Shoulder girdle compression syndrome or thoracic outlet syndrome (TOS) and cervical rib: modern therapy in outpatient thoracic surgery Berlin

In Berlin, specialized centers such as the VenaZiel DayClinic modern procedures of thoracic surgery to treat thoracic outlet syndrome gently and effectively. In particular the minimally invasive, uniportal VATS technique (video-assisted thoracoscopic surgery via a single access) enables safe decompression of the affected structures – often on an outpatient basis, i.e. without a lengthy hospital stay.

Below you will find out what TOS is, what its causes and symptoms are, how it is diagnosed and what treatment options are available. Particular attention is paid to surgical therapy using uniportal VATS procedureThe advantages for patients as well as the typical procedure, aftercare and prognosis. Finally, it is explained why the VenaZiel DayClinic Berlin is a trusted partner for the treatment of thoracic outlet syndrome.

What is Thoracic Outlet Syndrome (TOS)?

Thoracic outlet syndrome is the term used to describe a bottleneck syndrome in the upper chestin which nerves and vessels are constricted on their way from the neck to the arm.

The bundle of plexus nerves, artery and vein runs through several natural constrictions: between the neck muscles (
scalene gap
), between the first rib bone and the collarbone (
costoclavicular space
) and under the small pectoral muscle (
coracopectoral space
).

If there is not enough space at one of these points, this can lead to pressure damage to the structures running through it.

Who is affected? In principle, TOS can occur at any age and in any gender. However, statistics show that mainly younger to middle-aged women are affected, especially if a poor posture or insufficiently trained shoulder muscles.

People who use their arms overhead a lot for work or sport (e.g. swimmers, volleyball players) and therefore perform repetitive arm/shoulder movements are also at a higher risk.

Overall, however, TOS is a rather rare disease: it is estimated that around 1% of the population develop thoracic outlet syndrome.

Causes: How does thoracic outlet syndrome develop?

The causes of a TOS are varied and anatomical variants often play a role. anatomical variants or acquired changes play a role. The most common triggers include

• Congenital constrictions: A known congenital cause is an extra rib in the neck area, a so-called cervical rib (
  cervical rib
  ). This extra rib, which usually attaches to the 7th cervical vertebra, only occurs in about 0.5% of people before.
  In many cases, a cervical rib remains clinically inconspicuous, but it can further narrow the bottleneck in the neck-chest area and thus promote thoracic outlet syndrome. If a TOS occurs due to the presence of a cervical rib, this is also referred to as Cervical rib syndrome. (In addition to fully formed neck ribs, there are also incomplete cervical ribs or fibrous ligamentswhich can have a similar effect). Other bony abnormalities such as an unusually steep position or ossification of the first rib or exostoses (new bone formations) can also narrow the space.
• Soft tissue changes: A Thickening or tension of the neck muscles (especially the
  scalene muscles
  ) can narrow the passageway for nerves and vessels. Additional muscle cords (e.g. a fourth scalene muscle) or firm connective tissue cords that constrict the plexus and vessels are less common.
• Injuries and chronic stress: Accidents such as a whiplash injury or a previous fracture of the collarbone can lead to the formation of scar tissue or bone misalignments that reduce the space at the thoracic outlet. Chronic overloading – for example due to heavy loads on the shouldersintensive strength training (e.g. bodybuilding) or repetitive overhead movements – can lead to muscular hypertrophy, minor bleeding and scarring, which ultimately also cause constriction. Poor posture (hunched shoulders, “hunchback”) also favors the occurrence.
• Tumors or large lymph nodes in the upper chest or armpit area are rare causes, but can also provoke a TOS by taking up space. 

It is usually a combination of factors. Often there is a
congenital narrowing
(e.g. due to cervical ribs or a narrow throat), which is then living and working habits (posture, muscular strain). It is important to note: Not every detectable constriction automatically leads to symptoms. For example, many people have cervical ribs without ever developing TOS. Only when there is actually irritation or damage or damage to the nerves or vessels due to pressure is thoracic outlet syndrome diagnosed.

X-ray of a cervical spine with thorax: The arrows mark the cervical ribs on both sides.

cervical ribs
(small additional ribs above the first rib). Such anatomical variants are rare, but can trigger thoracic outlet syndrome if they constrict nerves or vessels.

Symptoms of TOS: How does it manifest itself?

