Endoscopic thoracic sympathectomy

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摘要

The description of the endoscopic thoracic sympathectomy covers all aspects of the surgical procedure used for the management of palmar hyperhidrosis.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure of sympathetic nerve, division of nerve, bleeding, other complications, evaluation after division.
Consequently, this operating technique is well standardized for the management of this condition.

媒體類型

刊物

2001-05

普通的

最愛

音訊

數位出版

WeBSurg.com, May 2001;1(05).
URL: http://www.websurg.com/doi-ot02en208.htm

Endoscopic thoracic sympathectomy

1. Introduction

Currently the main indication for endoscopic thoracic sympathectomy (ETS) is palmar hyperhidrosis. Rarer indications include vascular disorders and causalgia affecting the upper limbs.
In this chapter, we will focus on endoscopic sympathectomy as a surgical treatment for palmar hyperhidrosis, but the same technical principles apply for other indications.

2. Anatomy I

• Sympathetic nerve

The trunk of the sympathetic nerve courses along the neck of the ribs. It is generally visible through the posterior mediastinal pleura, especially in young and thin patients. Occasionally, it is hidden by fatty tissue or fibrotic changes in the pleura.
Numerous intercostal vein branches usually course behind the nerve. In certain cases, these branches course anterior to the trunk, especially on the right side, which may be a problem during dissection.

• Sympathetic trunk

Sympathetic trunk ganglia are generally situated in the intercostal spaces or, less often, at the inferior border of the corresponding rib.

• T1 ganglion

The most important anatomical landmark in the procedure is the first thoracic (T1) ganglion, which is usually almost entirely hidden by a fat pad.

• Cervicothoracic ganglion

The T1 ganglion is part of the cervicothoracic chain that includes the last cervical (C8) ganglion. The latter is usually not visible in thoracoscopic procedures.

3. Anatomy II

• Nerve trunks

Internodal nerve trunks run between the ganglia on the corresponding ribs. They are often both visible and palpable with endoscopic instruments.

• Rami communicantes

The rami communicantes join at the dorsal border of each ganglion.
The common trunk of the gray rami communicantes is generally visible through the pleura at the point of juncture with the intercostal nerve. However, the white rami communicantes coming from the rachis pass in a deeper plane that lies behind the ganglion.
It is important to bear in mind that the rami communicantes can anastomose via fibers that course along the contours of the ribs. The most common is the so-called ''Kuntz branch'' (Kuntz, 1927). Lack of knowledge of the existence of these fibers can lead to failure or recurrence (Wittmoser, 1992).
Visceral rami come from sympathetic trunk ganglia.
Cardiac and pulmonary rami are poorly visible behind the pleura.

• Splanchnic trunks

Splanchnic roots, including the main root from the sixth thoracic vertebrae (T6), are usually visible just below the parietal pleura. After crossing obliquely (caudally and anteriorly), the roots from T6 and T8 join to form the trunk of the greater splanchnic nerve, while the more distal roots unite to form the trunk of the lesser splanchnic nerve.
On the right side, the main splanchnic trunks course behind and parallel to the azygos vein.
On the left side, the splanchnic nerves course just behind the hemi-azygos vein.

4. Indications

The procedure is indicated for patients diagnosed with localized idiopathic hyperhidrosis that is incapacitating and refractory to dermatological treatment and iontophoresis (other causes of excessive sweating should be ruled out):
- palmar hyperhidrosis;
- axillary hyperhidrosis;
- scalp/facial hyperhidrosis: associated with palmar hyperhidrosis, isolated cases;
- plantar hyperhidrosis.

Other rare indications are causalgia, Raynaud’s syndrome, and angina.

5. Operating room set-up

• Patient

The procedure should be performed in an operating room equipped for both standard open thoracic surgery and endoscopic thoracic surgery.
Preoperative management:
- general anesthesia;
- exclusion of the lung (deflation of the lung on the operative side).
The patient is placed in the lateral thoracotomy position.
The arm on the operative side is extended, exposing the axilla. It must be placed high enough for the contours of the great dorsal and pectoral muscles to be visible. Over extension, which stretches or places traction on the brachial plexus, must be avoided.
It is not necessary to raise the kidney rest of the table. However, it should be placed in proper position for a conversion to thoracotomy if needed. An axillary roll (a rolled-up sheet of drape) should be placed beneath the contralateral axilla to prevent placement of undue pressure on the contralateral brachial plexus.

