title: Anatomical basis for a successful upper limb sympathectomy in the thoracoscopic era.
abstract: In this clinico-anatomical study, factors potentially responsible for unsuccessful upper limb sympathectomy (ULS) by the thoracoscopic route were evaluated. This study comprised two subsets: 1) in the clinical subset, 25 patients (n = 50 sides) underwent bilateral second thoracic ganglionectomy for palmar hyperhidrosis, and factors predisposing to unsuccessful ULS were identified; and 2) in the anatomical subset, the neural connections of the first and second intercostal spaces were bilaterally dissected in 22 adult cadavers (22 right, 21 left; n = 43 sides). Alternate neural pathways (ANP) were noted in 9 of 50 sides in the 25 clinical cases (18%). In three asthenic patients (5 sides), fascia overlying the longus colli muscle mimicked the sympathetic chain. The right superior intercostal vein (SIV) was located anterior to the second thoracic ganglion in 6 of 50 sides (12%) and predisposed to troublesome bleeding in 2 of 50 cases; the SIV was posterior to the ganglion in 19 of 50 sides (38%), posing no technical problem. On the left, the SIV was noted outside the field of dissection in all but one case. A successful outcome to sympathectomy was noted in all 25 patients. A spectrum of sympathetic contributions to the first thoracic ventral ramus for the first intercostal space was noted in 37 of 43 anatomical cases (86%). These were categorized according to the arrangements of the intrathoracic ramus between the second intercostal nerve and the first thoracic ventral ramus. The cervicothoracic ganglion (37/43 cases; 86%) and an independent inferior cervical ganglion (6/43 cases; 14%) were always located above the second rib. The second thoracic ganglion was consistently located in the second intercostal space. This study demonstrates that ANPs have little clinical significance when a second thoracic ganglionectomy is undertaken. Technical failures may be avoided if the surgeon is mindful of anatomical variations at surgery.
authors.affiliation: Discipline of Anatomy, School of Basic and Applied Medical Sciences, University of Durban-Westville, Durban, South Africa.
authors.forename: L
authors.initials: L
authors.lastname: Ramsaroop
authors.forename: B
authors.initials: B
authors.lastname: Singh
authors.forename: J
authors.initials: J
authors.lastname: Moodley
authors.forename: P
authors.initials: P
authors.lastname: Partab
authors.forename: K S
authors.initials: KS
authors.lastname: Satyapal
mesh_terms: D000328:Adult; D002102:Cadaver; D005205:Fascia / Q000033:anatomy & histology; D005728:Ganglia, Sympathetic / Q000033:anatomy & histology / Q000601:surgery*; D015171:Ganglionectomy; D006801:Humans; D006945:Hyperhidrosis / Q000601:surgery*; D007367:Intercostal Nerves / Q000033:anatomy & histology; D009434:Neural Pathways / Q000033:anatomy & histology; D010994:Pleura / Q000601:surgery; D035422:Pleural Cavity / Q000033:anatomy & histology / Q000294:innervation; D013562:Sympathectomy / Q000379:methods* / Q000592:standards; D013564:Sympathetic Nervous System / Q000033:anatomy & histology; D013900:Thoracic Nerves / Q000033:anatomy & histology; D013906:Thoracoscopy; D034941:Upper Extremity / Q000033:anatomy & histology / Q000294:innervation*; D014680:Veins / Q000293:injuries