内镜下胸交感神经切除术（图文演示）

10. Division/nerve

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The ribs are counted cephalad to caudad, from the second to the fourth rib.

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The mediastinal pleura is divided, as is the nerve, at T4 level. We tend to use scissors, but the operator may also use either the hook or the spatula. Scissors are then inserted under the mediastinal pleura to lift it like a tent and to divide it caudad to cephalad with electrocautery. Once the upper thorax is reached, cautery should no longer be used, to avoid diffusion of the current towards the cervicothoracic ganglion.
The 2 separate layers of the pleural opening are retracted by the grasper in order to expose the path of the sympathetic nerve.
The nerve, which has been divided at T4 level, is held by the grasper and retracted cephalad to free it from the deeper plane, and importantly, from the veins that cross posteriorly.

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The endoscope may be brought to about 3 cm from the target to benefit from a close-up view of the rami communicantes that were exposed by simple cephalad retraction of the sympathetic nerve. The nerve is carefully detached posteriorly, staying close to the nerve itself to avoid injuring the crossing veins (use of Metzenbaum scissors will facilitate this operative step).
The rami communicantes are divided using the scissors, or alternatively the spatula or hook.
When approaching the area of T2, it is important to take the 2 following precautions:
- high frequency (HF) cautery must no longer be used,
- the traction on the nerve should be reduced to avoid overstretching of the cervicothoracic ganglion.
This will reduce the risk of injury to the ganglion itself (if mild bleeding from the veins occurs at this juncture of the resection, it is of little consequence).

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The upper part of the nerve is divided using scissors (without cautery) at the level of T2, at the base of the cervicothoracic ganglion. The trunk of the freed nerve can then be extracted via one of the trocars.

• Variation

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Double sympathetic nerve and/or multiple rami communicantes
All visible nerves must be carefully dissected and divided.

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Sympathetic nerve crossed anteriorly by an intercostal vein
In most cases, the nerve crosses anterior to the intercostal veins. In about 10% of cases, a vein is encountered crossing in front of the nerve. During dissection, the nerve must be brought anterior to the vein. If by doing this, there appears to be a risk of major venous hemorrhage, the nerve can be divided above and below the vein. The nerve segment can then be retracted safely and the rami communicantes can be divided at a distance from the vein.

11. Bleeding

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Major bleeding needs to be distinguished from minor bleeding or oozing.
In most cases, this procedure is performed quickly and easily. However, intraoperative complications may occur. Timely and appropriate action requires some experience in thoracoscopy.

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A large vessel injury is very rare, but possible. We have had the case of an injury of the left subclavian artery by a cautery hook that slipped during the opening of the mediastinal pleura. Therefore, we now prefer using a spatula that potentially causes less trauma to tissue.
Such bleeding requires immediate conversion to thoracotomy. Tearing of the subclavian artery by the use of a 10 mm laparoscopic trocar was reported by Cameron in 1998. Hence the importance of working with appropriate instrumentation.

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Injury of an intercostal vessel is not uncommon. It can sometimes cause major bleeding (approx. 500 mL). We have always been able to control it endoscopically, although it may be difficult to control by means of a 3 mm suction device, which becomes easily clogged.
If such bleeding occurs, time must be taken to:
- replace the 5 mm optical trocar by a 10 mm trocar in order to create an air inlet,
- replace one of the 3 mm trocars by a 5 mm trocar for the suction-irrigation device.
Once the venous or arterial injury has been localized, the tip of the suction device may be applied to block it, leaving enough time for introduction of the hemostatic device or the dissector connected to the electrocautery unit.

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Slight bleeding or oozing is quite common during this procedure. Hemostasis is achieved by simple tamponade with a small gauze pad.

12. Other complications

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In most cases, this procedure is performed quickly and easily. However, intraoperative complications may occur. Timely and appropriate action requires some experience in thoracoscopy.
Chylothorax is a very rare complication, although it has been described. Any abnormal chylous effusion should prompt the surgeon to look for an accessory thoracic duct. Leakage is controlled with clips, and biological glue may also be applied if needed.

