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Endoscopic Surgery of the Thoracic Autonomic Nervous System
Endoscopic Surgery of the Thoracic Autonomic Nervous System HERBERT A. ROEDLING, M.D.* COLLIN S. MAcCARTY, M.D., F.A.C.S. ** GRACE M. ROTH, PH.D.t
THE endoscopic approach for diagnostic or therapeutic purposes in various body cavities has proved its value over many years. At the turn of the century endoscopy was still limited to the treatment of certain conditions of the urinary bladder. As early as 1902, however, Kelling reported that the abdominal cavity of dogs could be inspected without any hazard, and he predicted the future application of endoscopic examinations to man. In 1910 Jacobaeus published a paper in which he pointed out the possibilities of inspecting serous cavities in man by means of a cystoscope. He successfully performed laparoscopy and thoracoscopy, and considered endoscopic inspection of the pericardium. Bernheim in America reported on the diagnostic value of cystoscopy of the abdominal cavity in 1911. Laparoscopy was the center of interest at that time. Soon thoracoscopy became an important aid in the diagnosis of certain diseases of the lung and in the differential diagnosis of pleurisy. The superior visual conditions in the chest as compared with those in the abdomen, and the greater danger of diagnostic thoracic surgical exploration for undetermined surgical disease have made thoracic endoscopy especially helpful. Endoscopic intrapleural pneumolysis (endoscopic cutting of intrapleural adhesions) to make collapse therapy practicable for some patients with pulmonary tuberculosis without the trauma of thoracotomy was tried by Herve and J acobsson and perfected by Jacobaeus, Unverricht, Maurer and Kremer. All these early reports included good anatomic descriptions of the ... Research Fellow, Minnesota Heart Association 1956 and 1957; Fellow in Surgery, Mayo Foundation, Graduate School, University of Minnesota; Rochester, Minnesota.
** Consultant, Section of Neurologic Surgery, Mayo Clinic; Associate Professor of Neurologic Surgery, Mayo Foundation, Graduate School, University of Minnesota; Rochester, Minnesota. t Consultant, Section of Physiology, Mayo Clinic; Professor of Physiology, Mayo Foundation, Graduate School, University of Minnesota; Rochester, Minnesota. 1403
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Herbert A. Roedling, Collin S. MacCarty, Grace M. Roth
subpleural vascular system, the ribs and other structures. None of the investigators, however, seems to have given attention to the autonomic nervous system, that is, the vagus nerve and the thoracic sympathetic chain. In the early 1940's Hughes, Goetz and Marr, and Kux independently reported on the possibility of using an endoscopic approach for operations on the sympathetic chain in the chest. Hughes, in England, resected successfully the stellate ganglion and the greater splanchnic nerve in four cases. Goetz and Marr used the operation in order to resect the second thoracic ganglion in peripheral vascular disease of the upper extremity. Kux was using endoscopic intrapleural pneumolysis at the beginning of World War II and by this method was able to see the thoracic sympathetic chain and to resect segments in a limited number of cases. In 1947 he began to use thoracoscopy extensively, and in 1954 he published a book on this subject. 13 At that time he had utilized this convenient way of operating on the thoracic autonomic nervous system in 1104 patients. In 1956 we started to use this type of surgical procedure on animals. In this paper we shall discuss the pertinent anatomy and the technical aspects and possibilities of endoscopic surgery on the autonomic nervous system in man. ANATOMY
Thoracic SYIIlpathetic Nerves
The thoracic portion of the sympathetic chain is located along the ventrolateral aspects of the vertebral column and is covered only by the thin transparent parietal pleura, thus making resection or injection from within the thoracic cavity an easy and logical procedure (Fig. 404, A). The thoracic portion of the sympathetic chain includes usually 10 or 11 ganglia. These ganglia vary greatly in size and form. Their usual arrangement is segmental. The first of these ganglia is often fused with the inferior cervical ganglion and is then called the "stellate ganglion." The stellate ganglion, particularly the portion that is the inferior cervical ganglion, is located laterally and ventrally to the vertebral artery; however, some rami are located dorsal to this artery, which makes resection of this portioll of the sympathetic chain hazardous. The sympathetic nerve supply of the upper extremity is segmental in its distribution. The preganglionic fibers arise in the second to tenth thoracic spinal segments. They ascend without synapse in the sympathetic trunk. They then form synapses with the postganglionic fibers in the first thoracic ganglion and inferior cervical ganglion (stellate ganglion). Only a few synapses occur with the middle cervical ganglion. The postganglionic fibers, the majority of which are in the stellate ganglion, join the roots of the brachial plexus.
