Indications

There are several indications for the treatment of HH (palmar or axillary): craniofacial sweating, facial blushing, and social phobia. Other indications for sympathectomy include Raynaud disease, reflex sympathetic dystrophy (RSD), causalgia, long QT syndrome, and untreatable angina pectoris.

Nonsurgical Treatment

It is generally thought that patients undergoing thoracoscopic sympathectomy should have previously attempted a trial of nonoperative therapy. Patients with HH are generally offered topical agents such as Drysol (aluminum hydroxide). Occasionally a trial of iontophoresis is appropriate if the patient can tolerate the side effects of tingling and electrical shocks. Oral agents have been used with some success in patients with HH, including a trial of antidepressants or other psychotropic medications, which may allow the patient to “deal with” the psychological trauma caused by the socially debilitating symptoms of HH. Other medications, like β-blockers and cholinergics, do have a significant chance of resulting in some improvement in HH with, however, side effects such as fatigue, bradycardia, and dry mouth.

Surgical Techniques

Conventional approaches include the posterior approach and the supraclavicular approach, which is less painful than the posterior but is more prone to damaging important nerves and blood vessels. In recent years, minimally invasive surgical techniques have been developed that have made endoscopic thoracic sympathectomy (ETS) possible and popular.

Step 1

Surgical Anatomy

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  Each sympathetic trunk consists of a long chain of nerve ganglia lying along either side of the spine and is broadly divided into three segments: cervical, thoracic, and lumbar. The autonomic nervous system controls involuntary body functions, such as breathing, sweating, and blood pressure. The most common area targeted in sympathectomy is the upper thoracic region, the part of the sympathetic chain lying between the first and fifth thoracic vertebrae ( Fig. 23-1 ).

  
  

  
  

  
  

  

  
  
  
  
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  The upper sympathetic thoracic ganglion (T1) is the ganglion most responsible for sweating and heat loss of the face, hands, and to a minor degree the axillae T1, in conjunction with the eighth cervical ganglion form the stellate ganglion, which is responsible for the eyelid and pupillary response. They should be preserved because an injury may cause Horner syndrome.

  
  
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  The second thoracic ganglion (T2) controls the sweat response of the hands and face (except the interorbital portion), scalp, shoulders, and the anterior and posterior parts of the thorax above the breasts and contributes to facial blushing.

  
  
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  The third ganglion (T3) affects the sweating of the hands, axillae, shoulders, and anterior and posterior parts of thorax above the breast and of the face to a minor degree.

  
  
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  The fourth ganglion (T4) innervates the hands and the axillae. It should be noted that there is duplicate sympathetic innervation for the hands, face, and axillae.

  
  
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  ETS cuts or destroys the sympathetic ganglia, the collections of nerve cell bodies in clusters along the thoracic or lumbar spinal cord.

Step 2

Preoperative Considerations

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  Dermatologists, neurologists, endocrinologists, and cardiologists involved in diagnosing or treating HH should be consulted to evaluate the patient before referral to surgical treatment.

  
  
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  Contraindications before surgery are rare but include severe cardiovascular insufficiency or pulmonary insufficiency; severe pleural diseases (tracheobronchitis, pleuritis, empyema); and uncontrolled diabetes. Prior thoracic surgery, although perhaps difficult, is not an absolute contraindication.