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A small pulmonary injury may be caused by abrupt introduction of a trocar. It is generally of little or no consequence due to the small size of the trocars. A postoperative radiograph of the thorax should be performed, however, to rule out sequelae before removal of the drain.

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An injury of the brachial plexus has been described by Lange (1995). The authors stress that this occurred despite the fact that they had considerable experience with traditional open thoracic sympathectomies. This demonstrates the need for special training prior to performance of this type of procedure via the thoracoscopic approach.
In 1998, Cameron reported 2 severe cases of cerebral edema apparently related to the insufflation of carbon dioxide into the pleural cavity during thoracoscopic sympathectomy. In general, CO2 insufflation should not be utilized during thoracoscopy, especially during this procedure, where it is not necessary.

13. Evaluation after division

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The procedure is completed only after the operative field has been thoroughly evaluated.
Once the sympathetic nerve trunk has been resected, the following must be performed:
An accessory ramus (Kuntz nerve) is frequently visible on the contour of the second rib. It should be divided by cautious and brief cauterization.

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Other accessory rami are not always visible. They are divided by cauterization of the periosteum of the third and fourth ribs over a length of 3 to 4 cm starting from the neck of the ribs.

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At the end of the procedure, mild bleeding or oozing is common. It is preferable to achieve hemostasis by simple tamponade rather than by electrocautery. To do so, a small gauze pad is first rolled up, introduced via the 5 mm trocar, and gently spread over the resection bed (the thoracoscope is withdrawn temporarily to allow placement of this gauze).

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The lung is reinflated under visual guidance.
The endoscope and the 5 mm trocar are first removed to allow for introduction of a thoracic drain. A No.16 drain, preferably with a tip, is placed in the thorax via the same opening (the incisions for the 3 mm trocars do not accommodate a drain of this size). The two 3 mm incisions may be closed using glue.

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The pleural drain is removed a few hours after the procedure after evaluation of a postoperative chest radiograph. There is generally no need for a clamp test prior to drain removal.
The patient is typically able to leave the hospital on the day following surgery, occasionally on the same day of the procedure.

It is essential to inform the patients of what they may experience during the postoperative course:
- anterior and posterior thoracic pain, occasionally intermittently severe, for the first 3 to 4 weeks;
- feeling of chest heaviness, especially if a bilateral procedure has been performed during the same operation;
- pain in both arms lasting for a few days;
- temporary recurrence of hyperhidrosis lasting only for a few hours, commonly occurring between the second and the fifth postoperative days;
- compensatory excessive sweating.

16. Variations

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Local
It is theoretically possible, but it may be very difficult, at times even impossible, to manage an intraoperative complication.
General anesthesia with a single lumen endotracheal tube
Selective intubation is not absolutely necessary, but it aids greatly in exposure of the posterior mediastinum.
Some authors advocate positioning the patient in ventral decubitus (Wittmoser, 1992) or in a semi-seated position, and are able to perform the procedure without deflation of the lung, as the inflated lung will drop out of the operative field due to the effect of gravity. Others facilitate the exposure by insufflating CO2. In this case, a trocar with an airtight endoscopic valve must be used.

• Patient positioning

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Wittmoser (1992) is the only author known to recommend this position. It has the advantage of offering a good view of the posterior mediastinum without requiring separate pulmonary ventilation because the lung drops by itself due to gravity.
However, the endoscope has to be introduced through incisions in the patient’s back, which are both painful and less cosmetically satisfying. Moreover, conversion to an open thoracotomy is impossible with the patient in this position.

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A cushion is placed below the scapula of the patient on the side of the operation, and arms are abducted (Byrne et al., 1990). The endoscope is introduced via the axilla. The main disadvantage of this position is that, frequently, an additional trocar will need to be introduced on the anterior surface of the thorax to accommodate an instrument or a lung retractor.
Moreover, conversion to axillary thoracotomy is impossible in this position.

