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MMCTS (May 7, 2007). doi:10.1510/MMCTS.2004.000323
Copyright © 2007 European Association for Cardio-thoracic Surgery

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Procedure


Endoscopic VATS sympathectomy: the uniportal technique

Gaetano Rocco*

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: +44-114-2610350Gaetano.Rocco{at}btopenworld.com


   Summary
Top
 Summary
Introduction
 Surgical technique
 Results
 Discussion
 References
 
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: Hyperhidrosis • Sympathectomy • VATS


   Introduction
Top
 Summary
 Introduction
Surgical technique
 Results
 Discussion
 References
 
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 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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 Summary
 Introduction
 Surgical technique
Results
 Discussion
 References
 
The patient, under general anesthesia with a double lumen endotracheal tube, is placed in a semilateral decubitus position 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 – MMCTSLink 9 – is introduced in the chest parallel to the thoracoscope, taking full advantage of the laterality offered by the port (Photos 1 and 2).


Figure 1
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 not to stretch 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.
 

Figure 1
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  		Photo 1 Operative view showing the usual position of the thoracoscope-hook-grasper ensemble from behind the patient. H=head of the patient.

 

Figure 2
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  		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.

 
Should at this point adhesions be identified, the lung could be retracted with an endograsper (Photo 3) and the adhesions divided using the diathermy hook or endoscissors. Endoligaclips may also be used for tenacious, vascularized adhesions. The use of an endograsper is unnecessary when the lung is adequately collapsed: the thoracoscope can be gently pushed onto the lung apex to gain visibility on the sympathetic chain.


Figure 3
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  		Photo 3 Endograsper introduced parallel to the videothoracoscope to displace the lung from the posterior chest wall. Symp=sympathetic chain; *=thoracic inlet.

 
Since the anatomy of the sympathetic chain can be extremely variable [8], the surgeon must be prepared to adjust the surgical technique to the intrathoracic situation.

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 can 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).


Figure 4
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  		Photo 4 Prevascular position of the sympathetic chain. The second rib is marked for orientation.

 

Figure 5
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  		Photo 5 Intervascular position of the divided sympathetic ganglion. The vessels are clearly indicated.

 

Figure 2
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.
 

Figure 3
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.
 

Figure 6
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  		Photo 6 Localization of the second rib just caudal to the supreme intercostal vessels.

 

Figure 4
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.
 
The T2, T3 and T4 ganglia are identified and a diathermy hook is used to divide the pleura on the uppermost border of the rib. Monopolar cautery is used (coagulation with low current) while the heel of the diathermy hook is pressed against the ganglion and onto the rib until the periosteum becomes visible (Videos 5 and 6). At this point, the stumps of the divided nerve should appear at the edges of the pleural incision and are further separated with the hook to avoid possible future regeneration (Footnote 1) (Videos 7 and 8).


Figure 5
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.
 

Figure 6
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.
 

Figure 7
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.
 

Figure 8
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.
 
On the right side, care should be taken in pointing the tip of the diathermy hook laterally, to avoid transmission of current to the neighboring venous structures. No effort is made at localizing the Kuntz fibers, which can be present in 68% of the patients [8], but the severance is routinely extended laterally for 3–5 cm to include them in the cauterization field (Video 9).


Figure 9
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.
 
Once the desired ganglia are severed, a 16 F chest drain is placed under endoscopic guidance at the apex of the chest while the lung is expanded and the skin incision closed with reabsorbable sutures (Video 10).


Figure 10
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.
 
At the end of the bilateral procedure, the patient is transferred to the recovery area where a chest X-ray is performed and the right-sided drain removed. An hour later, the patient is moved to the ward where the left-sided drain is removed and a repeat chest X-ray is obtained to rule out residual pneumothoraces which would indicate an overnight stay.


   Results
Top
 Summary
 Introduction
 Surgical technique
 Results
Discussion
 References
 
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].


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  		Table 1 Outcome of VATS sympathectomy
 

   Discussion
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 Summary
 Introduction
 Surgical technique
 Results
 Discussion
References
 
Controversial issues
1. Patient position: on the operating table patient position 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: these 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 seems 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.


