Sympathectomy Procedures Research Articles

Case-Series: First experience outcome of t2 - t4 video-assisted thoracoscopic surgery (vats) sympathectomy bilateral for severe hyperhidrosis in Labuang Baji general hospital

Introduction: Hyperhidrosis is a clinical condition that causes excessive sweating that exceeds physiological needs and can interfere with the patient's daily activities Methods: This research is a retrospective study based on medical record data from March 2022 – March 2023 at Labuang Baji Hospital. Six cases of severe hyperhidrosis who underwent a bilateral T2-T4 VATS sympathectomy procedure were subsequently conducted through cell phone interviews to assess complications of the procedure, the incidence of Compensatory Hyperhidrosis, length of stay in hospital and assess patient satisfaction after 1 year of undergoing the procedure. Result: Four of the patients experienced improvement and were very satisfied with undergoing the VATS sympathectomy procedure, one patient was quite satisfied and the other was dissatisfied because the complaint of compensatory hyperhidrosis (CH) experienced was more disturbing to the patient's activities than before surgery. Complications found besides pain are subcutis emphysema, pleural effusion and bleeding. All patients experienced CH, which predominated in the chest and back areas. Conclusion: Bilateral VATS sympathectomy in cases of severe hyperhidrosis is a minimally invasive procedure that can be recommended for the future. This action gives results, a good level of satisfaction and can improve patients' quality of life after surgery.

Rhomboid intercostal block versus serratus block for postoperative analgesia after thoracoscopic sympathectomy for primary palmar hyperhidrosis: a randomized controlled trial

BackgroundAlthough thoracoscopic sympathectomy is made via small incisions, it is associated with severe postoperative pain. Both Rhomboid intercostal block (RIB) and serratus anterior plane block (SABP) are recent techniques used for pain control after such procedures. Herein, we compared RIB and SAPB regarding pain control in patients undergoing thoracoscopic sympathectomy for palmar hyperhidrosis.Patients and methodsThree groups were enrolled in this prospective randomized study (71 patients in each group); Group S received SAPB, Group R received RIB and Group C as controls. The block procedures were performed after general anesthesia and prior to the skin incision.ResultsThe three groups showed comparable demographics and operative time (P ˃ 0.05). Pain scores showed a significant decline with the two block procedures compared to controls during the first day following surgery (both P ˂ 0.05), but Group R had better scores compared to Group S. Both block techniques were associated with a significant prolongation of the time to first rescue analgesic and less fentanyl consumption compared to controls (both P ˂ 0.05). However, both parameters were improved with RIB rather than SAPB (both P ˂ 0.05). Both blocks led to a significant improvement in patient satisfaction than in the control group (both P ˂ 0.05), but it was comparable between the two approaches (P ˃ 0.05).ConclusionBoth RIB and SAPB are safe and effective in pain reduction after thoracoscopic sympathectomy procedures in patients with hyperhidrosis. Moreover, RIB is superior to SAPB as it is associated with better analgesic outcomes.Trial registrationPan African Trial Registry PACTR202203766891354. https://pactr.samrc.ac.za/Researcher/TrialRegister.aspx?TrialID=21522

Electrophysiological evaluation of efficacy of clipping in thoracic sympathectomy: An experimental cadaveric study

Background This study aims to examine the efficacy of clipping in thoracic sympathectomy based on electrophysiological evaluation and to investigate whether nerve conduction can be formed by collateral nerve extensions as a result of the clipping procedure to different levels of sympathetic nerve. Methods Newly sacrificed six sheep hemithoraces were studied between August 2016 and October 2016. Thoracic sympathectomy was performed by clipping at T2, T3, T4, and T5 sympathetic chain levels and their branches. Electrophysiological studies were performed with an electromyography device and the filter range was 1 Hz with 20 μV/D amplification. Signals were processed digitally; bipolar subdermal needle electrodes were used as stimulation and recording electrodes (Ø 0.75 mm); and the ground electrode was placed in the intercostal muscle where the thoracic sympathectomy procedure would be performed. Results Electrophysiological evaluations showed that clips placed on the main sympathetic chain branches and sympathetic nerve trunk prevented collateral impulse conduction and stimulated potentials were not recorded. However, sympathetic conduction continued at the same intensity after removal of the clips. Conclusion Clipping of different regions of the sympathetic nerve provides electrophysiological blockage of the sympathetic nerve, and conduction continues after removal of the clips. However, the shortand long-term postoperative electrophysiological results after removal of the clips over the sympathetic nerve is still a question mark.

