Endoscopic Transaxillary Decompression of Thoracic Outlet Via Pectoralis Minor Tenotomy- A Novel Approach

Heather A Ford, MD, Adam J Vernadakis, MD. Lahey Hospital and Medical Center

Endoscopic transaxillary surgical approaches have been used safely for thyroidectomy, breast augmentation, sternocleidomastoid release for torticollis, and first rib resection for thoracic outlet syndrome (TOS).  However, many cases of TOS simply require scalene release and/or pectoralis minor tenotomy to alleviate symptoms.  Typically, these decompressions are done through open supraclavicular, infraclavicular, or transaxillary approaches, which can lead to significant postoperative pain and scarrring.  We present a description and video of what we believe to be the first endoscopic transaxillary decompression of the thoracic outlet via pectoralis minor tenotomy in a patient with bilateral TOS.  She presented with symptoms of bilateral upper extremity pain, weakness and parethesias, which were disabiling and refractory to conservative management.  Dynamic MRI confirmed positional subclavian artery compression bilaterally, localized to the insertion of the pectoralis minor.  Three 5mm ipsilateral axillary ports were used to access and insufflate a working space beneath the pectoralis major muscle, which provided superior visualization over the open technique. The pectoralis minor tendon was dissected and divided with a laparoscopic Harmonic scalpel to decompress the underlying brachial plexus and subclavian artery.  Her postoperative course was remarkable only for complete resolution of her symptoms and an excellent aesthetic outcome.  We believe that an endoscopic transaxillary approach is a safe and effective way to treat patients with thoracic outlet syndrome associated with pectoralis minor tendon compression, providing superior visualization, shorter recovery and can offer a superior cosmetic result.

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