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  		Table 2 Extent of VATS sympathectomy

 
6. Updating 2007–New perspectives: despite controversies still existing as to the preferred level of symphatectomy for different indications and to the number of ports used to enter the chest, there have been recent reports describing the possibility of successfully performing bilateral sympathectomy on the awake patient and monitoring the peripheral perfusion as a means for assessing the efficacy of this procedure. A reiterated support for perfoming this procedure in patients with refractory angina pectoris has also been expressed. The most recent literature focuses on T2 severance as a means to effectively treat isolated facial blushing. However, other investigators find T2 ablation or transection unnecessary if one wants to reduce the incidence of compensatory sweating. Reportedly, there is consensus as to the candidate to sympathectomy needing to be provided with a detailed explanation of this complication in order to collect a reliable informed consent, especially from patients with merely facial or axillary symptoms. The need for a prospective, randomized trial to address the several unresolved issues (i.e. gustatory side effects) with thoracic sympathectomy has clearly emerged from the recently published papers [21,22,23,24,25,26,27,28,29,30,31].



   Footnotes
 
1 Krasna MJ, Xiaolong J. Thoracoscopic sympathectomy. CTSNET Experts' Techniques http://www.ctsnet.org/doc/6527. Back


   References
Top
 Summary
 Introduction
 Surgical technique
 Results
 Discussion
 References
 

