21 de Fevereiro de 2020 - 23:48
Medical Reference
[-] Hyper-Hidrosis
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HYPERHIDROSIS / DEFINITIVE SURGICAL TREATMENT
Hyperhidrosis - Excessive perspiration


VIDEOTHORACOSCOPY THORACIC SYMPATHECTOMY
Definitive treatment is already known since 1940 (KOTZAREFF), the cervical thoracic Sympathectomy is done through the resection of the sympathetic ganglions of thoracic trunk.

This method was not well divulged in Brazil because it was done through a large thoracotomy (a big incision on the thoracic wall) or cervical incision, and later, through a minor axillar thoracotomy, but still large and with a limited surgical field.

European authors, especially Scandinavian, using Thoracoscopy presented large series with excellent results since 1950. Dr. Kux, an Austrian surgeon was the great divulger of Thoracoscopy Thoracic Sympathectomy.

Later, the VIDEOTHORACOSCOPY arrived (Thoracic surgery done through video cameras). This surgical method utilizes a micro camera, which increases 20 times the surgical field and small incisions. So the complication and pain during the postoperative time is diminished, so is the time at hospital and the medical-hospital costs. There was a great divulgation of VIDEOTHORACOSCOPY Thoracic Sympathectomy for the treatment of Hyperhidrosis Palmar, Axillar, Craniofacial, Raynaud Disease, Reflex Sympathetic Dystrophy, Causalgia, Vascular Insufficiency of Superior Members, Long QT Syndrome, Facial blushing, Social phobia, and untreatable Angina Pectoris.
 
Sistema Nervoso Simpático Torácico e Cervical
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SURGERY INDICATION
A dermatologist, neurologist, endocrinologist and other professionals involved in diagnosing and/or treating Hyperhidrosis should evaluate patients and referred them to surgical treatment.

Our patients’ age varied from 9-64 years old and the majority of them was operated between 15-25 years old Even though they can be operated in any age, nowadays we advise them to have the surgery for Palmar Hyperhidrosis around 10 years old, so we will prevent the anguish and constraining problems during teenage years. The great majority of our patients were females (67%).
 
CONTRAINDICATIONS
Patients with pulmonary insufficiency, severe cardiovascular insufficiency and uncontrolled diabetes should not be operated. Contraindication is relative for patients with thoracic surgery sequel, thoracic trauma and pleural diseases.

Obese patients should not be operated or operated with restriction because of the difficulty in locating the Sympathetic trunk. Some can have their symptoms softened simply by loosing weight.
 
PRINCIPLES OF THORACIC SYMPATHECTOMY
Since the first publications about cervical thoracic sympathectomy in the treatment of hyperhidrosis there has been progress and a discussion about the level of the thoracic trunk and the number of thoracic ganglions to be removed. The majority of studies were published in the last ten years and their goals were the attainment of better results and more recently, the decrease of side effects such as the compensatory perspiration.

In brief – the sympathetic thoracic ganglion (T1) is the major responsible for sweating and heat loss of face, hands and in minor extension of armpits. T1 in conjunction with C8 (eighth cervical ganglion) form the Stellate Ganglion, which is responsible for the eyelid and pupillary response (orbital area). They should be preserved because an injury may cause Claude Bernard Horner Syndrome. In over 600 operated patients we never had such complication. The second thoracic ganglion (T2) controls the sweat response of hands and face (except the intra-orbital portion), scalp, shoulders and the anterior and posterior parts of the thorax above the mammilla and facial blushing. The third ganglion (T3) affects the sweating of hands, armpits, shoulders and the anterior and posterior parts of thorax above the mammilla and of face in a minor degree. The fourth ganglion (T4) innervates hands and armpits. As you should have noticed there is a sympathetic innervation superposition for hands, face and axillas.
Currently we perform a T2 Sympathectomy for craniofacial hyperhidrosis and for facial blushing, T3 for hyperhidrosis palmar, T3 and T4 for axillar hyperhidrosis associated or not to hyperhidrosis palmar. Literature reveals a tendency, although not unanimous, of clipping instead of sectioning or coagulating the ganglions of the sympathetic trunk, especially after the reports of Lin and Telaranta. This clipping is done at the same levels already mentioned with the advantage that the clips could be removed in case of a severe compensatory hyperhidrosis (more details in the compensatory perspiration section).
 
SURGICAL TECHNIQUE
The surgery is performed under general anesthesia using double lumen tube (Carlens’ tube) for intubation to allow the ventilation of each lung separately and to promote lung collapse in the side to be operated. The patient is in dorsal decumbent position with the trunk elevated 450. A 5mm incision is done in the fourth intercostal space in the medial axillar line. This position is adapted according to the form, dimension, breast position, and the previous presence of silicone implant prosthesis (which does not impede nor hamper the surgery). A second trocar or portal is introduced through the 5mm incision at the third intercostals space. Adjustments are made through direct vision by compressing the thoracic wall at the intercostal space so it stays at “thoracic portion of axilla” and a place for the introduction of the instruments can be chosen. The thoracic trunk can be seen at a sub-pleural position and at the junction of the head of ribs with the vertebra bodies. The first rib and its head over which the stellate ganglion is located cannot be seen. The second rib is the first one to be seen inside the thorax and it serves as a reparation point. By gentle palpation ribs and their respective ganglions can be identified (figure). With a cautery the pleura is opened. Dissection or coagulation of ganglions is performed, isolating the communicating sympathetic ramifications anterior and posterior so that there is no transmission of heat or energy to the intercostal nerves. Sympathectomy at T2 is done in case of craniofacial hyperhidrosis, at T3 for palmar hyperhidrosis, at T3 andT4 for axillar hyperhidrosis associated or not to palmar hyperhidrosis. Currently we opt to perform the clipping done at the same levels. When clipping T2, a clip is placed at the sympathetic trunk over the second rib and another at the sympathetic trunk over the third rib. If clipping T3, a clip is placed at the sympathetic trunk over the third and fourth ribs. For clipping of T3 and T4 a clip should be placed at the sympathetic trunk over the third, the fourth and the fifth ribs. After the end of sympathetic electrocoagulation / section or clipping a thin thoracic drain with a subaqueous external extremity is introduced through the trocar. The pulmonary expansion proceeds under direct vision and the optical is removed. The anesthesiologist keeps on performing pulmonary insufflation maneuvers in the operated side until no more air escapes through the thoracic drain, what means that a complete pulmonary re-expansion has happened. Then the thoracic drain can be removed. Seldom the need to keep the thoracic drain after the surgery happens. Surgery in both sides is done on the same anesthetic action, taking about 40 minutes. The subcutaneous tissue is stitched with monocryl 000 strand and the skin is hastened by surgical adhesive.

VIDEO DOWNLOAD
 
EXAMPLE
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HYPERHIDROSIS SURGERY POSTOPERATIVE
The patient stays at the Recovery Room until his/her complete recovery from anesthesia. Afterwards he/she will be taken to a hospital room where, according to his/her needs, analgesic medication will be administered. He/she will be able to eat in the afternoon after the surgery. Usually the patient is dismissed in the next day. We recommend three days of relative rest and after these he/she may go back to regular activities. Intense physical activities should be avoided for about 15 days.
 
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