Thoracoscopic Cervicodorsal Sympathectomywith Diathermy

Benoıt Cartier, MD, and Paul Cartier, MD, Valleyfield and Montreal, Canada

This study reports our experience of using thoracoscopic cervicodorsal sympathectomy withdiathermy. From December 1994 to September 1998, we performed 53 thoracoscopic sympa-thectomies in 35 patients. There were 15 men and 20 women, ages 18 to 61 years. Tensurgeries were performed on the right side, 7 were the left, and 18 were bilateral. Indications forsurgery were causalgia/reflex sympathetic dystrophy in 8 patients, Raynaud’s/vasculitis in 6,intractable Raynaud’s disease in 4, and hyperhydrosis in 17 (bilateral procedure). Operatingtime ranged from 10 to 50 min for unilateral procedures and from 45 to 80 min for bilateralprocedures. Patients stayed in the hospital 1 to 4 days. From favorable immediate and follow-upresults we conclude that thoracoscopic cervicodorsal sympathectomy using diathermy is fea-sible, safe, and effective. (Ann Vasc Surg 1999;13:582–585.)

INTRODUCTION

Until a few years ago, most surgeons performedthoracic sympathectomy either by supraclavicularor axillary access. The most common indications forupper extremity sympathectomy in modern vascu-lar practice are hyperhydrosis, ischemia, and, to alesser extent, post-traumatic pain syndromes.1,2

But with the open technique, about 20% of pa-tients who have had successful unilateral sympa-thectomy will not agree to have the other side op-erated on because of the pain experienced after theinitial operation.3-5 The supraclavicular approach iswell tolerated by patients but carries significant riskof complications such as Horner’s syndrome,phrenic nerve injury, brachial plexus injury, chy-lous leak, pneumothorax, and bleeding. The axil-lary approach carries the morbidity and mortality ofan open thoracotomy.1

In 1951, Kux described a minimally invasive tho-racoscopic approach for performing cervicodorsalsympathectomy.6 Although he reported excellentresults in 1978, his work went relatively unno-ticed.7 Recently, with the adaptation of laparoscopicsurgical techniques for thoracic application, endo-scopic sympathectomy is increasingly replacingopen operation.1,8-10 This study was undertaken todetermine the feasibility, safety, and efficacy of tho-rascopic cervicodorsal sympathectomy with dia-thermy.

PATIENTS AND METHODS

From December 1994 to September 1998, we per-formed 53 thoracoscopic sympathectomies in 35patients. There were 15 men and 20 women, ages18 to 61 years (mean 39.3 years). Seventeen uni-lateral procedures were performed, 10 on the rightside and 7 on the left; 18 were bilateral. Indicationsfor surgery were causalgia/reflex sympathetic dys-trophy in 8 patients, Raynaud’s disease/vasculitis in6 (with finger ulcerations), intractable Raynaud’sdisease in 4 (five procedures), and hyperhydrosis in17 patients (bilateral procedure). All 17 patientshad sweating hands, which caused a grave profes-sional and social handicap.

From the Centre Hospitalier Regional du Suroıt, Valleyfield(B.C.); Hotel - Dieu de Montreal, (P.C.), Hopital Jean-Talon,(B.C., P.C.), Montreal, Quebec, Canada.

Presented at the Annual Meeting of the Canadian Society forVascular Surgery, Toronto, Ontario, Canada, September 25-26,1998.

Correspondence to: B. Cartier, MD, CP 291 Valleyfield, Que-bec, Canada J6S 4V6.

582

During our apprenticeship with this procedurewe experimented with various techniques. In thefirst one, described by Ahn et al.,1 patients are un-der general anesthesia with a double lumen endo-tracheal tube. The ipsilateral lung is deflated andnonventilated during the procedure. The patient isplaced in a lateral decubitus position with the ipsi-lateral arm abducted on a mechanical arm holder.We used at least three ports: the scope port wentthrough the sixth intercostal space in the midaxil-lary line; an instrument port went in the same in-tercostal space but in the posterior axillary line; anda second instrument port was placed in the fourthintercostal space in the anterior axillary line. Con-trary to Ahn’s approach, the sympathetic chain wasnot resected but divided and coagulated. After theoperation a chest tube was inserted. Only one sidewas done in the same session.

In the second technique, described by Heder-man,11 the patient is under general anesthesia witha double-lumen endotracheal tube and is placed su-pine with the arms abducted at a right angle on armboards. A Verres needle is then introduced into thepleural cavity and a pneumothorax induced. Weused two ports: the scope port went through thefourth intercostal space in the anterior axillary line,and an instrument port went through the front ofthe chest, in the midclavicular line about the thirdintercostal space. No chest drains were used, but aroutine postoperative chest X-ray was taken.