Surgical Lumbal Sympathectomy Procedure as Favorable Treatment Modality for Complex Regional Pain Syndrome (CPRS)

Surgical Lumbal Sympathectomy Procedure as Favorable Treatment Modality for Complex Regional Pain Syndrome (CPRS)

Effectiveness, success rates, and complications of different thoracoscopic sympathectomy techniques in patients with palmar hyperhidrosis.

This study aims to investigate the effectiveness, success and complication rates of three different video-assisted thoracoscopic sympathectomy procedures performed for the treatment of primary focal hyperhidrosis; excision, cauterization and clipping. We retrospectively evaluated the records of 60 patients (33 males, 27 females; mean age 25.1±6.4 years; range 16 to 43 years) with primary focal hyperhidrosis and treated with videoassisted thoracoscopic sympathectomy between January 2010 and December 2013. The patients were treated bilaterally at the same session: the sympathetic chain and ganglia were excised from the spinal cord segments of T2-T4 in 20 patients (group 1), cauterized in 20 patients (group 2), and clipped in 20 patients (group 3). The procedural success and complication rates were compared among the groups. Sympathectomy was successfully performed in all patients. The mean operation time was found to be significantly shorter in group 2 (42.5±7.1 min) and group 3 (36.9±7.8 min), compared to group 1 (51.1±8.4 min) (p<0.05). Compensatory hyperhidrosis developed in 17 patients (28.3%) and was comparable among all groups (p<0.05). Our study results suggest that excision, cauterization, and clipping are effective and reliable in the treatment of primary focal hyperhidrosis. Based on our experience, we believe that sympathectomy with video-assisted excision may be preferable for the treatment of primary focal hyperhidrosis.

Alteration of Arterial Mechanical Impedance Greater than that of Photoplethysmogram and Laser Doppler Flowmetry during Endoscopic Thoracic Sympathectomy

Blood flow monitoring systems such as photoplethysmogram (PPG) and laser Doppler flowmetry (LDF) are useful for intraoperative determination of a successful endoscopic thoracic sympathectomy (ETS) procedure, as they are able to indicate a sympatholytic response. A recently developed novel arterial mechanical impedance monitor has been shown able to provide a value for peripheral arterial stiffness, shown as K. In this retrospective cohort study, we compared the intensity of K with that of PPG and LDF during ETS procedures. Seventy-nine patients with hyperhidrosis underwent a surgical sympathectomy procedure under general anesthesia, during which they were managed by monitors attached to the tips of their fingers. Circulatory variables before and after the surgical procedure were recorded during ETS, then the ratios of those indices were statistically compared. With a statistical significance level of p < 0.05, K was shown to have a greater alteration as compared to PPG and LDF at the time of skin incision as well as neural clipping in both hands. We concluded that arterial mechanical impedance shown by K is a more sensitive monitor of sympathetic activity derived from vasoconstriction and vasodilation during an ETS procedure as compared to PPG and LDF.

Electrocautery versus Ultracision versus LigaSure in Surgical Management of Hyperhidrosis.

