Ann Thorac Surg 1999;68:2361-2363
© 1999 The Society of Thoracic Surgeons
How to Do It
Clinical experience with video-assisted thoracic sympathectomy through the retrosternal pulmonary junction
Hidehiro Yamamoto, MDa,
Masayoshi Okada, MDa,
Akio Kanehira, MDb,
Akitoshi Yamada, MDa,
Munenori Kawamura, MDc
a Department of Surgery, Division II, Kobe University School of Medicine, Kobe, Japan
b Department of Surgery, Hyougo Hospital, Kobe, Japan
c Department of Surgery, Kyowa Hospital, Kobe, Japan
Address reprint requests to Dr Yamamoto, Department of Surgery, Division II, Kobe University School of Medicine, 7-5-2 Kusunoki-chou, Chuoku, Kobe, Japan 650-0017
 |
Abstract
|
|---|
A new technique of video-assisted thoracic sympathectomy through retrosternal pulmonary junction can be done safely using a scope guide and a flexible scope. Bilateral thoracic sympathectomy was performed, employing a single skin incision, in 18 patients with palmar hyperhidrosis. The advantages include minimal neuralgia and superior cosmesis.
|
Introduction
|
|---|
Video-assisted thoracic surgery (VATS) significantly reduces the length of skin incisions, compared to analogous thoracotomy, and results in less invasion and good cosmetic outcome. Endoscopic thoracic sympathectomy (ETS) is the simplest technique in VATS. Since palmar hyperhidrosis (PH) is frequent in Asians, a majority of ETS have been performed on patients with PH in Japan. The efficacy of ETS is very high (more than 98%) [1], and most surgeons are satisfied with the results. However, patients may not necessarily be satisfied because some experience postoperative pain and numbness, while others developed keroidal scars. We describe a bilateral ETS technique through a single skin incision on the left chest wall, which contributed to better cosmetic results.
|
Technique
|
|---|
The operation required the following equipment: (1) a double-lumen endobronchial tube for one-lung alternating ventilation; (2) a flexible digital bronchoscope (BFp-200, Olympus, Tokyo, Japan) and a digital monitor system (CV 200, CLV-U20D, and EVIP-230, Olympus, Tokyo, Japan); (3) a scope guide (Fig 1A); (4) a high-resolution video monitor and operative setup similar to that for usual VATS [2, 3]; (5) an electrocautery with a long, slender insulated electrode probe with a short, bare tip; (6) a KTP laser unit with a fiberoptic device measuring 0.6-mm in diameter and 20-mm in minimum bend radius, with an output power of 1 to 10 watts; and (7) a laser Doppler flow meter (PeriFlux PF 4001, Perimed, Stockholm, Sweden).
View larger version (84K):
[in this window]
[in a new window]
|
Fig 1. (A) The scope guide is a curved aluminum tube with an external diameter of 5.5 mm. There is some clearance between the flexible scope and internal lumen. There is a slit (arrow) in the middle through which air in the left pleural cavity can move into the right when right lung ventilation is switched to the left. (B) A postoperative photograph of the wound of a 20-year-old female with PH. The skin incision was determined, for its cosmetic outcome, by the patient preoperatively because the area could be covered by swimwear.
|
|
|
Patients and methods
|
|---|
Between July 1998 and December 1998, 18 patients with PH agreed to have this technique, and informed consent for operation was preoperatively obtained with the understanding that conversion to bilateral thoracotomy may be necessary. All patients underwent a preoperative evaluation with chest radiographs and computed tomography (CT).
The patients were all given general anesthesia through a double-lumen endotracheal tube and placed in a sitting position. The patients had the same preparation and general anesthesia for VATS techniques and analogous thoracostomy.
