Interruption of the thoracic sympathetic chain is associated

Transcription

1 Thoracoscopic Sympathicotomy King F. Kwong and Mark J. Krasna Interruption of the thoracic sympathetic chain is associated with alleviation of symptoms for a variety of maladies. Until fairly recently, with the advent and widespread adoption of minimally invasive thoracic surgical techniques, surgery on the thoracic sympathetic chain was previously relegated to those few patients with only the most severe symptoms. Nowadays, the most common indication for surgery on the thoracic sympathetic chain is hyperhidrosis, a not uncommon malady characterized by localized palmar and/or axillary sweating which can occur without relationship to physical or emotional stress and often refractory to known medical treatments. For these patients, large experiential series from Scandinavia and Asia have demonstrated significant relief of hyperhidrosis symptoms initially using the thoracoscopic sympathectomy procedure 1-3 and then subsequently showing equivalent clinical results using the thoracoscopic sympathicotomy procedure. 4-6 Operative Techniques in Thoracic and Cardiovascular Surgery, Vol 9, No 2 (Summer), 2004: pp

2 178 KWONG AND KRASNA SURGICAL TECHNIQUE 1 After induction of general anesthesia, the operation is performed using single-lung ventilation technique. A double-lumen endotracheal tube is placed by the anesthesiologist. Proper positioning of this tube is important for optimum operative visualization, and therefore, it is verified both clinically and with fiber-optic bronchoscopy before commencement of the surgical procedure. On rare occasion, the patient s airway anatomy may permit only single lumen endotracheal tube intubation and the surgery must be performed utilizing intermittent ventilation or the addition of intrathoracic carbon dioxide gas insufflation via the thoracoscopy port. The patient is then positioned with arms out-stretched and placed into semi-fowlers on the operating table. Both axillary regions are prepped and draped for sequential bilateral thoracoscopic procedures in the same anesthetic setting. A small transverse skin incision is placed in the lower axillary region lateral to the border of the pectoralis muscle. A subcutaneous tract is dissected bluntly behind the pectoralis muscles and the chest is entered via controlled blunt dissection.

3 2 A single thoracoscopic port is placed and general thoracoscopy is performed. With single lung-ventilation technique and semi-fowlers positioning, the collapsed lung often falls away from the intended operative field. If better visualization is needed, then carbon dioxide gas can be insufflated via the side-arm access of the thoracoscopy port. An operating thoracoscope with zero-degree lens is routinely used by our group for this procedure. An advantage of this approach is the use of a single incision per side, which results in excellent intraoperative visualization (larger lens scope), rapid recovery postoperatively (single port site), and very good incisional cosmesis (small incision at often inconspicuous site). The thoracic sympathetic chain is often visible through the overlying chest-wall pleura posteriorly. Proper rib identification and enumeration is important to determine the desired levels of the sympathetic chain. Care is taken to avoid unnecessary dissection in the region of the stellate ganglion. Although this is reasonably accomplished for surgeries in treating hyperhidrosis, this is more challenging in sympathicotomy for facial blushing. Therefore, the risk of postoperative Horner s is understandably greater in surgeries of this latter patient group.

4 180 KWONG AND KRASNA 3 After identifying the desired sympathicotomy level, the chest wall pleura is divided overlying the rib bed to expose and divide accessory sympathetic nerve fibers. Accessory nerve fibers were first described by Dr. Albert Kuntz, a noted pathologist of his time from St. Louis. 7 Because the sympathetic chain may develop asymmetrically, the presence of Kuntz fibers can be unilateral or bilateral.

5 THORACOSCOPIC SYMPATHICOTOMY The chest-wall pleura overlying the sympathetic chain are divided and the chain is dissected circumferentially free from its surrounding tissues. The chain is then divided using intermittent hook-electrocautery and the ends of the chain are briefly cauterized and distracted sufficiently apart.

6 182 KWONG AND KRASNA 5 Repeat the same operative maneuvers for each desired sympathicotomy level. Take care to avoid the nearby often large venous tributaries. After completion of the intended sympathicotomies, hemostasis is visually confirmed and the lung is re-expanded by the anesthesiologist. We routinely use a pediatric chest tube, which is then removed before complete closure of the surgical incision. Long-acting local anesthetic is often used peri-incisionally to minimize immediate postoperative pain. After bilateral thoracoscopic sympathicotomy surgeries, the patient is recovered in the post-anesthetic care unit and then discharged home with outpatient follow-up.