The aim of the study was to evaluate the sympathectomy procedures for primary hyperhidrosis in terms of complications and effectiveness. From January 2010 to September 2012 we performed 130 sympathectomies in 65 patients, 27 males (42%) and 38 females (58%). Electrocoagulation was used in 20 procedures (15%), ultrasonic scalpel in 54 (42%), and radiofrequency dissector in 56 (43%). Seven patients (11%) underwent bilateral sympathectomy in the same surgical session, while in 58 (89%) the right surgical approach was delayed 30 days from the first procedure. We noticed 12 complications (9%): (a) chest pain in 6 patients (4 with electrocoagulation, 1 with ultrasonic scalpel, and 1 with radiofrequency dissector), which disappeared in 20 ± 1 day; (b) paresthesias in 3 electrocoagulation patients, was solved in 23 ± 5 days; (c) bradycardia in 1 ultrasonic patient, normalized in 4th postoperative hour; (d) unilateral relapse in 2 electrocoagulation patients after the second side approach, positively treated in 1 patient by resurgery in video-assisted thoracoscopy (VAT). The quality-adjusted life year and the quality of life evaluation revealed a statistically significant improvement (p = 0.02) in excessive sweating and general satisfaction after surgery, with Ultracision and LigaSure showing better findings than electrocoagulation. The latest generation devices offered greater efficacy in the treatment of hyperhidrosis, minimizing complications and facilitating the resumption of normal work and social activity of patients.

Thoracoscopy: beyond the key hole

Background Lateral thoracotomy or median sternotomy causes significant morbidity. Thoracoscopy reduces the morbidity of the incision and provides a clear and magnified display of anatomy. It involves a learning curve. Objectives To evaluate the safety, efficacy and advantages of thoracoscopy. Method A retrospective analysis of 67 thoracoscopic procedures performed at the university surgical unit, Teaching Hospital, Peradeniya. Results The total number of 67 procedures included thymectomy, lymph node biopsy, lymph node dissection, excision of retrosternal goitre, sympathectomy, splanchnicectomy, oesophagectomy, lung biopsy and diagnostic procedures. The time taken was acceptable with minimum blood loss and selective use of intercostal drainage. There were no conversions. Intensive care was needed only for oesophagectomy, thymectomy and excision of retrosternal goiter. The need for narcotic analgesics was minimal. Feeding, mobilization and discharge from hospital were early except after oesophagectomy. There was a mortality of 13% in the oesophagectomy group. No morbidity or mortality was recorded among others. Conclusion Thoracoscopy permitted a wide range of surgeries to be done safely with reduced morbidity. DOI: http://dx.doi.org/10.4038/sljs.v32i1.6869 The Sri Lanka Journal of Surgery 2014; 32(1): 29-34

Renal Nerve Ablation for Resistant Hypertension

Sympathetic renal denervation, or renal nerve ablation (RNA), has become the new buzz word in hypertension and interventional cardiology. Recent advances in catheter-based approaches have allowed sympathetic fiber interruption through transvascular techniques that are minimally invasive and can be delivered expeditiously and safely. Radiofrequency (RF) energy sources are currently the preferred modalities, but other sources of energy, such as cryoablation, microwave, high-intensity focus ultrasound, and local neurotoxic agent infusion, are under intense investigation. Results thus far have been encouraging and offer promise for the future. The role of the sympathetic nervous system (SNS) in the development of resistant hypertension and cardiovascular disease has long been known, and a great deal of work has been done through the years trying to explore potential interventions to interrupt the sympathetic influence on systemic vasculature and target organs. In this article we attempt an overview of time-dependent interventions on the SNS and examine approaches used in humans and in the many experimental models that offer a better understanding of the role of sympathetic activity in cardiovascular disease. Naturally we focus on methods and techniques addressing sympathetic renal denervation in patients with drug-resistant hypertension, examine the current state of the art, and attempt a look into the future. In 1889, after meticulous experiments on dogs, Bradford1 reported that stimulation of dorsal and splanchnic nerves causes changes in blood pressure (BP) and kidney size measured by plethysmography. Whether BP increased or decreased depended on the anatomic area stimulated, as well as the electric impulse frequency, but outcomes were consistent and reproducible. Neurosurgical treatment of hypertension was independently suggested by researchers in 1923.2 Adson, however, was the first to performed surgical sympathectomy for the treatment of malignant hypertension in 1925.3 During the following years and in the 1930s, Peet in Ann Arbor, Page and …

René Leriche and "Philosophy of Surgery" in the light of contemporary medical ethics.

