Eur J Cardiothorac Surg 2000;17:697-701
© 2000 Elsevier Science NL
‘Needlescopic’ video-assisted thoracic surgery for palmar hyperhidrosis
Anthony P.C. Yima,
Hui Ping Liub,
Tak Wai Leea,
Song Wana,
Ahmed A. Arifia
a Division of Cardio-thoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong, People’s Republic of China
b Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
Corresponding author. Tel.: +852-2632-2629; fax: +852-2637-7974
e-mail: yimap{at}cuhk.edu.hk
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Abstract
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Objective: The video-assisted thoracic surgery (VATS) approach for thoracodorsal sympathectomy has been well accepted. We report the use of ultra-fine thoracoscopic equipment for this procedure, based on the experience from two centers in Asia. Materials and methods: Thirty-eight patients with palmar hyperhidrosis underwent bilateral VATS thoracodorsal sympathectomy using 2-mm instruments exclusively. General anesthesia with selective one lung ventilation was used. Carbon dioxide insufflation was used when lung collapse was found to be inadequate. In 11 patients, the sympathetic chain was excised (T2–T3 for palmar hyperhidrosis alone, extending to T4 for axillary hyperhidrosis), and in 27 patients, the chain was cauterized. The choice of procedure reflects the surgeon's preference. No chest drains were left after the procedure and no stitching of the wound was necessary. Results: There was no mortality or major complications. A small pneumothorax was found in the postoperative chest X-ray in three patients. They all resolved without further intervention. Twenty-seven patients were discharged on the same day of admission, and 11 patients were discharged on postoperative day one. After an average follow-up of 16 months (range 5–28), there has been no recurrence of symptoms. Compensatory truncal hyperhidrosis was encountered in two patients, but the symptoms were not severe enough to interfere with lifestyle, and this required no further treatment. Conclusion: Thoracodorsal sympathectomy using 2-mm instruments is technically feasible and is associated with an excellent clinical outcome. Limitations of the equipment, however, exist (narrow field of vision, lower resolution and difficulty in maintaining fine control), and we are currently restricting its use to relatively simple procedures.
Key Words: Video-assisted thoracic surgery • Palmar hyperhidrosis
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1. Introduction
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The last few years have seen video-assisted thoracic surgery (VATS) rapidly becoming the preferred approach for selected surgical procedures. Attempts at further reducing access trauma have resulted in the development of ultra-fine thoracoscopic instruments. This paper is a report of our initial experience with thoracodorsal sympathectomy, exclusively using these instruments from two centers in Asia.
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2. Material and methods
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From 1st January 1997 to 31st December 1998, 38 patients with palmar hyperhidrosis (11 males, 27 females, with a mean age of 28.2 years; range 22–39) underwent bilateral VATS thoracodorsal sympathectomy using 2-mm instruments exclusively (Fig. 1). Basic preoperative investigations were performed, including chest X-ray. CT thorax is not routinely requested unless suggested by history, or an abnormal chest X-ray.
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Fig. 1. MiniSite instrument series (US Surgical, Norwalk, CT). A scalpel handle is shown for comparison of size.
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2.1. Technique
The patient was positioned in the full lateral decubitus position, following selective one lung ventilation with a double lumen tube. The group of surgeons from Hong Kong prefer to excise a segment of the sympathetic chain, while the surgeons from Taipei prefer to cauterize, rather than excise, the segment. The port site strategy for excision is illustrated in Figs. 2a and 3. Three 2-mm ports were used for this technique. The extent of excision or cauterization was T2–T3 for patients with palmar hyperhidrosis, extending to include T3–T4 in those patients when axillary hyperhidrosis was an additional problem. For excision, the mediastinal pleura was incised over the sympathetic chain at the heads of the ribs at the corresponding level. The sympathetic chain was dissected free from the surrounding loose areolar tissue and the rami communicans divided. Care was taken not to injure the intercostal veins, which run just behind the sympathetic chain. The accessory sympathetic fibers (of Kuntz), which run lateral to the main chain, were routinely searched for. Once identified (in two of our patients), they were divided. Failure to do so may result in recurrence of symptoms. The port site strategy for the cautery technique is illustrated in Fig. 2b. Two 2-mm ports were used for this technique. The minishears with electrocautery was introduced just in front of the telescope in the third intercostal space. At the conclusion of the operation, all but one introducer unit was removed. The lung was expanded and gentle suction applied to the introducer trocar to help evacuate all the intrathoracic air prior to its removal. Chest drains were not used. The puncture site requires no suturing, but is closed with a steristrip.