  1. De Giacomo T, Rendina EA, Venuta F, Lauri D, Mercadante ES, Anile M, Coloni GF. Thoracoscopic sympathectomy for symptomatic arterial obstruction of the upper extremities. Ann Thorac Surg 2002;74:885–888.[Abstract/Free Full Text]
  2. Lin TS, Kuo SJ, Chou MC. Uniportal endoscopic thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases. Neurosurgery 2002;51:84–87.
  3. Lardinois D, Ris HB. Minimally invasive video-endoscopic sympathectomy by use of a transaxillary single port approach. Eur J Cardiothorac Surg 2002;21:67–70.[Abstract/Free Full Text]
  4. Yim APC, Liu HP, Lee TW, Wan S, Arifi AA. ‘Needlescopic’ video-assisted thoracic surgery for palmar hyperhidrosis. Eur J Cardiothorac Surg 2000;17:697–701.[Abstract/Free Full Text]
  5. Goh PMY, Keat Cheah W, De Costa M, Sim EKW. Needlescopic thoracic sympathectomy: treatment for palmar hyperhidrosis. Ann Thorac Surg 2000;70:240–242.[Abstract/Free Full Text]
  6. Lee DY, Yoon YH, Shin HK, Kim HK, Hong YJ. Needle thoracic sympathectomy for essential hyperhidrosis: intermediate-term follow-up. Ann Thorac Surg 2000;69:251–253.[Abstract/Free Full Text]
  7. Yamamoto H, Kanehira A, Kawamura M, Okada M, Ohkita Y. Needlescopic surgery for palmar hyperhidrosis. J Thorac Cardiovasc Surg 2000;120:276–279.[Abstract/Free Full Text]
  8. Hyuk Chung I, Seok Oh C, Seok K, Jin Kim H, Chae Paik H, Yun Lee D. Anatomic variations of the T2 nerve root (including the nerve of Kuntz) and their implications for sympathectomy. J Thorac Cardiovasc Surg 2002;123:498–501.[Abstract/Free Full Text]
  9. Kesler KA, Brooks-Brunn JA, Campbell RL, Brown JW. Thoracoscopic sympathectomy for hyperhidrosis palmaris: a periareolar approach. Ann Thorac Surg 2000;70:314–317.[Abstract/Free Full Text]
  10. Milanez de Campos JR, Kauffman P, de Campos Werebe E, Oliveira Andrade Filho L, Kusniek S, Wolosker N, Biscegli Jatene F. Quality of life, before and after thoracic sympathectomy: report on 378 operated patients. Ann Thorac Surg 2003;76:886–891.[Abstract/Free Full Text]
  11. Gossot D, Galetta D, Pascal A, Debrosse D, Caliandro R, Girard P, Stern JB, Grunenwald D. Long-term results of endoscopic thoracic sympathectomy for upper limb hyperhidrosis. Ann Thorac Surg 2003;75:1075–1079.[Abstract/Free Full Text]
  12. Claes G. Indications for endoscopic thoracic sympathectomy. Clin Auton Res 2003;13 (Suppl 1):I16–19.[CrossRef][Medline]
  13. Cameron E. Specific complications and mortality for endoscopic thoracic sympathectomy. Clin Auton Res 2003;13 :I31–35.[Medline]
  14. Doolabh N, Horswell S, Williams M, Huber L, Prince S, Meyer DM, Mack MJ. Thoracoscopic sympathectomy for hyperhidrosis. Indications and results. Ann Thorac Surg 2004;77:410–414.[Abstract/Free Full Text]
  15. Gossot D, Kabiri H, Caliandro R, Debrosse D, Girard P, Grunenwald D. Early complications of thoracic endoscopic sympathectomy: a prospective study of 940 procedures. Ann Thorac Surg 2001;71:1116–1119.[Abstract/Free Full Text]
  16. Kao MC. Thoracoscopic sympathectomy for craniofacial hyperhidrosis. Eur J Cardiothorac Surg 2001;19:951.[Free Full Text]
  17. Sung WS, Kim YT, Kim JH. Ultra-thin needle thoracoscopic surgery for hyperhidrosis with excellent cosmetic effects. Eur J Cardiothorac Surg 2000;17:691–696.[Abstract/Free Full Text]
  18. Hsia JY, Chen CY, Hsu CP, Shai SE, Yang SS. Outpatient thoracoscopic limited sympathectomy for hyperhidrosis palmaris. Ann Thorac Surg 1999;67:258–289.[Abstract/Free Full Text]
  19. Neumayer C, Zacherl J, Holak G, Függer R, Jakesz R, Herbst F, Bischof G. Limited endoscopic thoracic sympathetic block for hyperhidrosis of the upper limb: reduction of compensatory sweating by clipping T4. Surg Endosc 2004;18:152–156.[CrossRef][Medline]
  20. Callejas MA, Rubio M, Iglesias M, Belda J, Canalis E, Catalan M, Gimferrer JM. Video-assisted thoracoscopic sympathectomy for the treatment of facial flushing: ultrasonic scalpel versus diathermy. Arch Bronconeumol 2004;40:17–19.[CrossRef][Medline]
  21. Licht PB, Jørgensen OD, Ladegaard L, Pilegaard HK. Thoracoscopic sympathectomy for axillary hyperhidrosis: the influence of T4. Ann Thorac Surg 2005;80:455–460.[Abstract/Free Full Text]
  22. Elia S, Guggino G, Mineo D, Vanni G, Gatti A, Mineo TC. Awake one stage bilateral thoracoscopic sympathectomy for palmar hyperhidrosis: a safe outpatient procedure. Eur J Cardiothorac Surg 2005;28:312–317.[Abstract/Free Full Text]
  23. Murphy MO, Ghosh J, Khwaja N, Murray D, Halka AT, Carter A, Turner NJ, Walker MG. Upper dorsal endoscopic thoracic sympathectomy: a comparison of one- and two-port ablation techniques. Eur J Cardiothorac Surg 2006;30:223–227.[Abstract/Free Full Text]
  24. Kumagai K, Kawase H, Kawanishi M. Health-related quality of life after thoracoscopic sympathectomy for palmar hyperhidrosis. Ann Thorac Surg 2005;80:461–466.[Abstract/Free Full Text]
  25. Klodell CT, Lobato EB, Willert JL, Gravenstein N. Oximetry-derived perfusion index for intraoperative identification of successful thoracic sympathectomy. Ann Thorac Surg 2005;80:467–470.[Abstract/Free Full Text]
  26. Dewey TM, Herbert MA, Hill SL, Prince SL, Mack MJ. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis: outcomes and consequences. Ann Thorac Surg 2006;81:1227–1232.[Abstract/Free Full Text]
  27. Licht PB, Ladegaard L, Pilegaard HK. Thoracoscopic sympathectomy for isolated facial blushing. Ann Thorac Surg 2006;81:1863–1866.[Abstract/Free Full Text]
  28. Schmidt J, Bechara FG, Altmeyer P, Zirngibl H. Endoscopic thoracic sympathectomy for severe hyperhidrosis: impact of restrictive denervation on compensatory sweating. Ann Thorac Surg 2006;81:1048–1055.[Abstract/Free Full Text]
  29. Stritesky M, Dobias M, Demes R, Semrad M, Poliachova E, Cermak T, Jiri Charvat J, Malek I. Endoscopic thoracic sympathectomy – its effect in the treatment of refractory angina pectoris. Interact CardioVasc Thorac Surg 2006;5:464–468.[Abstract/Free Full Text]
  30. Licht PB, Pilegaard HK. Gustatory side effects after thoracoscopic sympathectomy. Ann Thorac Surg 2006;81:1043–1047.[Abstract/Free Full Text]
  31. Munia MA, Wolosker N, Kauffman P, de Campos JR, Puech-Leao P. A randomized trial of T3-T4 vs. T4 sympathectomy for isolated axillary hyperhidrosis. J Vasc Surg 2007;45:130–133.[CrossRef][Medline]



This Article
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May 7, 2007    most recent
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