Prof. Dr. René Leriche was a famous French surgeon who lived between 1879 and 1955. After working as a vascular surgeon in Lyon, he was appointed professor at the University of Strasbourg in 1924 and later the Paris Collége de France in 1937. Leriche had proposed vascular patches as the ideal treatment for obliterated vascular segments and advocated the necessity of sympathectomy in arterial diseases in the 1920s. He defined "Leriche Syndrome" in 1923 which is known by his name and which develops as a result of incomplete obstruction of the aortic bifurcation. René Leriche wrote a monograph entitled "La Chirurgie de la Douleur-Pain Surgery" in 1940 and he also became a pioneer in the sympathectomy procedure for pain treatment. René Leriche focused on topics that must be remembered again today, including surgery advanced into science, the physiological basis of surgery, research methods, as well as issues such as business technology, humanity in surgery, surgical essence and surgeon's qualifications in the book entitled "La Philosophie de la Chirurgie-Philosophy of Surgery" that he wrote in 1951. In this review, the issues that Prof. Dr. René Leriche addressed in middle of the 20(th) century were revised in the light of contemporary medical ethics.

Sensory and Autonomic Innervation of the Cervical Intervertebral Disc in Rats

An immunohistological analysis of the cervical intervertebral disc (IVD). To investigate sensory and autonomic innervation of the rat cervical IVD. Many clinicians are challenged with treating wide-ranging chronic neck pain. Several authors have reported that sympathetic nerves participate in chronic pain, and various sympathectomy procedures can effectively treat chronic pain. The neuro-tracer Fluoro-gold (FG) was applied to the anterior surfaces of C5-C6 IVDs from 10 Sprague-Dawley rats to label the neurons of the innervating dorsal root ganglion (DRG), stellate ganglion (SG; sympathetic ganglion), and nodose ganglion (NG; parasympathetic ganglion). Seven days postsurgery, DRGs from level C1-C8, SG, and NG neurons were harvested, sectioned, and immunostained for calcitonin gene-related peptide (CGRP; a marker for peptide-containing neurons) and isolectin B4 (IB4; a marker for nonpeptide-containing neurons). The proportion of FG-labeled DRG neurons that were CGRP-immunoreactive (CGRP-IR), IB4-binding, and non-CGRP-IR and IB4-binding, and the proportion of FG-labeled SG neurons and NG neurons were calculated. FG-labeled neurons innervating the C5-C6 IVD were distributed throughout the C2-C8 DRGs. The proportions of FG-labeled DRG neurons that were CGRP-IR, IB4-binding, non-CGRP-IR and IB4-binding, as well as SG neurons, and NG neurons were 20.6%, 3.3%, 55.7%, 8.9%, and 11.5%, respectively. The proportion of CGRP-IR FG-labeled DRG neurons was significantly higher than the proportion of IB4-binding FG-labeled DRG neurons at each level (P < 0.05). The C5-C6 IVD was innervated multisegmentally from neurons of the C2-C8 DRG, SG, and NG. Overall, 79.6% of the nerve fibers innervating the IVD were sensory nerves and 20.4% were autonomic nerves. Furthermore, 23.9% of the nerve fibers innervating the IVD were afferent sensory pain-related nerves, 8.9% were efferent sympathetic nerves, and 11.5% were efferent parasympathetic nerves. These findings may explain the wide-ranging and chronic discogenic pain that occurs via the somatosensory and autonomic nervous system.

Anestesia para simpatectomía torácica por videotoracoscopia en régimen ambulatorio o corta estancia: experiencia en 445 casos

