top of page

ATOS Surgical Approaches

Supraclavicular incision

SUPRACLAVICULAR

(above clavicle)

Paraclavicular incisions

PARACLAVICULAR

(above & below clavicle)

Transaxillary incision

TRANSAXILLARY

(through the armpit)

The three main surgical approaches used for ATOS are Supraclavicular, Paraclavicular and Transaxillary.  Which approach is used typically depends on surgeon preference, what they were trained in, and what they are most comfortable with.  From a safety standpoint, each of these approaches can be used safely as long as the surgeon is properly trained in both the surgery itself and the chosen approach.  TOS experts have stated pros and cons of each approach depending on which they prefer. Keep in mind that these experts have differing opinions about the pros and cons of each approach.  Below is a summary of the various pros and cons.

SUPRACLAVICULAR

Pros

  • Easy access to any cervical rib for complete removal

  • Complete removal of both anterior & middle scalene muscles

  • Ability to perform artery repair or reconstruction in some instances

  • Ability to treat coexisting NTOS with complete brachial plexus neurolysis

  • Ability to wrap all nerve roots to help prevent post-op scar tissue

  • Best view of brachial plexus nerves to prevent injury to the same

  • Ease of removal of posterior portion of first rib

  • Best view of surgical area for identifying & removing any fibrous bands or other anomalous structures

  • Ease of management of any intraoperative bleeding complications (although rare)

  • More vascular surgeon familiarity of surgical approach as it’s used for other vascular surgery conditions

Cons

  • Inability to remove the entire first rib

  • Inability to perform artery repair or reconstruction for larger aneurysm without adding additional infraclavicular incision

  • More manipulation of the nerves

  • Higher incidence of phrenic nerve injury

  • Higher incidence of thoracic duct lymph leak

  • Longer operating time

  • Less cosmetically appealing scar

  • Longer hospital stay

PARACLAVICULAR

Pros

  • Easy access to any cervical rib for complete removal

  • Complete removal of the entire first rib

  • Complete removal of both anterior & middle scalene muscles

  • Ability to perform artery repair or reconstruction

  • Ability to treat coexisting NTOS with complete brachial plexus neurolysis

  • Ability to wrap all nerve roots to help prevent post-op scar tissue

  • Best view of brachial plexus nerves to prevent injury to the same

  • Best view of surgical area for identifying & removing any fibrous bands or other anomalous structures

  • Ease of management of any intraoperative bleeding complications (although rare)

Cons

  • Higher incidence of phrenic nerve injury

  • Higher incidence of thoracic duct lymph leak

  • more technically challenging

  • more manipulation of the nerves

  • Longer operating time

  • Longer hospital stay

  • Less cosmetically appealing scar

TRANSAXILLARY

Pros

  • Ability to remove the entire first rib

  • Ability to work beneath the brachial plexus nerves to prevent injury to the same

  • Lower incidence of phrenic nerve injury

  • Lower incidence of thoracic duct lymph leak

  • Shorter operating time

  • Shorter hospital stay

  • Cosmetically appealing scar

Cons

  • Not as easy to completely remove any cervical rib

  • Unable to perform any artery repair or reconstruction without patient repositioning and additional incision(s)

  • Inability to completely remove anterior & middle scalene muscles (only about 25% of the muscles can be removed)

  • Inability to remove fibrous bands from upper brachial plexus

  • Only able to perform neurolysis on the lower 2-3 nerve roots

  • Inability to wrap nerve roots to prevent post-op scar tissue

  • Not as easy to remove posterior portion of first rib

  • More difficult management of intraoperative bleeding complication (although rare)

  • less surgeon familiarity with anatomy via this approach

GO BACK TO

bottom of page