Single-Port Vasoview Sympathectomy for Palmar Hyperhidrosis: A Clinical Update

Introduction

Surgical thoracic sympathectomy is an effective treatment for severe palmar hyperhidrosis that is refractory to more conservative forms of treatment such as topical antiperspirants, botox injections, and iontophoresis. Video-assisted thoracic surgery (VATS) thoracic sympathectomy is often performed through three-port access, ¹ which can be achieved through using a 5-mm thoracoscope and instruments, as well as needlescopic 3-mm instruments. Over the years, VATS sympathectomy has evolved to become a two-port, or even single-port (uniportal), procedure. Single-port techniques have the potential advantages of lesser access trauma and better cosmesis. Perhaps more important is that the surgical access of the single-port technique involves fewer intercostal spaces than conventional three-port VATS, which can potentially reduce the risk of intercostal nerve injury and subsequent neuralgia. ² Intrinsic to single-port VATS procedures is the problem of instrument crowding and fencing, which can hinder progress. Recently, Vasoview^® 7XS ³ and Hemopro2 ⁴ devices(Maquet Inc., Rastatt, Germany), originally designed for endoscopic vein harvesting, have been reported to be used in performing single-port thoracoscopic sympathectomy. We report here our series and initial experiences of using Vasoview 7XS, Hemopro, and Hemopro 2 endoscopic vein harvesting devices for bilateral single-port VATS sympathectomy.

Subjects and Methods

Between June 2011 and March 2012, 10 females and 6 males with a mean age of 23.8 (range, 17–36 years) underwent bilateral single-port sympathicotomy with the Vasoview device for severe palmar hyperhidrosis. Before the patient was accepted for surgery, secondary causes of palmar hyperhidrosis were excluded, as well as all patients having a pulse rate greater than 55 beats per minute at rest. ⁵ General anesthesia was administered, with a double-lumen endobronchial tube in all cases. A finger temperature probe was used to detect any rise in peripheral cutaneous temperature following sympathicotomy. Our technique was previously described ⁴ (Fig. 1). A 1-cm left chest wall axillary incision is made posterior to the lateral border of the pectoralis major muscle, in the third intercostal space. At the discretion of the surgeon, the Vasoview 7XS bipolar diathermy scissors or the Hemopro or Hemopro 2 dissecting grasper was used to achieve sympathicotomy with transection of the sympathetic chain at the top of the third rib and at the top of the fourth rib. The nerve segment in between, as well as their lateral aspects along the ribs containing the fibers of Kuntz, was subsequently ablated. Following the bilateral procedure, the patients were extubated and then discharged later in the day.

OPEN IN VIEWER

FIG. 1.

Operating room photograph illustrating the patient's position, equipment set-up, and surgical access for Vasoview sympathectomy.

Results

The Vasoview 7XS was used in 6 patients, the Hemopro with a dissecting grasper using Starion Instruments (Sunnyvale, CA) technology was used in 6 patients, and the Hemopro 2 with the additional feature of an overheating temperature sensor was used in 4 patients. Mean operative time to complete the bilateral procedure was 56 minutes (range, 42–81 minutes). The operative duration for all the energy devices decreased with increasing experience. The procedure was successfully completed in all patients, without the need to extend the incision or convert. No residual palmar hyperhidrosis was detected postoperatively. Mean postoperative hospital stay was 0.9 days (range, 0.7–1.9 days). The delayed discharge in 1 patient was due to nausea from the anesthesia. There were no postoperative complications such as pneumothorax, hemothorax, infections, or Horner's syndrome. The mean visual analogue pain score at discharge was 1.8 (range, 1.2–3.4). At a mean postoperative follow-up of 15 months (range, 12–20 months), mild compensatory hyperhidrosis (truncal predominance) was seen in 2 (12.5%) patients, and no palmar hyperhidrosis recurrence has been detected thus far.

Discussion

In the past two decades, VATS sympathectomy has matured from a three-port technique using 10-mm instruments to the modern needlescopic 3-mm instrument approach using two to three ports. More recently, single-port thoracic sympathectomy has been reported, although access through one incision often results in difficulties of instrument crowding and fencing. ⁶

The VasoView device was designed for and is widely used for endoscopic vein harvesting to retrieve conduits for procedures such as coronary artery bypass grafting surgery. The device incorporates a 7-mm high-resolution thoracoscope, CO₂ insufflation channel, retractable C-arm with in-built lens cleaner, and parallel working channel for dissecting diathermy scissors or other energy devices like Hemopro graspers. Single-port VasoView sympathectomy was first reported by Bouma et al. ³ in 2011. They successfully performed bilateral sympathectomy on 3 patients using the VasoView 7XS device with the bipolar diathermy scissors. ³ Since then, more modern versions of the device, the Vasoview Hemopro and Hemopro 2, have been introduced, which use a dissecting grasper with Starion technology that has a gradated thermal tip and pressure to cut and coagulate without electric current passing through tissues. ⁴ Consequently, collateral thermal tissue damage is minimized, ⁷ which in the context of sympathectomy may potentially reduce the risk of inadvertent superior sympathetic chain injury and associated complications including Horner's syndrome. In our experience, all three versions of the VasoView device are user friendly for sympathicotomy, with no difference in complication or operating duration among the systems. Although the 7XS scissors may achieve nerve division more rapidly, the Hemopro was better at ablating the nerve segment and grasping the nerve for sympathectomy.

Although we experienced no intraoperative difficulties, unlike three-port VATS, the ability of single-port VATS and indeed this device in dealing with pleural adhesions or bleeding from chest wall vessels may be limited. However, in 1 patient we did encounter apical vascular adhesion bands that were successfully divided by the Hemopro device with good hemostatic effect. This hemostatic ability is perhaps expected given that the Vasoview device was designed to divide and coagulate branches of the saphenous vein. The current series is relatively small, and a more prolonged and detailed follow-up is required to truly evaluate the benefits and long-term results of this approach. In particular, randomized trials are required to compare the single-port Vasoview technique with the two-port or three-port 3-mm VATS sympathectomy approaches for postoperative pain, cosmesis, and patient satisfaction, as well as the cost-effectiveness of using such disposable devices. To conclude, our initial results show that single-port bilateral sympathectomy with Vasoview incorporating the 7XS, Hemopro, or Hemopro 2 dissecting system can be safely and effectively performed with satisfactory outcomes. Further studies will better define the role of Vasoview devices in VATS thoracic sympathectomy.

Disclosure Statement

No competing financial interests exist.