The symptoms of thoracic outlet syndrome can vary from patient to patient, depending on which structure (nerve or vessel) is mainly pressed and where the compression occurs. In general, TOS affects the Upper extremity and the shoulder/neck area. Typical symptoms are Shoulder, neck and arm painoften associated with tingling, numbness or a feeling of or a feeling of weakness in the arm. Many sufferers report that the symptoms mainly occur or get worse when the arm is lifted – e.g. when washing hair or working overhead. The following is an overview of the most common symptom constellations depending on the type of TOS:

• Neurogenic TOS (nTOS): This most common form (around 95% of cases) mainly affects the nerves of the brachial plexus. Typical are radiating pain from the neck over the shoulder into the armoften right into the hand. In particular Sensory disturbances (tingling, numbness) occur on the ulnar side of the hand, i.e. in the little finger little finger and ring finger and on the inside of the forearm – this corresponds to compression of the lower nerve fibers (segments C8-Th1). Some patients notice weakness in the hand; in very severe cases, there may be a slight Atrophy (regression) of the hand muscles occur. The pain can be sharp and burning or dull and can occur both during movement and at rest. The symptoms are often one-sided, but can also occur on both sides with the appropriate strain. Headaches or neck pain can occur concomitantly, but are less prominent in purely neurogenic TOS than the arm symptoms.
• Venous TOS (vTOS): Is mainly the subclavian vein (subclavian vein) is constricted, one speaks of a venous TOS. This often manifests itself suddenly often noticeable after intensive arm use (also known as
  “Effort thrombosis”
  or Paget-von-Schroetter syndrome). As a result of the blood outflow disorder Swelling of the affected arm, hand and fingers, accompanied by a feeling of tightness. The skin may be bluish in color, and protruding veins in the shoulder and chest area are possible. Those affected often feel a Feeling of heaviness and weakness in the arm. Sometimes a blood clot (thrombosis) develops in the vein, leading to sudden pain and swelling. This scenario represents an acute need for medical action.
• Arterial TOS (aTOS): This form is the rarest (less than 5% of cases), but potentially the most dangerous. Here the Subclavian artery (subclavian artery) The neck is pinched off, usually by a bony anomaly such as a pronounced cervical rib. Those affected complain of Circulatory disorders in the arm and hands: the hand becomes slightly cold, pale and quickly tired under stress. It can lead to Pain in the fingers sometimes even small ulcers appear on the fingers because the blood supply is insufficient. The fingers may tingle or go numb. In extreme cases, turbulence in the constricted artery can cause blood clots to form, which can travel into the hand or, in rare cases, into the brain and cause vascular occlusion. However, such complications are very rare.

Thoracic outlet syndrome is characterized by the fact that certain positions or movements of the arms trigger or intensify the symptoms. Many people report that raising their arms above their head or stretching their shoulders back immediately leads to pain, numbness or weakness. This distinguishes TOS from heart complaints (angina pectoris), for example, which usually increase with physical exertion and do not depend on arm movements. At rest, especially if you relax your shoulders and lower your arms, TOS symptoms often improve again.

If left untreated chronic TOS over a long period of time can lead to permanent nerve damage (with persistent weakness or loss of feeling in the hand) or vascular damage. For example, venous compression can cause repeated thrombosis, and arterial compression can lead to aneurysms or vascular occlusion. This underlines the importance of timely diagnosis and treatment.

Diagnosis: How is TOS diagnosed?

The diagnosis Thoracic outlet syndrome can be challenging, as the symptoms are varied and not always clear. First of all, it is important to Thorough survey of the medical historyThe doctor asks about the exact symptoms, their progression over time and triggering factors (e.g. which arm position is causing the symptoms). This is followed by Clinical examinationin which specific attention is paid to neurological deficits and circulatory disorders.

Some special provocation tests can give indications of a TOS. Examples are

• Adson test: The patient turns the head to the affected side and breathes in deeply while the arm is stretched backwards and downwards. A weakening of the radial pulse or the occurrence of symptoms (tingling, pain) is considered an indication of compression of the artery by the scalene muscles or a cervical rib.
• Roos test (Elevated Arm Stress Test): Both arms are raised sideways (90° abduction) and the patient opens and closes the hands rhythmically for about 3 minutes. If pain, numbness or weakness occurs, this may be a sign of neurogenic TOS.
• Other tests such as the Wright test (hyperabduction of the arms) or the costoclavicular test (pushing the shoulders back down) are also used and can provoke the symptoms. However, these clinical tests are not 100% specific – i.e. they can also be positive for other problems. Therefore, they should only ever be evaluated in combination with other findings.  

