The technique of transaxillary first rib resection is as follows: The surgeon stands anterior to the patient. The patient is placed in the lateral decubitus position with the arm held upward on a pulley. An axillary incision is made at the base of the hairline down to the chest wall which is explored with the finger going all the way up to the first rib, avoiding the intercostal brachial nerve and the long thoracic nerve. The long thoracic nerve is avoided by not cutting the posterior portion of the serratus anterior. A periosteal elevator is then used to go underneath the first rib and clean off its inferior surface. The anterior scalene muscle, inserting on the first rib, is transected followed by the scalene medius, so the sub-clavian artery, vein and brachial plexus are avoided.
The entire first rib is cleaned anteriorly and posteriorly to the transverse process of T1. The first rib is then transected and removed. It is important to remember that the thoracic outlet syndrome may be a very difficult diagnosis to make and the differential diagnosis includes problems of the cervical spine with radicular pain, as well as brachial plexus problems such as superior sulcus tumors invading the lower roots of the brachial plexus. Also carpal tunnel syndrome may mimic thoracic outlet syndrome, as may other peripheral neuropathies.
If a cervical rib is present and is causing the thoracic outlet syndrome, then resection of the cervical rib can be accomplished along with the first rib resection via th etransaxillary approach. A sclenotomy is no longer performed; rather a scalenotomy should be done along with neurolysis of C5, C6 and C7 is upper brachial plexus symptomatology exists.
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