• Team

The surgeon (1) stands behind the patient’s back.
The assistant (2) stands opposite the surgeon, but generally does not directly assist with the operation, which can usually be performed by the surgeon alone.

• Equipment

1. Table
2. Anesthetic unit
3. Thoracoscopic unit
4. Monitors
5. Instrument table
6. Large table
The optical holder arm is placed opposite the surgeon.
A bilateral procedure requires a change in patient position. During the change, the instruments, endoscope and various cables, which must remain sterile, should be placed on a table meant for this purpose.

6. Trocar placement

• Principles

Three trocars are usually required to perform this procedure.
The trocar that accommodates the endoscope is 5 mm in diameter and the others are 3 mm in diameter.

• Optical

A
The endoscope is introduced via the 5 mm trocar into the fourth intercostal space in the posterior aspect of the axilla.

• Operating

B
A 3 mm trocar is introduced into the third intercostal space at the anterior aspect of the axillary fossa in patients with a large axilla.
If, as a result, the instrument trocar will be too close to the endoscope, the trocar can be introduced at the level of the submammary breast fold. However, placement of a trocar in this position may cause breast dysesthesia that may last for a few weeks.

• Retractor

C
The third trocar is introduced into the fourth or fifth intercostal space at the posterior axillary line.

7. Instruments

• Principles

A standard set of laparoscopic instruments is used, in addition to a set of microinstruments and an emergency open thoracotomy set.

• Optical devices

A: 5 mm 0° direct view lens endoscope
Because of the small size of the operative field, it is not necessary to use a 10 mm endoscope. A 5 mm endoscope is sufficient in terms of light intensity and resolution. Nevertheless, some authors prefer to use a 10 mm endoscope.

• Microinstruments

The following microinstruments are 3 mm in diameter:
1. Hook
2. Spatula
3. Metzenbaum scissors
4. Dissector
5. Suction-irrigation device
6. Grasper

• Conventional instruments

1. Mayo scissors
2. Needle holder
3. Crile clamp

• Emergency instruments

A set of emergency ancillary endoscopic instruments must be available to manage intraoperative complications, such as bleeding. For example, the usual 3 mm suction device may not always be adequate in the event of intraoperative bleeding.
Should this be the case, the 5 mm trocar is replaced by a 10 mm trocar to create an air inlet (in order to prevent the lung from re-expanding during the aspiration of blood). This instrument kit includes:
- two 5 mm trocars;
- one 10 mm trocar;
- a 5 mm suction-irrigation device.

8. Major principles

Sympathectomy for palmar hyperhidrosis usually requires a bilateral procedure.
Certain authors recommend a 2-phase procedure, with a 2 to 3 week interval between the first operation and the operation of the contralateral side. A major drawback to this method is the reluctance of certain patients to undergo the second phase of the procedure, especially after having experienced postoperative pain after the first procedure.
We prefer a one-phase procedure. As most of these patients are young and have healthy lungs, a one-phase procedure is usually well tolerated.

The sympathetic fibers are arranged in a segmental fashion, as has been described by Wittmoser (1992). This anatomical principle is the basis for a successful selection sympathectomy.
Surgical strategy:
- palmar involvement is treated by T2 to T4 sympathectomy;
- axillary involvement is treated by T3 to T5 sympathectomy;
- palmar and axillary involvement necessitates T2 to T5 sympathectomy;
- in case of facial involvement, the lower group of T1 rami communicantes is divided.
Important: postoperative Horner’s syndrome is a potential complication that may be avoided by the use of bipolar cautery (monopolar cauterization is not recommended).

Also, the division of the rami communicantes and their possible anastomoses is necessary to ensure definitive treatment.

9. Exposure/nerve

• Principles

The upper lobe of the deflated lung is retracted medially with a grasper that is initially used as a retractor. If the lung has been properly deflated, it is rarely necessary to continue to retract it further. Generally, the deflated lung will remain by itself at a good distance from the operative field.

• Sympathetic nerve localization

• Identification

Usually, the sympathetic nerve is immediately visible below the mediastinal pleura as a white, vertical line coursing along the neck of the ribs. The only difficulty involved is in verifying that the nerve is not duplicated and that there is not a collateral ramus.

