This document discusses the surgical anatomy and history of surgical sympathectomy. It begins with the anatomy of the sympathetic nervous system and sympathetic trunks. It then discusses the historical approaches to thoracic sympathectomy including open and minimally invasive techniques. The key points are: - Thoracoscopic sympathectomy has high success rates for treating hyperhidrosis with low complication rates. - It involves clipping or cutting the sympathetic chain and rami between T2-T3 to denervate the hands. Care must be taken to preserve T1 to avoid Horner's syndrome. - Compensatory hyperhidrosis is a common complication but most others are rare if T1 is preserved.

1. By
Mohammed Ezzat Algazar
Assistant lecturer of general surgery
,Faculty of medicine , Zagazig University
SURGICAL
SYMPATHECTOMY
PAST , PRESENT AND FUTURE

2. Surgical Anatomy

3. • THE SYMPATHETIC NERVOUS SYSTEM
IS FORMED FROM PREGANGLIONIC
FIBERS WHICH EXIT VENTRAL ROOTS
OF SPINAL CORD FROM T1-L2 AND
SYNAPSE WITH POSTGANGLIONIC
FIBERS IN SYMPATHETIC GANGLION
NEAR SPINAL CORD, OR TRAVELS
ALONG SYMPATHETIC TRUNK TO
ANOTHER GANGLION OR TRAVELS TO
COLLATERAL GANGLION NEARER THE
ORGAN OR GLAND

4. • Post ganglionic fibers supply vasoconstrictor nerves to blood
vessels , secretomotor fibers to eccrine sweat glands .
• Eccrine sweat glands are distributed over whole body but are
most numerous on the palms and soles . They secrets
hypotonic solution of NaCl and they have a thermoregulatory
function .
• Their action is inhibited by sympathectomy .

5. Sympathetic trunks
• There are 2 trunks extending from base of the skull to the coccyx ,
containing ganglia at irregular intervals .
• In cervical region they lie in front of cervical transverse processes , each
trunk have 3 ganglia .
• In thorax it lies in front of the heads of ribs , each trunk have 11 ganglia
• In the abdomen they lie anterolateral to lumbar bodies , they 4 ganglia
in each side .
• Sacral trunks lies medial to the anterior sacral foramina containing 4
ganglia. It terminates in front of the coccyx by joining with it` s fellow to
form ganglion impar .

6. Cervical sympathetic trunk
• The preganglionic fibers to the 3 cervical ganglia all arise from the upper
thoracic outflow and ascend in the cervical sympathetic trunk to reach
the cervical ganglia which give gray rami to each cervical nerves .
• The superior cervical ganglia lies behind the internal carotid artery just
above carotid sinus .
• Middle small ganglia lies at level of inferior thyroid artery when it
crosses the trunk
• Inferior ganglia present as single ganglia only in 20 % of population . In
80% it fuses with 1st thoracic ganglia to form

7. Cervicothoracic (Stellate) Ganglia
•Relations :
• Ant . : skin, subcutaneous tissue, platysma, investing cervical
fascia, sternocleidomastoid muscle, and the carotid sheath . The
lung apex lies anterior and inferior to the ganglion.
• Medial : the C7 vertebral body, esophagus, trachea, thoracic
duct, recurrent laryngeal nerve, and thyroid gland.
• Posterolateral : the anterior scalene muscle with the phrenic
nerve, brachial plexus and its branches, vertebral artery, and
longus colli muscles.

9. • The upper limb derives its sympathetic supply predominantly from
2nd and 3rd thoracic level and partly from 1st , 4th and 5th thoracic
levels .
• So , division sympathetic trunk between stellate ganglia and 2nd
thoracic ganglia nearly all ascending axons supplying the upper
limb will be divided .
• Major outflow of head and neck come from T1 level which pass to
stellate ganglia , so sympathectomy level must be below it to
avoid Horner's syndrome .

10. Anatomical pearl
Nerve of Kuntz
- This nerve is an inconsistent intrathoracic ramus described by Kuntz in
1927 connecting the first and second thoracic nerves bypassing the
sympathetic chain between T2 ganglion and stellate ganglion .
- Kuntz attributed instances of sympathetic recurrences to this neural
variant because it afforded an alternate pathway to the brachial plexus
following stellate ganglionectomy .
- So, it`s recommended that surgical dissection of pleura 1.5 cm lateral
to the sympathetic chain to recognize all KNs to avoid recurrence after
surgery .

