Anterior Thoracoscopic Sympathectomy

Curtis A. Dickman and Hasan A. Zaidi

Abstract

Anterior thoracoscopic sympathectomy is used to treat patients with hyperhidrosis resulting from an idiopathic disorder of autonomic function. In elective cases, approaches that offer cosmesis are ideal in ablating the sympathetic plexus to relieve symptoms. The biportal endoscopic technique allows for improved visualization while minimizing approach-related morbidity. In this chapter, we describe our institutional experience in treating hyperhidrosis and suggest technical nuances.

Keywords: endoscopic, minimally invasive, plexus, sympathectomy, thoracoscopic, thorax

24.1 Biportal Microsurgical Thoracoscopy

24.1.1 Definition of Problem

In this chapter, we detail the technical aspects of a biportal microsurgical thoracoscopic technique for sympathectomy. The primary goal of sympathectomy is to remove or destroy the second sympathetic ganglion (T2). The sympathetic ganglia of T3 and T4 are also usually ablated.¹ Hyperhidrosis, or excessive perspiration, results from an idiopathic disorder of autonomic function. Its cause is unknown and its reported incidence ranges from 0.15 to 1%.²^,³^,⁴^,⁵^,⁶ The palms of the hands are primarily affected ( Fig. 24.1), but the axillae and the plantar surfaces of the feet can also be involved. It rarely affects the scalp and face (craniofacial hyperhidrosis). Hyperhidrosis can also be generalized, affecting the entire body. The symptoms usually appear in childhood or early adulthood.

Hyperhidrosis significantly reduces quality of life.⁵^,⁷^,⁸ Patients with hyperhidrosis are affected socially, professionally, and psychologically in every activity of daily living. When palmar, axillary, or craniofacial hyperhidrosis is intractable to medical treatment, patients may consider surgical treatment by upper thoracic sympathectomy. Sympathectomy targets only the hands, axillae, and facial regions, and it is not used to treat hyperhidrosis of the whole body.

24.1.2 Evolution of Technique

Prior to the 1990s, options for patients with hyperhidrosis included medical management, which was often ineffective in resolving symptoms, and open thoracotomy for sympathectomy, which was associated with significant morbidity. With the advent of the video-assisted thoracoscopy as a cardiothoracic subspecialty in the early 1990s, our group developed a minimally invasive approach to sympathectomy using modified thoracoscopic instruments.

24.1.3 Advantages and Disadvantages

Open procedures are more invasive than thoracoscopic sympathectomy and thus are associated with increased morbidity. Minimally invasive thoracoscopic procedures permit direct visualization of the sympathetic ganglia and are associated with shorter operative times, shorter hospitalizations, and faster patient recovery.⁹^,¹⁰^,¹¹^,¹²^,¹³ However, as with open thoracoscopy, minimally invasive procedures have inherent risks, such as pneumothorax, hemothorax, major vascular injury (e.g., to the aorta, inferior vena cava, and heart), cardiac arrhythmias, lung contusion, pneumonitis, transient atelectasis, compensatory hyperhidrosis, intercostal neuralgia, and Horner’s syndrome.

Fig. 24.1 The hands of a patient with severe palmar hyperhidrosis. The palmar surfaces of the hands are saturated with sweat, which drips from the fingers and palms. This profound problem interferes with almost all activities of daily living. The sweat-soaked hands saturate everything and are apparent to anyone they touch. The problem permeates all aspects of the lives of patients: social, interpersonal, romantic, recreational, and vocational.

Table 24.1 Surgical indications and success rates for thoracoscopic sympathectomy

Clinical disorder	Success rate, %
Essential hyperhidrosis
• Palmar	95–100
• Axillary	75–85
• Craniofacial	90–95
Excessive craniofacial blushing	85–95
Hand ischemia due to Raynaud’s disease	50–60 (temporary)
Upper extremity reflex sympathetic dystrophy	30–70

24.2 Indications and Contraindications

Thoracoscopic sympathectomy is useful for the treatment of various problems ( Table 24.1). It is extraordinarily successful (in 75–100% of cases) for focal essential hyperhidrosis (i.e., palmar, axillary, or craniofacial) and excessive craniofacial blushing. Sympathectomy can also be used to treat reflex sympathetic dystrophy and hand ischemia caused by Raynaud’s disease. However, it is associated with lower success rates in patients being treated for pain and limb ischemia.

Patients with upper-extremity reflex sympathetic dystrophy whose pain improves significantly with a stellate ganglion block have a 30 to 70% likelihood of further improvement in pain after a sympathectomy. Sympathectomy results in arterial vasodilation and thus can be a temporizing measure in patients with vascular ischemia due to Raynaud’s disease. However, because Raynaud’s disease is progressive, sympathectomy is not curative; it only delays progression to the need for amputation. Other than medical contraindications to surgery, absolute contraindications include known evidence of pleural adhesions and medically limiting cardiopulmonary disease, such as that evident on poor pulmonary function tests that would prevent intraoperative deflation of a lung.

24.2.1 Patient Selection

Patients who have intractable and severe palmar, axillary, or craniofacial hyperhidrosis are the best candidates for sympathectomy. Thyroid function studies and general blood chemistries should be obtained to rule out endocrinological or metabolic abnormalities responsible for the hyperhidrosis. Patients must be able to tolerate single-lung ventilation during the procedure, and patients with severe pulmonary disease, extensive pleural adhesions, or tracheal stenosis should be excluded from consideration.

