Thoracoscopic Sympathectomy

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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.

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.

♦ Avoid the sympathetic chain above the level of the R2 ganglion to prevent Horner’s syndrome. Avoid cauterizing the cut proximal end of the R2 ganglion.

Video-Assisted Thoracoscopic Sympathectomy

Step 1. Setup for Sympathectomy

♦ Use general anesthesia with a single-lumen endotracheal tube and carbon dioxide insufflation to decompress the lung.

♦ Place the patient in a supine position with arms extended or in a semi-Fowler position.

♦ The arms are placed on armboards and rotated out (adducted) but left in a neutral position with padding under the ulnar nerve at the elbow to avoid postoperative neuralgia.

♦ Place a roll under the spine so the skin preparation can be done from the right posterior axillary line to the left posterior axillary line.

♦ Use a single 1-cm incision in the second intercostal space in the anterior axillary line, just posterior to the pectoralis muscle if the procedure is performed with a 0-degree, 10-mm thoracoscope, or use two 3-mm trocars in the second and fourth intercostal spaces in the anterior axillary line.

Step 2. Exposure of the Sympathetic Chain

♦ Stop the ventilation, and detach the ventilator from the endotracheal tube.

♦ Pass a Veress needle through the inferior incision. Carbon dioxide is insufflated at a rate of 2 L/min with a pressure limit of 10 mm Hg.⁴

♦ After 400 mL of carbon dioxide has been insufflated, insert the second trocar to confirm that the lung is deflating.

♦ When the lung has deflated sufficiently for exposure of the desired level of the sympathetic chain, resume ventilation.

Step 3. Sympathectomy

♦ Exposure: The apex of the chest is exposed as the insufflation deflates the lung.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed apically.

♦ Pass the hook electrocautery probes (2, 3, or 5 mm) through the working thoracoscope or the superior trocar.

♦ Identify the sympathetic chain over the middle of the rib where the rib head articulates with the transverse processes. Incise the parietal pleura first, and separate the lateral edges of the chain.

♦ With electrocautery, cut the chain, and coagulate the divided ends of the chain.

♦ Complete division of the sympathetic chain, including the nerve of Kuntz (identified in about 20% of cases), must be achieved to avoid a recurrence.

♦ For the clip procedure, encircle the chain with an L-shaped hook electrocautery, and mobilize the chain for about 1 cm.

Step 4. Lung Reexpansion

♦ The thoracoscope is pointed apically.

♦ Insufflation is stopped.

♦ After ensuring proper hemostasis, place a small catheter (chest tube or 12- to 20-French red rubber catheter) in the chest through the trocar. Reinflate the lung, and allow exsufflation of air and carbon dioxide from the chest.

♦ Alternatively, open the trocars to allow egress of the air from the chest and to allow the lung to expand as the anesthesiologist reexpands the lung. Place the thoracoscope back in the trocar to ensure that the lung is fully expanded. A large breath is held as the trocars are removed.

♦ Close the incisions with a subcutaneous 3-0 absorbable and 4-0 subcuticular suture.

♦ If 2- or 3-mm trocars are used, Johnson & Johnson’s Dermabond (Ethicon, Cincinnati, OH) may be used to seal the skin without sutures.

♦ The same procedure is then performed on the opposite side.

Results

In a series of 396 consecutive procedures (synchronous bilateral in 388 patients, right side alone in 6, left side alone in 1, staged in 1) included 191 (48%) men and 206 (52%) women. The mean age was 29 years (range, 9 to 65 years). Median hospital stay was 0.5 day (range, 0.5 to 3 days). Median follow-up was 2.6 years (range, 2 months to 9 years). The indications were hyperhidrosis in 370 patients, facial blushing in 21, Raynaud’s in 3, digital ischemia in 2, and reflex sympathetic dystrophy in 1 patient. Compensatory sweating occurred in 40% (n = 81 of 202).⁵

A series of 453 patients showed excellent (74.2%) or good (19.6%) quality of life at 5 years of follow-up.⁶ In another series of 222 patients, excellent results were reported for more than 90% and compensatory sweating for 85% of patients.⁷ Results of these two studies suggested that division of the R2 ganglion should be avoided because compensatory sweating developed in 48% of patients when R2 was transected but in only 16% when R2 was not transected. When severe compensatory sweating developed, more than 50% of patients wished that they had not undergone the procedure.

Miller and Force ⁸ described a novel approach to thoracoscopic sympathectomy. They devised a method to screen patients who would be more likely to develop compensatory sweating. They injected the nerve at the planned operative level and reassessed patients after they emerged from anesthesia.⁸ If the patients benefitted from the injection and did not develop intolerable compensatory sweating, they subsequently underwent sympathectomy.

Tools have been devised to evaluate quality of life (QOL) in terms of objective response, satisfaction, and complications after thoracoscopic sympathectomy. In 1998, Krasna and colleagues proposed a 4-point scoring system of the severity and social impact after thoracoscopic sympathectomy.⁹ Kwong described a QOL index,¹⁰ and Ribas and associates used a standard short-form health survey (SF-36).¹¹ Each of these systems attempts to quantitate the positive and negative results of this procedure for making decisions and assessing costs.