Thoracoscopic sympathectomy for hyperhidrosis palmaris: a periareolar approach Kenneth A. Kesler, JoAnn Brooks-Brunn, Robert L. Campbell and John W. Brown Ann Thorac Surg 2000;70:314-317
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The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association. Copyright © 2000 by The Society of Thoracic Surgeons. Print ISSN: 0003-4975; eISSN: 1552-6259.
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Thoracoscopic Sympathectomy for Hyperhidrosis Palmaris: A Periareolar Approach Kenneth A. Kesler, MD, JoAnn Brooks-Brunn, RN, Robert L. Campbell, MD, and John W. Brown, MD Divisions of Thoracic Surgery and Neurosurgery, Department of Surgery, Department of Medicine, Division of Pulmonary Medicine, Indiana University School of Medicine, Indianapolis, Indiana
Severe hyperhidrosis palmaris represents a disabling problem for many patients. Thoracoscopic techniques that involve dissection and removal of the upper thoracic sympathetic chain are believed to result in the lowest incidence of recurrent symptoms. However, aside from an axillary incision, an additional upper anterior chest wall approach is
usually required. Over the past 2 years, we have used a periareolar incision in eight patients to improve postoperative cosmesis for this benign condition.
H
ing selective lung ventilation. Patients are maintained in supine position with arms gently abducted (Fig 1). A small roll is placed transversely behind the scapulae to slightly elevate the axilla from the operating table. The neck, bilateral shoulders, axilla, chest, and upper abdomen are prepped and sterilely draped. The lower axillary folds are marked with a skin scribe for approximately 2 cm posterior to the anterior axillary line. The medial third of both clavicles are marked as well. For right-handed surgeons, we prefer standing on the patient’s right side throughout the procedure, with the video screen positioned above the patient’s head. A 2-cm incision is made with a #15 blade scalpel in previously marked lower axillary skin fold. Electrocautery dissection is used both to sweep the axillary fat pad cephalad and to enter the third intercostal space after lung deflation. We have found that a lighted mammary retractor (Codman, Randolph MA), which is designed for breast implant operation, is useful in developing a hemostatic tunnel. A first assistant can hold the lighted retractor cephalad, while the surgeon retracts tissues downward using a rigid sucker as cautery dissection proceeds to the chest wall. This technique allows establishment of a hemostatic tunnel as well as wide cautery entry into the pleural space under direct visualization. A 5- to 12-mm trocar (US Surgical, Norwalk CT) is directly inserted into the right pleural space and a zerodegree operating thoracoscope used to inspect the posterior apex of the right hemithorax. An approximately 3-cm periareolar incision is made along the superior quadrant of the areolar cutaneous junction of the right breast (Fig 2). Subcutaneous tissue is divided with electrocautery to the level of the breast tissue, at which point dissection proceeds superiorly toward the medial third of the ipsilateral clavicle in a plane between the subcutaneous fat and breast tissue to avoid overlying skin devascularization. Similar to the axillary dissection, this dissection is greatly facilitated by cephalad retraction using a lighted
yperhidrosis palmaris can result in severe emotional, social, and even occupational handicaps for many patients. As interruption of the upper thoracic sympathetic chain under thoracoscopic guidance was established as the treatment of choice for upperextremity hyperhidrosis over the past decade, thoracic surgeons are now being called upon to evaluate and treat these patients [1]. Numerous minimally invasive thoracoscopic techniques have been described from a “three-port ”approach. This approach allows excellent operative exposure, enabling endoscopic dissection and removal of the upper sympathetic chain to a “one-port” approach through the axilla where simple cautery destruction of the chain is performed [2– 4]. Although the chain can be disrupted without removal through a single axillary incision, or a so-called sympathicotomy, a concern was raised of higher recurrence in symptomatology using this least-invasive technique [5 ]. Indeed, Krasna and colleagues [6] recently reported that sympathetic chain-removal techniques are currently favored by four major thoracoscopic centers in United States. The use of periareolar incisions for excising benign and malignant breast tumors has long been recognized as cosmetically superior and leaves a virtually undetectable scar after healing [7]. To improve cosmesis, over a 24-month period we used axillary and periareolar incisions as a two-port approach in patients presenting for thoracoscopic sympathectomy.
Technique After induction of general anesthesia, an endobronchial tube is positioned into the left main stem airway, allowAccepted for publication Jan 18, 2000. Address reprint requests to Dr. Kesler, Division of Thoracic Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EM #212, Indianapolis, IN 46202; e-mail:
[email protected].