A skin incision of 6 mm was made on the fourth interocostal space of the anterior axillar line of the left chest wall (Fig 1B). After a brief pause in ventilation, the scope guide was inserted into the pleural space. The BFp-200 bronchoscope was placed into the pleural cavity through the scope guide. The inner surface of the chest wall was reached by angling the head using the flexible scope and scope guide, since the head of the bronchoscope could be controlled. With the relative positions of the anatomical landmarks found, including the azygos vein, and the first and second ribs with their costal vertebral junctions, we easily identified the sympathetic trunk. Fluorography was used to determine the sympathetic level. When the trunk was not clearly visible, the electrode probe, using the flexible scope, was applied to the presumed location of the trunk, which was located at the rib head region of the second, third, and fourth ribs. The trunk was located by palpating or feeling it as a vertical cord-like structure overlaying the rib head region. The presumed sympathetic segment was confirmed with the aid of its vasomotor response that resulted from electrical stimulation, and also by evaluating the change in temperature and microcirculation on the skin of the finger. A transient decrease in the microcirculation, without a change in temperature, of the finger in response to the electrocoagulation test, indicated that the proper sympathetic segment, including an occult nerve of the Kuntz branch [4] was stimulated (coagulation power at a low control setting was equivalent to 0.05 and 0.08 amperes from a Mera electrosurgical unit (MS7000SAS, Sneko Medical, Tokyo, Japan) (Fig 2). Subsequently, a stronger electric coagulation of 0.08 to 0.2 amperes or laser ablation (8 watts of KTP laser power for 1.0 second) was applied to the second ganglion and the sympathetic trunk on the second rib.
View larger version (15K):
[in this window]
[in a new window]
|
Fig 2. The value of perfusion from intraoperative monitoring using a laser Doppler flow meter demonstrated a remarkable and temporary decrease of microcirculation in the skin of the finger after a electrocoagulation test (arrow) of the sympathetic trunk.
|
|
A continued increase in microcirculation, along with a gradual elevation in finger temperature, indicated that a lesion was made on the correct target. A remarkable augmentation of microvascular perfusion and an elevation of temperature were noted, usually with an increase of more than 50% above the original level, in the laser Doppler perfusion unit and more than 2°C a few minutes later. This change was interpreted as the consequence of vasodilation resulting from sympathetic denervation. At this point, the sympathectomy was considered to be complete.
After ETS in the left side was performed, the scope guide was directed to the retrosternal pulmonary junction (Fig 3A). After a left mediastinal pleura, 10 mm in length, was incised using endoscopic cautery after a brief stop of ventilation, we could usually observe the movement of the right lung. Abnormal vessels were not recognized. Then, puncture of the right mediastinal pleura using the scope guide was performed after a brief stop of ventilation (Fig 3B). The scope guide could easily be guided into the right pleural cavity through the retrosternal pulmonary junction. After puncture, we started one lung ventilation of the left side. Right thoracic sympathectomy was performed in a similar fashion as on the left side. When no bleeding was confirmed, a chest drainage tube, 4.5 mm in external diameter (Gastric tube ST GT1410, Terumo, Japan), was placed into the right pleural cavity through the retrosternal pulmonary junction. Once lack of air leakage was noted, the chest drainage tube was removed from the right pleural cavity and then the tip of the tube was positioned in the left pleural cavity. When lack of air leakage from the left side was confirmed, the chest drainage tube was usually removed intraoperatively. The wound was then closed with one subcutaneous suture.
View larger version (99K):
[in this window]
[in a new window]
|
Fig 3. (A) The retrosternal pulmonary junction is usually noted in chest computed tomographic scan (arrow). There are usually thin bilateral parietal pleura and fat tissue. (B) A demonstration of this technique was performed using a cadaver. The arrow indicates the second thoracic sympathetic trunk. The scope guide brought an adequate visualization to the endoscopic thoracic sympathectomy.
|
|
|
Results
|
|---|
Patient ages ranged between 16 and 34 years. In a preoperative evaluation with chest radiographs and chest computed tomographic scan, all patients showed no anatomical abnormalities. There were no problems performing this technique in any of the patients. Operative bleeding was within 5 mL. In all patients except for one, the chest drainage tube was removed intraoperatively. The chest drainage tube in this patient was removed 30 minutes after operation, when lack of air leakage was confirmed. Complete alleviation of PH was noted in all 18 patients. There were no complications, including postoperative pneumothorax, hemithorax bleeding, Horner’s syndrome, gustatory sweating, and postoperative costal neuralgia. Wound pain was minimal. Compensatory hyperhidrosis over the trunk and thighs was mild and moderate, which was tolerable. There was no recurrence of PH between 6 and 11 months of follow-up (mean 8.1 months). All patients were discharged from the hospital on the second postoperative day.
|
Comment
|
|---|
A question may arise as to whether cauterization or laser ablation was adequate in this technique. In this technique, there was no pathological confirmation of ganglion tissue. In addition, if all of the ganglia were not destroyed, a return of symptoms may occur. Our preliminary data consisted of a 3-year follow-up of 151 sympathectomies on 81 patients with PH. All had undergone sympathectomies using the same manner in the left side. A recurrence was noted in one patient’s hand during the first year and in 4 hands at 3 years of follow-up. We thought that the judgment of sympathectomy, evaluated by the change in temperature and microcirculation on the skin of the finger, was adequate.
