How is endoscopic sympathectomy for axillary hyperhidrosis performed?

Updated: Feb 12, 2019
  • Author: Richard H S Karpinski, MD, FACS; Chief Editor: Gregory Gary Caputy, MD, PhD, FICS  more...
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For unilateral sympathectomy (or if the patient is to be turned during surgery), the lateral decubitus approach allows good visualization of the sympathetic chain in the upper thorax. Access to both sympathetic chains also can be achieved easily with the patient supine and both arms abducted. [18]

Make a small first incision in the anterior axillary line over the third rib and insert a needle into the pleural space to deflate the ipsilateral lung (or stop ipsilateral ventilation if using a double-lumen endotracheal tube).

Remove the needle and replace it with a 5.0 or smaller trocar matching the endoscope being used. Introduce the endoscope; the upper sympathetic chain and ganglia then are visualized easily lying over the costovertebral junctions. Pleural adhesions need to be taken down, avoiding (if possible) production of a parenchymal pleural leak. Many surgeons want a second port. This can be placed using a trocar at the fourth rib, also in the anterior axillary line. [19]

Identify the second rib within the chest cavity and open the pleura over it, starting just medial to the sympathetic chain and continuing laterally for approximately 1-2 inches.

Search for the nerves of Kuntz, a neural communication bypassing the sympathetic chain from the second or third thoracic segments and innervating the upper extremity. Although this anatomic variant is present in only approximately 10% of patients, it should be divided (if present) to avoid a failure of sympathectomy.

Make a longitudinal incision following the medial border of the sympathetic chain down to the fourth or fifth rib. Dissect thoracic ganglia T2, T3, and T4 free, and interrupt the sympathetic chain at the appropriate level. Small blood vessels are often encountered adjacent to the sympathetic chain and can be controlled by clips or cautery. Methods of interruption include cautery, harmonic scalpel, clip, or resection.

Individualize the sympathetic resection somewhat according to patient symptomatology. Since innervation of the head and neck is from T1 to T5, while that of the upper extremities is from T2 through T9, treatment for facial hyperhidrosis probably should include interruption above the T2 ganglion, while ablation of T5 probably is required to treat axillary hyperhidrosis. Extensive proximal dissection of the sympathetic chain (above the T1 ganglia) may lead to injury of the stellate ganglion, and injury to the cervical C7 component of this ganglion may result in permanent postoperative Horner syndrome. [20]

Gradually expand the lung by positive pressure ventilation while air in the pleural cavity exits via one of the cannulas.

Suture closed the trocar sites in layers. If clinically indicated and if the patient is doing well, a sympathectomy then can be performed on the opposite side.

Obtain a chest radiograph in the recovery room. A chest tube is not necessary unless a parenchymal air leak is noted. Flooding the operative field with saline while ventilating the lung may help demonstrate an air leak. If an air leak is present, a small drainage catheter can be introduced via one of the cannula sites and aimed toward the apex.

Thanks to Dr. Cliff Connery for editing and revising the above description of ETS. He is chief of the Thoracic Surgery Division at St. Luke's/Roosevelt Hospital in New York and Professor of Clinical Surgery at Columbia College of Physicians and Surgeons and has extensive experience in ETS.

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