Thoracic Thoracoscopic Sympathectomy

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Thoracic Thoracoscopic Sympathectomy
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A. ANATOMY

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

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Fig 43-1
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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
• Horners syndrome, which is ipsilateral
• ptosis, miosis and facial anhidrosis.

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A. ANATOMY

• 6. Kuntzs 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 Kuntzs nerve can provide a
• nearly complete autonomic innervation of
• the upper extremity.

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Fig 43-2
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B. INDICATIONS

• The main indications of thoracic thoracoscopic
  sympathectomy are primary hyperhidrosis of upper
  extremity and reflex sympathetic dystrophy.
• Hyperhidrosis has a slightly female predominance
  and increased incidence in Asians and Sephadic
  Jews.
• Treatment includes topical AlCl3, iontophoresis,
  systemic or topic anticholinergic drugs, or
  biofeedback.

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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
• Raynauds syndrome, Bergers disease,
• long QT syndrome, refractory angina.

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C. TECHNIQUE

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

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Fig43-3
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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.

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Fig43-4
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D. COMPLICATIONS

• Compensatory hyperhidrosis( in back and groin)
  occurs in 60 to 70 of patients. Its etiology is
  unknown.
• Gustatory sweating (facial sweating with salivary
  stimuli) is also reported.
• Horners syndrome has incidence of 5 to 10 .
• Recurrence, intercostal neuralgia, pneumothorax
  and injury to subclavian vessels and esophagus
  are also reported.