7 THORACOSCOPIC SYMPATHICOTOMY 183 SUMMARY At our institution, patients (105 women, 97 men) underwent thoracoscopic sympathicotomy surgery from March 1992 to April In this time period, 397 procedures were performed. Mean patient age was 29 (range 9-65). Indications for surgery included hyperhidrosis in 175 patients; facial blushing in 21 patients; Raynaud s in 3 patients; digital ischemia in 2 patients; and reflex sympathetic dystrophy in 1 patient. Synchronous bilateral sympathicotomies were performed in 194 patients; right side alone in 6 patients; left side alone in 1 patient; and one patient had staged bilateral sympathicotomies. A single incision per side with isolated lung ventilation strategy was used. There was no mortality. Compensatory sweating, a common, and unavoidable, side effect of thoracic sympathetic chain interruption occurred in 40% of patients. Complications included asymptomatic pleural effusion in 1 patient; pneumothorax in 1 patient; and re-operation for chylothorax that was identified early in 1 patient. Two patients treated for facial blushing developed Horner s syndrome postoperatively (an overall rate of 0.5%). Three patients developed hyperesthesias at the incision site. Preoperative symptoms resolved completely or significantly improved in greater than 90% of patients as measured by a quality-of-life index. Over 98% patients were discharged home on the day of surgery. Thoracoscopic sympathicotomy is an operation with excellent results and low morbidity in experienced centers. We believe that careful patient selection and frank preoperative discussion with prospective patients is paramount in determining overall patient satisfaction. At our center, we offer surgery to patients only after prescreening by an experienced registered nurse and a consultation with one of the surgical attending physicians. Our experience of 40% incidence of postoperative compensatory sweating is consistent with those found in other Western studies. Interestingly, Asian studies have often reported compensatory sweating rates as high as 90%. Fortunately, for those who experience postoperative compensatory sweating, the overwhelming majority has mild symptoms and rarely requires additional treatment. Another reassuring note is the low overall incidence of postoperative Horner s syndrome, even including facial blushing patients. We believe that accurate identification of intrathoracic anatomy by experienced thoracic surgeons is the main determinant keeping this statistic low. REFERENCES 1. Chou SH, Lee SH, Kao EL: Thoracic endoscopic T2 T3 sympathectomy in palmar hyperhidrosis: Experience of 112 cases. Jpn J Surg 23: , Hsu CP, Chen CY, Lin CT, et al: Video-assisted thoracoscopic T2 sympathectomy for hyperhidrosis palmaris. J Am Coll Surg 179:59-64, Dott C, Gothberg G, Claes G: Endoscopic transthoracic sympathectomy: An efficient and safe method for the treatment of hyperhidrosis. J Am Acad Dermatol 33:78-81, Kim BY, Oh BS, Park YK, et al: Microinvasive video-assisted thoracoscopic sympathicotomy for primary palmar hyperhidrosis. Am J Surg 181: , Rex LO, Drott C, Claes G, et al: The Boras experience of endoscopic thoracic sympathicotomy for palmar, axillary, facial hyperhidrosis, and facial blushing. Eur J Surg Suppl 580:23-26, Neumayer C, Bischof G, Fugger R, et al: Efficacy and safety of thoracoscopic sympathicotomy for hyperhidrosis of the upper limb Results of 734 sympathicotomies. Ann Chir Gynaecol 90: , Kuntz A: Distribution of the sympathetic rami to the brachial plexus: Its relation to sympathectomy affecting the upper extremity. Arch Surg 15: , Kwong KF, Cooper LB, Bennett LA, et al: 397 Consecutive Thoracoscopic Sympathectomies: University of Maryland Experience Presented at the 50th Anniversary Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, November 13-15, 2003 From the Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA. Address reprint requests to Mark J. Krasna, MD, Professor and Chief, Division of Thoracic Surgery, University of Maryland School of Medicine, 22 S. Greene Street, Room N4E35, Baltimore, MD 21201; mkrasna@smail. umaryland.edu Elsevier Inc. All rights reserved /04/ $30.00/0 doi: /j.optechstcvs