To the imaging doctors often use x-rays and magnetic resonance imaging back. A X-ray of the cervical spine can, for example, make a neck rib visible or rule out degenerative changes. Special Duplex ultrasound examinations of the arm vessels, sometimes in different arm positions, can show whether the blood flow is impaired by certain positions (e.g. the artery can be shown to be squeezed). A Magnetic resonance angiography (MRA) or computed tomography (CT) with contrast medium can provide a three-dimensional image of the constriction and reveal any vascular damage (such as aneurysms or occlusions). Vascular imaging in different arm positions is often very informative, especially if venous or arterial TOS is suspected.

In addition neurophysiological tests can be carried out: An electroneurography (ENG) or electromyography (EMG) tests nerve conduction velocity and muscle function to determine whether and where nerves are damaged. These tests help to differentiate other neurological causes (e.g. herniated disc in the cervical spine or carpal tunnel syndrome) and confirm that there is indeed irritation of the nerves in the outlet area.

The decisive factor is the overall pictureThe combination of typical symptoms, abnormal clinical tests and appropriate imaging findings supports the diagnosis of TOS. Sometimes it is necessary to consult other specialists – such as neurologists – to rule out similar clinical pictures. If the diagnosis is
Thoracic outlet syndrome
is confirmed, a suitable therapy concept can be created in the next step.

Treatment options: Conservative or surgical?

The treatment of thoracic outlet syndrome depends on the type of TOS (neurogenic vs. vascular), the severity of the symptoms and the individual findings (e.g. evidence of vascular changes). In principle, conservative treatment is usually attempted before surgery is considered – unless there are critical vascular complications that require immediate surgical relief. The most important therapeutic components are

• Physiotherapy and posture training: In the case of neurogenic TOS
  conservative therapy
  is the first choice. Targeted physical therapy (physiotherapy) can use stretching, strengthening and posture exercises to widen the chest and create space for nerves and blood vessels. For example, the muscles in the shoulder girdle are strengthened and posture corrections are practiced so that the shoulders are brought back down and the chest can be expanded. costoclavicular space (between the first rib and collarbone) is relieved. Relaxation exercises and Occupational therapy to adapt everyday movements can help. It is important that such exercises are specialized personnel The patient should be guided through the stretching exercises – improper or exaggerated stretching exercises could otherwise make the symptoms worse. Success does not happen overnight: As a rule, over several months (3-6 months) during which the symptoms can improve significantly in many patients.
• Medication support: Accompanying painkillers (e.g. NSAIDs such as ibuprofen or paracetamol) can be used to relieve pain. For severe muscular tension, the following may also help Muscle relaxants short-term. In the case of venous TOS with thrombosis Anticoagulants (blood thinners) and/or thrombolytics (medication that dissolves clots) are administered. This is intended to restore blood flow and reduce the risk of pulmonary embolism. If necessary, interventional measures are also used, e.g. a Catheterwhich is used to dissolve or aspirate a clot. A definitive relief operation is only planned once the acute vascular occlusion has been repaired. Similar steps may be necessary for arterial TOS (lysis of blood clots via catheter, temporary blood thinning).
• Surgical decompression: If conservative measures do not help sufficiently or vascular complications are present, surgery may be considered. Only around 10-20% of TOS patients ultimately require surgery – but this is mainly for venous and arterial forms, where surgical treatment is considered to be very effective. The aim of the procedure is to eliminate the source of the compression and permanently widen the bottleneck. As a rule, this means Removal of the first rib (and, if present, the cervical rib) and loosening or severing of tight muscles or connective tissue cords that constrict the nerve-vascular structure. Through this Decompression surgery creates more space in the thoracic outlet so that nerves and vessels are exposed and no longer pinched. If necessary Vascular reconstructions for example, if an artery has been damaged or narrowed by prolonged compression. The operation is technically demanding and should be performed by experienced thoracic surgeons as important structures in the confined space must be spared.

