[Thoracic Surgery Thoracoscopy] 4K Ultra HD Hand Hyperhidrosis Surgery

Are there any classmates around you who always need napkins during exams, otherwise the entire test paper will look like it has been soaked in water? When your friend holds hands with you, does it feel like you are holding a wet wipe?

Most people's hands rarely sweat, and are only slightly moist even when the weather is hot. However, patients with hand hyperhidrosis have wet hands most of the time throughout the year, no matter whether the weather is hot or not. Patients with severe hand hyperhidrosis Can even get the handkerchief wet.

So what's going on with hyperhidrosis of the hands? What impact will it have on life? How to treat hand hyperhidrosis?

What's the deal with hand hyperhidrosis?

Hyperhidrosis is a disease in which the sympathetic nerves are overexcited for unknown reasons, which in turn causes the sweat glands to secrete excessive sweat, resulting in excessive sweating of the hands. It is a type of hyperhidrosis.

Symptoms generally appear in childhood or adolescence, with the average age of onset being 13 years old. Symptoms gradually intensify during adolescence, and gradually decrease after the age of 50.

Clinical data shows that the incidence of hyperhidrosis is about 2% to 4%, and there is a 12.5% family genetic tendency. It is considered an autosomal dominant genetic disease. If one parent has hyperhidrosis, the probability of his or her children suffering from the disease is 25%.

Hand hyperhidrosis can be divided into two categories: primary and secondary.

The former is caused by over-excitation of the sympathetic nerves that control the hands. The vast majority of patients are of this type, and most of the patients have been suffering from the disease since childhood, and it becomes more serious in adolescence. Hot weather, tension, anxiety, etc. can aggravate the symptoms of hand sweat. In severe cases, the two palms of the hands feel like they are soaked in water. After the hands droop, sweat drips continuously from the fingers, and at the same time, there is a large amount of sweat on the soles of the feet. Sweat.

The latter is mostly secondary to some systemic diseases, such as endocrine and central nervous system diseases, and is mostly systemic sweating.

What are the symptoms of hand hyperhidrosis?

Symptoms of patients with hyperhidrosis are often aggravated by emotional stress, excitement, anxiety, exercise, or when the outside temperature rises, and sweating stops during sleep.

Hand hyperhidrosis can occur alone, or it can occur simultaneously with excessive sweating on the soles of the feet, armpits, and other parts of the body.

When you sweat, your hands feel clammy and the sweat is odorless. Winter also causes sweating, clammy hands, and often frostbite.

Many patients with hand hyperhidrosis will suffer from peeling hands, blisters, etc. due to long-term sweating.

The effects of hyperhidrosis

In the past, people did not pay much attention to hyperhidrosis. In fact, hyperhidrosis has a certain impact on life and study.

The skin of the hands is often in a moist and soaked state, and the palms peel off significantly, often accompanied by dermatitis. Damp and cold extremities in winter can easily cause chilblains, affecting daily study, work, social interaction, and life.

Surgery is the best treatment

Although hyperhidrosis is not a serious disease, it can bring a lot of inconvenience to life, causing work and social problems.

Moreover, most patients with hyperhidrosis of the hands have been suffering from it since childhood, which causes a lot of psychological pressure on the sensitive hearts of children, and their self-confidence is hit. In the long run, it will bring huge psychological burden and pain to the patients with hyperhidrosis of the hands.

From a certain perspective, treatment of hyperhidrosis of the hands is necessary.

1.Non-surgical treatment

Treatment options vary and include astringents, antiperspirants, sedatives, anticholinergics, etc.

2.Surgical treatment

Currently thoracic sympathectomy.

Traditional thoracotomy surgery brings many traumas and complications, which are difficult for patients to accept. Since the development of thoracoscopic surgery, thoracoscopic thoracic sympathotomy/clipping has been the most suitable surgical indication.

3. Pain treatment

Percutaneous CT-guided bilateral thoracic sympathetic nerve damage.

