Procedure

Endoscopic VATS sympathectomy: the uniportal technique

The Price-Thomas Thoracic Unit, Directorate of Cardiothoracic Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield S5 7AU, UK

^* Corresponding author: Tel.: +44-114-2714950; fax: +44-114-2610350. E-mail: Gaetano.Rocco{at}btopenworld.com

	Summary

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Presentation of the uniportal VATS sympathectomy technique: through a single port incision, a videothoracoscope, a diathermy hook and, if needed, a lung grasper are introduced into the pleural cavity. Upon identification of the sympathetic chain, the relevant ganglia are divided. By extending laterally the dissection, the aberrant accessory sympathetic nerve fibers are also severed. Anatomic variations are illustrated and an overview of the literature is presented.

Key Words: VATS • sympathectomy • hyperhidrosis

	Introduction

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VATS sympathectomy is used to provide symptoms relief in patients with facial, palmar and axillary hyperhidrosis or facial blushing (Footnote ¹). Other indications include vasomotor disorders of the upper limb, intractable splanchnic pain, and angina (see Footnote ¹ and De Giacomo et al. [1]). While the standard three-port approach is commonly used, there is an increasing consensus on the need for a minimally invasive endoscopic approach by using of a single port to perform the sympathectomy in order to perform this operation in an outpatient setting [2, 3, 4, 5, 6, 7].

	Surgical technique

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The patient, under general anesthesia with a double lumen endotracheal tube, is positioned on a semilateral decubitus on the operating table (Video 1). Upon completion of the sympathectomy on the right side, the patient is turned and the left side is approached in a similar fashion. A 2–2.5 cm incision is placed at the base of the hairline in the axilla and the dissection is carried down to the third rib. Upon entering the chest, digital exploration of the surrounding pleural cavity is done and a long 5 mm trocar is inserted. The port sleeve is retracted on the shaft of the thoracoscope and a diathermy hook along with, if needed, an endograsper (straight endograsper MMCTSLink 9 or roticulating endograsper MMCTSLink 10) are introduced in the chest parallel to the thoracoscope taking full advantage of the laterality offered by the port (Photos 1 and 2).

Click on image to view video Video 1 Patient position on the operating table. The upper limb on the operated side – usually the right side first – is elevated and suspended on an arm rest taking care at not stretching the brachial plexus. The skin mark delineates the base of the hairline. Close-up view of the incision usually measuring up to 2.5 cm.

View larger version (97K): [in this window] [in a new window]   Photo 1 Operative view showing the usual position of the thoracoscope-hook-grasper ensemble from behind the patient. H = head of the patient.

View larger version (97K): [in this window] [in a new window]   Photo 2 An anterior view of the same operative setting. The monitor is located at the head of the patient. The surgeon must take full advantage of the laterality offered by the port incision.

View larger version (94K): [in this window] [in a new window]   Photo 3 Endograsper introduced parallel to the videothoracoscope to displace the lung from the posterior chest wall. Symp = sympathetic chain; * = thoracic inlet.

As an example, the ganglia can be located in close proximity to major afferents to the intercostal or azygos vein (Photo 4), in between two venous branches (Photo 5) or even be found in a retrovascular position. At times, the first rib is not readily seen or palpated (Video 2) [9] but the stellate ganglion is almost always visible as a bulky conglomerate at the uppermost end of the chain (Video 3). In this setting, the identification of the supreme intercostal vein may help marking the second rib which usually lies below this vein (Photo 6, Video 4). The occasional need for dissection beyond the customary boundaries may force the surgeon to consider the use of additional instrumentation other than the operative thoracoscope (see Footnote ¹).

View larger version (105K): [in this window] [in a new window]   Photo 4 Prevascular position of the sympathetic chain. The second rib is marked for orientation.

View larger version (86K): [in this window] [in a new window]   Photo 5 Intervascular position of the divided sympathetic ganglion. The vessels are clearly indicated.

Click on image to view video Video 2 The hook is palpating the hidden first rib. The stellate ganglion is also nearly indistinguishable. The second ganglion is identified and palpated.

Click on image to view video Video 3 In this case, the second rib on the right side is visualized as well as the stellate ganglion. The latter is bulging from the parietal pleura at the thoracic inlet with a glossy appearance.

View larger version (108K): [in this window] [in a new window]   Photo 6 Localization of the second rib just caudal to the supreme intercostal vessels.

Click on image to view video Video 4 The upper sympathetic chain on the left side is visualized and the relationship with the supreme intercostal vein is clearly illustrated.