Classic surgical procedures for TOS were for a long time the transaxillary approach (incision in the armpit) or the supraclavicular approach (incision above the collarbone). Above this, the surgeon can expose and remove the first rib. These open procedures are effective, but require relatively large incisions and the severing of muscle and tissue, which can lead to post-operative pain and scarring. In recent years, therefore, the minimally invasive thoracic surgery technique established: the video-assisted thoracoscopy (VATS). The structures are operated on endoscopically via the rib cage. In the DayKlinik Berlin we rely specifically on the uniportal VATS methodi.e. an intervention through only a small incision with camera assistance. We present this method and its advantages in detail in the next section.

Advantages of the Uniportal-VATS technology at TOS

The
video-assisted thoracoscopy
(VATS) refers to a keyhole surgery Instead of making a large incision, the surgeon opens the chest wall only minimally and inserts a tiny video camera and instruments to operate inside the chest. Uniportal means that only a single access (port) is used – usually an approx. 3-4 cm long incision between the ribs in the lateral chest wall. For patients with thoracic outlet syndrome, this modern procedure offers a number of advantages over conventional open surgery:

• Protection of the tissue: By avoiding large incisions and spreading ribs, the surrounding muscles remain largely intact. No large muscles need to be severed, as would be necessary with an approach via the pit of the neck or armpit. This leads to Less postoperative pain and faster recovery. It also reduces the risk of damaging or irritating nerves or vessels in the area of the thoracic wall.
• Enlarged view and precision: The camera gives the surgeon a magnified, well-lit magnified, well-lit view on the anatomical structures. In particular, the area of the first rib and the vascular-nerve bundle can be viewed in high resolution. This improved imaging makes it possible to better visualize and preserve fine structures such as nerves. Hidden sections of the first rib, particularly towards the back of the spine, can also be easily reached and removed with VATS. This minimizes the risk of Rib remnants remainwhich could cause problems again later.
• Smaller scar and cosmetic advantage: The single skin incision can usually be placed inconspicuously on the lateral chest wall or in the armpit area. This is cosmetically advantageous, especially for young patients and women, as only a small scar often hidden in the natural skin fold of the armpit. In comparison, scars above the collarbone or in the armpit are much more visible with open procedures. Many patients appreciate this aesthetic benefit.
• Faster recovery and shorter stay: Thanks to the minimally invasive procedure, patients generally recover more quickly. Studies have shown that patients after VATS first rib resection often recover within 2-3 days be able to leave the hospital – sometimes even earlier, depending on the individual course of the procedure. In experienced facilities such as the VenaZiel DayKlinik Berlin, the procedure can be carefully planned and carried out so that outpatient surgery in suitable cases is possible. This means that patients come to the clinic on the day of the operation and can go home again a few hours after the procedure – as soon as they are sufficiently awake and pain-free. (Provided, of course, that everything is medically stable and that someone is present at home for the first night to provide support).
• High success rates: The minimally invasive technique is no less effective than open surgery. On the contrary, excellent results are achieved thanks to better visibility and complete removal of the compressive structures. The literature reports high success rates of surgical TOS therapy: In vascular TOS, more than over 90% of cases the symptoms are eliminated after surgery. In the case of neurogenic TOS, which is often more difficult to objectify, clinical experience shows improvement rates of approx. 80% and more. The VATS technique contributes to achieving these good results with less trauma thanks to its precise procedure. A study with VATS patients found that 9 out of 10 patients had a complete resolution of their main symptoms.

In summary, the uniportal VATS in experienced hands offers a gentle and at the same time effective methodto surgically treat thoracic outlet syndrome. In the next section, we explain how such a procedure is typically performed.

Procedure: Uniportal VATS decompression

Preparation: On the day of the operation, the patient is admitted to the clinic (in the DayClinic usually on the morning of the day of the operation). After being greeted by the team and final explanatory discussions (by the surgeon and anesthetist), preparation takes place in the operating room. The operation takes place under General anesthesia to immobilize the chest and allow one-sided ventilation of the lungs (the affected lung is temporarily deflated to facilitate access to the chest). In addition, a local anesthetic procedure like a serratus block or an intercostal nerve block to reduce the post-operative pain sensation.

Storage and cutting: The patient is placed in the lateral position – i.e. on the left side in the case of a right TOS. The arm on the side to be operated on is gently positioned upwards or forwards to expose the side of the chest. The surgeon then makes a small Skin incision (approx. 3 cm)typically in the area of the mid axillary line in the 4th or 5th intercostal space (lateral chest wall, approximately at the level of the armpit). This incision is used as access for the camera and instruments. A portal is created by careful spreading (without hard metal retractors – a soft retractor is usually used). In our specialized setting, we use a tiny HD camera with illumination that provides a clear image from inside the chest.

