec-

tomy is most likely necessary (through the same

incision and third intercostal space). The T4, T3,

T2, and only the lower third of the stellate

ganglion are removed by clipping and cutting

their rami. For further details see Management ofPeripheral Nerve Problems, Second Edition, 1998,

Chapter Eighteen [9].

The technique of scalenectomy

With the patient under general anesthesia, the

chest and head are elevated approximately 40. A

long piece of 3- to 4-inch thick foam is placed

across and under the shoulders to moderately

hyperextend the neck, which is turned to the side

opposite the surgical area. One or two pillows areplaced under the knees to keep them moderately

flexed. Skin markings are made at the edges of the

suprasternal notch, the clavicle, the AC joint, and

the sternocleidomastoid and trapezium muscles.

The external jugular vein, cervical plexus, and

spinal accessory nerves also are marked (Fig. 2A).

The skin incision is nearly 8 cm long along

the skin crease and approximately 1.52 cm above

the clavicle, starting at the medial border of the

sternocleidomastoid muscle and extending to

the anterior border of the trapezius muscle. Theincision is made through the skin, subcutaneous

tissue, and platysma. First, the proximal skin flap,

which includes the skin, subcutaneous tissue, and

platysma, is developed from the sternocleidomas-

toid fascia, omohyoid fascia, and prescalene fat

tissue. The external jugular vein is preserved and

dissection is continued upward until the lower

branch of the cervical plexus is visualized or until

the dissection is close to it (at the middle of the

lateral border of the sternocleidomastoid muscle).

During the proximal dissection, the transverse

cervical branches of the cervical plexus thatextend over the sternocleidomastoid fascia that

are encountered are elevated with the flap and

preserved. Next the distal flap is mobilized on the

omohyoid and sternocleidomastoid fascia down

to its insertion to the clavicle. The distal flap

should include the skin, platysma, and the full

thickness fatty tissue under the platysma and over

the sternocleidomastoid muscle. Using this dis-section technique protects the supraclavicular

branches of the cervical plexus and helps them

remain in the fatty tissue of the distal flap.

Then the omohyoid muscle and fascia are

divided with a cutting Bovie and most of the

clavicular insertion of the sternocleidomastoid

muscle is divided along the top of the clavicle

for better exposure of the prescalene fat and

internal jugular vein (Fig. 2B).

The lateral border of the sternocleidomastoid

muscle is freed from the prescalene fat until theinternal jugular vein becomes visible. Next the

exposed prescalene fat is incised and mobilized

with a dissecting scissor along the internal jugular

vein, staying approximately 1 cm away from the

vein on the right side and nearly 1.5 cm away on

the left side, because the left side has more

lymphatic tissue than the right side. This part of

the dissection is a little more bloody than usual

because of the abundant vascularity of the

prescalene fat. All bleeding points are cauterized

as the surgery progresses. The superficial (trans-

verse) cervical artery and accompanying vein,which generally can be visualized at the lower part

of the wound, are ligated and divided (Fig. 2C).

During the prescalene fatty tissue mobilization,

the phrenic nerve can be visualized and protected.

It usually crosses the anterior scalene muscle from

the lateral to medial direction, starting at the C5

root of the brachial plexus. If the phrenic nerve is

located more medial than usual, the prescalene fat

pad is mobilized medially first to provide better

exposure of the phrenic nerve, the ascending

cervical artery, and the accompanying vein. Thenthe fat pad is mobilized laterally over the brachial

plexus until the lateral border of the middle

scalene muscle becomes visible. Next the phrenic

nerve (sometimes one or two accessory phrenic

nerves can be present) is mobilized gently, leaving

some fatty tissue and possibly the ascending

cervical artery along the nerve to maintain an

abundant blood supply to the nerve. The nerve is

retracted gently with a wide silastic vascular loop

by the assistant surgeon.

After adequate mobilization of the prescalene

fat pad, the full length of the anterior scalenemuscle and the lower end of the scalene sheath are

well exposed. If the first rib resection has been



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performed just before the scalenectomy, the

surgeon can see some bloody fluid inside the

sheath of the anterior scalene muscle at its lower

end. The fascia is opened carefully to expose the

freshly cut and proximally retracted end of the

anterior scalene muscle. The subclavian artery is

visibile under the previously divided anterior

scalene muscle. To get full exposure of the

subclavian artery, the remaining intact muscle

fibers are divided carefully. Some of the fibers may

seem to be attached to the subclavian artery. The

anterior scalene muscle is mobilized medially andlaterally along the ascending cervical artery and

brachial plexus respectively (C5C6 roots) and is

mobilized posteriorly upward on the fibro-fatty

tissue covering the C7 and C8 roots. Then it is

divided at the C5 level just below the phrenic

nerve takeoff and is removed. Sometimes it is

easier to first divide the anterior scalene muscle

proximally using traction on the muscle with

a heavy pick-up below the phrenic nerve takeoff

from the C5. Then with the combined proximally

and distally oriented dissection, the anterior

scalene muscle can be removed.