11. • Chung and colleagues (2002) classified the KNs into four types according to its connection to the adjacent
nerves:
• Type A : connecting from the T2 to the T1 nerve (47%)
• Type B : connecting from the T2 to the first intercostal nerve (12.1%)
• Type C : connecting from the T2 nerve to gray ramus communicans between the stellate ganglion and the T1
nerve (7.6%)
• Type D : the branching and connecting from the T2 nerve to the T1 nerve and the first intercostal nerve (1.5%)

12. • The prevalence of the KNs, however, varies considerably between
surgical and anatomic literature. Clinical studies describe KNs in about
10% of cases , whereas anatomic investigations about 80% .
• pleural adhesions and increased fibrosis may in fact reduce the
recognizability of KNs in distinct cases, but are unlikely the major
factor for the low detection rate of KNs in general.
• Pronounced subpleural fat tissue may additionally aggravate the
low recognizability of KNs.
• The superior intercostal vein (sometimes called vein of Kuntz),
which is a large branch draining into the azygos vein on the right
side but lies lateral to the second thoracic ganglion on the left
side.

13. • Looking for superior intercostal
veins in the first intercostal space
may enhance the detection rate of
KNs intraoperative. As they give
better contrast compared with
small neural structures such as
KNs.
• These veins can sometimes cause
troublesome bleeding during
dissection of KNs .

14. Endoscopic view of KN

15. Lumbar sympathetic trunk
• The lumbar sympathetic trunk on each side lies retroperitoneal
• They are usually easily visible but may lie in a groove between psoas major
muscle and vertebral column or occasionally behind some fibers of psoas
muscle .
• The trunk lies in front of lumbar veins but some veins may pass in front of it ,
so care must be taken during dissection of trunk to avoid injury of this veins.
• On Rt side IVC overlaps the trunk .
• On Lt side aorta partially cover it .
• Gentiofemoral nerve and ureter lie lateral to the trunk in both sides
• Distal ends pass behind common iliac arteries to become pelvic sympathetic
trunks .

16. Lumbar sympathetic ganglia
• The number and situation of sympathetic ganglia are extremely variable
and often differ from one side of the body to the other side , but they
usually are 4 ganglia on each side is the
• 1st ganglia may lie above fascia of arcuate ligament .
• The most constant and largest ganglia lies at about the disc between L2
and L3 vertebrae , but unfortunately this level can`t be determined with
assurance at operation .
• If there`s a ganglion associated with L4 vertebrae it is usually behind
common iliac artery , thus in dissecting the trunk free the surgeon
should commerce behind CIA and dissect upwards for 4 to 5 cm or higher
if feasible.

17. Surgical Sympathectomy

18. INDICATIONS
1- The primary indication for sympathectomy is
primary hyperhidrosis of the extremity :
Thoracoscopic sympathectomy is highly
effective in the treatment of primary
hyperhidrosis and should be considered for all
patients with the disorder. As reported
by Edmondson (1992) , Gossot (1997) , and Krasna
(2000) and their associates, thoracoscopic
sympathectomy has a success rate of greater than
90% in the treatment of hyperhidrosis. The
complication rates are low, with the most
troublesome source of patient dissatisfaction
being compensatory hyperhidrosis.

19. 2- Raynaud's syndrome and Burger's disease : The results are not
satisfactory as in hyperhidrosis
3- Peripheral vascular diseases :
- patient with absent distal run off and has rest pain , pregangrene or dry
gangrene of the toes may benefit from sympathectomy , rest pain relieved
in 60 % of patient for up to 3 years .
- In non diabetics patients with ankle brachial index less than 0.35,
sympathectomy not beneficial , because deterioration is inevitable.
- Diabetic patients have autosympathectomy due to neuropathy and
therefore rarely benefit from sympathectomy .
4- Causalgia : burning pain associated with hypersensitivity and
vasomotor disturbance due to trauma to somatic nerve .

