Ann Thorac Surg 2010;90:1730-1731. doi:10.1016/j.athoracsur.2009.12.043
© 2010 The Society of Thoracic Surgeons
How to Do It
Sympathicotomy Under Local Anesthesia: A Simple Way to Treat Primary Hyperhidrosis
Jin Yong Jeong, MD*,
Hyung Joo Park, MD
Department of Thoracic and Cardiovascular Surgery, Korea University Medical Center, Ansan Hospital, Ansan, South Korea
Accepted for publication December 15, 2009.
* Address correspondence to Dr Jeong, Department of Thoracic and Cardiovascular Surgery, Korea University Medical Center, Ansan Hospital, 516 Gojan-Dong, Ansan, 425-707, South Korea (Email: cvvc2001{at}yahoo.co.kr).
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Abstract
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General anesthesia has been the standard approach for sympathicotomy to treat primary hyperhidrosis. Sympathicotomy through thoracoscopic guidance is a straightforward procedure with a short operation time. Therefore we propose using local anesthesia for the procedure. The advantages of local anesthesia include avoiding endotracheal intubation and systemic anesthetics, and allowing immediate assessment by means of verbal communication with the patient. We effectively treated primary hyperhidrosis in 3 patients by thoracoscopic sympathicotomy under local anesthesia.
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Introduction
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Primary hyperhidrosis is characterized by excessive sweating in certain areas of the body [1]. This abnormality is independent of thermoregulation. Thoracoscopic sympathetic surgery has been a widely accepted modality to treat primary hyperhidrosis [2]. Conventionally, sympathicotomy or sympathectomy has been performed routinely by means of general anesthesia with endotracheal intubation [2–6].
We propose that local anesthesia is suitable for thoracoscopic sympathicotomy. The three cases of primary hyperhidrosis that we describe in this article were treated under local anesthesia. We describe our novel technique and the results of the operations.
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Technique
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The procedure was performed under local anesthesia, free from endotracheal intubation. The patient was placed in the prone position and temperature probes (Skin Temperature Probe D-S18A [Exacon Scientific, Roskild, Denmark]) were applied on both palms. The local anesthetic (1% lidocaine) was infiltrated into the fifth intercostal space at the mid-axillary line for placement of a thoracoscopic trocar (MiniPort, 2 mm [Tyco Healthcare UK Ltd, Gosport, UK]). The thoracoscopic view was enhanced by CO2 insufflation into the pleural space. Another port for instrumentation was made in the third intercostal space on the mid-axillary line after lidocaine infiltration (Fig 1).
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Fig 1. The patient shown in the prone position with incisions for introduction of a thoracoscope and instrument into the lateral chest, and puncture of a spinal needle into the back of the chest.
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Once an adequate view of the thoracic sympathetic chain and ganglia in relation to the adjacent structures was obtained, the third rib (T3) level segment of the sympathetic chain was brought into focus. For local anesthesia of this T3 segment of the sympathetic chain, an 18-gauge spinal needle (18 G x 89 mm) (Hakko Co Ltd, Chikuma, Japan) was introduced through the second or third intercostal space on the paravertebral line from the patient's back, and 1% lidocaine was infiltrated extrapleurally (Fig 2).
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Fig 2. Right thoracic sympathicotomy at the level of T3 under local anesthesia. With the patient in the prone position, 1% lidocaine was infiltrated extrapleurally around the sympathetic chain. (Arrows = sympathetic chain; arrowheads = pleural bulging with extrapleural local anesthetic infiltration; T3 = third rib; T4 = forth rib.)
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The sympathetic chain at the level of T3 on the corresponding rib was transected with endo-scissors (2-mm Minishears [Auto Suture Company, Norwalk, CT]) and electrocautery (Fig 2).
The increase in the temperature of the ipsilateral palm after sympathicotomy was from 28.4 ± 2.9°C to 34.6 ± 1.1°C (mean ± standard error of the mean). Intrapleural air was evacuated through the ports with the patient's voluntary Valsalva maneuver. Re-expansion of the lung was visually confirmed. The patient was discharged on the day of surgery.
