Sympathectomy

Thoracoscopic

· Patient positioned supine, arm abducted, rolled away & head up

· Blunt insertion of 5mm trochar in 4th ICS AAL

— 1L CO2inserted

· 5mm trochars introduced 5th intercostal space @ anterior axillary line

· Sympathetic chain identified below parietal pleura over 2nd to 5th ribs

· Chain between 2nd and 4th ribs either diathermied or excised


Transaxillary

· Supine, arm abducted Sand bags under shoulder & hip

· Incision from lat dorsi ® posterio border pec major

· Divide skin, s/c tissue down to rib

· Divide periosteum on superior surface of rib

· Divide pleura on upper border of rib

· Indert rib retractor

· Displace apex of lung down with lung retractor

· Use headlight or illuminated retractor


Lumbar

· Supine with sandbag under hip

· 8-10cm transverse muscle splitting incision

— above the level of the umbilicus and lateral to the rectus

· Posterolateral retroperitoneal dissection

— Retract with Deaver

· Sweep ureter forward with peritoneum

· Follow anterior surface of psoas onto vertebral bodies

· Identify trunk and excise sympathetic chain and ganglia from L2 to L4

— More difficult on R 2° to IVC


Lumbar sympathectomy

 

Indications

-       Critical ischaemia unsuitable for reconstruction

o   Main purpose is the relief of rest pain

o   Not useful if AABI < 0.35

-       Peripheral vascular disease

-       Hyperhidrosis

-       Intractable vasospastic disease

o   Raynaud’s disease

o   Raynaud’s phenomenon due to scleroderma, polycythemia, cold agglutination, cryoglobulinaemia and sickle cell disease

-       Causalgia (reflex sympathetic dystrophy)

-       Cold injury (frost bite)

 

Carried out as an open operation or non-operatively by injecting phenol into lumbar chain

Usually four lumbar ganglia each side

Operation removes the 2nd and 3rd

L1 ganglion must be left on at least one side to preserve normal ejaculation

Sympathectomy does not increase blood flow to the muscle but causes dilatation of arteriovenous anastomoses.

 

Contraindications

-       Diabetics – often have an auto-sympathectomy due to peripheral neuropathy

 

Preoperative preparation

-       Consent

-       Complications

o   Dry ejaculation if L1 disturbed

o   Orthostatic hypotension

o   Post-sympathectomy neuralgia (burning pain in thigh)

 

Anaesthesia

-       General anaesthesia

 

Position of the patient

-       Supine

-       Sandbag beneath the side of the operation to give a 20 degree tilt

 

Special equipment

-       Assistant

 

Incision

-       8 – 10cm transverse incision at the level of the umbilicus starting just medial to the linea semilunaris

 

Exploration

-       Incise the lateral border of the rectus sheath

-       Split external oblique and incise internal oblique

-       Carefully separate transversalis fascia and muscle without entering the peritoneum

-       Sweep peritoneum away from the muscle using finger and swab dissection continuing mobilisation posteriorly and medially until the aorta on the left or the IVC on the right has been exposed

-       Repair any holes in the peritoneum

-       Deaver retractor placed over the peritoneum and pulled firmly opens the retroperitoneal space in front of quadratus lumborum and psoas and avoids entering the wrong plane behind these muscles

-       Left the ureter forwards with the peritoneum out of harm’s way

-       Avoid genitofemoral nerve, psoas minor tendon and para-aortic lymphatics (more friable than the sympathetic chain)

-       Sympathetic chain on the left is the easiest to approach as it lies on loose areolar tissue along the aorta and can be palpated as a ganglionated cord against the vertebral bodies where it runs just anterior to the insertion of psoas

o   Passes anterior to the lumbar vessels and posterior to the iliac vessels

-       On the right side it lies behind the IVC (retracted gently with the tip of the Deaver retractor

o   Avoid tension and tearing of the lumbar veins (occasionally pass in front of the sympathetic trunk on this side)

-       Lift the chain forwards with a nerve hook, diathermy and divide the rami communicantes then excise the segment containing the second and third ganglia after applying haemostatic clips

 

Options arising during surgery

 

Drainage

-       May need a drain in the retroperitoneal space

 

Closure

-       Repair muscles in layers with absorbable sutures

-       Close the skin

 

Dressing

-       Simple Primapore or equivalent

 

Post-operative instructions

-       Post-operative ileus

o   Usually brief unless a haematoma forms

 

 

 



Cervical sympathectomy – Thoracoscopic approach

 

Indications

-       Raynaud’s phenomenon

-       Palmar hyperhidrosis

-       Blushing/facial flushing

-       Digital artery thrombosis secondary to a cervical rib

 

Contraindications

 

Preoperative preparation

-       CXR to exclude pulmonary disease

-       Consent

o   Horner’s syndrome should not occur as the first rib with T1 ganglion not visualised (but warn patient anyway)

o   Compensatory hyperhidrosis on chest and back in up to 50% of patients.

 

Anaesthesia

-       General anaesthesia with a double-lumen ETT

 

Position of the patient

-       Supine position

-       Both arms abducted to 60 degrees

 

 

Special equipment

 

Incision

-       Anaesthetist deflates lung

-       Incision through 3rd intercostal space – anterior axillary line

-       Thoracoscope port inserted

 

Exploration

-       Ribs followed medially until the sympathetic ganglia and chain are seen over the necks of the ribs

 

      

-       Highest rib seen on either side is the second.

