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doi:10.1510/icvts.2010.252189

Interactive CardioVascular and Thoracic Surgery 12 (2011) 106–109

� 2011 Published by European Association for Cardio-Thoracic Surgery

New ideas - Thoracic non-oncologic

Bilateral single-port thoracoscopic sympathectomy with theVasoView device in the treatment of palmar and axillary�

hyperhidrosis�

Wobbe Bouma1,*, Theo J. Klinkenberg , Massimo A. Mariani1

Department of Cardiothoracic Surgery, University Medical Center Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands

Received 18 August 2010; received in revised form 6 October 2010; accepted 15 October 2010

Abstract

Primary or essential hyperhidrosis is a disorder characterized by excessive sweating beyond physiological needs. It is a common disease(with an incidence of up to 2.8%) that causes intense discomfort for patients. Video-assisted thoracoscopic bilateral sympathectomy is aneffective surgical treatment with high success rates and improvement in quality of life. In the last decade, the advantages of a single-portthoracoscopic approach have become clear. Problems with intraoperative bleeding management have been solved by using thoracoscopeswith integrated electrocautery scissors. In this report, we describe successful transaxillary bilateral single-port thoracoscopic T2-T5sympathectomy with the VasoView device in three patients with palmar and axillary hyperhidrosis. The VasoView device, with its� �

integrated electrocautery scissors, was originally designed for endoscopic vessel harvesting in coronary artery bypass surgery, but it hasproven highly effective for single-port thoracoscopic sympathectomy.� 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Keywords: Hyperhidrosis; Minimally invasive; Thoracoscopy; Sympathectomy; Sympathicotomy

1. Introduction

Primary or essential hyperhidrosis is a disorder with anunknown cause and is characterized by excessive sweatingbeyond physiological needs, particularly in response totemperature and emotional stimuli w1x. It is a commondisease that affects men and women equally, with a peakincidence in the late second and early third decades oflife, and an incidence in the Western world of up to 2.8%of the population w2x. Most affected patients have palmar(-plantar) hyperhidrosis, but combined palmar-axillaryhyperhidrosis, isolated axillary hyperhidrosis (AH) and cran-iofacial hyperhidrosis are relatively common as well w3x.The principal characteristic of this disease is the intensediscomfort of patients, which affects their social, affective,and professional life.

Medical management is often frustrating and the responseis usually transient w4x. Surgical therapy is effective, espe-cially for palmar(-plantar) hyperhidrosis, and is based onthe interruption of transmission of impulses from the sym-pathectic ganglia to the sweat glands w4x. The first sympa-thectomy by thoracoscopy was reported in 1951. After itsintroduction, endoscopic thoracic sympathectomy (ETS)evolved considerably and became a popular and well-established treatment modality for hyperhidrosis in the

� This study was financially supported by the University Medical CenterGroningen and the Groningen University Institute for Drug Exploration.

1Both authors contributed equally.*Corresponding author. Tel.: q31 503 613238; fax: q31 503 611347.E-mail address: w.bouma@thorax.umcg.nl (W. Bouma).

early 1990s. Large series have shown success rates of 71–100% following ETS for all forms of primary hyperhidrosiswith improved quality of life and treatment satisfaction of93–95% w5, 6x.

Comparing with the biportal or triportal thoracoscopicapproach, advantages of a single-port approach include lesspostoperative pain, shorter operation time and recoverytime, and better cosmetic results w7, 8x. A minor disadvan-tage of the single-port approach is the difficulty in dealingwith intraoperative bleeding; a problem that has beensolved by using ‘thoracoscopes’ with integrated coagulatingscissors w8x. This development has made the proceduresafer and does not require patient repositioning on bothsides.

Although the single-port approach and the use of a thor-acoscope with integrated electrocautery scissors have beendescribed before, this is the first description of transaxillarysingle-port thoracoscopic sympathectomy with the Vaso-View device, which is already available on a world-wide�

scale for a different purpose (i.e. endoscopic vessel har-vesting for coronary artery bypass surgery).

2. Materials and methods

Between July 2009 and February 2010, three patients(two male, one female) underwent bilateral single-portthoracoscopic T2-T5 sympathectomy with the VasoView�

device (Maquet Inc, Rastatt, Germany) (Fig. 1) for palmarhyperhidrosis (PH) and axillary hyperhidrosis. All patients

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Fig. 1. The VasoView device and a magnification of the working channel�

with the electrocautery scissors. Modified and reproduced with permissionfrom Maquet Inc, Rastatt, Germany.

Fig. 2. Single-port transaxillary thoracoscopic T2-T5 sympathectomy with the VasoView device. (A) Thoracoscopic view of the right superior mediastinum.�

Identification of the subclavian artery (A) and vein (V), the lung (L), the first (R1) and second rib (R2), and the sympathetic chain (S). (b) Schematic diagramof a showing the position of the sympathetic chain (S). The sympathetic chain runs over the anterior surface of the posterior rib heads. The sympathetic ganglia(T1, T2) are seen just below the respective rib level. (c, d) T2-T5 sympathicotomy with the VasoView electrocautery scissors. T2 sympathicotomy (c) and T4-�

T5 sympathicotomy (d) are shown. The sympathetic chain is transected above and below the ganglion with coagulation and cut with diathermy. The gangliathemselves are spared. A, subclavian artery; L, lung; R1, first rib; R2, second rib; R3, third rib; R4, fourth rib; R5, fifth rib; R6, sixth rib; S, sympathetic chain;T1, first thoracic ganglion (‘stellate ganglion’); T2, second thoracic ganglion; T3, third thoracic ganglion; T4, fourth thoracic ganglion; T5, fifth thoracic ganglion;V, subclavian vein.

were referred with disabling combined PH and AH, whichseverely interfered with their work or social activities.

