Uniportal Non-Intubated VATS Thoracic Sympathectomy

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Primary hyperhidrosis can be managed through both medical and surgical methods; however, surgery offers a significant improvement in quality of life. Traditionally, two primary surgical interventions were used to treat the condition: sympathectomy, which involves the excision of sympathetic chain and ganglia, and sympathetic blockade, which involves the positioning of titanium clips along the sympathetic chain (1). According to a meta-analysis by Divisi et al., sympathectomy has proven to be a safe and effective technique with a low reoccurrence rate. In contrast, the clipping method, while reducing the incidence of compensatory sweating poses challenges when it comes to removal of the implanted device, potentially necessitating a more invasive open surgical approach and exposing patients to greater risks (2). With the advent of minimally invasive techniques, video-assisted thoracoscopic surgery (VATS) has replaced conventional open surgical procedures (3). 

VATS is now a widely accepted technique for treating primary hyperhidrosis, a condition that significantly impairs the quality of life. Careful patient selection based on clinical history and the impact on the quality of life is crucial for VATS sympathectomy (4). Over time, uniportal or single-incision VATS has overtaken routine multiportal VATS, offering benefits such as minimal scars and quicker surgical recovery. Patients with palmar hyperhidrosis benefit the most and experience a substantial improvement in quality of life (4). 

Uniportal VATS also offers a significant advantage for performing non-intubated VATS (NI-VATS). The single-incision technique allows the thorax to be exposed to atmospheric pressure, which aids in partially collapsing the lung, even when the patient is breathing under sedation. This method has been effectively employed in various procedures, including thoracic sympathectomy, pleural biopsy, and pleural effusion drainage (5). 

Anesthesia plays a pivotal role in the authors’ approach to uniportal NI-VATS. Patients were placed under minimal sedation with a laryngeal mask to maintain the airway, ensuring early recovery from anesthesia and avoiding tracheal intubation. NI-VATS was previously implemented for fragile patients with compromised cardiopulmonary function (6). Recently, it has also been employed safely in ASA Class I and II patients for VATS, demonstrating its beneficial impact on the patients (7). NI-VATS can be considered for several thoracic procedures, offering key advantages such as faster recovery from surgery, minimal blood loss, and shorter hospital stays. Additionally, this approach helps avoid several injuries and complications associated with intubated surgery, such as ventilator-induced lung injury (VILI), lung atelectasis, injury to vocal cords consequent to intubation, postoperative pharyngodynia due to intubation maneuvers, and residual neuromuscular blockade in the postoperative period. 
There are, however, several contraindications for the NI-VATS procedure. Patients with known or suspected difficult intubation (Mallampati III–IV), a body mass index over 30 kg/m2, persistent cough, basal pO2 < 60 mmHg, basal pCO2 > 50 mmHg, coagulopathy (international normalized ratio >1.5), and contralateral phrenic nerve palsy are not eligible for this approach [8]. 

Uniportal NI-VATS thoracic sympathectomy is an emerging, minimally invasive technique for treating primary hyperhidrosis. It offers significant benefits, such as minimal scarring, fast recovery, shorter intensive care unit and hospital stays, and reduced complications. 

References

1. Kisielnicka A, Szczerkowska-Dobosz A, Purzycka-Bohdan D, Nowicki RJ. Hyperhidrosis: disease aetiology, classification and management in the light of modern treatment modalities. Postepy Dermatol Alergol. 2022;39(2):251-7.
2. Divisi D, Zaccagna G, Francescantonio W, Bardhi D, Calvaruso F, Bertolaccini L, et al. Endoscopic thoracic sympathectomy or sympathicotomy versus clipping in the surgical management of primary hyperhidrosis: a systematic review and meta-analysis. Shanghai Chest. 2019;3: doi:10.21037/shc.2019.07.08.
3. Luh SP, Liu HP. Video-assisted thoracic surgery—the past, present status, and the future. J Zhejiang Univ Sci B. 2006;7(2):118-28.
4. de Campos JR, Kauffman P, Werebe Ede C, Andrade Filho LO, Kusano PS, Jatene FB, et al. Quality of life, before and after thoracic sympathectomy: report on 378 operated patients. Ann Thorac Surg. 2003;76(3):886-91.
5. Zheng H, Hu XF, Jiang GN, Ding JA, Zhu YM. Nonintubated-awake anesthesia for uniportal video-assisted thoracic surgery procedures. Thorac Surg Clin. 2017;27(4):399-406. doi:10.1016/j.thorsurg.2017.06.008.
6. Wang ML, Hung MH, Hsu HH, Chan KC, Cheng YJ, Chen JS. Non-intubated thoracoscopic surgery for lung cancer in patients with impaired pulmonary function. Ann Transl Med. 2019;7(3):40. doi:10.21037/atm.2018.11.58.
7. Pompeo E, Dauri M; Awake Thoracic Surgery Research Group. Is there any benefit in using awake anesthesia with thoracic epidural in thoracoscopic talc pleurodesis? J Thorac Cardiovasc Surg. 2013;146(2):495-7.e1. doi:10.1016/j.jtcvs.2013.03.038.
8. Gonzalez-Rivas D, Bonome C, Fieira E, Aymerich H, Fernandez R, Delgado M, et al. Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery? Eur J Cardiothorac Surg. 2016;49(3):721-31. doi:10.1093.

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