Next the posterior fibro-fatty sheath of the

anterior scalene muscle is dissected. While goingthrough this structure and removing a portion of

it, one can see (if present) the deep transverse

Fig. 2. Right scalenectomy. (A) Incision and superficial anatomy for a right scalenectomy. (B) Elevation of the skin flaps

and the exposure of the sternocleidomastoid muscle and prescalene fat. (C) Mobilization of the prescalene fat along the

internal jugular vein as a laterally based flap; ligation, division of the superficial cervical artery and exposure of the

phrenic nerve, and division of most of the clavicular head of the sternocleidomastoid muscle. (D) Exposure of the divided

lower end of the middle scalene muscle (which was divided during the previously performed first rib resection) and

exposure of the long thoracic nerve. (E) Suturing prescalene fat along the internal jugular vein and covering the brachial

plexus.



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cervical artery (dorsal scapular artery) that lies

between the C6 and C7 and sometimes between

the C7 and C8. If this artery is in the way, it can

be divided and ligated to provide better exposure

of the C7, C8, and T1 roots. The scalenus

minimus, if present, usually lies near the C8 root,and it is removed. Following this, all branches of

the brachial plexus are dissected carefully, freed,

and exposed. Usually approximately 80% of the

anterior scalene muscle is removed.

If the scalenectomy is the only procedure to be

performed, the phrenic nerve is mobilized first, as

explained previously. Then the anterior scalene

muscle is divided slowly, carefully, and completelyat the middle part, keeping in mind that the sub-

clavian artery may pass through the muscle

Fig. 2 (continued)



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substance. Next the distal portion of the anterior

scalene muscle is dissected carefully from the

brachial plexus, which is just lateral and posterior,

the subclavian artery, which is deep and posterior,

and ascending cervical artery, which is medial. The

subclavian vein usually is not exposed; it isanterior to the muscle. The distal portion of the

anterior scalene muscle is removed at or near its

insertion to the first rib. Then the proximal portion

of the muscle is dissected and removed as

described previously.

Following the anterior scalenectomy, attention

is directed to the middle scalene muscle. First the

long thoracic nerve is exposed carefully and

preserved. Its usual location is at the lateral border

of the middle scalene muscle, and it exits this muscle

at the junction of the middle and lower third (Fig.2D). Sometimes an unusual location of the nerve is

observed; it may exit the muscle more anteriorly

through the substance of the lower part. On some

occasions more than one branch of the nerve is

observed, and these branches join further distally

beyond the exposed area. For this reason the sur-

geon must be careful during the dissection, before

and while dividing the middle scalene muscle.

If first rib resection has been performed just

before the scalenectomy, the intact middle scalene

muscle sheath is opened at its distal portion and

divided lower end of the middle scalene muscleexposed (see Fig. 2D), the remaining muscle fibers

are cut, and usually 40%50% of the muscle is

removed. During the dissection and removal of the

middle scalene muscle, again full attention should

be directed to the integrity of the long thoracic

nerve whose branches originate from C5, C6, and

C7, runthrough the middle scalene muscle, andjoin

together either inside or outside the muscle.

If the deep transverse cervical artery (dorsal

scapular artery) is present and is inthe way,it can be

re-ligated and divided in the middle scalene area forbetter exposure of the depth of the operative field.

At the deeper area of the middle scalene space, one

can see the tip of the previously inserted axillary

drain. If necessary, any remaining sharp end of the

first rib that can be palpated through the middle

scalene space can be exposed easily and removed

with a rongeur. If the first rib resection was not

done before the scalenectomy, after exposing and

protecting the long thoracic nerve, the middle

scalene muscle is divided carefully at or near its

insertion to the first rib, and at least the distal one

third to one half of it is removed.Following meticulous hemostasis, the wound

irrigation is performed first with a few hundred ml

of lactated Ringers solution and then bacitracin

solution (50,000 U in 1000 mL lactated Ringers

solution). Two small (0.25 in) drains are inserted

from the lateral corner of the incision, through the

prescalene fat pad, down to the middle and

anterior scalene spaces. The prescalene fat pad isapproximated with interrupted 5-0 polyglactin

910 (Vicryl) sutures by overlapping the medial

portion onto the lateral portion to give good fatty

tissue coverage to the brachial plexus (Fig. 2E).

Next the platysma and deep portion of the dermis

are approximated with interrupted 5-0 Vicryl

sutures and the skin is closed with running dermal

absorbable 5-0 Vicryl sutures. Then steri-strips are

placed on the skin and a mild compression

dressing is applied to the neck. Daily or twice

a day dressing changes can be performed, and thedrain sites can be cleaned with alcohol or

hydrogen peroxide solution. The neck drains are

removed in 24 hours, the axillary drain, which is

inserted right after the first rib resection, is

removed in 48 hours, and the patient is discharged

with postoperative instruction for wound care

and active neck and shoulder range-of-motion

exercises.