This is a minimally invasive interventional treatment, which is less invasive to the human body, has no incisions, and allows for quick recovery. Treatment can be done on the same day and you can leave the hospital the next day.

Surgical procedure and cutting plane

At present, ETS surgery mainly involves sympathotomy, resection has long been abolished, and the effect of communicating branch truncation is still inconclusive. Methods to block the sympathetic trunk include electrocoagulation and titanium clipping. This guideline recommends simple and effective electrocoagulation as the first choice. The surgical cutting position is only to cut off a single root (R3 or R4). Cutting off multiple roots is not recommended. Except for severe head and face hyperhidrosis and erythema, cutting off R2 is strictly prohibited.

Case

Patient's age: A 16-year-old patient with severe hand hyperhidrosis. Various other treatments were not effective, so he chose minimally invasive surgery.

Surgical methods

(1) Surgical operation: Choose tracheal intubation or non-intubation general anesthesia. The patient lies semi-supine at 30° to 45°, with the upper arm abducted and fixed. The operating hole in the third intercostal space of the chest wall under the armpit was taken. After instructing to pause breathing, the thoracoscope was advanced into the chest and an electrocoagulation hook was inserted along the same incision. The thoracic sympathetic nerve trunk is found near the head of the 3rd or 4th rib on the top of the chest and is cauterized with electrocoagulation. The cautery is extended 2 cm outward on the rib surface to prevent recurrence caused by the Kuntz bundle and communicating branches. After inflating the lungs and exhausting air, the incision is sutured or sealed with medical glue. There is no need to leave a chest drainage tube.

It must be pointed out that due to the different heights, fatness and thinness of patients and the different experiences of surgeons, the precise anatomical position of T2 is inconsistent during surgery. In order to accurately describe the location of the intraoperative cut, the American Society of Thoracic Surgeons Hyperhidrosis Committee recommends that surgical records be standardized as R (rib) instead of T (nerve), such as R3 or R4 cut. The name of the traditional surgery with complicated names is also standardized as: sympathectomy.

Generally, the incision is located under both armpits, with a length of about 0.5 cm, to remove the sympathetic nerve chain (the specific location of the disconnection is determined by the surgeon based on the patient's hand sweating and sweating in other parts)

Complications and treatment

ETS is the most typical, most convenient, most effective and most cosmetic minimally invasive surgery in thoracic surgery. Postoperative pneumothorax, focal pneumonia and pain are occasionally seen. There are 4 rare surgical complications.

1. Intraoperative bleeding: Intraoperative bleeding is commonly caused by injury to the branches of the azygos vein or intercostal vessels, but there is also bleeding from the entry point of the Trocar into the chest. When cutting off the right R4, pay attention to the nearby criss-crossing blood vessels. Once bleeding occurs during the operation, do not panic and blindly cauterize the blood vessels. You should immediately use endoscopic forceps to clamp the blood vessels to stop the bleeding, or clamp a small gauze ball to compress the bleeding. There are also rare cases of intraoperative massive bleeding. The author once encountered an emergency telephone consultation from the hospital. Due to tight adhesions in the left chest, the thoracic aorta was accidentally injured during the operation, causing massive bleeding of about 2000 mL. The patient was subsequently consulted by a cardiac surgeon and rescued. . This guideline emphasizes that the surgery should be performed by a senior attending physician or above, so that the rescue can go smoothly.

2. Cardiac arrest is very rare. There have been reports in the literature [12-13] of cases of intraoperative cardiac arrest or postoperative severe bradycardia requiring pacemaker maintenance. When performing ETS, the right side should be performed first because the left side is the dominant side dominated by the heart, and heart rate changes should be closely monitored during the operation.

3. Chylothorax: It is relatively rare and may occur when the accessory thoracic duct is damaged during thoracic sympathetic denervation. Gossot et al[14] reported 2 cases. All were cured by postoperative chest drainage tubes and parenteral nutrition. The best preventive method is to carefully observe whether there is any thoracic duct injury during surgery.