20. Approaches to Thoracic Sympathectomy
• The goals of any approach should be a complete autonomic denervation of the hands
without complications, no recurrence, minimal or no hospital stay, and the ability to
perform single-stage bilateral sympathectomies.
• Open
- Posterior: Adson et al (1935)
- Supraclavicular: Telford (1935)
- Transthoracic: Goetz and Marr (1944)
- Transaxillary : Atkins (1954)
• Minimally invasive
- Percutaneous radiofrequency ablation: Wilkinson (1984)
- Thoracoscopic: Kux (1954 , 1978)
- Robotic surgery

21. 1- Thoracoscopic sympathectomy technique
• Preparation and consent :
1- Preoperative CXR for all patients to exclude any pulmonary disease.
2- fully obtained consent for the procedure with explanation of the technique
, warning all patients about compensatory sweating , Horner`s syndrome ,
occasional need to insert an intercostal chest drain and there`s failure rate of
10% .
Patient position :
- A modified lateral decubitus position (i.e., leaning forward approximately 15
degrees beyond perpendicular ). This allows the ipsilateral lung to fall away
from the posteriorly located sympathetic chain.
- Both arms abducted to 60O

22. Anesthesia :
General anesthesia ideally with double lumen tube , standard endotracheal tube is
however sufficient if the double lumen tube can`t passed successfully .
Access :
- Once the lung is deflated , artificial pneumothorax is done by inserting Veress needle
in 5th intercostal space , slow insufflation of 1 liter of carbon dioxide into pleural space
• NB: Rapid insufflation will lead to mediastinum shifts away this lead to profound
bradycardia
• A 30-degree 5- or 10-mm thoracoscope is inserted .
• We then use one or two 5-mm working trocars under vision in the third intercostal
space, one anteriorly and one posteriorly.
• We use either hook cautery or harmonic scissors to open the pleura overlying the
sympathetic chain

23. •Action:
- Avoidance of Horner's syndrome depends on preservation of the
stellate ganglion at T1.
- If one limits dissection to below the upper border of the second
rib, injury to the stellate ganglion can usually be avoided.
- The first rib is often difficult to visualize thoracoscopically. It is
often covered by an area of bright yellow fat at its costovertebral
junction, which serves as a useful landmark.

24. - The surgeon should thoracoscopically palpate the soft tissue
above the apparent first rib to be sure there is no further
cephalad rib.
- Once the first rib is localized, the pleura is opened and the
second rib identified
- No further dissection is carried out above the upper border of
the second rib. This also decreases the chances for injury to the
T1 outflow to the lower cord of the brachial plexus

25. - The main sympathetic chain is then elevated from T2 to T3. It is then
clipped and cut with scissors or cut with the harmonic scissors.
- The rami from T2 and T3 are clipped and divided or divided with the
harmonic scissors.
- Cautery is avoided near the rami to prevent heat transfer to the nerve
roots.
- The bodies of ribs 2 and 3 are then scored horizontally with the cautery
from the costovertebral angle laterally for 3 to 4 cm to ablate any
accessory fibers of Kuntz.
- This lung is inflated with drain in the pleural space. The drain is
removed during a Valsalva maneuver, and the incision closed. The
pleural drain is then removed from the first side and the patient is
discharged .

27. • Sympathotomy appears to be quick and safe. Rates of compensatory
hyperhidrosis may be somewhat less, though persistent symptoms and
recurrences may be higher due to regeneration or incomplete division.
• At present, randomized controlled comparisons of sympathotomy
versus resection are lacking.
• The operation can be tailored somewhat based on symptoms and
anatomy. Craniofacial sweating and facial blushing can be ameliorated
with a T2 level lesion. T1 sympathectomy not advocated because of the
increased risk for Horner's syndrome.
• Predominantly palmar symptoms are treated with a T2 and T3 level
operation. Some surgeons include T2 “T4 or T5 for axillary denervation.

28. Troubleshoots
1- If the patient becomes bradycardic , hypotensive or O2 tension falls
from the mediastinal shift , stop surgical procedure offer to reduce
pneumothorax and allow the anesthesia to re-inflat the lung . Continue
with the procedure once patient is stable .
2- Hemorrhage may occur as a result of intercostal vessel trauma or
damage to the azygos vein during diathermy , to avoid azygos vein injury
rotate the operating table into anti Trendelenburg position to decompress
the veins .
3- Adhesions within the chest may cause you to abandon the procedure ,
however most adhesions are amenable to division with combination of
sharp dissection and diathermy