To demonstrate the safety of outpatient or short-stay bilateral videothoracoscopy-assisted thoracic sympathectomy. The medical records of 445 who underwent bilateral videothoracoscopy-assisted thoracic sympathectomy were reviewed; the same protocols were used to guide these outpatient or short-stay procedures in all cases. Intravenous anesthesia was provided. An orotracheal tube allowed for carrying out the sympathectomy procedure during short periods of apnea. A 2% lidocaine solution was infused through the thoracic drains, which were removed soon after surgery. Data on intraoperative respiratory variables, pain, and intra- and postoperative complications were gathered. The data for patients undergoing the procedure on an outpatient or short-stay basis were compared. No significant differences in demographic or perioperative variables were found between the 2 groups. In 3.6% of the patients in the series, there was a record of a postoperative pulmonary complication: 4 therapeutic minithoracotomies; 1 subcutaneous emphysema without radiologic changes; 9 residual pneumothoraces, 2 requiring pleural drainage; 1 chylothorax; and 1 delayed hemothorax. With the exception of the late-developing hemothorax, all complications were diagnosed and treated in the immediate postoperative period. In the outpatient surgery group, unplanned admissions because of patient refusal to leave occurred in 6.5% of the cases. The low incidence of complications, and especially the finding that complications are detected in the early recovery period, indicate that this procedure can be performed on an outpatient basis.

Minimally invasive endoscopic-assisted posterior thoracic sympathectomy

Palmar hyperhidrosis is a disorder of the autonomic nervous system characterized by excessive perspiration of the palms, but may involve other body parts as well. Traditional posterior approaches have been performed less often in favor of less invasive thoracoscopic sympathectomies, which have a high success rate with low associated morbidity. However, some patients are not candidates for a transthoracic surgery and may need an alternative treatment strategy. In situations in which a posterior approach may be necessary, the authors have developed a minimal access endoscopic-assisted dorsal sympathectomy procedure, applying minimally invasive spine muscle splitting techniques. The authors believe that the development of this technique may help to minimize surgical morbidity associated with the traditional posterior approach by reducing pain, tissue damage, and length of postoperative recovery. This paper is a report on the successful treatment of palmar hyperhidrosis using a minimally invasive posterior technique and describes the surgical approach and outcomes in 2 patients who have been treated in this manner. Two patients underwent minimally invasive endoscopic-assisted posterior thoracic sympathectomy for hyperhidrosis. Both patients experienced relief of their symptoms after surgery with follow-up durations of 32 and 9 months and length of stays of 0.9 and 2.8 days, respectively. One patient suffered a unilateral Horner syndrome and underwent an eyelid lift. The other patient was readmitted to the hospital 2 days after discharge with atelectasis. She was obese and suffered from chronic obstructive pulmonary disease at baseline, which were reasons she opted for a posterior approach. Neither patient suffered a pneumo- or hemothorax. Minimally invasive endoscopic-assisted posterior thoracic sympathectomy can be safely performed for relief of hyperhidrosis. The procedure has risks for the usual complications of sympathectomy. This technique may provide an alternative to thoracoscopic approaches, especially in those patients with pulmonary disease or obesity.

Thorascopic Sympathectomy Performed Using Laser

Thorascopic sympathectomy is accepted as an effective treatment for palmar hyperhidrosis, facial blushing and to a lesser extent for digital ischaemia and axillary hyperhidrosis. Data were collected retrospectively on patients undergoing thorascopic sympathectomy at St Peter's Hospital between 1987 and 2006. Patients were followed up by telephone interview. A total of 233 thorascopic sympathectomy procedures were performed by a single operator in 123 patients. Ages ranged from 9-71 years and 75 were women. In patients, 105 had a bilateral and 13 a unilateral procedure, 5 patients had a bilateral procedure performed in two stages. In 6 upper limbs, the procedure could not be done. Overall, 110 patients (90%) had the procedure performed for palmar hyperhidrosis, 8 (6%) for facial blushing and in 5 (4%) patients the operation was performed for digital ischaemia with tissue loss. There were no deaths and all patients were discharged on day 1 following the procedure. Complications included bleeding (2), pulmonary oedema (1) and failed procedure (2); however, no incidences of Horner's syndrome occurred. Only 40 of 123 (32.5%) patients gave follow-up information. Of this small group, 33 of 40 (83%) were cured, 4 of 40 (10%) were better, 2 of 40 (5%) were unchanged and 1 patient was worse. Only 22 out of 40 (55%) of these patients were troubled by compensatory sweating, with only 4 of 40 (10%) reporting this as a major problem. Thorascopic sympathectomy is safe and can be carried out as a single bilateral procedure in the majority of cases. The laser allows the use of a single port, requires less dissection than surgical or clipping techniques, is more precise than diathermy and may be less likely to cause a Horner's syndrome.

