Endoscopic transthoracic sympathetic surgery (ETS) is a collective term for a series of procedures that may differ significantly from each other.
Sympathetic surgery should be reserved to patients with severe forms of the following disorders, for which no satisfactory result was obtained by conventional measures:
NB: isolated Axillary Hyperhidrosis (armpit sweating) should be treated by other treatment options. ETS should only be considered in exceptional cases (severe distress and total failure of botulinum toxin therapy and local surgical procedures).
The type of surgery and the way it is carried out has a significant impact on the result, both regarding the effect and, in particular, regarding the side effects.
The exclusion of the T3 ganglion produces reliable results for excessive hand sweat. Cardiocirculatory side effects (slower heart rate and lower blood pressure) are almost absent and the risk for reactive (compensatory) hyperhidrosis is very low.
Under no circumstances should the ganglion T2 be involved at a first operation, nor should the sympathetic chain be interrupted above this ganglion, because of a more pronounced risk of developing intense compensatory sweating and side effects involving heart function and blood pressure.
The compression is performed by applying a single clip just above the ganglion T2. This usually corresponds to the lower edge of the second rib, which ensures a safe distance to the stellate ganglion (Th1).
We prefer the single-lumen intubation, a double-lumen intubation carries virtually no benefits and extends the duration of the surgery unnecessarily.
The lateral position seems more awkward because it requires the patient to be repositioned under anesthesia.
Two-stage procedures are almost always chosen in order to get double reimbursements from the health insurance or because the surgeon is not yet familiar with the procedure.
Alternative techniques include the 1-port method in which only one incision is required. For this purpose, either a special instrument with integrates both the optical system and an electrode (resectoscope), similar to devices used in urology for prostatic surgery, or an even thinner endoscope provided with a coagulation electrode is employed. Clamping is not possible with 1-port systems. In rare cases with extreme adhesions between the pleura and lung, the one-port method may be the only way to approach the nerve.
Exceptional events may require a third port, e.g. in the presence of particularly difficult anatomy or when copious bleeding occurs.
After proper interruption of the nervous signal flow, the effect is already apparent immediately upon awakening from anesthesia, and with special measuring devices even in the course of surgery. After a few months, a certain degree of moisture on the palms or in the face may become gradually noticeable in some patients, but it hardly ever reaches a cumbersome level and practically never the original intensity of hyperhidrosis. This phenomenon is generally caused by a redirection of nervous impulses via parallel pathways, thus bypassing the block, rarely by reconnection of the nerve fibers at the point of interruption.
Recurrence of facial blushing is more frequent (> 10%) and appears to be caused by the same mechanism.