Patient selection
Surgical interruption of intrathoracic autonomic neural pathways has several useful clinical applications, particularly thoracic sympathectomy for upper limb hyperhidrosis. (severe sweating of the hands and axillae.) Most patients with severe sweating of the hands and under the arms will benefit by this procedure.
Operative steps
Surgical techniques: general anesthesia is used, including one lung ventilation with a double lumen endobronchial tube. Co 2insufflation is used to help induce lung collapse. A semi-fowler’s position is preferred with the patient’s arms abducted and a roll behind the shoulders to improve access to the upper sympathetic chain.
With gravity the lung naturally falls downwards and away from the upper posterior chest wall. Only one 7mm or 10mm port with an operative-thoracoscope is needed for manipulation. Alternatively, one telescope port and one operating port are placed if an operating thoracoscope is not available. The sympathetic chain is easily identified under the parietal pleura, running vertically over the necks of the ribs in the upper costo-vertebral region.
We perform bilateral synchronous sympathectomy starting on the right side. An l-shaped hook cautery alternating cutting/coagulation is used to divide the sympathetic chain as this is easier and quicker than attempting to remove a segment of the chain. Special care is taken to make sure that complete ablation of ganglia and severance of the sympathetic chain is achieved. We generally continue the dissection by cauterizing/dividing the pleura for 5 cm lateral to the chain. If an aberrant nerve bundle of kuntz is identified, it too is severed. The transected ends of the sympathetic chain are separated as far as possible and cauterized to prevent regrowth of the nerve and recurrence of symptoms
Care should be taken not to divide the sympathetic chain above the level of the second rib for the treatment of palmar and plantar hyperhidrosis, because it increases the risk of Horner’s syndrome and contributes little benefit. Thoracic outlet syndrome or reflex sympathetic dystrophy is usually approached at t1-t3. For chronic pancreatic pain, we usually divide the sympathetic chain at the level of t4 to t10. Before closing the skin, a small chest tube is left in the chest and the subcutaneous tissue is closed with 3-0 Vicryl. After expanding both the patient’s lungs with positive pressure ventilation, the tube is removed from the chest quickly at positive pressure to avoid a residual pneumothorax, and then a final subcuticular suture is placed. Hence, no thoracic drain is needed postoperatively. The procedure is then repeated on the left side. A chest radiograph is immediately obtained after the operation in the operating room to ensure complete lung expansion. The operation is usually performed in an outpatient setting, and patients are discharged 6-8 hours after the operation. Some patients will stay overnight for observation.
Any shortness of breath or swelling at the operation site should be discussed with Doctor Botha.
This website is not intended to take the place of your discussion with your surgeon about the need for surgery. If you have questions about your need for surgery, your alternatives, billing or insurance coverage, or your surgeons training and experience, do not hesitate to ask Doctor Botha or his office staff about it. If you have questions about the operation or subsequent follow-up, please discuss them with Doctor Ignatius Botha before or after the operation.