4. Horner syndrome manifests as ptosis, enophthalmos, miosis, and anhidrosis on the injured side of the face. It is one of the most serious complications of upper thoracic sympathetic nerve surgery, with an incidence rate of less than 1%. Preventive measures are: ① The stellate ganglion is generally covered by a yellow fat pad, which can be used as an intraoperative identification mark, so be careful not to damage it; ② When electrocautery is used to cut off the thoracic sympathetic nerve, the action must be fast to avoid heat conduction from affecting the stellate ganglion through the nerve chain. If Horner syndrome is caused by heat conduction, most cases can heal on their own over time.

Selection and evaluation of anesthesia, incisions and surgical techniques

anaesthetization

Since the ETS operation is quite simple and can be completed in just a few minutes, single-lumen endotracheal intubation is often chosen for clinical safety. Inexperienced anesthesiologists who are not skilled in using double-lumen tracheal tubes may cause complications such as tracheal injury, and laryngeal masks and The application of the mask requires an experienced anesthesiologist with strong adaptability. For example, gastric juice reflux and aspiration into the lungs can cause serious respiratory complications. Local anesthesia is not recommended because the patient is extremely frightened when awake and cannot tolerate the asthma and chest tightness caused by artificial pneumothorax. Once an accident such as intraoperative bleeding occurs, it will be detrimental to rescue.

Incision

The number of incisions has been reduced from the original "three holes" or "two holes" to the "single hole" in recent years. "Transaxillary single port" and "transareolar single port" have been reported. The natural wrinkles and pigmentation of human skin are used to cover and hide the incisions. The incisions are not sutured and are bonded with medical glue. This incision is concealed, safe, effective and has excellent cosmetic results. Some people have used the navel-diaphragm incision route to perform ETS. This method requires first inflating the abdomen with carbon dioxide through the abdominal cavity, cauterizing the bilateral diaphragms and drilling holes into the chest cavity, and using gastroscopic biopsy forceps to cauterize the nerves. Some people also use the subxiphoid approach or one chest wall approach to perform bilateral surgeries for carbon dioxide pneumothorax. These 3 incision paths are “distant” from the thoracic sympathetic nerves and make the surgery complex and time-consuming. They have potential risks and are not recommended in this guideline.

R3 and R4 selection

Both surgical procedures R3 and R4 are effective methods for the treatment of hand hyperhidrosis [17-20]. The difference is that the palms of R3 are drier after surgery, and the incidence and severity of CH are higher than those of R4. A few patients have slightly moist palms after R4 surgery, but the CH is milder than after R3 resection. There is no clear-cut standard for dryness or dampness. The key lies in patients' subjective feelings and different tolerance levels. Therefore, it is more important to fully communicate with the patient before surgery to make them understand or provide them with choices.

Surgical efficacy

Compensatory hyperhidrosis

The cure rate of ETS in treating hand hyperhidrosis is almost 100%, and some axillary sweat (70%) and foot sweat (30%) are also reduced or disappeared. There are almost no serious complications. You can be discharged from the hospital on the same day or the next day after surgery, and the hospitalization expenses are covered. less, so ETS surgery is favored by patients. However, the only drawback of ETS is that the incidence of postoperative CH is as high as 14% to 90%. Very severe cases (3% to 5%) regret surgery because they need to change underwear multiple times a day. Therefore, doctors should attach great importance to and carefully select surgical indications.

Hand hyperhidrosis seriously affects the patient's life, study, job search and social interaction. At this stage, the best way to treat hand hyperhidrosis is still ETS. As long as patients are accurately selected, the expansion of surgical indications is prevented, and the prevention and treatment of CH are studied in depth, ETS is still the most safe and effective method worth promoting for the treatment of hand hyperhidrosis.