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Comment
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Thoracoscopic sympathetic surgery has been the technique of choice in treatment of primary hyperhidrosis. Several techniques have been advocated, including resection, transection, cauterization, and clipping of the nerve. These techniques yield equivalent success and complication rates [7]. In the majority of cases, the operation can be performed bilaterally. However, in some cases, a staged approach doing one side at a time is unavoidable, especially when single lung ventilation can not be tolerated [6, 7]. Treatment failure may necessitate reinterventions [2]. Some advocate sympathicotomy at the high level (T2) or at multiple levels to reduce the failure rate [2, 5–7], whereas others suggest selective sympathicotomy at the level of T3 or T4 to decease compensatory hyperhidrosis [3, 4]. However, sympathetic surgery requires general anesthesia. Problems related to general anesthesia include the need for endotracheal intubation and a considerable amount of time for recovery from anesthesia. The use of double lumen intubation to obtain single lung ventilation is cumbersome, and the tube may become malpositioned, resulting in hypoxemia [8].
Local anesthesia for thoracoscopic sympathicotomy at the T3 or T4 level is feasible, producing little patient discomfort, while facilitating quick recovery from the anesthesia. There are a number of advantages in comparison with general anesthesia. First, local anesthesia provides more comfort for patients who fear general anesthesia. Second, there are no systemic anesthetics or endotracheal intubation required. Third, communication between the patient and surgeon enables immediate result assessment, which facilitates easy decision making for reintervention during the procedure. Fourth, local anesthesia results in immediate recovery that permits outpatient surgery. Finally, there are reduced hospital costs. However, this approach may have a few limitations. Some of the patients may not tolerate the prone position. Other patients may not be able to adjust to the operating room atmosphere or be able to undergo the operation while being awake under local anesthesia. Proper patient selection will help alleviate these difficulties. The patient's prone position may result in limitation for intubation, but in our experience there have been no problems with the patient's breathing or other serious problems during the procedure. One important advantage with local anesthesia is that the operator can communicate with the patient during the operation. If a problem should arise, the operator can detect it immediately and act quickly during the procedure.
Recently, we performed three cases of sympathicotomy under local anesthesia. All 3 patients were satisfied with significant improvement in their sweating. None showed any adverse reactions to the procedure using local anesthesia.
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Acknowledgments
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The authors thank Ji Ho Yang, MD, for preparing the line drawing.
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References
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- Chwajol M, Barrenechea IJ, Chakraborty S, Lesser JB, Connery CP, Perin NI. Impact of compensatory hyperhidrosis on patient satisfaction after endoscopic thoracic sympathectomy Neurosurgery 2009;64:511-518.[Medline]
- Kwong KF, Hobbs JL, Cooper LB, Burrows W, Gamliel Z, Krasna MJ. Stratified analysis of clinical outcomes in thoracoscopic sympathicotomy for hyperhidrosis Ann Thorac Surg 2008;85:390-394.[Abstract/Free Full Text]
- Kim WO, Kil HK, Yoon KB, Yoon DM, Lee JS. Influence of T3 or T4 sympathicotomy for palmar hyperhidrosis Am J Surg 2009(in press).
- Liu Y, Yang J, Liu J, et al. Surgical treatment of primary palmar hyperhidrosis: a prospective randomized study comparing T3 and T4 sympathicotomy Eur J Cardiothorac Surg 2009;35:398-402.[Abstract/Free Full Text]
- Bachmann K, Standl N, Kaifi J, et al. Thoracoscopic sympathectomy for palmar and axillary hyperhidrosis: four-year outcome and quality of life after bilateral 5-mm dual port approach Surg Endosc 2009;23:1587-1593.[Medline]
- Moya J, Ramos R, Morera R, et al. Thoracic sympathicolysis for primary hyperhidrosis: a review of 918 procedures Surg Endosc 2006;20:598-602.[Medline]
- Inan K, Goksel OS, Ucak A, et al. Thoracic endoscopic surgery for hyperhidrosis: comparison of different techniques Thorac Cardiovasc Surg 2008;56:210-213.[Medline]
- Inoue S, Nishimine N, Kitaguchi K, Furuya H, Taniguchi S. Double lumen tube location predicts tube malposition and hypoxaemia during one lung ventilation Br J Anaesth 2004;92:195-201.[Abstract/Free Full Text]
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Abstract
Introduction
