Detailed Step-by-Step Guide to Thoracoscopic Sympathectomy by Dr. Sajal Chaudhary MBBS, MS, MMAS

1. Preoperative Preparation:

   • Obtain informed consent after explaining the risks and benefits of the procedure.
   • Conduct a thorough preoperative evaluation, including chest X-ray and pulmonary function tests if needed.
   • Ensure the patient fasts according to the standard preoperative guidelines.

2. Anesthesia:

   • Administer general anesthesia with intubation, preferably using a double-lumen endotracheal tube for single-lung ventilation.
   • Position the anesthesia equipment and team at the head of the patient.

3. Patient Positioning:

   • Position the patient in a semi-prone or lateral decubitus position, with the side of the planned sympathectomy facing upward.
   • Secure the patient’s arms and provide adequate padding to all pressure points.

4. Team Positioning:

   • The surgeon stands at the back of the patient, facing the thorax.
   • The first assistant stands at the front of the patient, opposite the surgeon.
   • The scrub nurse or technician is positioned at the lower end of the table with the surgical instruments.

5. Monitor Placement:

   • Position the monitor on the opposite side of the patient’s thorax, in direct view of the surgeon.

6. Establishment of Pneumothorax:

   • Create a controlled pneumothorax by insufflating CO2 into the thoracic cavity, if necessary, to collapse the lung and improve visualization.

7. Port Placement:

   • Insert the first 5-mm trocar in the midaxillary line at the level of the fourth or fifth intercostal space for the camera.
   • Place two additional 5-mm ports: one in the anterior axillary line at the third intercostal space, and the other in the posterior axillary line at the fifth or sixth intercostal space.

8. Thoracic Cavity Inspection:

   • Insert a thoracoscope through the camera port to inspect the thoracic cavity and identify the sympathetic chain.

9. Sympathetic Chain Identification:

   • Identify the sympathetic chain running along the necks of the ribs.
   • Locate the specific ganglia responsible for the symptoms (typically T2-T4 for palmar hyperhidrosis).

10. Sympathectomy Procedure:

    • Use electrocautery or a harmonic scalpel to divide the sympathetic chain at the predetermined levels.
    • Ensure hemostasis and avoid injury to surrounding structures.

11. Inspection and Closure:

    • After the sympathectomy, inspect the thoracic cavity for bleeding or other complications.
    • Reinflate the lung under direct vision.
    • Remove the trocars and close the incisions, typically with absorbable sutures.

12. Postoperative Management:

    • Monitor the patient in the recovery area, paying special attention to respiratory function.
    • Manage pain and provide instructions regarding activity, breathing exercises, and wound care.

13. Chest X-ray:

    • Obtain a postoperative chest X-ray to check for pneumothorax or other complications.

14. Follow-Up:

    • Schedule a follow-up appointment to assess the effectiveness of the sympathectomy and address any postoperative concerns.

This procedure should be performed by a surgeon skilled in thoracoscopic techniques. Adaptations to this protocol may be necessary based on individual patient anatomy and intraoperative findings.