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 gently and effectively treat Thoracic Outlet Syndrome. 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.

In the following, you will learn what TOS is, what its causes and symptoms are, how the diagnosis is made, and what treatment options are available. Special attention is paid to surgical therapy using uniportal VATS procedure, its advantages for patients, as well as the typical procedure, aftercare and prognosis. Finally, it will be 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? Basically, TOS can occur at any age and in either sex. However, statistics show that younger to middle-aged women are particularly 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 plays 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 TOS occurs due to the presence of a cervical rib, it 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 passage for nerves and vessels. Less frequently, additional muscle strands (e.g. a fourth scalene muscle) or solid connective tissue strands occur, which constrict the plexus and vessels.
• 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 shoulders, intensive 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, “round back”) also promotes 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. 

In most cases, it is 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 arm, often 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 as well as on the inside of the forearm – this corresponds to the compression of the lower nerve fibers (segments C8–Th1). Some patients notice a weakness in the hand; in very severe cases, there may be a slight Atrophy (regression) of the hand muscles occur. The pain can be stabbing-burning or dull and occur both during movement and during rest periods. Often the symptoms are unilateral, but can also occur bilaterally with appropriate stress. 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, it is called venous TOS. This often makes itself suddenly often noticeable after intensive arm use (also known as “Effort thrombosis” or Paget-von-Schroetter syndrome). Due to the impaired outflow of blood, Swelling of the affected arm, hand and fingers can occur, accompanied by a feeling of tension. 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) forms in the vein, leading to sudden pain and swelling. This scenario represents an acute medical need for 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) is clamped 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 become tired under stress. It can lead to Pain in the fingers occur, sometimes even small ulcers appear on the fingers because the blood supply is insufficient. The fingers may tingle or become numb. In extreme cases, turbulence in the constricted artery could form blood clots that migrate into the hand or, rarely, into the brain and cause vascular occlusions there. However, such complications are very rare.

Thoracic outlet syndrome is characterized by the fact that certain positions or movements of the arms trigger or exacerbate the symptoms. For example, many report that lifting their arms over their head or stretching their shoulders back immediately leads to pain, numbness, or weakness. This distinguishes TOS, for example, from heart problems (angina pectoris), which usually increase with physical exertion and do not depend on arm movements. At rest, especially when relaxing the shoulders and lowering the 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 sensation in the hand) or vascular damage. For example, venous compression can repeatedly cause thrombosis, and arterial compression could promote vascular bulging (aneurysms) or vascular occlusions. This underscores the importance of timely diagnosis and therapy.

Diagnosis: How is TOS diagnosed?

The diagnosis in Thoracic Outlet Syndrome can be challenging because the symptoms are varied and not always clear. The first important step is a Thorough survey of the medical history: The doctor asks about the exact complaints, their temporal course and triggering factors (e.g. which arm position causes the symptoms). This is followed by a Clinical examinationin which specific attention is paid to neurological deficits and circulatory disorders.

Some special provocation tests can provide indications of a TOS. Examples include:

• Adson test: The patient turns the head to the affected side and takes a deep breath while the arm is stretched back and down. 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 to the side (90° abduction) and the patient rhythmically opens and closes the hands 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 (pressing shoulders back and down) are also used and can provoke the symptoms. However, these clinical tests are not 100% specific – that is, they can also be positive for other problems. Therefore, they must always be evaluated only 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 cervical 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. squeezing of the artery detectable). One Magnetic resonance angiography (MRA) or computed tomography (CT) with contrast agent can image the constriction three-dimensionally and reveal any vascular damage (such as aneurysms or occlusions). Especially when venous or arterial TOS is suspected, vascular imaging in different arm positions is often very informative.

In addition neurophysiological tests can be carried out: An electroneurography (ENG) or electromyography (EMG) checks the nerve conduction velocity and muscle function to determine if 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 actually irritation of the nerves in the outlet area.