29. • Aftercare :
1- CXR performed after recovery to check for residual pneumothorax
2- You can predict that patient`s hands will be dry following the procedure
, Many surgeons advocate monitoring of the palmar skin temperature to
confirm sympathectomy . Temperature falls 0.8 after successful
sympathectomy
3- facial flushing resolution noted in 90% immediately
4- both sides can be done under one anesthetic
5- chest drains are not routinely needed

30. COMPLICATIONS
1- Compensatory hyperhidrosis: which occurs in 60% to 70% of patients. It
consists of excessive sweating in nondenervated areas, such as the back and groin. It is
often tolerable but can be severe. Its etiology is unclear but may well represent a
normal thermoregulatory compensation. Plantar sweating frequently increases as well.
2-Gustatory sweating : (i.e., facial sweating with salivary stimuli) , Edmondson
and associates (1992) reported a 48% incidence of gustatory sweating.
3- Horner's syndrome is rare with preservation of T1. It may occur in 5% or 10%
of patients, however, because of anatomic variability in the formation of the stellate
ganglion.
4- Others include recurrence, intercostal neuralgias, pneumothorax, and injury to
the subclavian vessels or the esophagus .

31. Advantage and disadvantage
1.The advantages are:
- Excellent exposure, easy access
and precise localization.
- Better cosmosis.
- Fewer post-operative
complications.
- Shorter duration of operation.
- Quicker return to work.
2.The main disadvantages for the
surgeon are:
- Loss of binocular vision.
- Entering the pleural cavity.
- Inability of intra-operative
palpation

32. 2- trans axillary sympathectomy
• Position :
Supine with sandbags under the shoulder, with abducted arm and flexed
forearm
• Access :
- 3rd rib is felt , 8 cm oblique incision from latissimus dorsi , running
forwards and down cross the 3rd rib as far as the posterior border of
pectoralis major.
- Incise the skin and fatty tissue down to the rib , divide the periosteum
longitudinally with cutting diathermy and reflect it from the superior
surface , thereby exposing the costal pleura .

33. - Divide the pleura along the upper border of the rib . Insert rib retractor
and open widely .
- Displace the lung apex downwards with cloth cover lung retractor.
Action :
- Palpate the neck of 1st rib where`s the stellate ganglia may present
- Open the pleura over the sympathetic chain on the second rib
- Grasp the chain immediately above the second ganglion , divide the
chain above it with clips or with diathermy .
- Lift the chain forwards to expose the rami communicants , divide the
rami with diathermy.

34. - Do not repair the costal pleura , If you are anxious about the bleeding
or lung expansion , bring out a chest tube .
- Use strong absorbable sutures around the second and third ribs to
close the chest , ask the anaesthestist to re-expand the lung then close
in layers
- Aftercare :
- CXR immediate after operation to determine whether the lung
expanded satisfactorily .
- Haemothorax may develop following damage to intercostal veins , If
there no drain , aspirate the blood and insert a drain if reaccumulates
- Aspirate air from pneumothorax only if it is symptomatic

35. Supraclavicular approach
Position :
- Supine , with sandbag under the shoulders , the head turned to the
opposite side and table tilted feet down to about 30 degree .
Access:
- Make 5cm incision placed 1 cm above the clavicle , so that the medial 1
cm overlies the lateral border of sternomastoid , divide the platysma
with the skin
- Locate the scalenus anterior muscle , which run down the center of the
field to be inserted into first rib . It `s obscured by fatty areolar tissue ,
which can be teased aside .
- Take care of thoracic duct in the left side. (If injured repair it ) .

36. - Identify the phrenic nerve passing oblique over the anterior surface of
scalenus anterior . Gently retract the nerve medially
- Transect the scalenus muscle in line with skin incision (scalenotomy)
- Avoid injury of subclavian artery which lies immediate behind the
muscle , place a tap around it and mobilize as far as possible
- Gently tear the suprapleural fascia immediately below the artery .
- Push the pleura downwards and laterally with swabs .
- Action :
- palpate the neck of 1st rib to identify the stellate ganglion and
sympathetic chain
- Divide the chain between T2 and T4 ganglia
- Close the wound without repair of scalenus anterior nor sternomastoid

