Transumbilical thoracic sympathectomy with an ultrathin flexible endoscope in a series of 38 patients

Abstract

We read with interest the article by Zhu et al. [1] that described a novel approach to thoracic sympathetic ablation. We also read their recently published online article on pigs, which presumably predated their experience on humans, a wise and correct approach [2]. Each surgical technique has its pros and cons. In the present case, there was only one skin wound, hiding within the umbilicus instead of two to four incisions on the thorax. Each pleural cavity had only one access wound instead of two in the standard thoracoscopic techniques. On the other hand, three access wound were created in the peritoneal cavity, two of them in the diaphragms. Furthermore, the technique described by Zhu et al. required an additional instrument not included in the standard endoscopic armamentarium. Each wound that penetrates a cavity may result in adhesions and also may damage internal organs. In the present method, not only the pleural cavities are violated, but the peritoneum as well. In view of all these remarks, we would appreciate their comment on the merits of their technique over the standard transthoracic approach. Pursuing the NOTES principle, transesophageal sympathectomy also has been performed [3]. These approaches are feasible. Are they desirable? Are they suitable for the general surgical practice? A further note of caution: the authors stated that the first rib was not visible in most of the cases. Did they apply a clip and perform a postoperative chest x-ray to confirm their count? Most authors claim that the first rib is usually visible during the procedure, mainly in its anterior part [4]. The majority of sympathectomies are performed by rib count and correct identification is of paramount importance.