• Duplicated nerve

• Collateral ramus

• Less common localization

In rare cases, the sympathetic nerve is not immediately visible:
- it may be hidden by fatty tissue or by a thick mediastinal pleura in overweight patients,
- intraoperative bleeding may hinder identification.
The surgeon should therefore identify the neck of the ribs and pass an instrument over the contour of the rib to search for the characteristic cord-like feel of the nerve.

• Upper limit of dissection

In a routine sympathectomy from T2 to T4, the second rib constitutes the superior boundary. This is typically the first visible rib in thoracoscopic procedures (the first rib is generally not visible).

• Cervicothoracic ganglion

The cervicothoracic (stellate) ganglion must be preserved. It is generally found underneath a fat pad at the superior limit of the dissection.
In a thin patient, this landmark may be absent, in which case the surgeon can often make out the characteristic appearance of the T1 ganglion, as it widens upward.

• Variation

In certain cases, one may encounter unexpected pleural adhesions. They must be freed by means of a cautery hook or scissors connected to an electrocautery unit. The surgeon should try to prevent bleeding as much as possible during this freeing, as any bleeding may impair vision.

10. Division/nerve

• Identification

The ribs are counted cephalad to caudad, from the second to the fourth rib.

• Exposure

The mediastinal pleura is divided, as is the nerve, at T4 level. We tend to use scissors, but the operator may also use either the hook or the spatula. Scissors are then inserted under the mediastinal pleura to lift it like a tent and to divide it caudad to cephalad with electrocautery. Once the upper thorax is reached, cautery should no longer be used, to avoid diffusion of the current towards the cervicothoracic ganglion.
The 2 separate layers of the pleural opening are retracted by the grasper in order to expose the path of the sympathetic nerve.
The nerve, which has been divided at T4 level, is held by the grasper and retracted cephalad to free it from the deeper plane, and importantly, from the veins that cross posteriorly.

• Rami communicantes

The endoscope may be brought to about 3 cm from the target to benefit from a close-up view of the rami communicantes that were exposed by simple cephalad retraction of the sympathetic nerve. The nerve is carefully detached posteriorly, staying close to the nerve itself to avoid injuring the crossing veins (use of Metzenbaum scissors will facilitate this operative step).
The rami communicantes are divided using the scissors, or alternatively the spatula or hook.
When approaching the area of T2, it is important to take the 2 following precautions:
- high frequency (HF) cautery must no longer be used,
- the traction on the nerve should be reduced to avoid overstretching of the cervicothoracic ganglion.
This will reduce the risk of injury to the ganglion itself (if mild bleeding from the veins occurs at this juncture of the resection, it is of little consequence).

• Upper part of the nerve

The upper part of the nerve is divided using scissors (without cautery) at the level of T2, at the base of the cervicothoracic ganglion. The trunk of the freed nerve can then be extracted via one of the trocars.

• Variation

• Anatomical variation 1

Double sympathetic nerve and/or multiple rami communicantes
All visible nerves must be carefully dissected and divided.

• Anatomical variation 2

Sympathetic nerve crossed anteriorly by an intercostal vein
In most cases, the nerve crosses anterior to the intercostal veins. In about 10% of cases, a vein is encountered crossing in front of the nerve. During dissection, the nerve must be brought anterior to the vein. If by doing this, there appears to be a risk of major venous hemorrhage, the nerve can be divided above and below the vein. The nerve segment can then be retracted safely and the rami communicantes can be divided at a distance from the vein.

11. Bleeding

• Distinctions

Major bleeding needs to be distinguished from minor bleeding or oozing.
In most cases, this procedure is performed quickly and easily. However, intraoperative complications may occur. Timely and appropriate action requires some experience in thoracoscopy.

• Major bleeding

A large vessel injury is very rare, but possible. We have had the case of an injury of the left subclavian artery by a cautery hook that slipped during the opening of the mediastinal pleura. Therefore, we now prefer using a spatula that potentially causes less trauma to tissue.
Such bleeding requires immediate conversion to thoracotomy. Tearing of the subclavian artery by the use of a 10 mm laparoscopic trocar was reported by Cameron in 1998. Hence the importance of working with appropriate instrumentation.

• Minor bleeding

Injury of an intercostal vessel is not uncommon. It can sometimes cause major bleeding (approx. 500 mL). We have always been able to control it endoscopically, although it may be difficult to control by means of a 3 mm suction device, which becomes easily clogged.
If such bleeding occurs, time must be taken to:
- replace the 5 mm optical trocar by a 10 mm trocar in order to create an air inlet,
- replace one of the 3 mm trocars by a 5 mm trocar for the suction-irrigation device.
Once the venous or arterial injury has been localized, the tip of the suction device may be applied to block it, leaving enough time for introduction of the hemostatic device or the dissector connected to the electrocautery unit.