Chest surgery: First the lung is lung is held to the side or collapsed so that the upper chest area is visible. The surgeon identifies the first rib from the inside. The Pleura (pleura) above the rib is carefully opened and the surrounding tissue (muscle attachments, ligaments) is detached from the rib bone. The exact orientation is important here: in front of the rib head (towards the neck) run the Nerves and vesselswhich must be spared. Thanks to the excellent visibility, the plexus and the artery/vein can be precisely visualized and carefully held aside with special instruments. Any thickened connective tissue cords or hypertrophic scalene muscles that constrict the plexus are cut directly at this point in order to free the nerves.

Now the 1st rib The entire length of the vertebra is exposed. Often one starts at the front section (at the connection to the sternum or cartilage) and works backwards to the vertebral base. The rib is dissected with a special endoscopic bone forceps cut in two places. First, it is separated at the base of the sternum, then further back near the spine. This allows the piece of rib in between, which is causing the bottleneck, to be removed, completely removed often in several smaller pieces (in bites), as the entire rib is difficult to salvage in one piece through the small incision. The important thing is, also all remnants of bone and periosteum (bone skin) to ensure that nothing grows back or that any remaining tissue continues to press. If a neck rib was present, this will of course also be removed.

During the entire procedure, the team takes great care to not to injure any nerves or vessels. The extended camera image helps to Clearly see and protect the neurovascular cord. If a vessel has been damaged, vascular surgery techniques are available (although this does not usually occur, as the procedure is very safe under good visibility conditions).

Once the decompression has been performed – i.e. the first rib is out and any scar cords have been cut – a final check is performed. The surgeon checks that all potentially constricting structures have been removed and that there is no bleeding. In most cases, a Thin drainage hose (thoracic drain) is inserted through the same incision or separately through a second minimal skin incision. This ensures that air and wound fluid are drained out of the chest and the lungs can fully expand again. The small access portal is then sutured with a few stitches (intradermally, i.e. under the skin, for an attractive cosmetic result).

Wake-up phase: The anesthesia is ended and the patient is taken to the recovery room. Vital parameters are monitored there. Patients who have undergone surgery usually feel the following due to the preventive regional anesthesia Only minor pain immediately after the procedure. However, if there is any pain, painkillers are available.

Outpatient or inpatient? At the VenaZiel DayClinic Berlin the procedure is planned in such a way that outpatient aftercare is possible. This means that if the general condition is stable, drainage is no longer required or can be removed the next day at the latest and home care is ensured, the patient may return home the same day in the evening. Otherwise a Short stationary monitoring (usually 1-2 days) is recommended, especially if, for example, the drainage is left in place with minimal residual drainage or if there are pre-existing conditions that require observation. In any case, the length of stay is significantly shorter than with traditional open surgery – thanks to the minimally invasive technique and proven outpatient care concept.

Aftercare and rehabilitation

The follow-up treatment after a uniportal VATS decompression is designed to promote healing. promote healing and to achieve optimal functional result to ensure the patient’s well-being. The patient is encouraged shortly after the procedure – if the pain allows it, stand up carefully and move your arm. It is not necessary to take it easy for too long; on the contrary, Early mobilization prevents complications such as thrombosis and supports lung function. The used Thoracic drainage is usually removed within the first 24 hours (often the next morning after the operation) as soon as there is no significant air leakage and only a small amount of wound fluid remains. Once the drain has been removed, no special restrictions on movement are required – most patients are able to perform all movements again after around 2 weeks.

As a rule, patients who have undergone surgery are given pain medication (tablets) home with you to make the healing process as comfortable as possible. The pain after a VATS is usually moderate and subside significantly within one to two weeks. It is important that there is no pain so that the Physiotherapy can be carried out effectively. As after every decompression operation, targeted follow-up treatment with physiotherapy is part of the program. Breathing exercises and light arm movement exercises are often started in the hospital or outpatient surgery center.

