title: Transthoracic video endoscopic electrocautery of sympathetic ganglia for hyperhidrosis palmaris: special reference to localization of the first and second ribs.
abstract: BACKGROUND
  The surgical technique for transthoracic endoscopic sympathectomy varies from one to three skin incisions, room air to carbon dioxide pneumothorax, and destruction of the second (T2), third (T3), and fourth sympathetic ganglia to destruction of the T2 ganglion only. A knowledge of the surgical anatomy of the apex may help the surgeon to safely use this technique.
  
  
  METHODS
  Forty-seven patients with palmar hyperhidrosis underwent video-assisted endoscopic electrocautery of the T2 and T3 ganglia with the use of one-lumen endotracheal tube for general anesthesia, one skin incision, and carbon dioxide pneumothorax. Surgical anatomy, palm temperature, and surgical results were analyzed.
  
  
  RESULTS
  The first ribs of 23 patients were endoscopically visible and most of these first ribs were not as parallel to the second ribs as the third ribs were. The first ribs of the remaining 24 patients were palpable with a diathermy bar. In all but three patients with dense pulmonary adhesions, the distal end of the intrathoracic segment of the subclavian artery was seen to pierce the pleura at the upper border of the first rib. Ninety-one palms remain dry and 27 patients develop compensatory sweating in an average follow-up of 12 months. Excluding three patients whose sympathetic ganglia could not be electrocauterized because of severe pulmonary adhesions, 95% of the remaining 44 patients are satisfied with the results.
  
  
  CONCLUSIONS
  Transthoracic video endoscopic electrocautery of the T2 and T3 ganglia for patients with palmar hyperhidrosis may yield excellent results if the first rib can be properly identified.
authors.affiliation: Division of Neurosurgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan, R.O.C.
authors.forename: C W
authors.initials: CW
authors.lastname: Wong
mesh_terms: D000293:Adolescent; D000328:Adult; D004564:Electrocoagulation / Q000379:methods*; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006225:Hand / Q000294:innervation*; D006801:Humans; D006945:Hyperhidrosis / Q000601:surgery*; D008297:Male; D012272:Ribs; D013562:Sympathectomy / Q000379:methods*; D013900:Thoracic Nerves / Q000601:surgery*; D013906:Thoracoscopy / Q000379:methods*; D016896:Treatment Outcome; D014741:Video Recording