A 7‐year Experience with Thoracoscopic Sympathectomy for Critical Upper Limb Ischemia

Severely symptomatic arterial insufficiency of an upper limb not suitable for revascularization is a difficult condition to manage. Thoracoscopic sympathectomy (TS) can be an effective procedure in this setting. Our experience with 18 consecutive thoracoscopic sympathectomy (TS) procedures over a period of 7 years has been reviewed. Indications, operative technique, complications, and outcome of surgery are analyzed. We performed 18 TS procedures on 17 patients during this period. There were no deaths. One patient had intraoperative hemorrhage necessitating conversion to open thoracotomy. Mean postoperative hospital stay was 2.3 days. Follow-up ranged from 6 to 72 months. All patients demonstrated clinical benefit from the procedure. Thoracoscopic sympathectomy is a useful option in patients with severely symptomatic hand and digital ischemia from occlusive small arterial disease like thromboangitis obliterans.

Cervico-thoracic ganglion: Its clinical implications

Lesions of the cervicothoracic ganglion (CTG) result in interruption of sympathetic fibers to the head, neck, upper limb, and thoracic viscera. The accurate understanding of the anatomy of the CTG is relevant to sympathectomy procedures that may be prescribed in cases where conventional intervention has failed. This study documents the incidence and distribution of the CTG to avoid potential complications such as Horner's syndrome and cardiac arrhythmias. This study utilized 48 cadavers, in which a total of 89 sympathetic chains were dissected. The inferior cervical ganglion (ICG) and the first thoracic ganglion was fused in 75 cases (84.3%) to form the CTG. It was present bilaterally in 48 of these specimens (65.3%). Three different shapes of CTG were differentiated, viz. spindle, dumbbell, and an inverted "L" shape. The dumbbell and inverted "L" shapes demonstrated a definite "waist" (i.e., a macroscopically visible union of the ICG and T1 components of the CTG). Rami from the CTG was distributed to the brachial plexus, the subclavian and vertebral arteries, the brachiocephalic trunk, and the cardiac plexus. This study demonstrates a high incidence of a double cardiac sympathetic nerve arising from CTG. It is therefore imperative that in the technique of sympathectomy, for intractable anginal pain, the surgeon excises both these rami but does not destroy the ganglion itself. The ever-improving technology in endoscopic surgery has made investigations into the nuances of the anatomy of the sympathetic chain essential.

Impedance Cardiography

Endoscopic thoracic sympathectomy (ETS) is a minimally invasive procedure for treating palmar hyperhidrosis (PH). Hemodynamic changes are associated with CO(2) insufflation during ETS. In the present study, we examined hemodynamic changes during general anesthesia using impedance cardiography (ICG) monitor. Seventeen adult patients (15 males) scheduled to undergo elective unilateral ETS for treatment of PH were enrolled in the study. Patients with cardiorespiratory diseases were excluded from the study. Their age and weight mean values were 26.5 +/- 5 years, 71.9 +/- 11.5 kg, respectively. Besides routine monitoring, impedance cardiography monitor was used to measure cardiac output (CO), cardiac index (CI), stroke volume (SV), thoracic fluid content (TFC), and systemic vascular resistance (SVR). Three phases were defined for data collection: A, prior to CO(2) insufflation; B during gas insufflation (at 10, 5, and 2 mm Hg intrathoracic pressures); and C, after gas deflation. Repeated-measures analysis of variance (ANOVA) was used for statistical analysis and post hoc Bonferroni test for multiple comparisons of the data obtained. For all comparisons, P < 0.05 was considered significant. Systemic vascular resistance significantly increased at stages B10 and 5 compared with stage A mean value (P < 0.05). CO, CI, and SV mean values decreased significantly at stage B compared with stage A mean values. The mean values of thoracic fluid content at stages A, B10, 5, 2, and C were 33 +/- 5, 30.6 +/- 3.5, 31 +/- 3.4, 31.6 +/- 3.3, and 32.5 +/- 6.8/kOmega, respectively with significant differences (P < 0.05). Significant reductions of cardiac parameters were reported in the present study, but they were of minimal clinical significance. Of interest was the significant reduction of thoracic fluid content during CO(2) insufflation, whether it correlates to the magnitude of compression, caused by CO(2) insufflation accompanied by high systemic vascular resistance or sympathectomy procedure, yet to be further studied.

