Ann Thorac Surg 2000;70:240-242
© 2000 The Society of Thoracic Surgeons
Original articles: General thoracic
Needlescopic thoracic sympathectomy: treatment for palmar hyperhidrosis
Peter M.Y. Goh, FRCSa,
Wei-Keat Cheah, FRACSa,
Mark De Costa, FRCSa,
Eugene K.W. Sim, FRCSa
a Minimally Invasive Surgical Center and Cardiac Center, Department of Surgery, National University Hospital, Singapore, China
Address reprints to Dr Goh, Minimally Invasive Surgical Center, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074
e-mail: surgohmy{at}nus.edu.sg
 |
Abstract
|
|---|
Background. Open thoracic sympathectomy has been the established option for patients with essential hyperhidrosis. Recently, video-assisted endoscopic sympathectomy has provided a simple, safe, reliable, and cost-effective alternative to the earlier technique. With advances in instrumentation, performing the procedure through 2-mm and 3-mm needlescopic ports is now possible. The authors evaluate the effectiveness of so-called needlescopic thoracic sympathectomy for the treatment of primary hyperhidrosis.
Methods. Thirty five consecutive patients with a mean age of 24 years, including 23 men and 12 women, underwent bilateral needlescopic thoracic sympathectomies at the National University Hospital of Singapore.
Results. The mean operative duration was 56 minutes, and the mean hospital stay was 1.2 days. In no patient did Horner’s syndrome or significant pneumothorax develop. The rate of success, defined as completely dry hands, was 97%. Two patients had unilateral recurrences that responded well to repeat needlescopic sympathectomies. We performed a total of 72 sympathectomies.
Conclusions. Our study demonstrates that the use of miniature port access sites produces excellent medical and cosmetic results and is associated with a short hospital stay and low risk of complications.
|
Introduction
|
|---|
The distressing symptoms of primary upper limb hyperhidrosis, or excessive sweating of the palms and axilla, can be treated by thoracic sympathectomy of the dorsal ganglia. The traditional open transthoracic approach through a lateral thoracotomy, which produces much trauma and pain, has been replaced in recent years by the video-assisted thoracoscopic approach. Even then, the operation has been done using 5-mm and 10-mm port access sites that still produced considerable pain and visible scarring. We describe our technique and evaluate the results of using tiny 2-mm and 3-mm needlescopic instruments through two miniature port sites for patients requiring thoracoscopic sympathectomy.
|
Material and methods
|
|---|
Patient characteristics
Of the 35 patients who underwent bilateral needlescopic sympathectomy included in this study, 23 were male and 12 female. Their average age was 24 years. All had experienced disabling hyperhidrosis of their palms since adolescence and had undergone medical therapy with topical agents without much improvement. The patients reported that the symptoms had significantly affected their work or social conditions. None had any lung or medical conditions such as thyrotoxicosis. All patients were admitted to hospital for the procedure.
Procedure
Prospective data were collected on patients who between 1996 and 1998 underwent bilateral so-called needlescopic thoracic sympathectomies for bilateral palmar hyperhidrosis. The operative times, hospital stays, recurrences, and complications were recorded. We used the following procedure: General anesthesia was given and a double-lumen endotracheal tube inserted. The patient was placed in the lateral position with the arm flexed over the head to expose the axilla. A finger temperature probe was used to record the rise in peripheral cutaneous temperature that results following the sympathectomy. The surgeon stood on the side facing the patient. Following deflation of the ipsilateral lung, a small skin puncture was made for insertion of a 3-mm cannula sheath (Ethicon, Cincinnati, OH), which was directed over the superior border of the forth rib in the midaxillary line into the thorax. With this form of "closed" insertion, we took great caution in patients who might have had a history of lung conditions or adhesions and were therefore at increased risk of injury to the lung. Carbon dioxide was insufflated under low pressure of 8 mm Hg. A 3-mm needlescope (Karl Storz, Tuttlingen, Germany) was introduced through the sheath to view the thoracic cavity and the sympathetic chain. With the patient in the lateral position and the lung collapsed, the view is unobstructed and clear. Next, a 2-mm trocar and sheath (MIST, Smithfield, NC) were inserted over the fifth rib in the posterior axillary line, through which a ball-tipped electrocautery (MIST, Smithfield, NC) was introduced. Instead of performing a ganglionectomy, we completely cauterized the ganglion over the neck of the rib with coagulation diathermy from the superior edge of the rib to just above the inferior edge (Fig 1). That was done at the second rib for ablation of the T2 ganglion and at the third rib for ablation of the T3 ganglion. The cautery was directed precisely over the nerve fibers so that the adjacent intercostal nerve or blood vessels would not be injured. The important stellate ganglion (Tl) was avoided because injury to it results in Horner’s syndrome. For axillary hyperhidrosis, the two-level ablation was adequate. We avoided going lower because that would increase the risk that compensatory hyperhidrosis would develop. After we achieved complete ablation of the ganglia—indicated by peripheral vasodilation, warm and dry hands, and a rise in cutaneous temperature of over 1°C within 5 to 10 minutes—the lung was inflated under direct vision, the carbon dioxide was released, the cannula sheaths were removed, and the minute wounds were opposed with steristrips. No intercostal drain was needed because the carbon dioxide is rapidly absorbed. For a bilateral sympathectomy, the patient was then positioned on the other side and a similar procedure carried out. A chest film was obtained to check for any residual pneumothorax.