(Ann Thorac Surg 2000;70:314 –7) © 2000 by The Society of Thoracic Surgeons
© 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
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Ann Thorac Surg 2000;70:314 –7
HOW TO DO IT KESLER ET AL PERIAREOLAR SYMPATHECTOMY
Fig 1. Arrangement of the operating room for right-handed surgeons performing right-sided sympathetic chain dissection. The surgeon stands on patient’s right, holding the thoracoscope placed through a trocar in the axilla in the left hand and hook diathermy directly through the periareolar tunnel in the right hand. An assistant can be used to hold the thoracoscope. The video screen is placed at the patient’s head.
mammary retractor held by a first assistant while the surgeon retracts the breast tissue downward with a rigid sucker. A wide hemostatic tunnel can then be developed with an extended electrocautery unit under direct visualization down to the pectoralis major, which is divided longitudinally overlying the second intercostal space (Fig 2). A wide interspace entry over the superior aspect of the third rib is made by angling the blade of the extended electrocautery blade. We emphasize that this dissection should be done meticulously to establish a wide tunnel that will ultimately facilitate sympathetic chain dissection and minimize the risk of chest wall or intrapleural hematoma formation. A diathermy hook (Wolf, Vernon Hills IL), placed directly through the periareolar tunnel without a trocar, is used to longitudinally divide the parietal pleura overlying the sympathetic chain, extending from 2–3 mm cephalad of the superior aspect of the second rib, exposing the lower aspect of the stellate ganglion inferiorly, to the superior aspect of the fourth rib. We have found that placing a small U-shaped bend in the middle aspect of the hook facilitates this dissection. These three ribs can be counted endoscopically by palpation with the diathermy hook. The first rib, however, is typically somewhat difficult to visualize and palpate because of both overlying soft tissue and its cephalad position. The sec-
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ond rib can easily be palpated and visualized as the most cephalad rib coursing the chest wall laterally. Using the hook as a dissecting instrument, the sympathetic chain can be judiciously isolated immediately cephalad to the second rib and inferior to the stellate ganglion (Fig 3). At this level, the chain is divided with diathermy cautery after gently holding anterior traction on the nerve but avoiding hook recoil after division, which may result in vascular or lung injury. Using bipolar electrocautery current minimizes dispersion of electrical energy and heat, which may injure the stellate ganglion. This technique of diathermy hook dissection proceeds inferiorly, isolating and then dividing all but one or two connecting rami of the sympathetic chain to the level of the superior aspect of the fourth rib. Isolating the rami before diathermy division is done cautiously, particularly along the inferior aspect of the ribs, because bleeding may occur from intercostal vessels positioned just posterior to the rami at these levels. We have found an endoscopic suction-irrigator (Stryker, Santa Clara CA) to be occasionally helpful when oozing obscures the operative field. The sympathetic chain is divided just superior to the fourth rib. The chain is now untethered, precluding further hook dissection without countertraction; therefore, the hook is removed. A dolphin-nose-shaped diathermy instrument (Aesculab, San Francisco CA) is placed through the periareolar working port to secure, then divide by coagulation, the remaining rami. The small segment of sympathetic chain, which includes the second and third thoracic ganglions, is removed for pathologic confirmation. Any oozing vessels may then be cauterized with this instrument. After placing a 20F chest tube through a small inframammary
Fig 2. Location of breast incision in the superior areolar quadrant (inset). A lighted mammary retractor facilitates dissection to establish a hemostatic tunnel.
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HOW TO DO IT KESLER ET AL PERIAREOLAR SYMPATHECTOMY
Fig 3. Hook diathermy dissection and isolation of the sympathetic chain, immediately cephlad to the second rib. Gentle anterior traction is placed on the chain just before diathermy division. The chain is similarly isolated and divided above the fourth rib. Hook cautery dissection and division of communicating rami may continue until the chain is attached to the chest wall by one or two communicating rami.
stab incision, the right lung is re-expanded under thoracoscopic visualization. Both axillary and periareolar incisions are closed with absorbable suture in three layers, including a subcuticular skin closure. A left-sided, upper thoracic sympathectomy is done using a similar approach. The right-handed surgeon may prefer to remain on the patient’s right side and maintain a left-to-right orientation with the thoracoscope, its trocar, and the hook diathermy (without a trocar, through the periareolar incision and axilla, respectively). Similar to the superior vena cava on the right, care is taken during dissection on the left to avoid left subclavian artery injury. On the left side, we have found an occasional benefit in using a 30-degree thoracosope and benefit to interchanging working and thoracoscope ports, for more difficult dissections. The patient is extubated in the operating room. Chest tubes are removed on the first postoperative day, and patients are discharged by the first or second postoperative days.
