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Video-assisted thoracoscopic surgery (VATS) sympathectomy
HISTORY
Dorsal sympathectomies have been performed since the beginning of the twentieth century, with the earliest reported by Alexander in 1889. 1 Initially, they were used to treat a variety of ailments unrelated to the sympathetic nervous system, such as epilepsy, angina pectoris, and glaucoma. Before the invention of endotracheal intubation, upper thoracic sympathectomies were performed via a posterior or supraclavicular approach. The initial video-assisted thoracoscopic surgery (VATS) sympathectomy, performed in 1978, demonstrated a less invasive and effective method to operate safely within the thoracic cavity. 2 Since then, the thoracoscopic approach has been the most widely used and accepted standard approach for sympathectomy. 3 The majority of these procedures are performed for primary palmar hyperhidrosis, with a smaller fraction of patients having a VATS sympathectomy for upper extremity ischemia. Currently, we use a bilateral video-assisted technique, with a 2 mm, 0-degree rigid thoracoscope, which allows it to be performed as an outpatient procedure.
PRINCIPLES AND JUSTIFICATION
Hyperhidrosis is a condition characterized by excess secretion from eccrine sweat glands that are stimulated by acetylcholine released from postganglionic neurons. Although not life threatening, hyperhidrosis can be psychologically traumatic and socially disabling for the individual. Topical creams and lotions are usually ineffective and are accompanied by side effects that are intolerable for most. Iontophoresis—electrical water bath—can be effective; however, it requires frequent use to maintain its efficacy, with infrequent, though trouble-some, side effects of paresthesias, scaling, and fissure of the skin. Patients may be placed on beta-blockers or antidepressants by some physicians, but these therapies are generally ineffective. The only oral preparation found to be effective is Robinul (glycopyrrolate), a synthetic anticholinergic, but this also causes blurred vision, dry mouth, and urinary retention as side effects. We routinely give oral sympatholytic agents to all hyperhidrosis patients. Approximately 65% of patients are well controlled on this regimen, and we reserve sympathectomy for those who fail. While botulinum toxin has been demonstrated to be an effective alternative therapy, the effects are temporary, with a median duration of 3-6 months, and thus repetitive treatments are required, which can be expensive.
In addition to their use for palmar and axillary hyperhidrosis, thoracic sympathectomies may be performed to treat severe facial blushing and ischemic distal upper extremities due to small vessel disease of varying etiology.
TERMINOLOGY AND NOMENCLATURE
Historically, sympathectomy was performed without a uniform standard nomenclature to describe the various techniques used, the anatomic levels of blockade, and descriptions of symptoms, making comparison of outcome data between various institutions difficult. There was no consensus on the optimal level of sympathectomy for blockade of craniofacial, axillary, or palmar hyperhidrosis. As a result, the Society of Thoracic Surgeons released its “Expert consensus for the surgical treatment of hyperhidrosis” in 2011. 4 A new inter-national nomenclature was recommended for describing the level of sympathectomy by referring to the rib level (R) rather than the vertebral level. In addition, the nomenclature includes terms for describing the techniques used in the procedure; specifically, “cauterized,” “clipped,” “cut,” and “removal” of a segment of the sympathetic chain.
PREOPERATIVE ASSESSMENT ANDPREPARATION
As the majority of patients presenting for a sympathetomy are young and healthy, we do not routinely perform any pre-operative testing other than a complete history and physical examination. Any history of endocrine disorders should be completely evaluated prior to performing the operation. For those patients with comorbidities, the standard preoperative guidelines for general endotracheal anesthesia should be observed. Patients should be counseled preoperatively about the risks of sympathectomy, which include, but are not limited to, compensatory sweating, bradycardia, gustatory sweating, and Horner’s syndrome. While Horner’s syndrome or bradycardia are rarely seen (0.7%-3.0% incidence), compensatory sweating is common, with an incidence range of 30%-98%, and patients should be made well aware of this possibility prior to agreeing to the procedure. In our experience, the majority of patients experience some degree of compensatory sweating; it is the rare patient who does not. The lower incidence noted in the range described was probably reported in series where the authors either didn’t look for compensatory sweating or simply ignored it. We tell all patients to expect compensatory sweating. The mechanism for sweating will be interrupted for the dermatome affected by the level of the sympathectomy. Thus, for thermoregulation, other parts of the body must secrete more sweat to maintain body temperature during periods of exercise or warm weather. It is important to set patients’ expectations in advance, as this affects their satisfaction with the procedure overall.
ANESTHESIA
- Our current technique uses a 2 mm thoracoscope, a Veress needle, and a 5 mm port. The procedure is performed under general anesthesia with a single-lumen endotracheal tube. The patient is positioned supine, with arms abducted to 90 degrees at the shoulder and the elbows flexed. One needs to pay special attention to positioning of the arms to avoid an inadvertent brachial plexus injury. (See Figure 23.1).
- After draping, the table is flexed to bring the torso up to approximately 45 degrees. This maneuver allows gravity to assist in dropping the lungs away from the apex to allow for optimal visualization. Bilateral upper extremity temperature probes are placed and baseline temperatures are recorded for each hand. However, we have found increased digital temperature less reliable when the nerve is clipped as opposed to being divided. (See Figure 23.2.)
23.1
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