Palmar Skin Blood Flow and Temperature Responses Throughout Endoscopic Sympathectomy

Thoracic surgical sympathectomy is often performed to treat primary palmar and axillary hyperhidrosis. An increase in palmar skin temperature is frequently used to identify the success of the procedure. Because changes in palmar skin temperature occur secondary to changes in skin blood flow, the objective of this study was to test the hypothesis that monitoring palmar skin blood flow would provide greater temporal resolution relative to monitoring palmar skin temperature. In 11 patients with palmar and/or axillary hyperhidrosis, we measured palmar skin temperature and blood flow (via laser Doppler flowmetry) throughout the sympathectomy procedure. Five minutes after the initial cautery, skin blood flow increased from 48 +/- 7 perfusion units to 121 +/- 17 perfusion units (P <0.001), whereas no significant change in temperature was observed (31.0 degrees C +/- 0.5 degrees C to 31.3 degrees C +/- 0.5 degrees C; P >0.05). The time required to reach peak skin blood flow (22 +/- 3 min) was significantly less than the time required to reach peak skin temperature (34 +/- 0.3 min; P <0.001). Finally at 5, 10, and 15 min after the initial cautery, skin blood flow increased to a larger percentage of the total increase in skin blood flow relative skin temperature (all P <0.006). These data suggest that monitoring skin blood flow provides greater temporal resolution when compared with monitoring skin temperature during thoracic sympathectomy. However, the initial cautery of the parietal pleura over the ganglion may result in increases in skin blood flow before physical disruption of the ganglion. This occurrence may limit the utility of skin blood-flow measurements in identifying the success of the procedure.

Palmar hyperhidrosis: intraoperative monitoring with laser Doppler blood flow as a guide for success after endoscopic thoracic sympathectomy.

Video-assisted endoscopic thoracic sympathectomy is an effective surgical procedure for treating patients with palmar hyperhidrosis. An increase by more than 1 degrees C in palmar temperature has been observed to be predictive of good outcome. In this study, we investigated the use of palmar laser Doppler flowmetry as an intraoperative assessment of the efficacy of the operation. One hundred sixty-six patients underwent a total of 330 endoscopic thoracic sympathectomy procedures from March 1996 to June 2001. We studied 17 patients (15 men, 2 women) who underwent a total of 33 procedures. The patients' mean age was 27.07 +/- 7.92 years, and the mean hospital stay was 2.23 +/- 0.66 days. Mean baseline laser Doppler blood flow was 2.63 +/- 2.56 ml/min/100 g. After the procedure, mean blood flow increased significantly to 7.24 +/- 5.88 ml/min/100 g (r = 0.768, P < 0.000, 95% confidence limit, -6.1060, -3.0946), a 232.18 +/- 219.12% increase. Mean palmar temperature increased to 1.44 +/- 1.44 degrees C. All patients experienced relief after the operation. Compensatory hyperhidrosis occurred in 10 (58.8%) of 17 patients. Monitoring of palmar laser Doppler blood flow changes is a useful adjunct during endoscopic thoracic sympathectomy surgery, and, when coupled with the established methods of endoscopic visualization and palmar temperature, it can predict the success of the procedure accurately.

Uniportal and Biportal Endoscopic Thoracic Sympathectomy

Sypathectomy for treatment of hyperhidrosis and pain syndromes of the upper extremities has recently evolved from invasive open procedures to endoscopic procedures. These minimally invasive techniques also have evolved, from complex staged procedures with multiple ports to more simplified biportal and uniportal procedures that require minimal tissue disruption and more limited yet effective sympathectomy procedures. We describe our techniques, experience, and results using endoscopic sympathectomy procedures with further reduced invasiveness, morbidity, and complications.