The last 40 procedures were done in a supineposition with a single-lumen endotracheal tube andan induced pneumothorax, a technique shown tous by Dr. Shapiro from Jerusalem, Israel. We usedtwo cannulae on the axillary line in 20 proceduresand 1 cannula in the other 20 procedures, using ascope with a working channel. Here patients areplaced in a supine position with their arms overtheir head on a mechanical arm holder. A Verresneedle is then introduced just under the axillaryhair line; this is usually the fourth space. About 2.5L of carbon dioxide is carefully insufflated, whilethe pressure in the gas line is monitored so that itdoes not go above 12 and varies with respiration.The Verres needle is then removed and the laparo-scope introduced via a cannula at the same site. Inmost cases the sympathetic chain can be identifiedunder the pleura. At the apex of the pleura it isimportant to note a yellow fat pad that covers thestellate ganglion. The second rib is usually the high-est rib that we can see and the second ganglion lieson or just below its neck. If the sympathetic chain isnot visible on inspection, it can be identified by pal-pating with the tip of the diathermy probe. Theganglion is divided and coagulated right down onto

the underlying rib; we carry the incision in thepleura laterally along the surface of the rib in casethe nerve of Kuntz is present, which may occur inabout 10% of cases. It may carry sympathetic fiberand cause recurrence of symptoms if not de-stroyed.12 A chest radiogram is obtained at the endof the operation. We used underwater chest drain-age only if the estimated pneumothorax was >30%.In 13 cases the T2-T3 were divided, in 23 cases T2-T3-T4 were divided, and in 17 cases, T2-T3-T4-T5.One case required conversion to an open anteriorsupraclavular approach because of dense scarringand was excluded from this study.

RESULTS

Operating time for the last 40 procedures rangedfrom 10 to 50 min for the unilateral procedure(mean 30 min) and from 45 to 80 min for the bi-lateral procedure (mean 54 min). Estimated bloodloss (EBL) was <30 cc. Seven patients needed chesttube placement (five included in the technique andtwo for the pneomothorax). Postoperative slight re-sidual pneumothorax (<2 cm) occurred in 11 casesand resolved spontaneously without any furthertreatment.

After the operation all patients demonstrated asatisfactory clinical sympathectomy response,manifested by a warm, dry hand and upper extrem-ity. The patients stayed in the hospital 1 to 4 days,with a mean of 1.6 days. Transient Horner’s syn-drome developed in four patients and was resolvedwithin 1 week. Six patients experienced transientintercostal neuralgia, which was resolved withinweeks. Postoperative pain was well controlled withoral analgesics.

The follow-up period ranged from 1 to 45months (mean 27.8 months). All patients were ex-amined in the outpatient clinic until they fully re-covered from the operation. Follow-up was ob-tained in all patients by means of a telephone in-terview with a detailed standard questionnaire. Allpatients with hyperhydrosis showed good results(warm and dry upper limbs) and were satisfied withtheir operations. No recurrence was noticed in thiscategory. In 4/6 patients with Raynaud’s disease/vasculitis ulcer healing improved and pain was re-lieved with no recurrence at the end of the follow-up. In 2/4 patients with intractable Raynaud’sdisease, permanent relief of symptoms was experi-enced; the others noted a recurrence of their coldhypersensibility despite a satisfactory immediatepostoperative sympathectomy response. Five ofeight patients with causalgia/reflex sympatheticdystrophy showed improvement of symptoms and

Vol. 13, No. 6, 1999 Thoracoscopic cervicodorsal sympathectomy with diathermy 583

required less pain medication. Well-tolerated com-pensatory sweating of the trunk occurred in 50% ofcases and sweating of the face in 29%.

We didn’t notice any difference in terms ofclinical outcome and complications among thethree techniques. The last technique was promotedbecause it was the simplest and quickest with thesame results.

We compared our results with those from 23 bi-lateral supraclavicular access surgeries that we per-formed for hyperhydrosis. The mean operating timewas 145 min and the mean hospital stay was 2.8days, instead of 54 min and 1.6 days for the presentreport. In our experience it took longer to set up theequipment than to do the procedure itself and wewere able to see the ganglia much better.

DISCUSSION

As other authors have stated, thoracoscopic accesshas become the approach of choice for cervicodor-sale sympathectomy and gives results as good asthose from the open technique.1,8-10,13,14

The major sympathetic distribution to the upperextremity is below T1 contribution15, as shown byHyndman and Wolkin in 194216 and confirmed byO’Riordan et al. in 1993.17 Only the second dorsalganglion needed to be removed for complete sym-pathectomy of the upper limb; the preservationof the stellate ganglion reduced the incidence ofHorner’s syndrome.18 As in the open technique,the best results are obtained for hyperhydro-sis.1,7-10,13,16 Primary hyperhydrosis of the handsand axillae is a condition that can have devastatingconsequences on the patients’ social well-being. Re-ports of conservative treatment for palmar hyper-hydrosis have not been enthusiastic.8 In our expe-rience a section of T2-T3 gives good results for pal-mar hyperhydrosis. T2-T3-T4 is good for palmarand axillary sweating, and for an unknown reason,we have noticed that in about 40% of cases, a re-duction of plantar hyperhydrosis occurs if the sec-tion is lengthened out to T5. In patients withRaynaud’s disease/vasculitis and intractableRaynaud’s disease, our observations have indicatedthat although the immediate sympathetomy re-sponse (warm upper limbs) was temporary in cer-tain patients, there was a sustained healing of thefingertips and amelioration of their cold hypersen-sibility for others. We tend to agree with Kirtley etal.,19 Tsur et al.,20 and Welch et al.2 that resultsjustify the procedure in view of the initial improve-ment and some longer-term results, particularly inpromoting healing of the fingertips. All patientswith causalgia/reflex sympathetic dystrophy were

sent from the pain clinic and have shown good re-sponse to stellate ganglion blocks. Considering thedramatic problems these patients suffer we believethe sympathectomy was worthwhile. The best re-sults occur in patients who have been treated earlyin the process of the disease. Even the patientswhose symptoms were only partially improved bythe surgery were pleased to have had it done.

