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
-
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.
-
Diabetics – often have an
auto-sympathectomy due
to peripheral neuropathy
-
Consent
-
Complications
o Dry
ejaculation
if L1 disturbed
o Orthostatic
hypotension
o Post-sympathectomy
neuralgia
(burning pain in thigh)
-
General anaesthesia
-
Supine
-
Sandbag beneath the side of
the operation to
give a 20 degree tilt
-
Assistant
-
8 – 10cm transverse
incision at the level of the
umbilicus starting just medial to the linea semilunaris
-
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
-
May need a drain in the
retroperitoneal space
-
Repair muscles in layers
with absorbable sutures
-
Close the skin
-
Simple Primapore or
equivalent
-
Post-operative ileus
o Usually
brief
unless a haematoma forms
-
Raynaud’s phenomenon
-
Palmar hyperhidrosis
-
Blushing/facial flushing
-
Digital artery thrombosis
secondary to a
cervical rib
-
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.
-
General anaesthesia with a
double-lumen ETT
-
Supine position
-
Both arms abducted to 60
degrees
-
Anaesthetist deflates lung
-
Incision through 3rd
intercostal
space – anterior axillary line
-
Thoracoscope port inserted
-
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
-
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
-
Chest drain not routinely
required
-
2/0 Vicryl
-
3/0 monocryl to skin
-
Primapore
-
CXR in recovery
-
General anaesthesia
-
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
-
One assistant
-
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
-
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
-
May require an ICC
-
Interrupted 0 Vicryl to
oppose ribs
-
2/0 Vicryl to close
muscle/fascia
-
Staples to skin
-
CXR after operation
-
Supine
-
Sandbag under shoulders
-
Head turned to the opposite
side
-
Table tilted feet-down to
30 degrees
-
One assistant
-
5cm incision 1cm above the
clavicle so the
medial 1cm overlies the lateral border of SCM
-
Divide the platysma with
the skin
-
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)
-
Not routine
-
Subcutaneous tissue –
absorbable sutures
-
Staples or subcuticular
sutures to skin