Overview
Definition:
Video-assisted thoracoscopic sympathectomy (VATS) is a minimally invasive surgical procedure that involves the resection or ablation of sympathetic nerve chains in the thoracic region to treat conditions like palmar hyperhidrosis.
Epidemiology:
Palmar hyperhidrosis affects approximately 1-3% of the population, with onset typically in adolescence
It can significantly impact quality of life
While prevalent, only a subset seeks surgical intervention
VATS sympathectomy is a definitive treatment option for severe, recalcitrant cases.
Clinical Significance:
Palmar hyperhidrosis causes excessive sweating of the hands, leading to social embarrassment, functional impairment (e.g., difficulty holding tools, writing), and increased risk of infections
VATS sympathectomy offers a permanent solution when conservative measures fail, improving patient well-being and daily function.
Indications
Indications For Surgery:
Failure of conservative management for at least 6-12 months
Symptoms causing significant psychosocial distress or functional impairment
Patient understanding and acceptance of potential risks and sequelae, especially compensatory sweating
Exclusion of secondary causes of hyperhidrosis.
Patient Selection:
Patients with primary focal hyperhidrosis (palmar, axillary, facial)
Absence of significant pulmonary disease that would contraindicate general anesthesia and pneumothorax
Realistic expectations regarding outcomes and potential complications.
Contraindications:
Severe cardiopulmonary disease
Bleeding diathesis
Active infection
Pregnancy
Known anatomical abnormalities of the thoracic cavity that would preclude safe VATS
Patients unwilling or unable to tolerate potential compensatory sweating.
Preoperative Preparation
History And Examination:
Detailed history of hyperhidrosis onset, duration, severity, and impact on daily life
Thorough physical examination to assess the extent of sweating and rule out secondary causes
Assessment of comorbidities, especially cardiovascular and pulmonary.
Investigations:
Routine pre-operative blood work (CBC, electrolytes, coagulation profile)
Chest X-ray to assess lung fields and pleura
ECG
Pulmonary function tests may be considered in patients with respiratory symptoms or significant smoking history.
Patient Counseling:
Informed consent regarding the procedure, benefits, risks (including compensatory sweating, Horner's syndrome, pneumothorax, nerve injury), and alternatives
Discuss the likely success rate and the potential for recurrence
Emphasize the permanence of the procedure.
Procedure Steps
Anesthesia And Positioning:
General anesthesia with double-lumen endotracheal tube for single-lung ventilation
Patient positioned in lateral decubitus position.
Thoracoscopic Approach:
Typically performed via two or three small incisions (portals) in the chest wall
A video camera and instruments are inserted through these ports.
Sympathetic Chain Identification:
The sympathetic chain is identified within the posterior mediastinum, usually located anterior to the heads of the ribs
The target is typically the T2-T4 ganglia for palmar hyperhidrosis.
Sympathetic Ablation:
The sympathetic chain is divided, resected, or ablated using electrocautery or radiofrequency ablation
Care is taken to avoid injury to the intercostal vessels and nerves
Complete visualization and careful dissection are crucial.
Closure:
Insertion of a chest tube if significant pleural contamination or pneumothorax
Portals are closed in layers
Chest tube removed once lung re-expanded and air leak ceases.
Postoperative Care
Immediate Postoperative Care:
Continuous cardiorespiratory monitoring
Pain management with analgesics
Chest tube management if inserted
Early mobilization to prevent deep vein thrombosis and pulmonary complications.
Pain Management:
Intravenous or oral analgesics
Epidural analgesia may be considered for severe pain
Assessment and management of incisional pain.
Complication Monitoring:
Vigilant monitoring for signs of pneumothorax, hemothorax, infection, and Horner's syndrome
Assessment of hand sweating postoperatively.
Discharge Criteria:
Patient is hemodynamically stable, pain is controlled, chest tube (if present) is removed, and ambulation is satisfactory
Typically discharged within 1-3 days post-surgery.
Complications
Early Complications:
Pneumothorax
Hemothorax
Persistent air leak
Wound infection
Post-thoracotomy pain syndrome
Horner's syndrome (ptosis, miosis, anhidrosis of ipsilateral face), usually temporary but can be permanent
Bradycardia.
Late Complications:
Recurrence of hyperhidrosis (rare)
Compensatory hyperhidrosis (sweating in other areas, e.g., back, abdomen, legs), which can be severe and debilitating, affecting quality of life more than the original condition
Gustatory sweating
Chronic pain.
Prevention Strategies:
Meticulous surgical technique to avoid nerve injury and ensure complete sympathetic chain interruption at the targeted level
Appropriate preoperative counseling regarding compensatory sweating
Careful patient selection
Management of comorbidities.
Prognosis
Recurrence Rate:
The recurrence rate for palmar hyperhidrosis after VATS sympathectomy is generally low, estimated to be less than 5% in most series, especially with complete T2-T3 ganglionectomy.
Compensatory Sweating:
Compensatory hyperhidrosis is the most common and significant sequela, occurring in 30-90% of patients, with severity varying from mild to severe
This is a critical aspect to discuss during counseling.
Long Term Outcomes:
For patients who do not experience severe compensatory sweating, the long-term outcomes are excellent, with significant improvement in quality of life and resolution of palmar hyperhidrosis
Patient satisfaction is high when managed appropriately.
Key Points
Exam Focus:
Target sympathetic chain levels for palmar hyperhidrosis (T2-T4)
Differentiate between primary and secondary hyperhidrosis
Recognize complications like Horner's syndrome and compensatory sweating
Understand VATS principles for thoracic procedures.
Clinical Pearls:
Thorough counseling on compensatory sweating is paramount before surgery
Bilateral sympathectomy is often staged to assess individual tolerance for compensatory sweating
Reoperation for recurrence is challenging and often ineffective
Consider sympathetic denervation of T2-T3 for palmar and T4 for axillary hyperhidrosis.
Common Mistakes:
Inadequate sympathetic chain resection leading to recurrence
Performing bilateral sympathectomy simultaneously without assessing tolerance
Underestimating the severity and impact of compensatory sweating
Failing to counsel patients adequately on potential risks and sequelae.