Chapter 9: Sympathectomy

INDICATIONS

VATS sympathectomy is indicated for patients with socially disabling axillary or palmar hyperhidrosis refractory to all conservative measures.

PREOPERATIVE PREPARATION

Prior to surgery, a chest x-ray is performed to rule out unsuspected pathology in the chest. A preoperative type and screen is also obtained. The patient is informed about possible aftereffects of sympathectomy, including chest wall paresthesias and compensatory truncal sweating (present in 30%–70% of patients).

ANESTHESIA

General anesthesia with single-lung ventilation via a double-lumen endotracheal tube or single-lumen tube with bronchial blocker is usually performed. Intraoperative monitoring includes a Foley catheter and pulse oximetry.

POSITION

The patient is placed supine with a beanbag under the back with their arms out. The chest and axillae are prepped. The surgeon stands on the operative side with the assistant. The surgical scrub nurse stands on the opposite side. The anesthesiologist stands at the head of the bed. Monitors are positioned at the head of the bed and on either side of the patient (Figure 1).

INCISION AND EXPOSURE

Bilateral sympathectomies are performed during the same operation. For the right thorax, 0.5% bupivacaine is infiltrated into the right 3rd intercostal space (ICS) in the anterior axillary line. Because of the position of the heart, the primary incision is made more laterally (midaxillary line) on the left. A stab incision is made with a #15 blade, and using a tonsil clamp the subcutaneous tissue is dissected up to the intercostal (IC) muscle. A 5-mm port is introduced into the chest as described in Chapter 3. The ipsilateral lung is deflated, and CO₂ is insufflated into the chest to a pressure limit of 8 mm Hg. A 5-mm-angled laparoscope is placed through this port. A second incision is made in the 5th ICS in the midclavicular line on the right, and the anterior axillary line on the left. A second 5-mm trocar is placed under thoracoscopic visualization.

DETAILS OF THE PROCEDURE

A Kittner sponge stick is introduced into the chest, the lung is retracted inferiorly, and the Kittner is removed. Should it be necessary to keep the Kittner in place, another 5-mm port may be placed farther laterally. On the left side, extra care is taken to direct the trocars away from the heart. The 5-mm thoracoscope is introduced via the 3rd IC port and a hook cautery through the 5th IC port. The electrosurgical unit is set at 20 W for coagulation and cutting currents. The sympathetic chain is identified running over the neck of the ribs posteriorly (Figure 2). The ribs are counted from superior to inferior, making note of the 2nd to 4th ...