We concur with the opinion expressed by otherauthors that diathermy gives as good results as re-section. In fact, Claes et al. reported a 99% initialsuccess rate and 2% recurrence14; Herbst et al. re-ported a 98% success rate and 1.5% recurrence8;and Henderman reported a 98% success rate and2% recurrence.11

CONCLUSION

We conclude that thoracoscopic cervicodorsal sym-pathectomy with diathermy is feasible, safe, and ef-fective. It is preferable to an open technique. Theuse of diathermy and a scope with a working chan-nel requires a shorter time period under anesthesia,shorter operating time, and shorter period of hos-pitalization, giving results as good as those from re-section, as well as better aesthetic results.

REFERENCES

1. Samuel S, Ahn HI, Machleder BC, Moore WS. Thoracoscopiccervicodorsal sympathectomy: preliminary results. J VascSurg 1994;20:511-519.

2. Welch E, Geary J. Current status of thoracic dorsal sympa-thectomy. J Vasc Surg 1984;1:202-214.

3. Adams DCR, Poskitt KR. Surgical management of primaryhyperhidrosis [letter]. Br J Surg 1991;78:1019.

4. Sternberg A, Brickman S, Kott I. Transaxillary thoracic sym-pathectomy for primary hyperhidrosis of the upper limbs.World J Surg 1982;6:458.

5. Harris JP. Upper extremity sympathectomy. In RutherfordRB, ed. Vascular Surgery. Philadelphia: W.B. Saunders,1995, pp 1008-1016.

6. Kux E. The endoscopic approach to the vegetative nervoussystem and its therapeutic possibilities. Dis Chest 1951;20:139-147.

7. Kux M. Thoracic endoscopic sympathectomy in palmar andaxillary hyperhidrosis. Arch Surg 1978;113:264-266.

8. Herbst F, Plas EG, Fugger R, Fritsch A. Endoscopic sympa-thectomy for primary hyperhidrosis of the upper limbs. AnnSurg 1994;220:86-90.

9. Drott C, Gothbey G, Claes G. Endoscopic procedures of theupper thoracic sympathetic chain: a review. Arch Surg 1993;128:237-241.

10. Edmonson RA, Banerjee AK, Rennie JA. Endoscopic trans-thoracic sympathectomy in the treatment of hyperhydrosis.Ann Surg 1992;215:289-293.

11. Henderman WP. Endoscopic sympathectomy. Br J Surg1993;80:687-688.

12. Kuntz A. Distribution of sympathetic rami to the brachialplexus. Arch Surg 1927;15:871-877.

584 Cartier and Cartier Annals of Vascular Surgery

13. Kopelman D, Hashmonai M, Ehrenreich M, Bahous H, As-salia A. Upper dorsal thoracoscopic sympathectomy for pal-mar hyperhydrosis: improved intermediate-term results. JVasc Surg 1996;24:194-199.

14. Claes G, Gothbey G, Drott C. Endoscopic electrocautery ofthe thoracic sympathetic chain: a minimally invasivemethod to treat palmar hyperhydrosis. Scand J Plast Recon-str Surg Hand Surg 1993;27:29-33.

15. Smithwick RH. Modified dorsal sympathectomy for vascularspasm (Raynaud’s disease) of the upper extremity. Ann Surg1936;104:339.

16. Hyndman OR, Wolkin J. Sympathectomy of the upper ex-tremity. Evidence that only the second dorsal ganglion needbe removed for complete sympathectomy. Arch Surg 1942;45:145-155.

17. O’Riordan DS, Maher M, Waldron DJ. Limiting the ana-tomical extent of upper thoracic sympathectomy for primarypalmar hyperhidrosis. Surg Gynecol Obstet 1993;176:151-154.

18. Ross DB. Sympathectomy for the upper extremity: anatomy,indications and techniques. In Rutherford RB, ed. Vascu-lar Surgery. Philadelphia: W.B. Saunders, 1977, pp 623-628.

19. Kirtley J, Riddell DH. Stoney WS, Wright JK. Cervicotho-racic sympathectomy in neurovascular abnormalities of theupper extremity. Arch Surg 1967;165:869-879.

20. Tsur N, Adar E, Bechor I, Bogokowsky H, Mozes M. Upperthoracic sympathectomy: immediate and late results. IsrMed Sci 1973;9:53-58.

Vol. 13, No. 6, 1999 Thoracoscopic cervicodorsal sympathectomy with diathermy 585