A chest X-ray was performed prior to surgery to excludegross pulmonary and pleural abnormalities. General anes-thesia was given and a single lumen endotracheal tube wasinserted. Single lung ventilation was obtained with the EZ-blocker (EZ-blocker Inc, Delft, The Netherlands). Thepatient was positioned on the left side with the arm flexed

over the head to expose the axilla. The right side wasapproached first. A finger temperature probe was used torecord the rise in peripheral cutaneous temperature thatresults following sympathectomy. After deflation of theright lung, a single 1-cm long axillary incision was made inthe third intercostal space posterior to the pectoralismuscle. A 7-mm trocar was inserted in the third intercostalspace followed by CO insufflation and introduction of the2

VasoView device. The dorsal sympathetic chain was iden-�

tified running along the neck of the ribs close to thecostovertebral junctions (Fig. 2a,b and Video 1). The firstand second rib were identified under direct vision (Fig.2a,b and Video 1). The sympathetic chain was then tran-sected above and below the ganglia (segments T2-T5) withcoagulation and cut with diathermy (Fig. 2c,d and Video1). A rise in peripheral cutaneous temperature of over 1 8Cwithin 5–10 min confirmed complete sympathectomy. Thesurgical procedure was completed by reinsufflation of thecollapsed lung under direct vision, insertion of an 8-Fthoracic catheter through the same incision, and closure ofthe wound with a single skin suture. The patient wasrepositioned on the right side and the entire procedure

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108 W. Bouma et al. / Interactive CardioVascular and Thoracic Surgery 12 (2011) 106–109

Video 1. Single-port transaxillary thoracoscopic T2-T5 sympathectomy withthe VasoView� device.

was then repeated on the left side. Before detubation thepleural drain on the right side was removed.

Operative time, hospital stay, complications, and recur-rences were recorded. Outcome was assessed by a clinicalevaluation three months after surgery.

3. Results

Three consecutive patients, including two men and onewoman with a mean age of 25 years (23–27 years), under-went bilateral single-port thoracoscopic T2-T5 sympathec-tomy with the VasoView device.�

The mean operation time was 91 min (53–120 min). Con-version to an open procedure was not required in anypatient. A rise in ipsilateral peripheral cutaneous temper-ature of over 1 8C within 5–10 min after sympathectomywas recorded in all patients.

Pleural drains were removed at the end of the day andall patients were discharged from the hospital on the nextday. Complications, such as intraoperative bleeding, post-operative pneumothorax, infections, and Horner’s syn-drome were not observed.

A follow-up of three months revealed excellent functionaland cosmetic results, without residual pain. There was norecurrence of hyperhidrosis or occurrence of compensatoryhyperhidrosis (CH) (compensatory sweating of other bodyareas) in all three patients.

4. Discussion

Since the 1990s, ETS has become a well-established sur-gical treatment for hyperhidrosis. Further refinementinvolved single-port sympathectomy w7, 8x and use of thor-acoscopes with coagulating scissors w8x. We report our earlyexperience with the VasoView device in bilateral single-�

port thoracoscopic sympathectomy for PH and AH in threepatients. Our technique provided excellent visualisation ofthe sympathetic chain up to the first rib. We did notencounter any perioperative complications and follow-upafter three months showed excellent functional and cos-metic results without residual pain. CH did not occur aftera three-month follow-up, which is encouraging, since thereis evidence that if CH does not occur within the first twoto four weeks after sympathectomy, it will not developlater w9x.

The term sympathectomy is widely used in the literaturewithout clear definitions and may be referred to as resec-tion of a portion of the sympathectic chain with ablationof ganglia (true sympathectomy), clipping of the sympa-thectic chain (sympathetic block), or transection of the

chain above and below the ganglia (sympathicotomy). Inthis preliminary study, we used the last option.

Controversy exists as to which levels and how many levelsof sympathectomy ensure the highest success rate andcarry the lowest incidence of CH. In patients with PH, aT2-T3 sympathectomy is highly effective (success rate of99–100%) and shows a low incidence of severe CH of 1.3–12% w4, 10, 11x. Lower level sympathectomy (T3 andyorT4) may decrease the incidence and severity of CH, butmay be less effective than T2-T3 sympathectomy w4, 12x.The treatment of AH by sympathectomy remains contro-versial. T4-T5 sympathectomy is successful in 86% with aCH incidence of 29% w13x.

We prefer sympathicotomy of segments T2-T5 for com-bined PH and AH to adequately treat this condition andprevent recurrence. We therefore accept a somewhat high-er level of CH, since it has been shown that in up to 90%of cases, CH is well-tolerated w14x. Discussing this risk ofCH with each patient preoperatively is of paramount impor-tance, because it can be a major cause of regret.

Postoperative pain can further be reduced by preinjectionof a local anaesthetic (short acting, such as lidocaine)before ETS. This suppresses local pain mediators, henceresulting in significantly less pain in the first postoperative24 hours w15x. The clinical advantage may be the possibilityof early discharge in an outpatient setting and early returnto active life.

A limitation of this study is the small number of patients.Obviously, a larger study cohort with a longer follow-up isrequired to evaluate the long-term results of thistechnique.

In conclusion, our preliminary results are promising andsuggest that single-port thoracoscopic sympathectomy withthe VasoView device may offer excellent functional and�

cosmetic results. The VasoView device may play an impor-�

tant role in the future of outpatient single-port ETS forhyperhidrosis.

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