Minimally invasive endoscopic-assisted posterior thoracic sympathectomy

Sympathectomy via a posterior approach after a failed trans-thoracic approach: a case of its use for arrhythmia

OBJECTIVE

Congenital long QT syndrome (LQTS) provides an opportunity for neurosurgical intervention. Medication and implantable cardiac defibrillator (ICD)-refractory patients often require left cardiac sympathetic denervation (LCSD) via anterior video-assisted thoracoscopic surgery (VATS). However, this approach has major pulmonary contraindications and risks, with a common concern in children being their inability to tolerate single-lung ventilation. At Oregon Health & Science University, the authors have developed a posterior approach-extrapleural, minimally invasive, T1-5 LCSD-that minimizes this risk.

METHODS

A 9-year-old girl with LQTS type III presented to the emergency department while experiencing ventricular tachycardia (VT) and ventricular fibrillation (VF) with multiple ICD firings. Medical management failed to resolve the VF/VT. VATS was attempted but could not be safely performed due to respiratory insufficiency. The patient was reintubated for dual-lung ventilation and repositioned prone. Her respiratory insufficiency resolved. Using METRx serial dilating tubes under the microscope, the left T1-5 sympathetic ganglia were sectioned and removed.

RESULTS

Postoperatively, the patient had no episodes of VF/VT, pneumothorax, hemothorax, or Horner syndrome. With mexiletine and propranolol, she has remained largely VF/VT free, with only one VT episode during the 2-year follow-up period.

CONCLUSIONS

Minimally invasive, posterior, extrapleural, T1-5 LCSD is safe and effective for treating congenital LQTS in children, while minimizing the risks associated with VATS.

Minimal Access Posterior Approach for Extrapleural Thoracic Sympathectomy: A Cadaveric Study and Cases

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.

Endoscopic minimally invasive neurosurgery: emerging techniques and expanding role through an extensive review of the literature and our own experience - part II: extraendoscopic neurosurgery

BACKGROUND/AIMS

The field of minimally invasive neurosurgery has grown dramatically especially in the last decades. This has been possible, in the most part, due to the advancements in technology especially in tools such as the endoscope. The contemporary classification scheme for endoscopic procedures needs to advance as well.

METHODS

The present classification scheme for neuroendoscopic procedures has become confusing because it mainly describes the use of the endoscope as an assisting device to the microscope. The authors propose an update to the current classification that reflects the independence of the endoscope as a tool in minimally invasive neurosurgery.

RESULTS

The proposed classification groups the procedures as 'intraendoscopic' neurosurgery or 'extraendoscopic' neurosurgery (XEN) in relation to the 'axis' of the endoscope. A review of the literature for the XEN group together with exemplary cases is presented.

CONCLUSION

We presented our proposed classification for the endoscope-only surgical procedures. The XEN group is expanded in this article.