Since PH is a benign disease, surgical interventions must be a safety technique. Any complications relating to the operation will effect the value of ETS. Postoperative keroidal scars will also reduce patient satisfaction, since patients with PH are looking to ETS to improve their quality of life. Specifically, the number and length of skin incisions may affect postoperative cosmetic results, which relate to the patient’s quality of life. We believe that this technique improves the patient’s cosmetic outcome. We believe the combination of a flexible scope and a scope guide provide some advantages [5]. We have performed lung wedge resection in more than a 100 cases through a single small skin incision (18 mm) using a flexible scope. This technique contributed to not only less invasive operation but also to patient cosmetic outcome. Since cosmetic results are of great importance to the patient, we believe it will become a important operative factor in the future.
Reduction of surgical invasion is a continuous problem which has to be considered. VATS has been accepted to be a less invasive technique than conventional thoracotomy. Factors of surgical invasion are thought to include location, number, length, and depth of incisions. The retrosternal pulmonary junction is usually composed of bilateral parietal pleura and thin fat tissue. The location has not been used for endoscopic operation, but the thickness is usually thinner than the chest wall. When some structure such as the thymus is noted, this technique is considered to be inappropriate. When the puncture is to the chest wall, there is a possibility of intercostal nerve injury, but there is not in the retrosternal pulmonary junction. Also, the thickness of the retrosternal pulmonary junction is thinner than chest wall. We concluded that there was less surgical invasion through the retrosternal pulmonary junction than through the chest wall. We believe that the performance of a single skin incision is worthy of using a scope guide, through the retrosternal pulmonary junction, in order to reduce the surgical invasion and improve cosmetic outcomes.
The limitations of this technique include pneumopleural adhesions, thick width of the retrosternal pulmonary junction, and anatomical abnormalities on chest computed tomographic scan. We do not think that safety is sacrificed when these limitations are maintained. We did not experience any intraoperative complications, but we were ready to make additional skin incisions in the right chest at any sign of trouble, which would be difficult to deal with in the right pleural cavity.
We conclude that bilateral ETS could be performed through retrosternal pulmonary junction using a flexible scope and a scope guide. In addition, bilateral ETS from one side with a small skin incision (6 mm) resulted in minimal neuralgia and an improvement in cosmesis.
|
Acknowledgments
|
|---|
The authors gratefully appreciate the operative assistance of Yoshimasa Nishio, MD, and Hidetsugu Sekino, MD.
|
References
|
|---|
-
Shachor D., Jedeikin R., Olsfanger D., et al. Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis. Arch Surg 1994;129:241-244.[Abstract/Free Full Text]
-
Landreneau R.J., Mack M.J., Hazelrigg S.R., et al. Video-assisted thoracic surgery. Ann Thorac Surg 1992;54:800-807.[Abstract]
-
Josephs L.G., Menzoiam J.O. Technical considerations in endoscopic cerviothoracic sympathectomy. Arch Surg 1996;131:355-359.[Abstract/Free Full Text]
-
Kuntz A. Distribution of the sympathetic rami to the brachial plexus. Arch Surg 1927;15:871-877.[Abstract/Free Full Text]
-
Yamamoto H., Okada M., Takada M., et al. Video-assisted thoracic surgery through a single skin incision. Arch Surg 1998;133:145-147.[Abstract/Free Full Text]
Accepted for publication July 8, 1999.
This article has been cited by other articles:
|
|
|
|
 
H. Yamamoto, A. Kanehira, M. Kawamura, M. Okada, and Y. Ohkita
Needlescopic surgery for palmar hyperhidrosis
J. Thorac. Cardiovasc. Surg.,
August 1, 2000;
120(2):
276 - 279.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
