Selective block of grey communicantes in upper thoracic sympathectomy. A feasibility study on human cadaveric specimens

Abstract

Background: Sympathetic chain interruption is the gold standard treatment for essential hyperhidrosis. Postoperative compensatory hyperhidrosis, the main reason for patients’ dissatisfaction, is reduced by selectively lesioning white and grey rami communicantes (ramicotomy).

Objective: To develop an endoscopic surgical technique that interrupts only T₃ and T₄ grey rami communicantes to minimize compensatory hyperhidrosis.

Material and Methods: T₃ and T₄ grey rami communicantes ramicotomy in fifteen cold-preserved cadavers through a uniportal axillary endoscopic approach. The sympathetic chain, its ganglia, and white rami communicantes were left intact. On opening the chest, the sympathetic chain, rami communicantes and ganglia were dissected, photographed, measured and excised for histological examination.

Results: Dissecting the grey rami communicantes is feasible as they consistently lie between the intercostal nerve and the homonymous sympathetic ganglion. At some levels, Kuntz nerves, as well as more than one grey ramus communicans, can be found. White rami communicantes are more medial, therefore damaging them can be avoided. Intercostal veins can be obstructive, but these can be controlled via coagulation or clipping if necessary.

Conclusion: Uniportal endoscopic selective excision of the T₃ and T₄ grey rami communicantes is feasible without damaging the white rami communicantes, the sympathetic chain or its ganglia. Clipping the grey rami communicantes is technically possible but not reliable due to their thin diameter. This study confirms that T₃ and T₄ grey rami sympathetic block is technically feasible. Its application might reduce compensatory hyperhidrosis, but clinical studies are needed.

Keywords:

• Hyperhidrosis
• ramicotomy
• sympathectomy
• sympathicotomy
• compensatory hyperhidrosis

Acknowledgments

To the Department of Human Anatomy and Embryology of the Faculty of Medicine of the University of Valencia, particularly to the laboratory curators Lucia and Carmina and to Doctor Tomás Hernández Gil de Tejada and to all personnel of the Instituto de Medicina Legal de Valencia for their assistance in this study.

Disclosure statement

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interests (such as honoraria; educational grants; participation in speaker’s bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interests (such as personal or professional relationships, affiliations, knowledge or belief(s) in the subject matter or materials discussed in this manuscript.