内镜下胸交感神经切除术（图文演示）

中文版：内镜下胸交感神经切除术（中文图文演示）

ENDOSCOPIC   THORACIC   SYMPATHECTOMY
Authors
D Gossot
Abstract
The description of the endoscopic thoracic sympathectomy covers all aspects of the surgical procedure used for the management of palmar hyperhidrosis.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure of sympathetic nerve, division of nerve, bleeding, other complications, evaluation after division.
Consequently, this operating technique is well standardized for the management of this condition.

1. Introduction
Currently the main indication for endoscopic thoracic sympathectomy (ETS) is palmar hyperhidrosis. Rarer indications include vascular disorders and causalgia affecting the upper limbs.
In this chapter, we will focus on endoscopic sympathectomy as a surgical treatment for palmar hyperhidrosis, but the same technical principles apply for other indications.

2. Anatomy I

[点击按纽展开更多->收起->回放]

The trunk of the sympathetic nerve courses along the neck of the ribs. It is generally visible through the posterior mediastinal pleura, especially in young and thin patients. Occasionally, it is hidden by fatty tissue or fibrotic changes in the pleura.
Numerous intercostal vein branches usually course behind the nerve. In certain cases, these branches course anterior to the trunk, especially on the right side, which may be a problem during dissection.

[点击按纽展开更多->收起->回放]

Sympathetic trunk ganglia are generally situated in the intercostal spaces or, less often, at the inferior border of the corresponding rib.

[点击按纽展开更多->收起->回放]

The most important anatomical landmark in the procedure is the first thoracic (T1) ganglion, which is usually almost entirely hidden by a fat pad.

[点击按纽展开更多->收起->回放]

The T1 ganglion is part of the cervicothoracic chain that includes the last cervical (C8) ganglion. The latter is usually not visible in thoracoscopic procedures.

3. Anatomy II

[点击按纽展开更多->收起->回放]

Internodal nerve trunks run between the ganglia on the corresponding ribs. They are often both visible and palpable with endoscopic instruments.

[点击按纽展开更多->收起->回放]

The rami communicantes join at the dorsal border of each ganglion.
The common trunk of the gray rami communicantes is generally visible through the pleura at the point of juncture with the intercostal nerve. However, the white rami communicantes coming from the rachis pass in a deeper plane that lies behind the ganglion.
It is important to bear in mind that the rami communicantes can anastomose via fibers that course along the contours of the ribs. The most common is the so-called ''Kuntz branch'' (Kuntz, 1927). Lack of knowledge of the existence of these fibers can lead to failure or recurrence (Wittmoser, 1992).
Visceral rami come from sympathetic trunk ganglia.
Cardiac and pulmonary rami are poorly visible behind the pleura.

[点击按纽展开更多->收起->回放]

Splanchnic roots, including the main root from the sixth thoracic vertebrae (T6), are usually visible just below the parietal pleura. After crossing obliquely (caudally and anteriorly), the roots from T6 and T8 join to form the trunk of the greater splanchnic nerve, while the more distal roots unite to form the trunk of the lesser splanchnic nerve.
On the right side, the main splanchnic trunks course behind and parallel to the azygos vein.
On the left side, the splanchnic nerves course just behind the hemi-azygos vein.

[点击按纽展开更多->收起->回放]

The procedure is indicated for patients diagnosed with localized idiopathic hyperhidrosis that is incapacitating and refractory to dermatological treatment and iontophoresis (other causes of excessive sweating should be ruled out):
- palmar hyperhidrosis;
- axillary hyperhidrosis;
- scalp/facial hyperhidrosis: associated with palmar hyperhidrosis, isolated cases;
- plantar hyperhidrosis.

Other rare indications are causalgia, Raynaud’s syndrome, and angina.

5. Operating room set-up

[点击按纽展开更多->收起->回放]

The procedure should be performed in an operating room equipped for both standard open thoracic surgery and endoscopic thoracic surgery.
Preoperative management:
- general anesthesia;
- exclusion of the lung (deflation of the lung on the operative side).
The patient is placed in the lateral thoracotomy position.
The arm on the operative side is extended, exposing the axilla. It must be placed high enough for the contours of the great dorsal and pectoral muscles to be visible. Over extension, which stretches or places traction on the brachial plexus, must be avoided.
It is not necessary to raise the kidney rest of the table. However, it should be placed in proper position for a conversion to thoracotomy if needed. An axillary roll (a rolled-up sheet of drape) should be placed beneath the contralateral axilla to prevent placement of undue pressure on the contralateral brachial plexus.

[点击按纽展开更多->收起->回放]

The surgeon (1) stands behind the patient’s back.
The assistant (2) stands opposite the surgeon, but generally does not directly assist with the operation, which can usually be performed by the surgeon alone.

[点击按纽展开更多->收起->回放]

1. Table
2. Anesthetic unit
3. Thoracoscopic unit
4. Monitors
5. Instrument table
6. Large table
The optical holder arm is placed opposite the surgeon.
A bilateral procedure requires a change in patient position. During the change, the instruments, endoscope and various cables, which must remain sterile, should be placed on a table meant for this purpose.