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The endoscope is introduced via the axilla. This gives excellent exposure of the apex of the superior mediastinum, and offers the advantage of easily allowing for a bilateral procedure, but its drawbacks are similar to those previously described.

• Instrumentation

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Some authors recommend a 10 or 11 mm endoscope with an operating channel. A cautery hook, suction device or any other 5 mm instrument can be introduced via the operating channel.
However, operative trocars placed in a triangulated pattern, as we have described, allow a more precise dissection.

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The technique may be easily performed, as described above, utilizing 3 mm instruments. Other surgeons recommend 5 mm instruments.
These larger instruments may be cumbersome due to the small dimensions of the elements dissected. In addition, the larger trocars produce less satisfying cosmetic results.
Certain authors use a urologic resectoscope (Drott et al., 1995). The sympathetic nerve is cauterized with a diathermy loop and resected.

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Monopolar HF current may increase the risk of heat injury of the cervicothoracic ganglion. Bipolar cauterization is preferable, but currently only 5 mm bipolar instruments are available.
The use of ultrasonic scissors has also been reported but again, the smallest size available is 5 mm.

17. Variations/surgical tech

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Simple cauterization of the sympathetic nerve is advocated by Drott et al. (1995), who used it successfully on more than 1000 patients.
The technique is simple. It consists of using a diathermy loop introduced via a urologic resectoscope. The loop passes along the pathway of the nerve from cephalad to caudad.

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Compensatory excessive sweating is the most serious side-effect of thoracic sympathectomy and many authors have tried to find a way to limit its incidence and importance.
One way is the performance of a sympathectomy that is limited in length. Bonjer et al. (1996) proposed resecting only the third thoracic ganglion (T3). They used this technique in 19 patients and no compensatory excessive sweating was observed.
Hsia et al. perform an even more limited sympathectomy, as the nerve is simply divided (Hsia et al., 1999). Out of 47 patients followed up over 12 months, no failure was reported. The rate of compensatory excessive sweating was 74%, though the symptoms were moderate.

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Resection or division of the sympathetic nerve is obviously irreversible. According to Lin et al. (1998), certain patients may regret having undergone the procedure after experiencing the discomfort of compensatory excessive sweating. Lin et al. have thus developed a procedure in which the nerve is merely clipped after being placed at each end of T2 ganglion. It is dissected for approximately 2 cm. This technique offers the advantage of being reversible.
In a series of 326 patients who underwent the procedure, 5 patients (1.5%) requested reversal of the procedure afterwards. In these cases, the clips were removable. Three patients reported disappearance of compensatory excessive sweating (with one recurrence of palmar hyperhidrosis). No improvement of compensatory excessive sweating was reported in 2 patients.

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Wittmoser (1992) was one of the pioneers of the endoscopic approach to thoracic sympathectomy in which only the rami communicantes are divided. The sympathetic nerve itself is preserved. This technique was reproduced by our team (Gossot et al., 1997). The aim was to reduce the rate of compensatory excessive sweating.

Of 62 patients who underwent the procedure at the beginning of our experience, the recurrence rate at 1 year was 5%, and we observed no recurrence in 350 patients who had complete nerve resection. Compared with 54 patients who underwent a conventional procedure, the rate of compensatory excessive sweating was not significantly reduced (Gossot et al., 1997). We therefore stopped performing this procedure because of the excessively high recurrence rate.

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Sympathectomies for palmar hyperhidrosis most often require a bilateral procedure.
Certain authors recommend a 2-phase procedure, with a 2 to 3 week interval between operations.
We prefer a one-phase procedure. As most patients are young, and therefore have healthy lungs, the procedure is usually well tolerated. When the procedure is performed in 2 phases, some patients are reluctant to undergo the second phase of the procedure after experiencing postoperative pain following the first phase.

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