Complications following scalenectomy may

include neck hematoma, chylous drainage (mostly

from the left side), occasionally long-lasting

dyspnea (caused by phrenic nerve irritation ordisturbed blood supply to the nerve), and rarely

mild Horner syndrome. Hematoma may require

surgical intervention if it is extensive. Chylous

drainage may require repeated aspiration, and if it

persists, surgical exploration and ligation of the

lymph vessel may be necessary. Dyspnea and mild

Horner syndrome require observation, although

they usually improve spontaneously.

From late 1989 through the end of 2002, 532

surgeries were performed in the authors institu-

tion using the combined surgical procedure forTOS. The patients on whom these surgeries were

performed included 44 males and 396 females. The

most common age range was 2540 years and the

mean age was 38 years. The youngest patient was

10 years and the oldest was 63 years of age.

Results of combined surgical procedure for TOS

A simple grading system has been set up based

on the patients opinions of their percentage of

improvement following combined primary sur-

gery for TOS. The rate of symptom improvementafter combined primary surgery was graded

empirically (Table 2).



12/12

One hundred two patients returned a mailed

questionnaire regarding the outcome of their

surgery. Ninety-five percent of the patients re-

ported improvement of their symptoms after the

combined procedure. Only three patients who had

surgery using the combined procedure techniquedeveloped symptomatic recurrent symptoms.

These patients were operated on a second time.

One of these patients had good improvement after

the secondary surgery, another experienced a

30%50% improvement in symptoms, and the

third had an initial improvement and 6 months

later developed recurrent symptoms again.

Although the author has had only three

patients who have required secondary surgery

for recurrent symptoms, our overall no improve-

ment or recurrence rate after the combined

procedure is 5%10%. Several patients (approx-imately 40%50%) [4] were diagnosed with

associated peripheral nerve compression in the

involved extremity and had additional surgery for

their peripheral nerve compressions before or

after the combined procedure.

The authors complications with the combined

procedure are as follows: less than 10% had

pneumothorax, several patients had temporary

phrenic nerve palsy caused by surgical manipula-

tion and traction, and 1012 patients (approxi-

mately 2%) experienced neck seroma thatrequired aspiration only. No major vessel injuries

occurred, except a small tear (less than 0.5 in) in

the subclavian vein in two patients, which were

repaired without incident. In addition, no major

wound infections, neck hematomas, or chylous

drainages were observed.

References

[1] Coote H. Pressure on the axillary vessels and nerve

by an exostosis from cervical rib: interference with

the circulation of the arm, removal of the rib and

exostosis; recovery. Med Times Gazette 1861;2:108.

[2] Qvarfordt PG, Ehrenfeld WK, Stoney RJ. Supra-

clavicular radical scalenectomy and transaxillary

first rib resection for the thoracic outlet syndrome.

Am J Surg 1984;148:1116.

[3] Wiley E. Discussion in Roos D.B. The place for

scalenectomy and first rib resection in TOC.

Surgery 1982;92:1084.

[4] Atasoy E. Thoracic outlet compression syndrome.

Ortho Clin N Am 1996;27(2):265303.

[5] Roos DB. Experience with first rib resection for

thoracic outlet syndrome. Ann Surg 1971;173:

42942.

[6] Murphy T. Brachial neuritis caused by pressure of

first rib. Aus Med J 1910;15:5825.

[7] Adson AW, Coffey JR. Cervical rib: a method of

anterior approach for relief of symptoms by division

of the scalenus anticus. Ann Surg 1927;85:83957.

[8] Atasoy E, Majd M. Scapulothoracic stabilization

for winging of the scapula using strips of autoge-

nous fascia lata. J Bone Joint Surg [Br] 2000;82(6):8137.

[9] Atasoy E, Kleinert HE. Surgical sympathectomy

sympathetic blocksupper and lower extremity,

local plexus level. In: Omer GE, Van Beek AL,

editors. Management of peripheral nerve problems.

2nd edition. Philadelphia: WB Saunders; 1998.

p. 15771.

[10] Clagett OT. Presidential address: research and pro-

search. J Thorac Cardiovasc Surg 1962;44:15366.

[11] Roos DB. Transaxillary approach to first rib

resection to relieve thoracic outlet treatment. Ann

Surg 1966;163:354.

[12] Sanders RJ, Monsour JW, Gerber WF, et al.Scalenectomy versus first rib resection for treatment

of the thoracic outlet syndrome. Surgery 1979;

85:10921.

Table 2

Results of combined first rib resection and scalenectomy

Percent improvement Description No of patients

70%100% Excellent 36

50%70% Good 24

30%50% Better 26

10%30% Fair 9

Less than 10% Very poor 5

Results based on 102 respondents to a questionnaire,

out of 532 surgeries.


Combined Surgical Treatment of Thoracic Outlet

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