1. Totally Endoscopic (VATS) First Rib Resection for Thoracic Outlet Syndrome 
Robert S. George, PhD, FRCS-CTh, Richard Milton, FRCS-CTh, Nilanjan Chaudhuri, MClinSci, FRCS-CTh, Emmanuel Kefaloyannis, MD, PhD, Kostas Papagiannopoulos, MMED THORAX, MD CTh 
The Annals of Thoracic Surgery 
Volume 103, Issue 1, Pages (January 2017)
DOI: /j.athoracsur
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Patient positioned in the lateral decubitus position with markings of the ribs and the port sites.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
Instruments used to perform VATS rib resection: 2 periosteal elevators, 2 endoscopic bone nibblers, and a rib cutter. The rib cutter has a distal edge to stop the blade from cutting beyond the groove.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
(A) Parietal pleura and periosteum overlying the first rib are stripped off using the harmonic scalpel. (B) A long Roberts artery clamp is used to retract the rib and a peanut is used to blunt dissect the neurovascular bundle from the superior aspect of the first rib. (C) Once a clear space is confirmed, the distal edge of the rib cutter is passed around the anterior aspect of the first rib. (D) The rib cutter is used to cut the posterior aspect of the first rib. (E) Rongeurs are used to trim the anterior and posterior stumps while a long suction device is protecting the herniating neurovascular bundle. (F) The neurovascular bundle descends into the pleural space with no compression.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions