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84 Video-assisted thoracic surgery

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Thoracoscopic sympathectomy

Thoracoscopic sympathectomy has been the treatment of choice for palmar hyperhidrosis, and also for facial and axillary hyperhidrosis. Other indications are Raynaud’s disease and reﬂex causalgia. Unlike the classical open operation, in which section of stellate ganglion or brachial plexus was a common complication, the thoracoscopic approach allows a very simple operation without major risks.

Thoracic sympathectomy has become one of the straightforward procedures to be approached through VATS.

An adequate sympathetic denervation of the upper limb can be achieved through an operation with an upper level at the T2 ganglia. Operations as simple as a section of the sympathetic trunk over the second rib had been widely employed with good results achieving a dry hand, but with an important side-effect, with a high incidence of severe compensatory sweating that could adversely affect quality of life of patients.

This uncomfortable result led to several technical modiﬁcations of the operation in order to decrease compensatory sweating (also called reﬂex hyperhidrosis). Soon it become clear for most surgeons that a sympathectomy or sympathicotomy performed at T2 level can be associated with severe

compensatory sweating and should be avoided when possible.

Therefore, our technique aims to spare the T2 ganglion in all cases of palmar and axillary hyperhidrosis. At the same time, it is very important to remember that sympathetic innervation to the axilla is provided not only by ﬁbers that reach the axilla through brachial plexus, but also those sympathetic ﬁbers that reach the axillary region from intercostal nerves, though rami communicantes. In our current technique we perform a true sympathectomy (with resection) using an ultrasonic scalpel. We adopt a T3-T4 resection for palmar hyperhidrosis and a T3-T5 sympathectomy for axillary hyperhidrosis.

Under special conditions where a T2 section is mandatory (craniofacial hyperhidrosis or facial blushing) the procedure can be performed through a section of the sympathetic chain over the second rib (sympathicotomy). Alternatively, this procedure can be performed with clipping of the sympathetic chain over the second rib.

Most of the operation is performed with a double-lumen tube and one-lung ventilation, although in some cases a tracheal tube and apnea during the sympathectomy can be used.

Some surgeons may prefer to routinely use a single lumen tracheal tube, under CO2insufﬂation through a Veress needle.

Patients are placed in a semisitting position with

of patient on the operative table is important to avoid any chance of brachial plexus injury.

camera. The 4- or 5-mm telescope is usually placed in the third or fourth intercostal space in the line of the anterior iliac spine. The second port is placed in the midaxillary line, generally one intercostal space above.

both arms abducted about 60°. Adequate positioning

Two 5-mm access ports are used, one for the telescope and

Around

After the anesthesiologist deﬂates the right lung, the

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are identiﬁed. The ﬁrst rib runs in a completely different plane and the second rib is usually easily identiﬁed.

surgical manipulation is essential. One must identify correctly the sympathetic trunk, ganglia and ribs. A very important point to remember is that anatomical variations are very common, and a mistake may result in an asymmetric result or failure of the procedure.

sympathetic chain is identiﬁed, and ribs and ganglia

A careful identiﬁcation of all anatomic points before any

Operation 85

Second rib

Second ganglion

Third rib

Third ganglion

Fourth rib

Fourth ganglion

When all the ganglia to be resected are identiﬁed, we

and laterally.

begin slowly cutting each side of the chain, medially

Incision marks

Ultrasonic scalpel

We begin the procedure performing small incisions

each ganglion.

at each side of the sympathetic chain, usually next to

Incision (lateral)

Incision (medial)

Ultrasonic hook-probe

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The hook probe of the ultrasonic scalpel is useful to

If necessary, a nerve hook can be placed along the sympathetic chain, to be sure that no loose attachments are present. The cranial and caudal ends of nerves to be resected are sectioned. Usually, the lateral side of the rami communicantes are easily identiﬁed and sectioned.

retract and dissect the sympathetic chain at each side.

Dissection bed

Nerve resected

Sympathetic trunk (sectioned)

Proposed course of section

The left side operation is essentially the same, but

landmarks and identify subclavian artery, esophagus, descending aorta and the phrenic nerve. Any imprecise maneuver may lead to disaster. On the left side the exposure of the caudal end of the sympathetic trunk is usually more easily achieved. If necessary for downward retraction of the lung or laterally descending aorta, a third 3 to 5 mm port may be necessary and endo-peanuts may be used to apply gentle retraction.

catheter placed through one of the ports. Lung expansion is achieved with gentle positive pressure delivered by the anesthesiologist and aspiration of the catheter in the operative ﬁeld; ﬁnal check is made by placing the end of this catheter in a water seal system over the operating table. Once bubbling disappears, the catheter is withdrawn, and the skin is closed with a subcuticular suture or surgical skin glue. The same procedure is performed on the left side. A radiograph is taken in the recovery room, and the patient usually can leave the hospital after 12–24 hours.

again it is very important to identify the anatomic

Air is evacuated from the thoracic cavity through a 14F

The portion of the sympathetic nerve specimen is

stasis is performed in dissected bed.

grasped with a dissector and resected. Careful hemo-

Phrenic nerve

Subclavian artery

Esophagus

Second gangli Third rib

Third ganglia Fourth rib

Fourth ganglia

Fifth rib

Vagus nerve

Aorta

Pericardium

FURTHER READING

Daniel TM. A proposed diagnostic approach to the patient with the

subcentimeter pulmonary nodule: techniques that facilitate videoassisted thoracic surgery excision. Seminars In Thoracacic and Cardiovascular Surgery 2005; 17(2): 115–22.

de Hoyos A, Litle VR, Luketich JD. Minimally invasive esophagectomy.

Surgical Clinics of North America 2005; 85(3): 631–47.

Leao LEV, Almeida R, Oliveira R, Cameron AEP, Franco M.

Sympathectomy (resectional) sparing T2 with ultrasonic scalpel – an excellent operative technique for ETS. Clinical Autonomic Research 2005; 15(2): 136.

Manlulu A, Lee TW, Wan I, Law CY, Chang C, Garzon JC, Yim A. Video-

assisted thoracic surgery thymectomy for nonthymomatous myasthenia gravis. Chest 2005; 128(5): 3454–60.

McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery

lobectomy: experience with 1,100 cases. Annals of Thoracic Surgery 2006; 81(2): 421–5; discussion 425–6.

Reisfeld R. Video-assisted thoracic surgery sympathectomy for

hyperhidrosis. Archives of Surgery 2004; 139(6): 586–9; discussion

589.

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Video-assisted thorascopic sympathectomy

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M. BLAIR MARSHALL, MD

Chief, Division of Thoracic Surgery, Georgetown University Medical Center, Washington DC, USA

HISTORY

Dorsal sympathectomies have been performed since the ﬁrst part of the twentieth century. Initially, they were used to treat a variety of ailments unrelated to the sympathetic nervous system. Before the invention of endotracheal intubation, upper thoracic sympathectomies were performed via a posterior or supraclavicular approach. Once the ability to operate safely within the thoracic cavity was established, the intrathoracic approach was widely adopted. Over the past few decades, the thorascopic approach has been most widely utilized. The majority of these procedures are performed for primary hyperhidrosis with a smaller fraction of patients having a thorascopic sympathectomy for upper extremity ischemia. Currently, we use a bilateral video-assisted technique with a 2 mm 0 degree rigid thoracoscope. This procedure is performed as an outpatient.

PRINCIPLES AND JUSTIFICATION

No long-term effective therapies exist for the treatment of hyperhidrosis other than sympathectomy. Although not life threatening, this problem can be psychologically traumatic and socially disabling. Topical creams and lotions do not work well, and the side effects are usually intolerable for most. Iontophoresis, electrical water baths, can be effective;

however they require frequent use to maintain their effect. Patients may be placed on beta-blockers or antidepressants by some physicians, but these therapies are generally ineffective. The only oral preparation we have found to be effective is Robinul (glycopyrrolate), a synthetic anticholinergic. Recently, botulinum toxin has demonstrated to be an effective alternative therapy. However, the effects are temporary, and the treatments are expensive. Also, for those with palmar symptoms, the injections are painful and not always effective. Occasionally, one can see decreased strength of the intrinsic muscles of the hand with this treatment.

Besides palmar and axillary hyperhidrosis, thoracic sympathectomies are performed to treat severe facial blushing and ischemic distal upper extremities due to small vessel disease of varying etiology.

PREOPERATIVE ASSESSMENT AND PREPARATION

Because the majority of patients presenting for a sympathectomy are young and healthy, we do not routinely perform any preoperative testing other than a complete history and physical. If there is any history of endocrine disorders, these should be completely evaluated before performing surgery. For those patients with co-morbidities, one should follow the standard preoperative guidelines for general endotracheal anesthesia.

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ANESTHESIA

Our current technique uses a 2 mm thoracoscope and

two Veress needle ports. The procedure is performed under general anesthesia with a single-lumen endotracheal tube. The patient is positioned supine with the arms extended to 90 degrees at the shoulder and the elbows ﬂexed. Pay special attention to positioning of the arms to avoid an inadvertent brachial plexus injury.

OPERATION

The table is rotated away from the operative side. Two

intercostal spaces along the anterior axillary line are marked for the placement of trocars. The superior one is located in the inferior margin of the axillary hair line, in approximately the second or third intercostal space just posterior to the border of the pectoralis.

After draping, the table is ﬂexed to bring the patient’s

head up approximately 45 degrees. This maneuver allows gravity to assist in visualizing the apex of the chest. Bilateral temperature probes are placed on the distal upper extremities, and baseline temperatures are recorded for each hand.

The second trocar is placed in the ﬁfth intercostal space

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in the midaxillary line. The ﬁrst trocar is placed through the inferior site while ventilation is being held. Carbon dioxide insufﬂation is used to compress the lung. One must insure that the pressure gauge on the CO2is set below 10 mmHg to avoid hemodynamic compromise.

Operation 91

Once the apex of the lung is sufﬁciently away

5a–c

placed under direct vision. The sympathetic chain is identiﬁed, and the ribs are counted by initially identifying the ﬁrst rib, the majority of which is mostly hidden. Cautery is used to divide the pleura and then the sympathetic chain overlying the rib head. For facial and palmar symptoms, we divide the chain at the level of T2. We continue this incision out laterally for 3 cm to include the Kuntz ﬁbers. For axillary symptoms, we divide the chain at both T3 and T4. Once an increase in temperature has been observed, the CO2is evacuated, and the lung is allowed to re-expand. The identical procedure is performed on the opposite side. No skin sutures are needed, and dressings are placed.

from the apical chest wall, the second trocar is

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POSTOPERATIVE CARE

In recovery, a chest X-ray is performed. It is not uncommon to have one or even bilateral small apical pneumothoraces from residual CO2left in the pleural space. We usually place the patients on nasal cannula oxygen to expedite reabsorption while they are in the postoperative recovery area. If any question of a parenchymal injury exists, we repeat a chest X-ray 2 hours following the initial one. For those with an increasing pneumothorax, a small pleural catheter is placed. The leak usually seals in less than 24hours. The majority of patients are discharged home on the same day.

OUTCOME

For those patients undergoing sympathectomy for hyperhidrosis, the results are immediate. Most patients are very satisﬁed with the result. The reported success of the procedure ranges from 85-98% for palmar hyperhidrosis and is approximately 70% for axillary hyperhidrosis. Although the sympathetic innervation of the feet should not be affected with this approach, 50% of patients will report improvement in pedal symptoms. In those patients who fail or develop a recurrence, we have performed repeat sympathectomies with this approach. In this circumstance, we usually cut the pleura and

underlying tissue out along the rib head to potentially divide any aberrant nerves.

The majority of morbidity with this procedure is compensatory hyperhidrosis. This problem occurs in approximately 30–80% of patients. For most, the issue of compensatory sweating is insigniﬁcant; however, in a small fraction of patients, the compensatory sweating is worse than their presenting complaints. Reversal of a sympathectomy has been reported but is not commonly performed.

Additional complications include gustatory sweating in approximately 35% of patients. Other complications include Horner’s syndrome, parenchymal injury, bleeding, and prolonged pain. These problems are rare (1%).