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.

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

Approach to Video-Assisted Thoracoscopic Sympathectomy