|
Results
|
|---|
The average duration of each bilateral procedure was 56 minutes, and the mean increase in the temperature probe was 1.2°C. Nearly all patients were discharged from hospital the next day and the average postoperative hospital stay was 1.2 days. All but 2 patients had complete relief of sweating, resulting in drier and warmer hands. The overall success rate of the 70 sympathectomies was 97%. Of the 2 patients in whom the procedure was not successful, 1 had a unilateral recurrence of palmar sweating and the other had a unilateral recurrence of axillary sweating; both recurrences became apparent after about 3 months. The patients underwent repeat needlescopic sympathectomies and achieved good results. In the first patient, we identified and ablated the nerve of Kuntz, the fibers of which pass from the first to the second ganglion, thus creating a neurophysiologic shunt. In the second patient, who had experienced axillary sweating, the third ganglion was found to be incompletely ablated; following complete division, the patient’s symptoms abated completely. Neither Horner’s syndrome nor significant pneumothoraces needing treatment with a chest tube developed in any patient. Compensatory hyperhidrosis that especially affected the lower abdomen and thighs developed in 12 patients, but none of whom were significantly distressed. In general, patients felt that symptomatic relief was excellent. Pain after the operation did not appear to be severe: 30 patients consumed on average one dose of oral analgesia postoperatively, and the other 5 needed no analgesia. The wounds were small and required no suturing. The final cosmetic result was excellent (Fig 2). At follow-up (mean, 8 months), all patients maintained dry hands.
|
Comment
|
|---|
Video-assisted thoracoscopic sympathectomy is a progression from open thoracic sympathectomy, and the needlescopic procedure is a further refinement. Since its introduction, this popular technique has revolutionized the treatment of primary hyperhidrosis. Video-assisted needlescopic sympathectomy provides excellent anatomical exposure without the need for a morbid incision [1]. The excellent view of the ganglion, together with adequate magnification, allows for the precise ablation of the ganglion and results in lower incidences of Horner’s syndrome when endoscopic treatment is compared to open sympathectomy through the transaxillary or supraclavicular approaches [2]. This is consistent with our series that had no complications of Horner’s syndrome. The needlescopic procedure avoids encountering great vessels and major organs such as the heart and lungs. The safety of this minimally invasive technique is evidenced by the absence of injuries to major blood vessels and intercostal vessels, and the low rate of significant pneumothorax. The immediate results of thoracoscopic sympathectomy are excellent, producing dramatic diminution of sweating of the palms and axilla; more than 95% of patients report satisfaction [3]. Those findings are consistent with our results. Excision of a segment of the sympathetic chain, compared with ablation alone, may improve long-term results and reduce recurrences, but longer follow-up periods are needed to determine efficacy. Improper identification of the target ganglion has been reported as one of the major causes of failure in immediate symptomatic relief, whereas extensive resection distal to the T4 ganglion will lead to severe compensatory hyperhidrosis [4–6]. It is recognized that compensatory truncal sweating occurs in more than half of patients, some of whom are significantly affected [7]; that finding prompted us to discourage ablating any ganglia lower than T3. We believe that the reduction in the number of port sites and reduction in the sizes of the incision to just 2-mm and 3-mm will contribute to lower morbidity rates, general relief to the patients, less pain, and excellent cosmetic effects. There may be less risk of injuring the intercostal structures during the insertions of these slim instruments than during insertion of the 5-mm and 10-mm instruments. The resulting imperceptible wounds left by the smaller instruments are hardly visible after a few months. The short discharge period and early return to work should in turn lead to significant financial benefits. The needlescopic instruments we use are a further refinement of the older, larger laparoscopic devices, being relatively thin but achieving similar results. (Fig 3). Although the slimmer instruments may be liable to bend with rough handling, we have not found that to be a problem in this procedure. The 3-mm needlescope offers a clear view of the sympathetic chain, and new-generation 2-mm scopes are also adequate to the task. With an ever-expanding list of needlescopic instruments, including grasping forceps, scissors, and suction-irrigation devices, more needlescopic procedures such as cholecystectomy, inguinal hemiorrhaphy, appendectomy, and fundoplication are being performed [8, 9]. In conclusion, needlescopic thoracic sympathectomy is a safe, reliable, cost-effective, easy, and quick way to treat hyperhidrosis, providing low morbidity, short hospital stay, and an excellent cosmetic result. It is the least invasive available technique for performing a sympathectomy, and it should be considered a standard of reference for other sympathectomies.
