Thoracic Thoracoscopic Sympathectomy

A. ANATOMY 1.Sympathetic fibers emanate from T1 to L2 or L3 and travel out on the ventral roots, then via white rami into the sympathetic chain. 2.The T2 and T3 roots contain most of the vasoconstrictor fiber to the upper extremity. 3.Axillary sympathetic innervation derives from T4 and T5.

Fig 43-1

A. ANATOMY 4. The sympathetic outflow to the ciliary muscle and pupillary constrictor of the eye is from T1. 5. The knowledge is important to prevent Horner’s syndrome, which is ipsilateral ptosis, miosis and facial anhidrosis.

A. ANATOMY 6. Kuntz’s nerve is the intrathoracic nerve, which arises from approximately T2 and bypasses the sympathetic chain to the lower brachial plexus. 7. En bloc T2-T3 gangionectomy with ablation of the Kuntz’s nerve can provide a nearly complete autonomic innervation of the upper extremity.

Fig 43-2

B. INDICATIONS 1.The main indications of thoracic thoracoscopic sympathectomy are primary hyperhidrosis of upper extremity and reflex sympathetic dystrophy. 2.Hyperhidrosis has a slightly female predominance and increased incidence in Asians and Sephadic Jews. 3.Treatment includes topical AlCl 3, iontophoresis, systemic or topic anticholinergic drugs, or biofeedback.

B. INDICATIONS 4. Excision of the axillary gland is also used. 5. Thoracic thoracoscopic sympathecomy has success rate of 90% for hyperhidrosis. 6. Sympathectomy is rarely indicated for Raynaud’s syndrome, Berger’s disease, long QT syndrome, refractory angina.

C. TECHNIQUE 1.A 30-degree thoracoscope was inserted the 5th intercostal space at midaxillary line. 2.Two 5-mm trocars are used via 3rd intercostal space one anteriorly and one posteriorly. 3.The 1st rib is often difficult to see and often covered by bright yellow fat at its costovertebral junction. 4.Dissection on the upper border of 2nd rib is avoided to preserve the stellate ganglion( T1- C8 ).

Fig43-3

C. TECHNIQUE 5. The rami of T2 and T3 are hemoclipped and divided. 6. The sympathetic chain was hemoclipped and divided proximally and distally. 7. The T2 and T3 are removed en bloc. 8. The bodies of 2nd and 3rd ribs are scored horizontally with cautery from the costovertebral angle laterally 3-4 cm. 9. A chest tube is not needed if hemostasis is adequate.

Fig43-4

D. COMPLICATIONS 1.Compensatory hyperhidrosis( in back and groin…) occurs in 60 to 70% of patients. Its etiology is unknown. 2.Gustatory sweating (facial sweating with salivary stimuli) is also reported. 3.Horner’s syndrome has incidence of 5 to 10 %. 4.Recurrence, intercostal neuralgia, pneumothorax and injury to subclavian vessels and esophagus are also reported.