Endoscopic Thoracic Sympathectomy

What is Thoracic Sympathectomy?

It is a minimally invasive (VATS) procedure in which the sympathetic nerves inside the chest at the level of the second, third, or fourth ribs are divided.

When Would You Have a Thoracic Sympathectomy?

Thoracic Sympathectomy is used to treat hyperhidrosis, causalgia, and reflex sympathetic dystrophy of the upper extremities. Hyperhydrosis is a condition characterized by excess sweating of the hands and armpits. (Sometimes the feet, trunk, and face are involved.) Causalgia and Reflex Sympathetic Dystrophy are sub-types of Complex Regional Pain Syndrome (CRPS.) CRPS is characterized by severe, even disabling, pain that persists long after what would otherwise appear to be a healed injury.

How is it done? Thoracic Sympathectomy is a minimally invasive thoracic surgical procedure, done with the use of thoracoscopy, also known as VATS (Video Assisted Thoracic Surgery.) In our practice, we utilize 5 mm endoscopes, and three millimeter diameter instruments. These instruments are smaller than a soda straw, and allow us to use very small incisions, usually less than .25 inch each.

The patient is placed under general anesthesia, and positioned comfortably on their side. A quarter inch incision is made near the tip of the shoulder blade. Through this incision, a tiny endoscope, less than a quarter inch in diameter, is introduced into the chest between the ribs. The lung is retracted out of the way, and the sympathetic nerves are visualized with the endoscope. Through a second tiny incision, another small instrument, approximately one eighth inch in diameter, is introduced between the ribs. Using the endoscope to see, this instrument is used to divide the sympathetic nerves at the level of the second and third ribs.

The instruments are then withdrawn from the chest. The lung is allowed to re-expand to its normal position. Usually, a drain is not required. The results of the sympathectomy are apparent within minutes after the surgery.

The patient is observed for several hours in the outpatient recovery area, and then is discharged home. If a drain is required, the patient will spend the night.

Are there Risks With Endoscopic Thoracic Sympathectomy?

Risks include the general risks of surgery, and the specific risks of sympathectomy. Risks include those of general anesthesia, the small risk of wound infection, a small risk of bleeding, and a small risk of air leak from the lung that would require a drain and overnight hospital stay. The normal effects of thoracic sympathectomy are a dry hand and axilla (armpit). The hand will appear more flushed than prior to surgery.

A side effect of sympathectomy for palmar hyperhidrosis in some patients is the appearance of new hyperhidrosis on the chest wall or abdominal wall. This abdominal hyperhydrosis appears to be a compensatory form of sweating as a result of eliminating sweating of the hands and axillae. Although statistics vary, the incidence of compensatory abdominal hyperhydrosis ranges from three percent to 40 percent.

A risk of thoracic sympathectomy for causalgia is failure to eliminate the pain. There is a spectrum of results that is seen as a result of this treatment for causalgia. Some patients get excellent long term relief, some get partial relief, some get no relief.

The chief risk of sympathectomy is thermal injury to the Stellate Ganglion, a portion of the sympathetic nervous system that lies above the first rib. Injury to the Stellate Ganglion results in Horner’s Syndrome. Horner’s Syndrome includes dilation of the pupil and slight ptosis, or drooping of the eyelid, on the same side as the surgery.