Thoracoscopic Sympathectomy

CHAPTER 28 Thoracoscopic Sympathectomy



Mark J. Krasna



Introduction


Thoracoscopic sympathectomy has been used for the treatment of sympathetic dysfunction since it was first described by Kux and colleagues in the 1940s.1 With the advent of video-assisted thoracic surgery (VATS), the procedure has become more widely applied.2 VATS allows excellent visual acuity and the possibility of doing the procedure more quickly and with fewer complications. It is the most effective treatment for palmar hyperhidrosis.


Thoracic sympathectomy is indicated for a variety of sympathetic disorders, but it is most commonly performed for hyperhidrosis. Reflex sympathetic dystrophy, upper extremity ischemia, Raynaud’s disease, debilitating facial blushing, and splanchnicectomy for pancreatic pain are less common indications.


Patients undergoing thoracoscopic sympathectomy usually have tried nonoperative therapy, such as topical agents (e.g., Drysol [aluminum hydroxide]) or iontophoresis (if the patient can tolerate the side effects of tingling and electrical shocks). Unfortunately, the effects usually wear off, and patients often cannot tolerate the uncomfortable sensation. Antidepressants or other psychotropic medications have not provided significant benefit. Beta-blockers and cholinergics may provide short-term improvement, but most patients stop these medications because of the side effects, including fatigue, dry mouth, and bradycardia.



Nomenclature


Many terms have been used in different studies to describe the procedure that is performed. Unfortunately, the terminology used in international papers is inconsistent and often leads to confusion. The following glossary has been proposed and corresponds to the diagrams and intraoperative photographs found in the chapter.


♦ Ablation: procedures in which the chain is destroyed using electrocautery or laser without directed division.

♦ Clipping: placing one clip above the ganglion; placing one clip each above and below the ganglion; placing a clip across the nerve over the middle of the rib; or placing clips above or below the ganglion.3

♦ Sympathectomy: procedure in which the sympathetic chain is resected, ablated, or divided.

♦ Sympathicotomy: division of the sympathetic chain without removal of any section thereof. Unless otherwise specified, this excludes ablation techniques that are done without a directed division of the chain.

♦ R2 sympathectomy or sympathicotomy: division or resection of the chain overlying the second (R2 rib) and third rib (R3). This division accomplishes isolation of the R2 ganglion, which is found in between the two cuts (Figure 28-1). This nomenclature should be used for all subsequent levels; for example, R3 sympathectomy or sympathicotomy means division of the nerve chain over the third and fourth ribs, achieving R3 ganglion isolation.

♦ Thoracoscopic procedure: done with any means of thoracoscopy, including video-assisted and standard eyepiece-assisted procedures.

♦ Video-assisted thoracoscopic surgery (VATS): procedure using a video camera to help with visualization of the intrathoracic cavity.

image

Figure 28-1 The sympathetic chain is transected above and below the third ganglion to correct palmar hyperhidrosis.



Approach to Video-Assisted Thoracoscopic Sympathectomy



Choice of Transection Level


The transection level is based on the recommendations of the Society of Thoracic Surgeons Workforce on Hyperhidrosis. Choice of the appropriate level depends on the location of the primary symptoms:


♦ Facial sweating: The R2 level is isolated by dividing over the R2 and R3 ribs. Alternatively, some surgeons treat facial sweating or blushing with division of the chain over the R2 rib, taking care to avoid injuring the stellate ganglion, although the lower third of the stellate ganglion can be transected without causing Horner’s syndrome.

♦ Palmar sweating: Transect the chain at R3 and R4.

♦ Axillary sweating: Transect the chain at R4 and R5.

♦ Reflex sympathetic dystrophy or thoracic outlet syndrome: A R2 to R3 sympathectomy is performed.

♦ Chronic pancreatic pain: Sympathectomy and splanchnicectomy are performed from R4 to R10 levels.


Key Points



♦ Avoid damage to the underlying periosteum, because it can cause severe discomfort and sunburn-like pain in the postoperative period.

Related posts:

  1. Sleeve Lobectomy: Right Upper Lobe
  2. Right Upper Lobe Anterior Segmentectomy—Video 19
  3. Left Upper Lobe Apical Trisegmentectomy—Video 16-1
  4. Pneumonectomy—Video 7

Stay updated, free articles. Join our Telegram channel
Tags:
Jun 4, 2016 | Posted by in CARDIAC SURGERY | Comments Off on Thoracoscopic Sympathectomy

Full access? Get Clinical Tree
Get Clinical Tree app for offline access