DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Hyperhidrosis involving the face, hands and underarms.
POSTOPERATIVE DIAGNOSIS: Hyperhidrosis involving the face, hands and underarms.
OPERATION PERFORMED: Bilateral endoscopic thoracic sympathectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF OPERATION: The patient was brought to the operating room. After the establishment of general endotracheal anesthesia, the patient was prepped with Betadine and sterile drapes. The left side was approached first. The patient was placed in a reverse Trendelenburg position and rotated to the right. The patient’s breast was retracted medially and a small incision was made alongside the breast in the fourth intercostal space. The internal intercostal nerve block was first administered. Hemostat was then used to puncture in the thoracic cavity. An operating trocar and thoracoscope were passed in the thorax.
Once we had assured access to the chest, CO2 insufflation was begun to displace the lung. Additional Marcaine was administered in the axilla and a second trocar was inserted at this level. Thoracic trunk was readily identifiable. Because of the patient’s symptoms, we felt that at T2-T3, sympathectomy was warranted. The pleura adjacent to the sympathetic trunk was incised overlying the second and third ribs. The pleura was mobilized free from the underlying sympathetic trunk. The nerve was then gently manipulated with an L-hook. Two clips were placed at each level without difficulty. We looked before but did not identify any accessory nerves. Once, the clips were applied, CO2 insufflation was stopped. Additional 5 mL of Marcaine solution was instilled in the thoracic cavity. The lung was then re-expanded and the gas vented from the trocars. The trocars were removed as the lung expanded. Once the trocar was removed, the skin was closed with subcuticular suture of 4-0 Monocryl.
We then directed attention to the right side. The patient was rotated to the left. Mirror image incisions were made on the right side. Access to the thorax was achieved in the similar fashion. On this side, the sympathetic trunk was very difficult to identify. We thought we could notice something beneath the pleurae overlying T2 and in fact the pleurae were incised and we were not able to identify the sympathetic trunk at this level. We placed traction on the nerve but still could not identify at T3. Further dissection was then undertaken at T4 and again, based more on hunch and the anticipated anatomic location, we were able to incise the pleura and identify the nerve at T4. Dissecting superiorly and inferiorly from T2 and T4, we were then unable to trace the nerve in a location posterior to azygos vessel. At the T3 level then, we were able to incise the pleura laterally and mobilize it in a lateral to medial fashion. In so doing, we were then able to get behind the azygos vessel and hook the nerve with a hook. In so doing, we were able to mobilize it and pull it medially; however, we did not feel we safely applied clips without likely injury to the azygos vessel. Accordingly, we opted not to put clips at this level.
At this point, we applied 2 clips at the T2 level; this being the most important level in this patient. We then again hooked the nerve with an L-hook and then cauterized the nerve until it was divided. No significant bleeding was encountered. Once the nerve had been clipped and cauterized and there was no bleeding, we stopped CO2 insufflation. Additional 5 mL of Marcaine was instilled in the thoracic cavity. The gas was vented from the chest without difficulty. The trocars were removed as the lung was re-inflated. Skin was closed with subcuticular sutures of 4-0 Monocryl reinforced with Steri-Strips. The patient was then awoken from anesthesia and sent to recovery in satisfactory condition.
