Endoscopic Thoracic Sympathectomy
This topic features in the Vascular part of the curriculum, but is included here as it requires thoracoscopy.
The curriculum asks us to explain 'the principles and anaesthetic implications of sympathectomy, including thoracoscopic procedures'.
It hasn't featured as an SAQ or CRQ and, given the single resource I could find is 15yrs old, one may wish to skip this topic if short on time.
| Indications for sympathectomy |
| Primary hyperhidrosis (palms, axillae, plantar surfaces, craniofacial) |
| Primary facial blushing |
| Chronic regional pain syndromes |
| Ischaemic pain e.g. refractory angina, digital ischaemia |
| Congenital long QT syndromes |
- Thoracic sympathectomy was historically performed as an open procedure
- This carried a high morbidity and thoracoscopic sympathectomy is now preferred
- A VATS technique is used
- CO2 insufflation (capnothorax) is used, which can cause cardiovascular instability or even tension capnothorax
- Endoscopic thoracic sympathectomy aims to clip the sympathetic chain at the relevant level to reduce symptoms of hyperhidrosis:
- 3rd rib: craniofacial
- 3rd - 4th rib: palmar only
- 4th - 5th rib: palmar + axillary | axillary alone | palmar + axillary + plantar
- There is a small risk of conversion to thoracotomy and significant blood loss
Perioperative management of the patient undergoing sympathectomy
- The majority of patients undergoing sympathectomy are young, with few comorbidities
- Patients presenting for other indications need a standard anaesthetic pre-assessment individualised to their comorbidities, which could include:
- AAGBI
- Invasive monitoring may be indicated by patient's comorbidities
- Wide-bore IV access is required owing to the risk of major blood loss
- Supine with 20 - 30° head up tilt
- Arm on operative side abducted to 90° to enable surgical access in anterior axillary line via two thoracoscopic port
- If bilateral procedure then patient will be in crucifix position
- Choice of airway device is highly influenced by surgical technique and exposure
- In general, one-lung ventilation is required as it:
- Provides optimal surgical access
- Reduces risk of iatrogenic lung injury
- There is a greater risk of hypoxia than with one-lung ventilation in the lateral position
- Other putative options include:
| Option |
Advantages |
Disadvantages |
| Standard ETT |
Familiar
Less hypoxia than OLV |
Sub-optimal surgical access
Risk of lung injury
Risk of tension pneumothorax |
| Supraglottic device |
Avoids risks of ETT
Easy to place |
Aspiration risk
If conversion to open will need ETT |
| Regional anaesthesia |
Avoids GA
Good analgesia |
Requires expertise
Requires cooperative patient
Requires GA if conversion |
- Tube malpositioning (DLT or bronchial blocker)
- Hypoxia from shunt due to OLV
- Hypotension 2° capnothorax
- Hypercarbia 2° capnothorax
- Cardiac arrhythmia due to intra-thoracic diathermy
- Bleeding
- Pain arises from pleural stretching, manifesting as retrosternal or upper back pain
- Management is with:
- Intrapleural local anaesthetic
- A standard multi-modal analgesic regimen
- Respiratory
- Pneumothorax (4%)
- Hypoxia from pneumothorax or atelectasis
- Haemothorax or chylothorax (0.5%)
- Acute lung injury
- Transient pleural effusion
- Surgical emphysema
- Horner's syndrome (0.5%)
- Chest pain
- Failure
- Recurrence (4%)
- Compensatory hyperhidrosis (50%)
- Gustatory sweating