Alternative nonsurgical treatments should be discussed with patients. These options include botulinum toxin type A injections in the hands, anticholinergic medications (e.g., Ditropan [oxybutynin chloride] and Robinul [glycopyrrolate]), topical antiperspirants (e.g., Drysol [topical aluminum chloride] and Certain Dri [aluminum chloride hexahydrate]), and iontophoresis (Drionic; General Medical Co., Pasadena, CA). These nonsurgical measures are temporizing, usually only partially effective, and often have adverse side effects. Therefore, the possibility of a permanent cure via endoscopic sympathectomy is likely to be appealing to many patients.

24.2.2 Patient Profiles

Patients who have undergone a previous thoracotomy and who have evidence of severe pleural adhesions may not be good candidates for this procedure, as the lung would not be able to be deflated to allow for adequate visualization. Patients with poor cardiac function and severe cardiovascular disease are also poor candidates for this elective procedure.

24.3 Preoperative Planning

24.3.1 Physical Examination

Hyperhidrosis can be disabling to patients, disrupting their work and their social, personal, and recreational activities. Physical findings of patients with severe symptoms include sweat dripping spontaneously from the affected region. Hyperhidrosis results in considerable occupational, social, and psychological impairment. Numerous patients report that they do not leave home because of the embarrassing and disabling nature of the disease. Although palmar hyperhidrosis is the most common presentation, some patients present with primary axillary hyperhidrosis. In addition to primary axillary hyperhidrosis as their primary complaint, many patients also report less severe hyperhidrosis in the plantar or craniofacial regions.

24.3.2 Radiographic Work-up and Preoperative Imaging

Anteroposterior chest radiographs should be obtained prior to surgical intervention. These are useful in evaluating the patient for any cardiopulmonary anomalies, such as atelectasis, pulmonary effusion, and pneumothorax.

24.4 Instrumentation

A double-lumen endotracheal tube is required to secure the airway and allow the anesthesiologist to deflate the ipsilateral lung during surgical manipulation. Visualization is performed using a 5-mm thoracoscope (Karl Storz Endoscopy-America, Inc., El Segundo, CA). The sympathectomy is performed using endoscopic monopolar cautery scissors (or an ultrasonic scalpel [Harmonic Scalpel, Ethicon Endo-Surgery, Cincinnati, OH]).

24.5 Surgical Approach and Technique

24.5.1 Patient Positioning

The patient is placed on the operating room table in the supine position. General anesthesia is administered, and the patient is intubated with a double-lumen endotracheal tube. Correct positioning of the endotracheal tube is confirmed with a bronchoscope by the anesthesiologist. Palmar cutaneous temperature monitors (Mallinckrodt, Juarez, Mexico) are applied bilaterally. An intraoperative increase of 1 °C or more indicates an adequate sympathectomy.

The sympathectomy procedures are performed bilaterally in one operation. The patient is placed in a lateral decubitus position, and a unilateral sympathectomy is performed. An axillary roll is placed under the axilla. The dependent arm is supported on an arm board, and the nondependent arm is placed in an airplane splint in an abducted position to expose the axilla and thorax. The patient’s right arm and thorax are prepared and draped using routine techniques ( Fig. 24.2a). Patients are taped securely to the operating table with wide cloth tape to permit intraoperative rotation.

The ipsilateral lung is deflated by the anesthesiologist using a double-lumen endotracheal tube. Rapid dense atelectasis is achieved when air is suctioned from the lumen of the endotracheal tube on the side without insufflation.

24.5.2 Incision

Two 5-mm incisions are made after the skin is injected with 0.5% bupivacaine hydrochloride with epinephrine ( Fig. 24.2b). The endoscope is inserted in the fifth intercostal space in the posterior axillary line. The working portal (for tools, cautery scissors, and chest tube) is placed in the middle or anterior axillary line in the third intercostal space. An entry puncture over the superior surface of the underlying rib is made in the thoracic cavity with a hemostat. Through the first incision, a 6-mm-diameter trocar and stylet are inserted for the 5-mm thoracoscope (Karl Storz Endoscopy-America, Inc.), which is inserted into the chest cavity. Under direct endoscopic visualization, the lung and contents of the mediastinum are inspected. Through the second portal site, a hemostat is placed through the inner pleura under direct visualization. The second 5-mm portal is placed into the chest under endoscopic visualization. The endoscopic monopolar cautery scissors (or an ultrasonic scalpel [Harmonic Scalpel, Ethicon Endo-Surgery]) are inserted through the second portal. The patient is rotated ventrally to allow gravity to retract the lung away from the surface of the spine.

Fig. 24.2 Patient positioning for a right-sided sympathectomy. (a) A lateral decubitus position is used. The dependent axilla is padded with an axillary roll. The other arm is abducted and placed in an airplane splint. Abduction of the arm provides unobstructed access to the chest wall for the surgery. (b) Two small (5-mm) incisions are used for the endoscopic sympathectomy. They are placed in the middle and posterior axillary lines over the third and fifth intercostal spaces.

24.5.3 Step-by-Step Surgical Technique

Under direct thoracoscopic visualization, the sympathetic chain is identified and ablated ( Fig. 24.3a, b and Fig. 24.4a–c). The first rib and stellate ganglia are usually obscured by an apical fat pad, but the first rib can be palpated. The brachiocephalic or subclavian vessels can be visualized adjacent to the first rib. The second rib is identified at its articulation with the spine. The extent of sympathectomy is dictated by the symptoms of the patient. For palmar or craniofacial hyperhidrosis, the sympathetic chain is transected over the second and third rib heads to isolate the second sympathetic ganglia. For axillary hyperhidrosis, the sympathetic chain is transected over the second, third, and fourth rib heads to isolate the second, third, and fourth ganglia. The sympathetic chain ganglia are tented laterally and transected with cauterization to create a gap of 10 mm or more between the ends of the sympathetic chain. Care is taken to preserve the surrounding vascular structures.