Thoracic Sympathectomy
What is it?
Thoracic Sympathectomy is a minimally invasive (VATS) procedure
in which the sympathetic nerves inside the chest at the level
of the second, third, or fourth ribs are divided.
What is it used for?
Thoracic Sympathectomy is used to treat hyperhidrosis, causalgia,
and reflex sympathetic dystrophy of the upper extremities. Hyperhydrosis
is a condition characterized by excess sweating of the hands and
armpits. (Sometimes the feet, trunk, and face are involved.) Causalgia
and Reflex Sympathetic Dystrophy are sub-types of Complex Regional
Pain Syndrome (CRPS.) CRPS is characterized by severe, even disabling,
pain that persists long after what would otherwise appear to be
a healed injury.
How is it done?
Thoracic Sympathectomy is a minimally invasive thoracic surgical
procedure, done with the use of thoracoscopy, also known as VATS
(Video Assisted Thoracic Surgery.) In our practice, we utilize
5 mm endoscopes, and 3 mm diameter instruments. These instruments
are smaller than a soda straw, and allow us to use very small
incisions, usually less than .25 inch each.
The patient is placed under general anesthesia, and positioned
comfortably on their side. A quarter inch incision is made near
the tip of the shoulder blade. Through this incision, a tiny endoscope,
less than a quarter inch in diameter, is introduced into the chest
between the ribs. The lung is retracted out of the way, and the
sympathetic nerves are visualized with the endoscope. Through
a second tiny incision, another small instrument, approximately
one eighth inch in diameter, is introduced between the ribs. Using
the endoscope to see, this instrument is used to divide the sympathetic
nerves at the level of the second and third ribs.
The instruments are then withdrawn from the chest. The lung is
allowed to re-expand to its normal position. Usually, a drain
is not required. The results of the sympathectomy are apparent
within minutes after the surgery.
The patient is observed for several hours in the outpatient recovery
area, and then is discharged home. If a drain is required, the
patient will spend the night.
What are the risks?
Risks include the general risks of surgery, and the specific risks
of sympathectomy. Risks include those of general anesthesia, the
small risk of wound infection, a small risk of bleeding, and a
small risk of air leak from the lung that would require a drain
and overnight hospital stay.
The normal effects of thoracic sympathectomy are a dry hand and
axilla (armpit). The hand will appear more flushed than prior
to surgery.
A side effect of sympathectomy for palmar hyperhidrosis in some
patients is the appearance of new hyperhidrosis on the chest wall
or abdominal wall. This abdominal hyperhydrosis appears to be
a compensatory form of sweating as a result of eliminating sweating
of the hands and axillae. Although statistics vary, the incidence
of compensatory abdominal hyperhydrosis ranges from 3% to 40%.
A risk of thoracic sympathectomy for causalgia is failure to eliminate
the pain. There is a spectrum of results that is seen as a result
of this treatment for causalgia. Some patients get excellent long
term relief, some get partial relief, some get no relief.
The chief risk of sympathectomy is thermal injury to the Stellate
Ganglion, a portion of the sympathetic nervous system that lies
above the first rib. Injury to the Stellate Ganglion results in
Horner’s Syndrome. Horner’s Syndrome includes dilation
of the pupil and slight ptosis, or drooping of the eyelid, on
the same side as the surgery.
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