Thoracoscopic sympathectomy

Aim:

• To ablate the T2 ganglion without disturbing the stellate ganglion above

Anatomy:

• Sympathetic fibres to the arm synapse in ganglia T2-3 (hand = T2, axilla = T2+3)
• Upper ganglion (T1) fuses with inferior cervical ganglion to form the stellate ganglion
• Damage to stellate ganglion produces Horner's syndrome

Technique

• First port 3rd IC space, mid-axillary line
• Further port 5th IC space
• Confirm lung down
• Identify ganglion just lateral to neck of rib, near azygos
  • Usually highest rib you see is the second
  • Need to avoid operating on T1 ganglion
• Start at level of third rib
• Divide nerve under vision with diathermy
• Position inferior cut end below rib to avoid later regeneration

Complications

• Compensatory sweating (usually on chest and back)
• Horner's syndrome
• Pain
• Chest drain
• Conversion to open
• Failure rate 10%