• Slight bleeding

Slight bleeding or oozing is quite common during this procedure. Hemostasis is achieved by simple tamponade with a small gauze pad.

12. Other complications

• Chylothorax

In most cases, this procedure is performed quickly and easily. However, intraoperative complications may occur. Timely and appropriate action requires some experience in thoracoscopy.
Chylothorax is a very rare complication, although it has been described. Any abnormal chylous effusion should prompt the surgeon to look for an accessory thoracic duct. Leakage is controlled with clips, and biological glue may also be applied if needed.

• Lung injury

A small pulmonary injury may be caused by abrupt introduction of a trocar. It is generally of little or no consequence due to the small size of the trocars. A postoperative radiograph of the thorax should be performed, however, to rule out sequelae before removal of the drain.

• Other complications

An injury of the brachial plexus has been described by Lange (1995). The authors stress that this occurred despite the fact that they had considerable experience with traditional open thoracic sympathectomies. This demonstrates the need for special training prior to performance of this type of procedure via the thoracoscopic approach.
In 1998, Cameron reported 2 severe cases of cerebral edema apparently related to the insufflation of carbon dioxide into the pleural cavity during thoracoscopic sympathectomy. In general, CO2 insufflation should not be utilized during thoracoscopy, especially during this procedure, where it is not necessary.

13. Evaluation after division

• Accessory fibers

The procedure is completed only after the operative field has been thoroughly evaluated.
Once the sympathetic nerve trunk has been resected, the following must be performed:
An accessory ramus (Kuntz nerve) is frequently visible on the contour of the second rib. It should be divided by cautious and brief cauterization.

• Accessory rami

Other accessory rami are not always visible. They are divided by cauterization of the periosteum of the third and fourth ribs over a length of 3 to 4 cm starting from the neck of the ribs.

• Achievement of hemostasis

At the end of the procedure, mild bleeding or oozing is common. It is preferable to achieve hemostasis by simple tamponade rather than by electrocautery. To do so, a small gauze pad is first rolled up, introduced via the 5 mm trocar, and gently spread over the resection bed (the thoracoscope is withdrawn temporarily to allow placement of this gauze).

14. End of procedure

The lung is reinflated under visual guidance.
The endoscope and the 5 mm trocar are first removed to allow for introduction of a thoracic drain. A No.16 drain, preferably with a tip, is placed in the thorax via the same opening (the incisions for the 3 mm trocars do not accommodate a drain of this size). The two 3 mm incisions may be closed using glue.

15. Postop period

The pleural drain is removed a few hours after the procedure after evaluation of a postoperative chest radiograph. There is generally no need for a clamp test prior to drain removal.
The patient is typically able to leave the hospital on the day following surgery, occasionally on the same day of the procedure.

It is essential to inform the patients of what they may experience during the postoperative course:
- anterior and posterior thoracic pain, occasionally intermittently severe, for the first 3 to 4 weeks;
- feeling of chest heaviness, especially if a bilateral procedure has been performed during the same operation;
- pain in both arms lasting for a few days;
- temporary recurrence of hyperhidrosis lasting only for a few hours, commonly occurring between the second and the fifth postoperative days;
- compensatory excessive sweating.

16. Variations

• Type of anesthesia

Local
It is theoretically possible, but it may be very difficult, at times even impossible, to manage an intraoperative complication.
General anesthesia with a single lumen endotracheal tube
Selective intubation is not absolutely necessary, but it aids greatly in exposure of the posterior mediastinum.
Some authors advocate positioning the patient in ventral decubitus (Wittmoser, 1992) or in a semi-seated position, and are able to perform the procedure without deflation of the lung, as the inflated lung will drop out of the operative field due to the effect of gravity. Others facilitate the exposure by insufflating CO2. In this case, a trocar with an airtight endoscopic valve must be used.

• Patient positioning

• Ventral decubitus

Wittmoser (1992) is the only author known to recommend this position. It has the advantage of offering a good view of the posterior mediastinum without requiring separate pulmonary ventilation because the lung drops by itself due to gravity.
However, the endoscope has to be introduced through incisions in the patient’s back, which are both painful and less cosmetically satisfying. Moreover, conversion to an open thoracotomy is impossible with the patient in this position.