Click on image to view video Video 5 Severance of the second ganglion on the left side. The diathermy hook is used to palpate the ganglion and divide the parietal pleura. By exerting a light pressure while cauterizing, the ganglion is divided down to the periosteum. The tip of the hook is directed medially since no significant venous branches are present. In the uniportal approach, the thoracoscope-hook ensemble moves consensually depending on the area to be treated.

Click on image to view video Video 6 Another view of the sympathetic chain. The first rib is hidden by some extrapleural fat. The stellate ganglion is visible just cranial to the cauterized second ganglion.

Click on image to view video Video 7 The cauterization is started at the uppermost border of the rib. The third ganglion is divided. The hook is maneuvered to achieve both severance and separation of the nerve stumps.

Click on image to view video Video 8 Detail of the separation of the nerve stumps which are clearly visible at the end of the cauterization which is performed using the heel of the diathermy hook.

Click on image to view video Video 9 An accessory nerve is possibly seen running from the chain (T2–T3 segment) laterally to the second intercostal nerve [8]. The cauterization is extended laterally to include any recurrent Kuntz fibers.

Click on image to view video Video 10 Severance of T2, T3 and T4 ganglia has been performed. The fifth ganglion is left untouched. A small bore chest drain is introduced through the same port and left in the chest at the end of the procedure.

	Results

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• Reportedly, there is no mortality for this procedure [4].
  
• Well recognized complications of VATS sympathectomy are Horner's syndrome, compensatory sweating (reported as intolerable in 5% of the patients), gustatory sweating, persistent pneumothorax and, intercostal nerve pain (see Footnote ¹ and Ref. [10]).
  
• The results after VATS sympathectomy are reported to be excellent when the operation is carried out for palmar hyperhidrosis and, to a minor extent, for facial blushing. Less impressive are the results for axillary hyperhidrosis in view of the increased incidence of disturbing compensatory sweating due to the division of the lower sympathetic ganglia [11, 12, 13, 14]. However, the quality of life has been shown to improve in up to 86% of the patients after VATS sympathectomy [10]. Table 1 shows the outcome of a meta-analysis of the results in the most recent series in the literature.
  
• Despite being considered a simple and established procedure, there is a recognized learning curve influenced by the surgeon's ability to identify the second rib and properly dissect the chain [10, 15, 16, 17].
  

	Discussion

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1. Patient position on the operating table may vary, from completely supine and sitting or semisitting with both arms abducted to a semilateral decubitus with the upper limb on the operated side elevated to expose the axilla (Footnote ¹ and Ref. [7]).
   
2. Port incisions are usually placed according to the standard three-port technique or in the axillary fold; periareolar port incisions have been also described [9].
   
3. CO₂ insufflation; there is no consensus as to whether CO₂ insufflation or lung isolation from ventilation should be used to cause lung collapse and subsequently gain access to the sympathetic chain. In the most recent literature there seem to be a predilection towards lung isolation [10]. However, the use of chest drains at the end of the procedure does not depend on the use of CO₂ [18].
   
4. Interruption of the sympathetic chain; two major surgical tenets of VATS sympathectomy are consistently found in the literature. The first is to interrupt the sympathetic chain below the stellate ganglion (T1) since the division or thermal injury of the upper two thirds of T1 may cause an ipsilateral Horner's syndrome (see Footnote ¹). The second is to include in the sympathectomy the sympathetic fibers described by Kuntz, usually found laterally to the sympathetic chain, which represent an aberrant accessory pathway of nerve conduction to be severed lest a higher likelihood of symptoms recurrence [8]. The division of the sympathetic chain can be achieved in two ways. The first is to divide with electrocautery the nerve and the accessory fibers by extending the dissection laterally onto the rib for 3–5 cm (see Footnote ¹). The second is to remove the tract of chain in an effort to provide medicolegal evidence of the sympathectomy. Some authors have also described clipping, without division, of the chain as a method to provide symptom control which can be reversed should severe compensatory sweating occur [19]. Recently, the use of the ultrasonic scalpel to divide the chain has been advocated in view of a reduced likelihood of Horner's syndrome [20].
   
5. Extent of sympathectomy; despite some variability among the authors (Table 2), the common practice is to divide or remove the segments of chain between T2 and T4 depending on the level of the hyperhidrosis and T2 only for facial blushing, along with the corresponding aberrant accessory fibers, respectively.
   

	Footnotes

	References

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