Thoracic outlet syndrome (TOS) encompasses a range of symptomatology including paresthesia, pain, and swelling of the upper extremities secondary to compression of the brachial plexus or subclavian vasculature in the thoracic outlet(1, 2). TOS is broad, and is further delineated between the neurogenic, arterial, and venous subtypes, as well as a number of patient population considerations such as athletes and hemodialysis dependency(1, 2). Of the subtypes, neurogenic TOS (nTOS) comprises 95% of TOS cases(3). Physical therapy is the first-line treatment of nTOS, however is not effective in a majority of patients(4). When non-surgical treatment methods fail, the mainstay of treatment is first rib resection (FRR) with anterior and middle scalenectomy for decompression of the thoracic outlet structures.

Throughout the past 6 decades, first rib resection has been performed via various approaches including the supraclavicular, posterior, infraclavicular, trans-axillary, and transthoracic techniques(5, 6). While minimally invasive techniques were first described in 1999, the utilization of thoracoscopy was not initially favored due to the limitations of mobility of thoracoscopic instruments(6, 7). With the introduction of robotic-assisted surgery, however, minimally invasive techniques have been adopted and often preferred over open techniques due to retraction-free, improved exposure of the thoracic outlet structures, superior maneuverability of the instruments, and excellent post-operative outcomes.