6. Trocar placement

[点击按纽展开更多->收起->回放]

Three trocars are usually required to perform this procedure.
The trocar that accommodates the endoscope is 5 mm in diameter and the others are 3 mm in diameter.

[点击按纽展开更多->收起->回放]

A
The endoscope is introduced via the 5 mm trocar into the fourth intercostal space in the posterior aspect of the axilla.

[点击按纽展开更多->收起->回放]

B
A 3 mm trocar is introduced into the third intercostal space at the anterior aspect of the axillary fossa in patients with a large axilla.
If, as a result, the instrument trocar will be too close to the endoscope, the trocar can be introduced at the level of the submammary breast fold. However, placement of a trocar in this position may cause breast dysesthesia that may last for a few weeks.

[点击按纽展开更多->收起->回放]

C
The third trocar is introduced into the fourth or fifth intercostal space at the posterior axillary line.

7. Instruments

[点击按纽展开更多->收起->回放]

A standard set of laparoscopic instruments is used, in addition to a set of microinstruments and an emergency open thoracotomy set.

[点击按纽展开更多->收起->回放]

A: 5 mm 0° direct view lens endoscope
Because of the small size of the operative field, it is not necessary to use a 10 mm endoscope. A 5 mm endoscope is sufficient in terms of light intensity and resolution. Nevertheless, some authors prefer to use a 10 mm endoscope.

[点击按纽展开更多->收起->回放]

The following microinstruments are 3 mm in diameter:
1. Hook
2. Spatula
3. Metzenbaum scissors
4. Dissector
5. Suction-irrigation device
6. Grasper

[点击按纽展开更多->收起->回放]

1. Mayo scissors
2. Needle holder
3. Crile clamp

[点击按纽展开更多->收起->回放]

A set of emergency ancillary endoscopic instruments must be available to manage intraoperative complications, such as bleeding. For example, the usual 3 mm suction device may not always be adequate in the event of intraoperative bleeding.
Should this be the case, the 5 mm trocar is replaced by a 10 mm trocar to create an air inlet (in order to prevent the lung from re-expanding during the aspiration of blood). This instrument kit includes:
- two 5 mm trocars;
- one 10 mm trocar;
- a 5 mm suction-irrigation device.

[点击按纽展开更多->收起->回放]

Sympathectomy for palmar hyperhidrosis usually requires a bilateral procedure.
Certain authors recommend a 2-phase procedure, with a 2 to 3 week interval between the first operation and the operation of the contralateral side. A major drawback to this method is the reluctance of certain patients to undergo the second phase of the procedure, especially after having experienced postoperative pain after the first procedure.
We prefer a one-phase procedure. As most of these patients are young and have healthy lungs, a one-phase procedure is usually well tolerated.

The sympathetic fibers are arranged in a segmental fashion, as has been described by Wittmoser (1992). This anatomical principle is the basis for a successful selection sympathectomy.
Surgical strategy:
- palmar involvement is treated by T2 to T4 sympathectomy;
- axillary involvement is treated by T3 to T5 sympathectomy;
- palmar and axillary involvement necessitates T2 to T5 sympathectomy;
- in case of facial involvement, the lower group of T1 rami communicantes is divided.
Important: postoperative Horner’s syndrome is a potential complication that may be avoided by the use of bipolar cautery (monopolar cauterization is not recommended).

Also, the division of the rami communicantes and their possible anastomoses is necessary to ensure definitive treatment.

9. Exposure/nerve

[点击按纽展开更多->收起->回放]

The upper lobe of the deflated lung is retracted medially with a grasper that is initially used as a retractor. If the lung has been properly deflated, it is rarely necessary to continue to retract it further. Generally, the deflated lung will remain by itself at a good distance from the operative field.

• Sympathetic nerve localization

[点击按纽展开更多->收起->回放]

Usually, the sympathetic nerve is immediately visible below the mediastinal pleura as a white, vertical line coursing along the neck of the ribs. The only difficulty involved is in verifying that the nerve is not duplicated and that there is not a collateral ramus.

[点击按纽展开更多->收起->回放]

[点击按纽展开更多->收起->回放]

[点击按纽展开更多->收起->回放]

In rare cases, the sympathetic nerve is not immediately visible:
- it may be hidden by fatty tissue or by a thick mediastinal pleura in overweight patients,
- intraoperative bleeding may hinder identification.
The surgeon should therefore identify the neck of the ribs and pass an instrument over the contour of the rib to search for the characteristic cord-like feel of the nerve.

[点击按纽展开更多->收起->回放]

In a routine sympathectomy from T2 to T4, the second rib constitutes the superior boundary. This is typically the first visible rib in thoracoscopic procedures (the first rib is generally not visible).

[点击按纽展开更多->收起->回放]

The cervicothoracic (stellate) ganglion must be preserved. It is generally found underneath a fat pad at the superior limit of the dissection.
In a thin patient, this landmark may be absent, in which case the surgeon can often make out the characteristic appearance of the T1 ganglion, as it widens upward.

[点击按纽展开更多->收起->回放]

In certain cases, one may encounter unexpected pleural adhesions. They must be freed by means of a cautery hook or scissors connected to an electrocautery unit. The surgeon should try to prevent bleeding as much as possible during this freeing, as any bleeding may impair vision.