In the physiotherapy after discharge, the focus is on keeping scar tissue supple to keep scar tissue supple shoulder mobility mobility and, above all, working on posture and muscle balance to continue working. The cause (e.g. poor posture, muscle imbalance) should remain eliminated. Patients also learn ergonomic tricks for everyday life to relieve the shoulder girdle. Follow-up appointments with the thoracic surgeon are typically arranged after approx. 2 weeks (wound check, stitches are usually self-dissolving) and after 4-6 weeks (final check, X-ray if necessary).

Many patients are surprised at how quickly they are fit again after the minimally invasive procedure. Occupational activities can often be resumed within a few weeks, depending on the job; in the case of office work possibly after 2 weeks, in the case of heavy physical work rather after 4-6 weeks in consultation with the doctor. SportLight activities such as walking are possible almost immediately. More intensive training (gym, swimming, etc.) should wait until the wound has healed and the doctor has given the green light (usually approx. 4 weeks).

Overall, patients benefit enormously from the outpatient, gentle procedure: They can recover in familiar surroundings at home, have less pain and are reintegrated into everyday life more quickly. Of course, the team at the VenaZiel DayClinic The aftercare is structured and organized close to the patient. A further advantage of outpatient care is the reduced risk of hospital infection and the patient’s relief from the feeling of actively helping to shape their own recovery.

Prognosis: prospects for TOS patients

The prognosis of thoracic outlet syndrome depends on which type is present and how consistently it is treated. Neurogenic TOS can be significantly improved in many cases by conservative measures – studies show that around
30-40%
of patients achieve complete or at least significant pain relief through physiotherapy alone. In more severe cases, where conservative therapy is ineffective, surgery provides the desired relief for a large proportion of patients. 80% of nTOS patients who have undergone surgery report sustained freedom from symptoms or marked improvement. It is important to know that nerves need time to recover from prolonged compression. This means that the tingling or numbness does not always disappear immediately after the operation, but sometimes gradually disappears over a period of weeks as the nerve regenerates. Early surgery, before irreversible nerve damage occurs, has a better chance of success in this case.

With venous TOS the prognosis after decompression is very good. After the constricted vein segment has been decompressed and clots have been removed if necessary over 90% of cases, a complete restoration of normal blood flow and freedom from symptoms can be achieved. However, patients who have undergone surgery sometimes have to continue taking blood thinners for a certain period of time (or permanently, depending on the vascular status) in order to prevent new thromboses.

Also the arterial TOS can be cured in most cases by removing the bony constriction (first rib/neck rib) and possibly repairing the vessels. Surgery is practically always indicated here, as there is a risk of serious vascular problems if left untreated. After successful surgery, the vast majority of patients report a significantly warmer hand with a stronger blood supply and the disappearance of pain.

Complications of the operation are rare overall. As with any procedure, post-operative bleeding (in less than 2% of cases) or infections can occur, but these are very unlikely nowadays thanks to modern techniques and prophylaxis. Nerve injuries caused by the operation are also rare; the greatest risk is with the transaxillary approach for the long thoracic nerve, which is significantly lower with the VATS method. Also Recurrences – i.e. a recurrence of the TOS – are possible, but are usually the result of incomplete decompression (e.g. remaining rib fragments). In experienced hands and with a thorough view via thoracoscopy, this risk is minimized. However, if scarring causes symptoms again years later, a new minimally invasive procedure can sometimes be considered.

In summary, there is a good chance that patients will be able to recover after treatment – especially after a successful uniportal VATS decompression – a pain-free life again can lead. Many report finally being able to move their arm freely again, without pain or numbness, which is a huge improvement in quality of life. It is important to take personal responsibility afterwards: good posture, regular shoulder exercises and avoiding extreme overhead strain can help prevent the symptoms from returning.

Why VenaZiel DayKlinik Berlin? – Your advantages in our thoracic surgery department

For patients with thoracic outlet syndrome in Berlin and the surrounding area, the VenaZiel DayClinic an excellent place to go. Our facility stands for High-performance outpatient medicine at hospital level. But what does this mean for you in concrete terms?

Specialization and experience: Under the direction of Dr. med. Hamidreza Mahoozi – Specialist in thoracic surgery With over 20 years of experience, our team specializes in minimally invasive chest surgery. We are familiar with the particular challenges of TOS and perform the First rib resection via uniportal VATS routinely. As Pioneer of ambulantization As the leading provider of surgical services in Germany, Dr. Mahoozi attaches particular importance to using new techniques for the benefit of patients. For you, this means: the highest level of professional expertise paired with the latest surgical methods.