Ann Thorac Surg 2000;70:314 –7
Six women and two men, at an average age of 27 years, have undergone bilateral upper thoracic sympathectomies through this combined axillary and periareolar two-port approach for a total of 16 sympathetectomies. All patients in this series suffered from lifelong bilateral upper extremity hyperhidrosis, which would be classified as “dripping” [7]. They also uniformly described severe plantar hyperhidrosis; however, this symptom was not felt to be disabling. The length of these bilateral surgical procedures varied from 77 to 245 minutes (mean 162 ⫾ 47). Although operative time decreased substantially as we gained experience, an anomalous right supreme intercostal vein overlying the sympathetic chain was encountered in two patients, requiring 245 minutes for sympathetic chain removal in one patient. In a more recent patient, the chain was divided above the second and fourth ribs, then the remaining segment coagulated with a dolphin-nose clamp without removal. One left-sided chain was positioned behind an overriding subclavian artery, and only nerve division beneath the stellate ganglion could be accomplished. A large man early in our series required limited right anterior thoracotomy for suture repair of a small superior vena cava perforation, which occurred during medial dissection of a sympathetic chain ramus after recoil of the hook diathermy. Blood loss was minimal in the remainder of the patients. There were no other intraoperative or postoperative complications, including Horner’s syndrome. Patients were followed from 1 to 24 months (mean 9 months). The average length of recovery time required before they returned to work was 2 weeks; range was from 1 to 4 weeks. Although patients reported a sensation of upper anterior chest wall swelling and discomfort in early follow-up, these symptoms were resolved by the second postoperative month. No patient experienced temporary or permanent nipple or areolar numbness. All but one patient (88%) experienced at least temporary compensatory sweating—mainly in the back, trunk, and thigh regions—that is uniformly described as mild and tolerable. All eight patients reported complete relief of palmar hyperhidrosis and either complete relief or major improvement of plantar hyperhidrosis. All eight patients reported satisfaction with the final cosmetic result as well.
Comment A two-port approach, using a hook diathermy instrument not only to isolate but also to divide the sympathetic chain and connecting rami will allow chain removal without the need for an additional third port in most patients. Although two access ports can both be established through an axillary approach, to accomplish an unencumbered sympathetic chain dissection, the “working” port needs to be distant from the “thoracoscope” trocar port. An incision overlying the second interspace anteriorly will allow relatively easily access to the upper posterior chest wall in this regard. We found that placing the anterior trocar port through a lower incision in the
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Ann Thorac Surg 2000;70:314 –7
HOW TO DO IT KESLER ET AL PERIAREOLAR SYMPATHECTOMY
areolar-skin junction as described provides an excellent long-term cosmetic result and helps to avoid the sensory nerves that enter the medial and lateral borders of the nipple/areolar complex [8]. Although we believe this approach is superior to other two-port approaches with respect to cosmesis, there are some disadvantages. Establishing a hemostatic tunnel from the areola to the second interspace is somewhat more time consuming and technically demanding. Using cautery dissection under direct visualization with a lighted retractor as described, we were recently able to create these tunnels within a 10-minute time interval. Cautery dissection helped to avoid the bruising that can result from blunt trocar insertion. Moreover, with experience we have found the establishment of wide subcutaneous tunnels with wide interspace entry will expedite two-port hook diathermy dissection and minimize the tendency for the hook to recoil during nerve division. Severe hyperhidrosis palmaris can be a socially and even professionally disabling problem, which is usually refractory to nonoperative therapy. Efforts to use thoracoscopic techniques that minimize operative morbidity are appropriate for this benign condition. Thoracoscopic approaches that involve dissection and removal of the upper thoracic sympathetic chain appear to have the lowest failure rates; however, with current instrumentation, these approaches require establishing at least two separate trocar ports. We believe that there are not only women but also men who justify the additional operative time required for avoiding conspicuous upper anterior chest wall incisions with a periareolar approach. As endoscopic instrument
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technology improves, modifications of all sympathectomy techniques will follow. We also believe that a periareolar approach allows sympathetic chain removal with excellent cosmetic results and offer this option to interested patients. The authors acknowledge and appreciate the Indiana University Illustration Department for their contribution to this manuscript.
References 1. Drott C, Guthberg G, Claes G. Endoscopic transthoracic sympathectomy: an efficient and safe method for the treatment of hyperhidrosis. J Am Acad Dermatol 1995;33:78– 81. 2. Daniel TM. Thoracoscopic sympathectomy. Chest Surg Clin N Am 1996;6:69– 83. 3. Drott C, Claes G. Hyperhidrosis treated by thoracoscopic sympathicotomy. Cardiovasc Surg 1996;4:788 –91. 4. Hsia JY, Chen CY, Hsu CP, et al. Outpatient thoracoscopic limited sympathectomy for hyperhidrosis palmaris. Ann Thorac Surg 1999;67:258–9. 5. Hashmonai M, Kopelman D. Reply: Letter to Editor regarding “Upper dorsal thoracoscopic sympathectomy for palmar hyperhidrosis: improved intermediate-term results” [Letter]. J Vasc Surg 1997;25:961–2. 6. Krasna MJ, Demmy TL, McKenna RJ, Mack MJ. Thoracoscopic sympathectomy: the U.S. experience. Eur J Surg 1998; 580 (Suppl):19–21. 7. Bensimon RH, Bergmeyer JM. Improved aesthetics in breast reconstruction: modified mastectomy incision and immediate autogenous tissue reconstruction. Ann Plast Surg 1995;34: 229–35. 8. Jaspars JJ, Posma AN, van Immerseel AA, et al. The cutaneous innervation of the female breast and nipple-areola complex: implications for surgery. Br J Plast Surg 1997;50:249–59.
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Thoracoscopic sympathectomy for hyperhidrosis palmaris: a periareolar approach Kenneth A. Kesler, JoAnn Brooks-Brunn, Robert L. Campbell and John W. Brown Ann Thorac Surg 2000;70:314-317
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