Endoscopic Thoracic Sympathectomy

Indications

•

Indications for thoracoscopic sympathectomy include palmar hyperhidrosis, axillary hyperhidrosis, craniofacial hyperhidrosis and blushing, reflex sympathetic dystrophy, Raynaud disease, splanchnic pain, vascular insufficiency, angina pectoris, and heart arrhythmias such as long QT syndrome. Currently, the most common indication, and the indication for which the results are most satisfactory, is palmar hyperhidrosis.
•

Patients undergoing thoracic sympathectomy should have previously completed and failed a trial of nonoperative therapy. Nonoperative options include topical therapy (primarily aluminum chloride hexahydrate [AlCl ₃-6H ₂O]) and iontophoresis, intradermal botulinum toxin injections, or glycopyrrolate.

•

Severe cardiocirculatory or pulmonary insufficiency and severe pleural disease (pleuritis, empyema) greatly increase the risks of thoracic endoscopic sympathectomy and are contraindications.
•

Untreated hyperthyroidism, menopause, and obesity all may cause secondary hyperhidrosis. These conditions should be ruled out as etiologies for the patient’s excess sweating before proceeding to surgical intervention.

•

The anesthesiologist should be aware that double-lumen endotracheal tube placement is needed for single-lung ventilation of the contralateral lung and deflation of the ipsilateral lung. Frequent, noninvasive arterial pressure monitoring should be considered during periods of lung deflation. Invasive monitoring may be useful in patients with impaired cardiovascular function.

Figure 91-1:

The patient is placed in the lateral decubitus position.
•

An axillary roll rests under the contralateral side, and the ipsilateral arm rests abducted at a gentle angle on an elevated arm rest.
•

Surgical preparation and exposure includes the entire thorax in the event that conversion to an open thoracotomy is necessary.
•

The operating surgeon stands ventral to the patient, with the anesthesiologist at the head and the scrub nurse at the base of the field. Monitors for the endoscope should be placed opposite the operating surgeon and, if present, the assisting surgeon.
•

The right side is usually operated on first because the proximity of the sympathetic chain to the hemiazygos vein can make the operation difficult, particularly if an extensive sympathectomy down to T4 is planned.