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Fig. 2. (a) Positioning of ports for thoracodorsal sympathectomy (excision technique). (b) Positioning of ports for thoracodorsal sympathicotomy (cautery technique).
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Fig. 3. The three-port technique for thoracodorsal sympathectomy. One of the introducers is connected to the carbon dioxide insufflator and this is used to collapse the lung if necessary.
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2.2. Technical consideration
Unlike conventional VATS, where the initial port for the thoracoscopy was created by ‘finger-clamp’ technique (as in the insertion of a chest drain), the 2-mm port (with the blunt introducer) was placed percutaneously into the chest after a tiny stab incision was made in the dermis (MiniSite 2-mm Introducer System, US Surgical, Norwalk, CT). The lung should be collapsed prior to introduction of the 2-mm port. Therefore, it is of paramount importance that the surgeon and the anesthesiologist are happy with the position of the double lumen tube after the patient has been turned to the side. The introducer unit should be advanced slowly and stopped after the initial resistance has been encountered. The characteristic ‘pop’ signifies that the pleural cavity has been entered. The telescope should then be placed through the introducer to examine the pleural cavity. If the lung is not adequately collapsed, as we found in six cases, carbon dioxide insufflation is initiated at a low flow-rate to maintain the intrathoracic pressure below 10 mmHg. This invariably helps to collapse the lung and allow the procedure to proceed. The instrument ports can then be placed under direct thoracoscopic vision.
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3. Results
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There was no mortality or intraoperative complications. The average actual operating time is about 15 min for each side. The sympathetic chain was excised in 11 patients, and cauterized in 27 patients. Hospital stay was very short, with 27 patients discharged on the same day of admission, and the rest discharged on postoperative day 1. Complications were few, and include three patients with a small pneumothorax postoperatively. They all resolved on their own without further intervention. All the patients had immediate relief of palmar hyperhidrosis and were all happy with the cosmetic results. Parenteral analgesia was not required and all patients were well managed on oral analgesics alone.
After an average of 16 months of follow-up (range, 5–28), there was no recurrence of symptoms. Compensatory hyperhidrosis in the trunk was complained of by two patients on follow-up, but this symptom was tolerated by the two patients and no further treatment was sought.
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4. Discussion
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The past few years have seen VATS gradually becoming the preferred approach for selected surgical procedures including thoracodorsal sympathectomy [1]. VATS is still in evolution. The question is, does VATS, as we currently practice it, represent an end point that only requires minor refinements, or is it an intermediate step to an even less invasive approach? We believe that both views may be correct. VATS represents a spectrum with a purely endoscopic approach at one end and a video-assisted approach (with a utility minithoracotomy) at the other end. For the purely endoscopic procedures, there have been attempts to modify further the surgical access and mode of anesthesia. The former resulted in the development of these 2-mm ‘needlescopic’ instruments, and the latter in therapeutic thoracoscopy under local anesthesia [2].
The MiniSite series (Autosuture, US Surgical, Norwalk, CT) represent an example of the first generation of such miniaturized instruments (Fig. 2). Most of them are reusable instruments made of stainless steel and are not insulated for electrocautery. More recently, they have available a disposable scissors (MinSite Mini Shears) which allows monopolar cautery. There are technical limitations associated with these new instruments. Compared to the conventional telescope, the 2-mm scope has a much narrower field of vision. In addition, in contrast to the rod lens used in conventional scopes, the 2-mm scope is composed of fibreoptics, and hence, its resolution is inferior. Because of their narrow diameter, the scope and instruments are flexible, which make it difficult to control very fine movements.