View larger version (76K):
[in this window]
[in a new window]
|
Fig 3. Needlescopic instruments, including 3-mm needlescope, 2-mm diathermy probe, and 3-mm needle port.
|
|
|
References
|
|---|
-
Kux M. Thoracic endoscopic sympathectomy in palmar and axillary hyperhidrosis. Arch Surg 1978;113:264-266.[Abstract/Free Full Text]
-
Josephs L.G., Menzoin J.O. Technical considerations in endoscopic cervicothoracic sympathectomy. Arch Surg 1996;131:355-359.[Abstract/Free Full Text]
-
Drott C., Claes G. Hyperhidrosis treated by thoracoscopic sympathectomy. Cardiovasc Surg 1996;4:788-790.[Medline]
-
Bryne J., Walsh T.N., Hederman W.P., et al. Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis. Br J Surg 1990;77:104-109.
-
Moran K.T., Brady M.P. Surgical management of primary hyperhidrosis. Br J Surg 1991;78:270-283.[Medline]
-
O’Riordain D.S., Maher M., Waldron D.J., et al. Limiting the anatomic extent of upper thoracic sympathectomy for primary palmar hyperhidrosis. Surg Gynecol Obstet 1993;176:151-154.[Medline]
-
Andrews B.T., Rennie J.A. Predicting changes in the distribution of sweating following thoracoscopic sympathectomy. Br J Surg 1997;84:1702-1704.[Medline]
-
Goh P.M.Y., Alponet A., Kum C.K. Super minimally invasive laparoscopic cholecystectomy. Asian J Surgery 1998;21:12-14.
-
Gagner M. Needlescopic surgery. Chir Int 1996;3:1-2.
Accepted for publication November 15, 1999.
This article has been cited by other articles:
|
|
|
|
 
G. F. Tassi, R. J. O. Davies, and M. Noppen
Advanced techniques in medical thoracoscopy.
Eur. Respir. J.,
November 1, 2006;
28(5):
1051 - 1059.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. O. Murphy, J. Ghosh, N. Khwaja, D. Murray, A. T. Halka, A. Carter, N. J. Turner, and M. G. Walker
Upper dorsal endoscopic thoracic sympathectomy: a comparison of one- and two-port ablation techniques.
Eur. J. Cardiothorac. Surg.,
August 1, 2006;
30(2):
223 - 227.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. M. Dewey, M. A. Herbert, S. L. Hill, S. L. Prince, and M. J. Mack
One-Year Follow-Up After Thoracoscopic Sympathectomy for Hyperhidrosis: Outcomes and Consequences
Ann. Thorac. Surg.,
April 1, 2006;
81(4):
1227 - 1233.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. D.L. Sihoe, C. S.K. Cheung, H.-K. Lai, T.-W. Lee, K.-H. Thung, and A. P.C. Yim
Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis
Eur. J. Cardiothorac. Surg.,
February 1, 2005;
27(2):
313 - 319.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. P. Georghiou, M. Berman, V. Bobovnikov, B. A. Vidne, and M. Saute
Minimally invasive thoracoscopic sympathectomy for palmar hyperhidrosis via a transaxillary single-port approach
Interactive CardioVascular and Thoracic Surgery,
September 1, 2004;
3(3):
437 - 441.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. Doolabh, S. Horswell, M. Williams, L. Huber, S. Prince, D. M. Meyer, and M. J. Mack
Thoracoscopic sympathectomy for hyperhidrosis: indications and results
Ann. Thorac. Surg.,
February 1, 2004;
77(2):
410 - 414.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Lardinois and H.B. Ris
Minimally invasive video-endoscopic sympathectomy by use of a transaxillary single port approach
Eur. J. Cardiothorac. Surg.,
January 1, 2002;
21(1):
67 - 70.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M.-C. Kao
Video thoracoscopic sympathectomy with intraoperative monitoring of Palmar skin temperature for Palmar hyperhidrosis
Ann. Thorac. Surg.,
November 1, 2001;
72(5):
1801 - 1801.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