• Dorsal decubitus

A cushion is placed below the scapula of the patient on the side of the operation, and arms are abducted (Byrne et al., 1990). The endoscope is introduced via the axilla. The main disadvantage of this position is that, frequently, an additional trocar will need to be introduced on the anterior surface of the thorax to accommodate an instrument or a lung retractor.
Moreover, conversion to axillary thoracotomy is impossible in this position.

• Semi-seated position

The endoscope is introduced via the axilla. This gives excellent exposure of the apex of the superior mediastinum, and offers the advantage of easily allowing for a bilateral procedure, but its drawbacks are similar to those previously described.

• Instrumentation

• Principles

Some authors recommend a 10 or 11 mm endoscope with an operating channel. A cautery hook, suction device or any other 5 mm instrument can be introduced via the operating channel.
However, operative trocars placed in a triangulated pattern, as we have described, allow a more precise dissection.

• 5 mm instruments

The technique may be easily performed, as described above, utilizing 3 mm instruments. Other surgeons recommend 5 mm instruments.
These larger instruments may be cumbersome due to the small dimensions of the elements dissected. In addition, the larger trocars produce less satisfying cosmetic results.
Certain authors use a urologic resectoscope (Drott et al., 1995). The sympathetic nerve is cauterized with a diathermy loop and resected.

• Monopolar HF current

Monopolar HF current may increase the risk of heat injury of the cervicothoracic ganglion. Bipolar cauterization is preferable, but currently only 5 mm bipolar instruments are available.
The use of ultrasonic scissors has also been reported but again, the smallest size available is 5 mm.

17. Variations/surgical tech

• Cauterization

Simple cauterization of the sympathetic nerve is advocated by Drott et al. (1995), who used it successfully on more than 1000 patients.
The technique is simple. It consists of using a diathermy loop introduced via a urologic resectoscope. The loop passes along the pathway of the nerve from cephalad to caudad.

• Limited sympathectomy

Compensatory excessive sweating is the most serious side-effect of thoracic sympathectomy and many authors have tried to find a way to limit its incidence and importance.
One way is the performance of a sympathectomy that is limited in length. Bonjer et al. (1996) proposed resecting only the third thoracic ganglion (T3). They used this technique in 19 patients and no compensatory excessive sweating was observed.
Hsia et al. perform an even more limited sympathectomy, as the nerve is simply divided (Hsia et al., 1999). Out of 47 patients followed up over 12 months, no failure was reported. The rate of compensatory excessive sweating was 74%, though the symptoms were moderate.

• Clipping of the nerve

Resection or division of the sympathetic nerve is obviously irreversible. According to Lin et al. (1998), certain patients may regret having undergone the procedure after experiencing the discomfort of compensatory excessive sweating. Lin et al. have thus developed a procedure in which the nerve is merely clipped after being placed at each end of T2 ganglion. It is dissected for approximately 2 cm. This technique offers the advantage of being reversible.
In a series of 326 patients who underwent the procedure, 5 patients (1.5%) requested reversal of the procedure afterwards. In these cases, the clips were removable. Three patients reported disappearance of compensatory excessive sweating (with one recurrence of palmar hyperhidrosis). No improvement of compensatory excessive sweating was reported in 2 patients.

• Selective sympathectomy

Wittmoser (1992) was one of the pioneers of the endoscopic approach to thoracic sympathectomy in which only the rami communicantes are divided. The sympathetic nerve itself is preserved. This technique was reproduced by our team (Gossot et al., 1997). The aim was to reduce the rate of compensatory excessive sweating.

Of 62 patients who underwent the procedure at the beginning of our experience, the recurrence rate at 1 year was 5%, and we observed no recurrence in 350 patients who had complete nerve resection. Compared with 54 patients who underwent a conventional procedure, the rate of compensatory excessive sweating was not significantly reduced (Gossot et al., 1997). We therefore stopped performing this procedure because of the excessively high recurrence rate.

• Bilateral procedure timing

Sympathectomies for palmar hyperhidrosis most often require a bilateral procedure.
Certain authors recommend a 2-phase procedure, with a 2 to 3 week interval between operations.
We prefer a one-phase procedure. As most patients are young, and therefore have healthy lungs, the procedure is usually well tolerated. When the procedure is performed in 2 phases, some patients are reluctant to undergo the second phase of the procedure after experiencing postoperative pain following the first phase.

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