Palmar hyperhidrosis is a disabling condition that could cause severe social embarrassment. It often affects the young, and adversely affects the patient's lifestyle and work. Although medical treatments are available, these are often ineffective. Surgical management with thoracodorsal sympathectomy was advocated by Adson and colleagues in 1935 [3]. However, the different open surgical approaches (supraclavicular, transaxillary, dorsal and transthoracic) were associated with significant surgical morbidity. The thoracoscopic approach to this procedure was first described by Kux in 1951 [4] and revolutionized the surgical treatment of this condition. The use of video assistance in VATS greatly enhances the accuracy of the endoscopic procedure as it provides a magnified view of high resolution [5]. The use of ultra-fine instruments represents a further refinement of the VATS approach.
Although VATS is now widely accepted as the preferred approach to thoracodorsal sympathectomy, the optimal surgical technique has remained a subject of continued controversy. Many surgeons from North American centers prefer resection of the chain, while across the Atlantic, many European surgeons use electrocautery-ablation of the sympathetic chain as the technique of choice. Similarly, in Asia, opinions differ among surgeons. In this paper, the approach at the Chang Gung Memorial Hospital in Taipei is to cauterize the sympathetic chain, while the surgeons at the Prince of Wales Hospital, Hong Kong, continue to resect the chain as they did with conventional VATS. These different techniques influence the strategic planning of the access ports, as resection requires at least two (a technique using an ureteroscope loop described by Drott and Claes [6]) and more commonly three ports, whereas electrocautery ablation could potentially be performed through a single puncture approach. Advocates of the resection technique argue that only through this technique would a surgical specimen be made available to the pathologists, and ‘proof’ of the operation exists if medico-legal issues arise. They further question the long-term results of the ablation technique when the chain is not excised. Gossot and colleagues recently showed that a highly selective sympathectomy, which only divides the rami communicantes and preserves the main trunk (Wittmoser's technique [7]), is associated with a higher incidence of recurrence than a conventional resection [8].
On the other hand, advocates of the ablation technique argue for its simplicity. Zacherl and colleagues recently demonstrated in 369 patients treated by electrocautery-ablation of the sympathetic chain that after a median follow-up period of 16 years, the incidence of recurrence of palmar hyperhidrosis was very low [5]. This paper argues that excision of the sympathetic trunk is not mandatory for good long-term results. In our own study, even though the follow-up is much shorter, we concur that both techniques appear to be equally effective. Irrespective of the exact technique used, it is critical that the nerve of Kuntz (accessory nerve fiber which runs parallel and lateral to the main trunk) has to be routinely searched for. Failure to do so could result in a high incidence of recurrence [9]. We regard a degree of compensatory sweating to be an expected sequel to the procedure and we carefully explained this to the patients preoperatively. We only count it as a complication if the patient complains, or when further treatment is required. This may explain why our incidence of palamar hyperhidrosis (2/38) seems lower than that generally reported in the literature.
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5. Conclusion
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Our initial experience with thoracodorsal sympathectomy using 2-mm instruments shows that the ‘needlescopic’ VATS approach is technically feasible and is associated with excellent clinical outcome. The sympathetic chain could be either coagulated or excised, and so far, our own observations and that of others seem to suggest that both techniques are equally effective, even though the coagulation technique is simpler. However, limitations of these miniaturized instruments exist (narrow field of vision, lower resolution and difficulty in maintaining fine control) and therefore, we are currently restricting its use to relatively simple procedures that require little or no dissection, such as pleural biopsy or thoracodorsal sympathectomy as described here.
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Footnotes
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Presented at the 13th Annual Meeting of the European Association for Cardio-thoracic Surgery, Glasgow, Scotland, UK, September 5–8, 1999.
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Appendix A Conference discussion
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Dr E.A. Rendina (Rome, Italy): I think this is one of those procedures in thoracic surgery, where the aesthetic result is very important, because the disease affects mostly women in the young age group. Miniaturization of the access and of the instruments is therefore fully justified. You mentioned that in a number of patients cauterization was employed, and I would like to ask you whether this caused any problem to the adjacent nervous tissue. Secondly, how do you handle the first side you operate on, from the point of view of the drainage tube? Do you keep it in place while you do the second side and then draw it before the patient is awake?
