THORACOSCOPIC SYMPATHECTOMY: EL-MINIA EXPERIENCE

The endoscopic upper thoracic sympathectomy, amply documented by Kux 1954, did not gain wide spread popularity until 1980. Preservation of the stellate ganglion is advocated nowadays to minimize the risk of Horner’s syndrome as resection of T2 through T4 including the chain in between and any direct branches to the brachial plexus including nerve of Kuntz is enough. Compensatory hyperhidrosis and Horner’s syndrome are uncommon after limited thoracoscopic sympathectomy. 
Patients and Methods: In the period from October 2000 till February 2003, a total of 75 thoracoscopic sympathectomies in 55 patients were done. They were suffering from primary hyperhidrosis either palmar, axillary or both (40 patients), Raynaud's disease (10 patients) or both (5 patients). We used two ports, 10 mm port in the 4th space in the mid-axillary line for the telescope and the other is 5mm in the 3rd space in the mid-axillary line for the dissector. The sympathetic chain was resected from T2 to just below T4.
Results: There were no intra-operative complications. Resection of the chain and ganglia was done easily using the electrocautery. The 2nd thoracic ganglion was found in the 2nd space in all cases and there was a well formed stellate ganglion in only 59 sides, in the rest of the sides the 1st thoracic ganglion was small and seen on the upper border of the 2nd rib. Surgical emphysema was encountered in 4 patients (7.3%), 3 of them were managed conservatively while the remaining one needed insertion of an intercostal tube. One patient (1.8%) developed pneumothorax, it was managed by intercostal tube insertion. We reported no cases of Horner's syndrome. Compensatory hyperhidrosis of the trunk and lower limbs was encountered in 21 patients (38.2%) but it was mild and needed no surgical intervention. Recurrence of symptoms was encountered in 7 patients in the Raynaud's disease group (70%). Four out of five patients (80%) with both vascular and sweating symptoms developed recurrence of their vascular symptoms after 8 to 10 months.
Conclusion: Thoracoscopy is the ideal approach for cervicodorsal sympathetic ganglia, so the thoracoscopic sympathectomy is the treatment of choice for palmar and axillary hyperhidrosis. In peripheral vascular diseases, sympathectomy must be reserved for cases that will not benefit from direct arterial surgery as recurrence after sympathectomy is the fate in most cases