-       2nd port inserted into 5th intercostal space

-       Ganglia identified by soft consistency and glistening surface

-       May need to rotate operating table to head up (anti-Trendelenburg) position

-       Dissect the second thoracic ganglia over the 2nd rib using sharp dissection and diathermy

o   Once cleanly dissected, divide under direct vision

-       Also cut or diathermy the chain as it crosses the third rib to isolate the second ganglion (T2/3 or T2-5)

 

      

-       May divide an aberrant nerve bundle of Kuntz

-       Remove scissors and cannula, reinflate lung

 

Options arising during surgery

-       Right side

o   Azygos vein lies close to the sympathetic ganglia

o   May need to incise pleura along lateral border of azygos vein to fully expose the sympathetic chain.

-       Patient becomes bradycardic or hypotensive with mediastinal shift or hypoxic

o   Re-inflate the lung and continue with procedure when patient stabilised

-       Transient Horner’s syndrome

o   Too high diathermy

-       Bleeding

o   From azygos vein or intercostal vessels

o   Suction device available and thoracotomy tray available

-       Adhesions

o   May result in procedure abandonment

o   Most amenable to division with sharp dissection and diathermy

 

Drainage

-       Chest drain not routinely required

 

Closure

-       2/0 Vicryl

-       3/0 monocryl to skin

 

Dressing

-       Primapore

 

Post-operative instructions

-       CXR in recovery

 

Trans-axillary approach

Anaesthesia

-       General anaesthesia

 

Position of the patient

-       Supine position

-       Sandbag under shoulder and iliac crest

-       Abduct the arm and flex the forearm – secure to an arm rest by a crepe bandage

-       Stand behind the patient

 

Special equipment

-       One assistant

 

Incision

-       Make an 8cm oblique incision from latissimus dorsi, running forwards and down across the third rib roughly in the mid-axilla as far as the posterior border of pectoralis major

 

Exploration

-       Divide the skin and fatty tissue down to the rib

-       Divide the periosteum longitudinally and reflect it from the superior surface, exposing the costal pleura

-       Divide the pleura along the upper border of the rib, insert a rib retractor and open

-       Displace the apex of the lung downwards with a lung retractor

o   Helpful to have a retractor with a light attachment

-       Define the ganglia and chain as they run beneath the costal pleura over the necks of the corresponding ribs

-       Neck of the first rib is palpable (stellate ganglion may be difficult to visualise)

-       Open the pleura over the sympathetic chain on the second rib

-       Grasp the chain immediately above the second ganglion with long forceps

-       Divide the chain above T2 ganglion after clamping the chain above and below with haemostatic clips

-       Lift the chain forwards to expose the rami communicantes (divide the rami between clips or with diathermy)

-       Intercostal nerve block with marcain at the end of the operation

 

Options arising during surgery

 

Drainage

-       May require an ICC

 

Closure

-       Interrupted 0 Vicryl to oppose ribs

-       2/0 Vicryl to close muscle/fascia

-       Staples to skin

 

Dressing

 

Post-operative instructions

-       CXR after operation

 

 

Cervical approach

Position of the patient

-       Supine

-       Sandbag under shoulders

-       Head turned to the opposite side

-       Table tilted feet-down to 30 degrees

 

Special equipment

-       One assistant

 

Incision

-       5cm incision 1cm above the clavicle so the medial 1cm overlies the lateral border of SCM

-       Divide the platysma with the skin

 

Exploration

-       Divide lateral fibres of SCM

-       Locate and divide any large veins in this area including the external jugular vein

-       Locate scalenus anterior (runs down the centre of the field to be inserted into the first rib)

o   Obscured by fatty areolar tissue

o   Avoid the thoracic duct on the left hand side

-       Identify the phrenic nerve passing obliquely over the anterior surface of the scalenus muscle

-       Tape the nerve and retract medially

-       Transect scalenus muscle in line with the skin by grasping the muscle bundles with toothed forceps and dividing them with scissors

-       Divide the posterior surface of the muscle (tendinous)

-       Avoid damaging the subclavian artery – lies immediately behind these fibres

-       Expose the arch of the subclavian artery

o   Place a tape around it and mobilise it as far as possible

o   Tear through the suprapleural (Gibson’s) fascia immediately below the subclavian artery

-       Push the pleura down and laterally with swabs from the neck of the first 4 ribs

-       Seal damaged intercostal veins with diathermy or haemostatic clips

-       Retract subclavian artery up or downwards

-       Excise sympathetic chain

-       Identify stellate ganglion which overlies the neck of the first rib (chain runs down from this)

-       Pick up the chain with a nerve hook or artery forceps between stellate ganglion and the second thoracic ganglion

-       Maintain tension on the chain and divide the rami of the second and subsequent ganglia between haemostatic clips

-       Divide the chain below the T4 ganglion and below the stellate ganglion

-       Lift out

-       Allow the lung to re-expand (don’t repair scalenus or SCM)

 

Options arising during surgery

-       Repair or ligate thoracic duct if injured

-       If cervical rib present, retract the subclavian artery forwards to expose the band or rib

o   Excise the band or remove the rib with bone-nibbling forceps until there is no projection left above or at its articulation with the first rib

 

Drainage

-       Not routine

 

Closure

-       Subcutaneous tissue – absorbable sutures

-       Staples or subcuticular sutures to skin