Professor Yim: We do not use chest drains. When we finish with one side, we put the introducer trocar on suction to evacuate all the air. We then remove the trocar and reposition the patient and repeat the sequence. One needs to be certain that the lung has not been injured when it is done this way. Therefore, it may be safer when you are a beginner with this approach to leave a small drain on the first side before you turn the patient.
Regarding coagulation, this is not a technique I routinely use, but there have been several large series from Taiwan using this approach with excellent results and very few complications.
Dr K. Naunheim (St. Louis, MO, USA): I have a comment first and then some questions. The comment has to do with the instrumentation. Having used in the past a 2-mm scope, I absolutely agree that the lighting and the visual discrimination are suboptimal. I personally use 5-mm instruments through two ports in the axilla. I am not certain that three 2-mm incisions will be different than two 5-mm incisions, either from a cosmetic standpoint or from an analgesic standpoint. I personally like the control you get with the larger instruments and I think it makes it an easier operation. I think 5-mm axillary incisions, really from a cosmetic standpoint, are quite acceptable.
I would like to ask you, first of all, you had a relatively low rate of compensatory hyperhidrosis. In the literature, it is generally quoted from as low as 25 to as high as 60%, and you only had about a 5 or 6% incidence. It is remarkably low and I wonder if that has to do with how aggressive the follow-up was, or if there is some trick you have during your operation that would prevent compensatory hyperhidrosis, which is really the bete noire of this particular procedure.
The other question I have is whether or not you have any experience with, or have any thoughts specifically regarding clipping the nerves. As you know, there are some people who are doing nerve clipping, essentially placing a hemoclip directly across the trunk, with the idea that if compensatory hyperhidrosis occurs, the clip can be removed and therefore the sympathectomy could be ‘reversed’; in half to two-thirds of the cases the compensatory hyperhidrosis will allegedly improve. I wonder what your thoughts are on that.
Professor Yim: We have not had any experience with clips. When you are using 2-mm instruments, there are not any clips available that are small enough to go through the ports. Regarding compensatory hyperhidrosis, the reported rate is usually quite high as you pointed out. However, it depends on how you define it, and when you start to count it as a complication rather than an expected sequel to the procedure.
I think an element of compensatory hyperhidrosis is to be expected following thoracodorsal sympathectomy, and we do explain this clearly to the patient. We only record compensatory hyperhidrosis as a complication when the patient starts to complain about it, as it happened in the two cases in our series. A few more patients reported increased truncal sweating, but as this was what they expected and did not bother them, it was not recorded as a complication.
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References
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Adson A.W., Craig W.M., Brown G.E. Essential hyperhidrosis cured by sympathetic ganglionectomy and trunk resection. Arch Surg 1935;3:794-798.
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Kux E. The endoscopic approach to the vegetative nervous system and its therapeutic possibilities. Dis Chest 1951;20:139-147.
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Zacherl J., Imhof M., Huber E.R., Plas E.G., Herbst F., Jakesz R., Fugger R. Video assistance reduces complication rate of thoracoscopic sympathicotomy for hyperhidrosis. Ann Thorac Surg 1999;68:1177-1181.[Abstract/Free Full Text]
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Drott C., Clase G. Hyperhidrosis treated by thoracoscopic sympathectomy. Cardiovasc Surg 1996;4:788-790.[Medline]
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Wittmoser R. Thoracoscopic sympathectomy and vagotomy. In: Cuschieri A., Buess G., Perissat J., eds. Operative manual of endoscopic surgery. New York: Springer, 1992:110-133.
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Gossot D., Toledo L., Fritsch S., Celerier M. Thoracoscopic sympathectomy for upper limb hyperhidrosis: looking for the right operation. Ann Thorac Surg 1997;64:975-978.[Abstract/Free Full Text]
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Kohno T., Takamoto S. In: Yim A.P.C., Hazelrigg S.R., Izzat M.B., Landreneau R.J., Mack M.J., Naunheim K.S., eds. Thoracoscopic thoracic sympathectomy. Minimal access cardio-thoracic surgery. Pliladelphia, PA: WB Saunders, 1999:232-238.
Received September 8, 1999;
received in revised form December 30, 1999;
accepted February 8, 2000.
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Abstract
1. Introduction