38. Lumbar
sympathectomy

39. Open Lumbar Sympathectomy
• Position :
supine position with a sandbag beneath the side of the operation to give a
20 degree tilt .
• Access:
- 8-10 cm transverse incision at the level of the umbilicus , starting just
medial to the linea semilunaris
- Incise the lateral border of the rectus sheath . Split the external oblique
muscle and incise the internal oblique with diathermy
- Carefully separate the fascia transversalis and muscle without entering
the peritoneum

40. •action :
- Sweep the peritoneum away from the muscle using finger and
swap dissection , continuing this mobilization posteriorly and
medially until the aorta on the left or IVC on the right
- Repair any holes created in the peritoneum before preceeding.
- Open the retroperitoneal space in front of quadratus lumbourm
and Psoas
- Lift the ureter forwards with the peritoneum out of harm`s way.
- The genitofemoral nerve is seen descending downwards and
obliquely along the psoas muscle not far from its medial edge.

41. - sympathetic chain on the left side is easiest to approach as it lies
on loose areolar tissue alongside the aorta and can be palpated
as ganglionated cord against vertebral bodies
- On the right side it lies behind IVC which retracted gently , avoid
injury of lumbar veins which may pass in front of sympathetic
chain
- Lift the chain forwards with nerve hook , diathermize and divide
the rami communicantes , then excise the segment containing
the second and third ganglia after applying haemoclips from
lower border of L2 to the lower border of L4 .

42. Endoscopic Retroperitoneal lumbar sympathectomy
Anesthesia : General anesthesia
Patient position : Lateral decubitus position, and the table is flexed at the
level of the umbilicus to create maximal space between the lower margin
of the rib cage and the iliac crest

43. • Access:
- 15-mm incision is made midway between the costal margin and the iliac
crest at the anterior axillary line. The incision is carried down through the
external and internal oblique muscles .
- With S-shaped retractors and blunt finger or sponge stick dissection, the
areolar fatty tissue is dissected while the peritoneal sac is gently pushed
forward (ventrally) , which creates a safe space for the insertion of the
distention balloon system into the retroperitoneum.
- The balloon then is inflated with vision via a 30° scope introduced into
the balloon trocar. The fully inflated balloon is left in place for a couple of
minutes to achieve hemostasis and then is deflated and removed.

44. - A Hasson trocar is introduced into the space created and secured with
two sutures to the fascia to avoid gas leakage. The space created is
insufflated with CO2 to a pressure of 10 to 12 mm Hg.
- Two to three additional 5-mm ports are inserted with direct vision into
the retroperitoneal space along a line 2 to 3 cm posterior to the first
trocar, at the mid and posterior axillary
• Action :
- The ureter and gonadal vessels usually remain adherent to the
peritoneum, but they should be clearly identified before any dissection
is attempted.
- The genitofemoral nerve is visualized descending downwards and
obliquely along the psoas muscle not far from its medial edge.

45. • The vertebrae in the paravertebral space are palpated with laparoscopic
instruments, and the dissection of this space is started at the medial
border of the psoas muscle and close to the vertebrae.
• The sympathetic chain is identified in front of the vertebral column along
the inner margin of the psoas muscle and small communicating rami and
blood vessels are divided with cautery or clips and endoscissors to
ensure hemostasis
• Care should be exercised to dissect close to the sympathetic trunk and
ganglia to avoid injury to lumbar or other communicating vessels in the
Such area.

46. • The sympathetic ganglion that is most obviously visualized in the
operative field after the dissection of the sympathetic trunk is L3.
Ganglion L2 is located below the lower pole of the kidney, and L4
is located in the area of the promontorium and is sometimes
extremely difficult or even impossible to locate

47. •Aftercare :
- Ileus is brief except if a retroperitoneal hematoma forms , when
it may prolonged the hematoma may need draining
- Some patients complaining of postsympathectomy neuralgia ,
the explanation is unknown but resolves after few .
- Men whom both first ganglia are removed will have dry orgasm
as a result of damage to the ejaculatory mechanism .

48. Important links :
• https://www.youtube.com/watch?v=-7zPve0pgMg

49. •‫والجود‬ ‫والعلى‬ ‫التفرد‬ ‫وله‬ ‫محمود‬ ‫وربنا‬ ‫الكالم‬ ‫تم‬
•‫عود‬ ‫وأورق‬ ‫قمرى‬ ‫ماغرد‬ ‫وآله‬ ‫النبى‬ ‫على‬ ‫الصالة‬ ‫ثم‬