The decisive factor is the overall picture: The combination of typical symptoms, conspicuous clinical tests and matching imaging findings supports the TOS diagnosis. Sometimes it is necessary to consult other specialist areas – such as neurologists – to rule out similar clinical pictures. Once 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. detection of vascular changes). Basically, a conservative treatment attempt is usually made at the beginning before surgery is considered – unless there are critical vascular complications that require immediate surgical relief. The most important therapy components are:

• Physiotherapy and posture training: In the case of neurogenic TOS conservative therapy is the first choice. Targeted physical therapy (physiotherapy) can widen the rib cage and create space for nerves and vessels through stretching, strengthening and posture exercises. For example, the muscles in the shoulder girdle are strengthened and posture corrections are practiced so that the shoulders are brought back and down and the costoclavicular space (between the first rib and collarbone) is relieved. Relaxation exercises and Occupational therapy to adapt everyday movements can also help. It is important that such exercises are performed by specialized personnel are instructed – improper or exaggerated stretching exercises could otherwise worsen the symptoms. Successes do 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 muscle tension, may also help Muscle relaxants in the short term. In the case of venous TOS with thrombosis, Anticoagulants (blood thinners) and/or thrombolytics (medications that dissolve 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 Catheter, through which a clot is specifically dissolved or suctioned off. Only after the acute vascular occlusion has been resolved is a definitive relief operation planned. 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 about 10–20% of TOS patients ultimately need surgery – but especially in venous and arterial forms, where surgical treatment is considered very effective. The aim of the procedure is to eliminate the source of compression and permanently widen the bottleneck. As a rule, this means: Removal of the first rib (and, if present, the cervical rib) as well as loosening or cutting through narrow muscles or connective tissue strands that constrict the nerve-vessel structure. Through this Decompression surgery more space is created in the Thoracic Outlet so that nerves and vessels are exposed and no longer pinched. If necessary, also Vascular reconstructions are performed, e.g. if an artery is damaged or narrowed by long 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). The surgeon can expose and remove the first rib through this. These open procedures are effective, but require relatively large incisions and cutting through muscle and tissue, which can lead to postoperative pain and scarring. In recent years, the minimally invasive thoracic surgery technique established: the video-assisted thoracoscopy (VATS). The structures are operated on endoscopically over the rib cage. In the VenaZiel DayKlinik Berlin we rely specifically on the uniportal VATS methodi.e. an intervention through only a small incision with camera assistance. We will present this procedure 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 a 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 operations:

• Protection of the tissue: By avoiding large incisions and spreading ribs, the surrounding muscles remain largely intact. No large muscles have to be cut through, as would be necessary with access via the jugular notch or armpit. This leads to Less postoperative pain and faster recovery. In addition, the risk of injuring or irritating nerves or vessels in the area of the thoracic wall is reduced.
• 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 visualization makes it possible to better visualize and protect fine structures such as nerves. Also hidden sections of the first rib, especially towards the back towards the spine, can be easily reached and removed with VATS. This minimizes the risk that Rib remnants remainwhich could cause problems again later.
• Smaller scar and cosmetic advantage: The only 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 remains, often hidden in the natural skin fold of the armpit. In comparison, scars above the collarbone or in the armpit are much more visible in open procedures. Many patients appreciate this aesthetic benefit.
• Faster recovery and shorter stay: Thanks to the minimally invasive procedure, patients usually recover faster. Studies have shown that patients after VATS first rib resection often within 2-3 days can leave the hospital – sometimes even earlier, depending on the individual course. In experienced facilities such as the VenaZiel DayKlinik Berlin, the procedure can be carefully planned and performed, so that outpatient surgery in suitable cases is possible. That is, patients come to the clinic on the day of the operation and can go home a few hours after the procedure – as soon as they are sufficiently awake and pain-free. (The prerequisite, of course, is that everything is medically stable and someone is present at home to provide support for the first night.)
• High success rates: The minimally invasive technique is in no way inferior to open surgery in terms of effectiveness. On the contrary, excellent results are achieved through better insight and complete removal of the compressing structures. The literature reports of high success rates of surgical TOS therapy: In vascular TOS, more than over 90% of cases, the symptoms are eliminated after the operation. In neurogenic TOS, which is often more difficult to objectify, clinical experience shows improvement rates of approx. 80% and more. The VATS technique helps to achieve these good results with less trauma through its precise approach. For example, 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 will explain how such a procedure typically works.

