Dorsal Sympathectomy

Dorsal (thoracic) sympathectomy for hyperhidrosis or causalgia (posttraumatic vasomotor dystrophy) can be accomplished successfully using video-thora-coscopic techniques (see Chapter 22). The sympathetic chain is located paravertebral^ in the posterior mediastinum and is easily accessible by endoscopy. Although double-lumen endotracheal intubation and the lateral decubitus position are reliable with excellent results, we prefer the supine position with single-lumen endot-

racheal intubation and insufflation of the pleural space with CO2. Intrathoracic pressures of up to 15 mm Hg are generally well-tolerated for short periods of time, but higher pressures, especially in the left hemithorax, should be carefully monitored hemodynamically for tension pneumothorax-related electromechanical dissociation (EMD). The endoscope is inserted into the pleural space through the 4th interspace in the anterior axillary line. Another port is placed at the base of the axillary hairline and a spatula cautery is used to cautery-transect the sympathectic chain at the level of the 2nd and 3rd ganglia. Reverse Trendelenburg and rotation of the patient away from the side of surgery facilitates exposure. Generally the 1st ganglion is avoided to prevent any danger of Horner's syndrome.

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