Top-class outpatient surgery center: Our DayKlinik in Berlin-Mitte combines state-of-the-art medical equipment (class 1B operating theatres) with digitally optimized processes. Procedures that used to require inpatient admission can now be performed on an outpatient basis. without compromising on safety. The entire patient journey is digitally supported and yet personal: from making appointments to preliminary examinations and structured aftercare, we focus on efficiency so that there is more time for you as a person. Short distances, individual time slots and clear processes ensure that you feel you are in good hands with us.

Interdisciplinary concept: Thoracic outlet syndrome lies at the interface between vascular medicine and nerve surgery. At VenaZiel, interdisciplinary care is a matter of course. As Vein Center and Thoracic Surgery we ensure that vascular surgeons, radiologists and physiotherapists work closely together. If, for example, catheter treatment to dissolve a thrombus is necessary before the operation, we organize this seamlessly with our partners. Collaboration with neurologists and pain therapists is also part of our network in order to plan the optimal treatment for each patient.

Human and individual: Despite high-tech and digitalization, our focus is on people. We take time for your concerns and questions – be it during the initial consultation, the decision for or against an operation, or during aftercare. Outpatient does not mean anonymous: on the contrary, personal support and friendly atmosphere are very important to us. Many patients appreciate the fact that they do not get lost in the hustle and bustle of a large clinic at our day clinic, but instead find a quiet environment in which they can relax. trustworthy care be cared for.

Short recovery time – in familiar surroundings: The possibility of being allowed to return home on the same day after a TOS operation is seen by many as a great advantage. No hospital bed at night, but your own home – this promotes well-being. Of course, you will be given detailed instructions and a direct emergency number in case anything should happen after discharge. In our Aftercare we combine digital elements (e.g. telemedicine: video follow-up checks, digital transmission of findings) with traditional check-up appointments. This keeps you in close contact with us without unnecessary travel.

Innovative spirit: VenaZiel stands for the aspiration to to rethink outpatient care in Germany. We bring Hospital standard in the city center – i.e. top medicine without long waiting times or bureaucracy. Our center is unique in Berlin because it offers a wide range of disciplines under one roof and consistently relies on modern technology. For you as a patient, this means state-of-the-art treatment that is also tailored to your needs.

Summary: The treatment of thoracic outlet syndrome, in particular the demanding decompression surgerybelongs in experienced hands. In the VenaZiel DayClinic Berlin you will receive this expertise – minimally invasive and on an outpatient basis, in a facility that is characterized by quality, innovation and humanity. Benefit from less stress, faster recovery and comprehensive care on site. We will be happy to advise you personally on your TOS clinical picture and the possible treatment options. Please do not hesitate to contact us – we are here for you so that you can get back on your feet soon.
breathe freely and get to grips
can!

Sources and further reading

1. Peek J. et al. Outcome of Surgical Treatment for Thoracic Outlet Syndrome: Systematic Review and Meta-Analysis. Ann Vasc Surg. 2017;40:303-326 (Surgical outcomes in TOS).
2. George RS et al. Totally Endoscopic (VATS) First Rib Resection for Thoracic Outlet Syndrome. Ann Thorac Surg. 2017;103(1):241-245. (Study: endoscopic removal of the first rib, advantages of VATS)
3. Macía I et al. Uniportal Robotic-assisted Thoracoscopic Surgery: Resection of the First Rib. Ann Cardiothorac Surg. 2023;12(1):112-114. (Case report: world’s first uniportal robot-assisted rib resection, commentary on VATS advantages)
4. Esslingen Hospital. Thoracic outlet syndrome (TOS) – Patient information. 2025. (Causes, forms and diagnosis of TOS clearly explained)
5. Bethel Protestant Hospital (Bielefeld). Thoracic outlet syndrome (TOS) – Information from thoracic surgery. 2023. (Explanation of surgical technique and success rates, minimally invasive procedure)
6. StatPearls (NIH). Anatomy, Thorax, Cervical Rib. Last Update: Jul 2023 (Background on cervical ribs, frequency and effects on nerves/vessels)
7. Monitor health services research. New outpatient surgery center opens in Berlin: VenaZiel brings hospital standard to the city center. 27.05.2025 (Article about the VenaZiel DayKlinik Berlin and its outpatient concept)
8. Wikipedia (en). Thoracic outlet syndrome. (General background information on the TOS).