title: Minimal Access Posterior Approach for Extrapleural Thoracic Sympathectomy: A Cadaveric Study and Cases.
abstract: OBJECTIVE
  Operatively, video-assisted thoracoscopic sympathectomy (VATS) involves pleural entry and poses risk in small children and patients with pulmonary disease. A conventional posterior sympathectomy is more invasive than VATS. We investigated a cadaveric feasibility study of a minimal access posterior approach for endoscopic extrapleural sympathectomy and discuss this minimal approach in children with cardiac sympathectomy.
  
  
  METHODS
  A posterior endoscopic extrapleural approach for thoracic sympathectomy was performed using lightly embalmed cadavers; surgical corridor depth, width, and associated pleural violation were recorded. Two pediatric cases undergoing secondary prevention for breakthrough cardiac dysrhythmias using this approach are discussed: case 1, a 9-year-old girl with refractory long QT syndrome; and case 2, a 13-year-old boy with hypertrophic cardiomyopathy.
  
  
  RESULTS
  The cadaveric study supported 100% identification of a craniocaudal-oriented sympathetic chain using an 18-mm tubular retractor, and a 10% pleural violation rate. There were no clinically significant pneumothoracies in either proof of concept cases.
  
  
  CONCLUSIONS
  Minimal access posterior extrapleural sympathectomy is feasible to expose the sympathetic chain in the thoracic region with good visualization using either endoscopic or microscopic magnification. Single-position bilateral thoracic sympathectomy can be performed in pediatric patients with life-threatening ventricular arrhythmias. Based on the cadaveric study and the 2 preliminary cases, we believe that a posterior minimal access approach allows safe and effective access to the thoracic sympathetic chain for causes requiring sympathectomy using single positioning, with minimal risk of pneumothorax or Horner syndrome.
authors.affiliation: Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Raskin
authors.affiliation: Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.
authors.forename: Jesse J
authors.initials: JJ
authors.lastname: Liu
authors.affiliation: University Neurosurgery, LSU Health Sciences Center, Shreveport, Louisiana, USA.
authors.forename: Hai
authors.initials: H
authors.lastname: Sun
authors.affiliation: Rebound Neurosurgery, Vancouver, Washington, DC, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Nemecek
authors.affiliation: Department of Pediatric Cardiology, Oregon Health & Science University, Portland, Oregon, USA.
authors.forename: Seshadri
authors.initials: S
authors.lastname: Balaji
authors.affiliation: Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA. Electronic address: raslana@ohsu.edu.
authors.forename: Ahmed M
authors.initials: AM
authors.lastname: Raslan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002102:Cadaver; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D044583:Neuroendoscopy / Q000379:methods*; D010865:Pilot Projects; D013562:Sympathectomy / Q000379:methods*; D013900:Thoracic Nerves / Q000473:pathology* / Q000601:surgery*; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D013904:Thoracic Vertebrae / Q000473:pathology / Q000601:surgery; D016896:Treatment Outcome; D055815:Young Adult
keywords: Cadaver; Minimal access; Posterior sympathectomy