Procedure: Uniportal VATS decompression

Preparation: On the day of the operation, the patient is admitted to the clinic (in the DayKlinik usually on the morning of the day of the operation). After being greeted by the team and final clarification discussions (by the surgeon and anesthesia), preparation takes place in the operating room. The operation takes place under General anesthesia so that the rib cage can be immobilized and one-sided ventilation of the lungs can be enabled (the affected lung is temporarily deflated to facilitate access to the rib cage). 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 positioned in a lateral position – in the case of a right TOS, i.e. placed on the left side. The arm on the side to be operated on is gently positioned upwards or forwards to expose the lateral rib cage. The surgeon then makes a small Skin incision (approx. 3 cm), typically in the area of the middle 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 carefully spreading (without hard metal spreaders – usually a soft wound spreader is 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 collapses so that the upper chest area becomes visible. The surgeon identifies the first rib from the inside. The Pleura (pleura) over the rib is carefully opened and the surrounding tissues (muscle attachments, ligaments) are detached from the rib bone. The exact orientation is important here: The Nerves and vessels, which must be protected. The excellent view allows the plexus and the artery/vein to be precisely visualized and carefully held to the side with special instruments. Any thickened connective tissue strands or hypertrophic scalene muscles that constrict the plexus are cut through directly at this point to free the nerves.

Now the 1st rib is dissected free along its entire length. Often one starts at the front section (at the connection to the sternum or cartilage) and works one’s way back to the vertebral attachment. The rib is made with a special endoscopic bone forceps cut through in two places. First, it is separated from the sternal attachment, then further back near the spine. So the rib piece in between, which causes the bottleneck, completely removed be salvaged – often in several smaller pieces (bit by bit), as the entire rib is difficult to recover in one piece through the small incision. It is important also all remnants of bone and periosteum (bone skin) to remove to ensure that nothing grows back or 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 carried out. The surgeon checks whether all potentially constricting structures have been removed and whether there is any bleeding. In most cases, a Thin drainage hose (thoracic drain) is inserted through the same incision or separately through a second minimal skin stitch. This ensures that air and wound fluid are drained from the chest and the lungs can fully expand again. Then, the small access port is sutured with a few stitches (intradermal, i.e., under the skin, for a nice cosmetic result).

Wake-up phase: The anesthesia is stopped, and the patient is taken to the recovery room. There, the vital signs are monitored. Most patients experience this due to the preventive regional anesthesia Only minor pain immediately after the procedure. If it still hurts, pain medication is 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, no drainage is required, or it can be removed the next day at the latest, and home care is ensured, the patient may go home the same evening. Otherwise, a Short stationary monitoring (usually 1–2 days) is recommended, especially if, for example, the drainage is still left on minimal residual support 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 minimally invasive technology and a 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 secure. Shortly after the procedure – provided the pain conditions allow it – the patient is encouraged 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 Thoracic drainage is usually removed within the first 24 hours (often the next morning after the surgery) as soon as there is no significant air leak and only a small amount of wound fluid is draining. After removing the drainage, no special movement restrictions are required – most patients are allowed to fully perform all movements again after about 2 weeks.

As a rule, patients who have undergone surgery are given pain medication (tablets) home to make the healing process as pleasant as possible. The pain after a VATS is usually moderate and subsides significantly within one to two weeks. It is important that there is freedom from pain so that the Physiotherapy can be carried out effectively. Because, as after any decompression surgery, targeted aftercare with physiotherapy is part of the program. Often, breathing exercises and light arm movement exercises are 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 be eliminated. In addition, patients 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. Sport: Light activities such as walking are possible practically immediately. With more intensive training (gym, swimming, etc.), you should wait until the wound has healed and the doctor has given the green light (usually about 4 weeks).

Overall, patients benefit enormously from the outpatient, gentle procedure: They can recover at home in familiar surroundings, have less pain and are integrated back into everyday life more quickly. Of course, the team at VenaZiel VenaZiel DayClinic is always available for questions or problems that may arise – the aftercare is structured and patient-oriented. Another advantage of outpatient care is the lower risk of hospital infection and the relief of the patient through the feeling of actively participating in the recovery themselves.