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Visceral sensory fibers from the heart travel over the middle and inferior cardiac nerves and upper five thoracic sympathetic ganglia. The superior cardiac nerve does not seem to carry visceral afferent fibers from the heart. Because of this anatomic structure, destruction of the stellate ganglion by injection of alcohol eliminates the afferent portion of the cardiac nerves, but it does not interfere with the direct supply in the upper thoracic cardiac nerves. Therefore, to obtain best relief from cardiac pain the upper five thoracic sympathetic ganglia through which most of the visceral sensory fibers from the heart run should be destroyed or resected in addition to the stellate ganglion. 14 The splanchnic nerves carry mostly visceral afferent fibers and preganglionic visceral efferent fibers. The greater splanchnic nerve is formed by fusion of many rami arising from the main sympathetic chain between the fifth and tenth thoracic ganglia. It descends into the posterior mediastinum. Occasionally a ganglion is present in the course of the nerve. The lesser splanchnic nerve originates by the union of some rami from the ninth and tenth sympathetic thoracic ganglia. Finally, the least splanchnic nerve originates from the last thoracic and first lumbar ganglia, or even from the lesser splanchnic nerve, and fuses with the other splanchnic nerves in the celiac plexus subdiaphragmatically.12 Vagus Nerve
The right and the left vagus nerves enter the thorax in close relationship to the carotid arteries. The left vagus runs with the aorta and esophagus distally and is located laterally and finally anteriorly to the esophagus. The right vagus, however, swings in the mid chest region to the posterior lateral aspect of the esophagus. The close relationship of the lower part of the right vagus and the thoracic duct should be pointed out. Thoracic Duct
Van Pernis dissected 1081 cadavers in a study of the variations of the thoracic duct. In performing splanchnicectomy in the right lower part of the chest of a patient in the fasting state the invisible thoracic duct is of importance to the surgeon. The cisterna chyli usually is located at the level of the second lumbar vertebra; however, in 33 per cent of persons it is located at the level of the first lumbar vertebra, and in 10 per cent at the level of the twelfth thoracic vertebra. Below the eighth thoracic vertebra the duct is always single. The average diameter is 2 to 4 rom. Topographically the duct is usually medial to the azygos vein and lateral to the aorta, and together with these vessels it passes through the diaphragm. PRELIMINARY ARTIFICIAL PNEUMOTHORAX
In order to make thoracoscopy possible, especially in the therapeutic aspect of operating on the autonomic nervous system, it is necessary to
•
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Herbert A. Roedling, Collin S. MacCarty, Grace M. Roth
Fig. 403. The thoracic endoscope with its various parts.
collapse the lung on the side of the operation. The only contraindications are extensive pleural adhesions which make preliminary endoscopic intrapleural pneumolysis impossible. Hughes induced unilateral pneumothorax over a period of some days before operation; however, this seems to place an unnecessary strain on the patient. Endoscopy should be performed immediately after induction of the pneumothorax, and roentgenologic examination should always be done after the pneumothorax in order to insure that the lung has collapsed uniformly.13 It is not the purpose of this paper to point out the technical details and safeguards for the induction of artificial pneumothorax. INSTRUMENTS USED FOR THORACOSCOPY
Hughes operated through two cannulas, which is certainly convenient for performing endoscopic intrapleural pneumolysis, because the location of intrapleural adhesions is unpredictable. However, for operations on the thoracic autonomic nervous system, with its known anatomic location, the work is much easier to perform through one cannula. The instrument we use was made in Germany.* All the parts of this instrument are shown in Figure 403. The various parts, such as lampholder, needle for injection of anesthetic agents or for absolute alcohol for sympathetic block, cautery tips and different optical systems, can all be changed through the cannula. THORACOSCOPY
Previously it was pointed out that our experience with endoscopic operations on the thoracic autonomic nervous system is still limited to experimental animals. Although the thoracic sympathetic chain in
* Wolf Endoscopic manufacturers,
Knittlingen-Wurett, Germany.
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monkeys or even dogs shows few anatomic variations in comparison with those in man, the technical difficulties seem to have been overcome by our studies on these animals. The technique of thoracoscopy is essentially the same in animals as in man. After a rather small number of endoscopies on living animals or on animals killed immediately before operation (since the pleura becomes translucent a few hours after death), the surgeon becomes adept at identifying the various structures in the chest wall seen through the endoscope. Study of published reports of procedures performed in man2, 4, 13 indicates that the procedure is about as follows: The site of the thoracentesis should be chosen rather carefully. The site of the thoracentesis and the position of the patient depend on which nerve is to be operated on. The upper part of the thoracic sympathetic chain is best approached by inserting the trocar in the anterior axillary line at the level of the third intercostal space, with the patient in a supine position. An equally satisfactory approach is anteriorly through the second intercostal space, with the patient in a sitting position. The lower thoracic part of the sympathetic chain with the splanchnic branches can be observed through the endoscope when thoracentesis is done in the midaxillary line in the fourth to seventh intercostal space, the patient or the animal lying on the side. The vagus nerves are located close to the aorta, esophagus, azygos vein and vena cava, thus making endoscopic approach possible only if the patient is lying on his stomach so that the collapsed lung moves anteriorly and exposes the nerve. The further posterior the paracentesis is performed, the better the view of the vagus through the endoscope. This posterior approach, however, makes it more difficult to see the vagus and the sympathetic chain simultaneously. A second or even a third thoracentesis for extensive resections is advisable and is not of any disadvantage to the patient. 13 After the patient or the animal is placed in the proper position, exact site of the thoracentesis should be marked on the skin. The operation can be performed under either general or local anesthesia. Since some patients are highly sensitive to pain, general anesthesia might be used for extensive sympathetic resection which is painful. If local anesthesia is used, procaine hydrochloride should be infiltrated into the skin at the site of the thoracentesis and into deeper tissues as far as the pleural surface. Thoracentesis is performed in the specific intercostal space chosen after a small incision (0.5 to 1 cm.) is made in the skin to simplify insertion of the trocar. The trocar is slowly advanced until the pleura is entered. The cannula is cleaned with a sponge tightly affixed to a sponge holder, and thus it is impossible for bits of tissue or blood to obstruct the optical system or the lamp. If the lung has been successfully collapsed, the insertion of the lamp-
Herbert A. Roedling, Collin S. MacCarty, Grace M. Roth A
B
c
D
Fig. 404. A, The thoracic portion of the sympathetic chain, as seen through the covering transparent parietal pleura, is located to the left, that is, lateral to the azygos vein. Intercostal venous branches and two ribs are crossed by the sympathetic trunk (dog). B, Injection of a thoracic sympathetic ganglion. Illustrated is the endoscope with the needle in position for injection (dog). C, In the upper left part and below the center are two circular areas where pleura and sympathetic trunk have been cauterized (dog). D, Extirpation of a thoracic sympathetic segment. Note the nerve twisted around the forceps (dog).
