The therapeutic rationale in the treatment of hyperhidrosis is based on the interruption of transmission of sympathetic impulses from the lower sympathetic ganglia through stellate ganglia to the hands. Thoracoscopic T2-sympathectomy or sympathicotomy (without removal of ganglia) is considered the best treatment for hyperhidrosis. However, the main disadvantage of this procedure is its irreversibility. As sympathetic nerve regeneration is impossible to control after sympathectomy, this usually leads to compensatory sweating over the trunk or back - a consequence some patients regret, even to the extent of preferring the original sweaty hands.
Denny-Brown and Brenner proved that without transecting the nerve trunk, nerve conduction could be interrupted by a compression force of more than 44 grams. The present endoscopic clips exert a force of approximately 150 grams. This force is obviously high enough to block the transmission of sympathetic impulses. Based on this principle, thoracoscopic T2-sympathetic blockade by endoscopic clipping was performed for hyperhidrotic patients.
PATIENTS AND METHODS
From March 18 to September 30, 1996, a total of 326 patients with hyperhidrosis (190 female and 136 male),ranging in age from 5 to 52 years with a mean age of 20.5 years, underwent thoracoscopic T2-sympathetic block by clipping. All operations were performed as outpatients.
The procedure used is a modification of our original method. Under general anesthesia, with a single lumen tracheal intubation, the patient is placed in semi-Fowler’s position with his arms abducted. Two ports are made. For case of operation and cosmetic reasons, a port of 0.5 cm is made in the axilla for the insertion of the hooked diathermy probe and the endoscopic clip-applicator. Another port of 1.0 cm in the middle or posterior axillary line at the level of the nipple is made for the introduction of the thoracoscope. The lung is deflated under the control of the anesthesiologist, while a trocar is inserted through the large port. The sympathetic trunk con be seen through the thoracoscope, unless there are severe pleural adhesions, which contraindicate thoracoscopic clipping. Then the hooked diathermy probe is passed through the small port after a 0.5 cm trocar is inserted. Under video-assistance, the pleura is opened along the sympathetic trunk with the hooked diathermy probe. A segment of T2-sympathetic trunk is then meticulously mobilized from adjacent tissue without transecting the sympathetic trunk and its branches. The Ligaclip Allport endoscopic clip (Ethicon, Inc., NJ, USA) is preferred for its special design that keeps a constant compression force even if the nerve trunk atrophies during the compression. Both ends of T2-sympathetic ganglion are clipped. One single clip at either end is enough to block the transmission of sympathetic impulse. Any Kuntz’s fibre found may or may not be transected before the clips are applied. Trocars are removed while the lung is inflated by the anesthesiologist. The ports are then closed with a single stitch, which is removed 4 days later.
A single port at one side of the axilla is enough to perform a reverse operation - removal of the clips - when the patient cannot tolerate postoperative compensatory sweating.
RESULTS
342 patients had thoracoscopic operations for the treatment of hyperhidrosis. Of these, 16 underwent sympathectomy, and 326 (95.0%) (190 female and 136 male with a mean age of 20.5 years) underwent thoracoscopic sympathetic block by clipping. These patients were followed up by telephone questionnaire in March 1997. The post-operative results were satisfactory except for one woman who had persistent minor sweating of the right hand and two children aged 7 years in whom sweating recurred after two months. Because severe pleural adhesion in the right thoracic cavity in the first case, we were able to apply only one clip, on the upper end of the right T2-symapthetic trunk. There was, however, no recurrence of excessive sweating of her right hand. Clips applied at an inappropriate level of the sympathetic trunk (shown by chest roentgenography) was the reason for the failure in the two children. No infection or pneumo- haemothorax was encountered.
Of the 326 patients, 5 (1.5%) had a reverse operation for intolerable compensatory sweating over back or hip. Three cases recovered from compensatory sweating and resumed their sweaty hands within two months while one of the remaining two had some lessening of compensatory sweating and the other had no improvement.
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