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 the patients achieve a complete or at least significant relief of symptoms through physiotherapy & co. alone. In more severe cases, where conservative therapy does not work, the operation brings the desired relief in a large proportion: Around 80% of the operated nTOS patients report sustained freedom from symptoms or significant improvement. It is important to know that nerves need time to recover from a long compression. The tingling or numbness may not always disappear immediately after the surgery, but sometimes gradually recedes over weeks as the nerve regenerates. Early surgery, before irreversible nerve damage occurs, has better chances of success here.

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

Also the arterial TOS can be cured in most cases by removing the bony constriction (first rib/cervical rib) and any vascular repairs. Here, the operation is practically always indicated, as untreated there is a risk of serious vascular problems. After successful surgery, most patients report a significantly warmer, stronger perfused hand and the disappearance of pain.

Complications of the operation are rare overall. As with any procedure, secondary bleeding (in less than 2% of cases) or infections can occur, but these are very unlikely today thanks to modern techniques and prophylaxis. Nerve injuries from the surgery are also rare; the greatest risk exists 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 usually the result of incomplete decompression (e.g. remaining rib fragments). In experienced hands and with the thorough view via thoracoscopy, this risk is minimized. If scarring should cause discomfort again years later, another 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 to. Many report finally being able to move their arm freely again without pain or numbness, which means an enormous increase in the quality of life. Important is the subsequent self-responsibility: good posture, regular shoulder exercises and avoiding extreme overhead loads can help to ensure that the symptoms do not return.

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

For patients with thoracic outlet syndrome in Berlin and the surrounding area, the VenaZiel DayClinic an excellent point of contact. Our facility stands for High-performance outpatient medicine at clinic level. But what does that mean specifically for you?

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 procedures in the chest. We are familiar with the special challenges of TOS and perform the First rib resection via uniportal VATS routinely. As Pioneer of ambulantization of surgical services in Germany, Dr. Mahoozi places particular emphasis on using new techniques for the benefit of patients. This means for you: the highest professional competence paired with the most modern surgical methods.

Top-class outpatient surgery center: Our DayKlinik in Berlin-Mitte combines state-of-the-art medical equipment (Class 1B operating rooms) with digitally optimized processes. Procedures that used to be inevitably associated with 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 appointment scheduling and preliminary examinations to 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: The Thoracic Outlet Syndrome lies at the interface of 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 the thrombus is necessary before the surgery, we organize this seamlessly with our partners. The cooperation with neurologists and pain therapists is also part of our network in order to plan the optimal therapy for each patient.

Human and individual: Despite high-tech and digitization, people are at the center of our attention. We take time for your worries and questions – be it during the first conversation, the decision for or against an operation, or in the aftercare. Outpatient does not mean anonymous: On the contrary, personal support and friendly atmosphere are very important to us. Many patients appreciate that in our DayKlinik they do not get lost in the hustle and bustle of a large clinic, but find a quiet environment in which they trustworthy care be cared for.

Short recovery time – in familiar surroundings: The possibility of being allowed to go 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 – that promotes well-being. Of course, you will receive detailed instructions and a direct emergency number in case something should happen after discharge. In our Aftercare we combine digital elements (e.g. telemedicine: video follow-up checks, digital transmission of findings) with classic control appointments. This way you stay in close contact with us without unnecessary routes.

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 treatment at the cutting edge of science, which is also oriented towards your needs.

Summary: The treatment of thoracic outlet syndrome, in particular the demanding decompression surgery, belongs in experienced hands. In the VenaZiel VenaZiel DayClinic Berlin you will receive this expertise – minimally invasive and outpatient, in a facility that is characterized by quality, innovation and humanity. Benefit from VenaZiel less stress, faster recovery and comprehensive care on site. We would be happy to advise you personally on your clinical picture TOS and the possible therapy paths. Do not hesitate to contact us – we are here for you so that you can 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 results 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 to the cervical rib, 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).