Hyperhidrosis is a disorder ersulting in debilitating, excess sweating on one, or more commonly both sides of the body due to overactivity of the upper thoracic sympathetic chain. It usually involves the upper extremities, frequently coexistent with hyperhidrosis of the feet, and frequently has a hereditary component. In severe cases conservative measures including topical aluminum chloride compounds (Drysol), oral anticholinergics, iontophoresis (electrcial current transmission via tap water) and Botulinum toxin injections are wholly unsatisfactory. The single most effective treatment is thoracic sympathectomy which is curative for palmar hyperhidrosis and frequently markedly improves hyperhidrosis of the feet as well.

The approach for thoracic sympathectomy for either hyperhidrosis or causal-gia can be done open under direct vision through the transaxillary approach.

A double lumen endotracheal tube is employed, as is the lateral decubitus position. Transaxillary incision is performed sparing the intercostal brachial nerve and long thoracic nerve, and the third intercostal space is entered. The posterior mediastinal pleura is incised and the sympathetic chain is exposed from the level of T3 to T1. T1 is the lower portion of the stellate ganglia at the top of the first rib. The rami communicantes are individually clamped with clips and transected. It should be noted that only the lower portion of the stellate ganglia, i.e., T1, should be taken because removal of the C8 portion of the stellate ganglia will result in Horner's syndrome, i.e., ptosis, meiosis and anhidrosis of that side of the face.

Alternatively, the entire ganglia and rami at the level of the second and third sympathetic ganglia are cauterized-transected. Patients should be informed of the possibility of compensatory hyperhidrosis affecting areas other than the upper extremities. Video-assisted thoracoscopic techniques may also be utilized for thoracic sympathectomy. Compared with the open procedure, thoracoscopic sympa-thectomy is faster, less painful, and achieves better visualization of the thoracic sympathetic chain and can commonly be done on an outpatient basis. It is the procedure of choice for surgical sympathectomy. The procedure is described in Chapter 25.

Suggested Reading

1. Roos DB. Congenital anomolies associated with thoracic outlet syndrome-anatomy, symptoms, diagnosis and treatment. Am J Surg 1976; 132:771-778.

2. Urschel HD Jr., Paulson DI, McNamara JJ. Thoracic outlet syndrome. Ann Thorac Surg 1968; 6:1-10.

3. Urschel HD, Pualson DL, McNamara JJ. Thoracic outlet syndrome. Ann Thorac Surg 1968; 6:1.

4. Pollak EW. Surgical anatomy of the thoracic outlet syndrome. Surg Gynecol Obstet 1980; 150:97.

5. Baumgartner F, Nelson RJ, Robertson JM. The rudimentary first rib: a cause of thoracic outlet syndrome with arterial compromise. Arch Surg 1989; 124:1090-1092.

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