holder and optical systems can be achieved without further difficulties. However, if the instruments are not heated to 37° C. before insertion, vision will be obscured for about one to two minutes because of the higher temperature and humidity in the thoracic cavity. Therefore warming instruments is helpful. For inspection of the thoracic cavity and for localization of the sympathetic chain, vagus nerves or both, a wide-angle optical system
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should be used. Mter all the pertinent anatomic structures have been identified with the aid of this wide-angle lens, this optical system should be exchanged for a.r:egular lens which magnifies when the object to be inspected is only a short distance away. A long needle can be inserted through the endoscope for injection of procaine hydrochloride into the parietal pleura at the site of the operation or for the injection of absolute alcohol into sympathetic ganglia (Fig. 404, B). Cauterization is performed by exchanging the needle, if previously used, for the cautery. After the desired point of interruption of the sympathetic chain or vagus nerve is located, the thin pleura covering the nerve is cauterized with diathermy, and the sympathetic chain or vagus nerve is exposed. With the cautery cold the nerve is underhooked and pulled away from the chest wall, and then is cut with galvanic current. This technique makes injuries to the underlying chest wall and somatic nerves impossible. Mter the sympathetic nerve has been cut, the same procedure should be done at a lower or higher level of the nerve in order to resect the nerve (Fig. 404, C). This segment then can be removed by special forceps which will grip the nerve segment in its center after it is exposed from the covering pleura by cauterization. A twisting motion of the forceps then will remove this loose segment (Fig. 404, D). The length of such a segment should not exceed 8 cm. TECHNICAL DIFFICULTffiS
Bleeding. Although bleeding is seemingly the difficulty most likely to be encountered in endoscopic operations on the thoracic portion of the autonomic nervous system, the large vessels can easily be seen through the endoscope and readily avoided. However, the lower part of the right vagus nerve is close to the azygos vein, and sometimes an injury to this vessel can be avoided only by separating the nerve from the vein by means of injection of a solution of sodium chloride or procaine hydrochloride between the two. 13 As mentioned before, the close relationship of the stellate ganglion to the vertebral artery makes endoscopic resection of this part of the sympathetic chain rather hazardous. However, the results of alcohol injection into the ganglion under direct vision seem to be equal to surgical removal. Hemorrhages from small branches of the intercostal vessels can be controlled at the time of operation by cauterization or injection of locally acting coagulants. It seems also important not to operate on patients with prothrombin deficiency from anticoagulant drugs. Injury of the Thoracic Duct. The close anatomic relationship of the right vagus nerve, the azygos vein, the right splanchnic nerves, and the main lymphatic duct in the right lower part of the thorax has been mentioned. When operations are performed in this region, the surgeon must beware of injuring the thoracic duct, which is invisible in the fasting state.
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Herbert A. Roedling, Collin S. MacCarty, Grace M. Roth
Foreign Bodies. The instruments should always be checked by the surgeon himself. Loose light bulbs could fall into the thoracic cavity. Precautionary Measures. In order to be prepared to treat problems such as large hemorrhages, the operation should be done in the operating room, and instruments for an emergency thoracotomy should always be available. COMPLICATIONS
Infection. Kux, who has the largest series of cases, has never observed postoperative infections. In some cases, a small amount of fluid can be seen postoperatively at the costophrenic angle; this is absorbed within a few days. Adhesions. It is uncommon for adhesions to form between the two layers of the pleura at the site of operation. INDICATIONS
The value of sympathetic or parasympathetic interruptions in the chest is not altered by the endoscopic approach; however, we consider that many thoracic conditions which could be treated by sympathectomy or vagotomy are not so treated because of the major operative trauma inherent in orthodox approaches. For some patients the operative risk is high; others refuse operation because their symptoms do not seem sufficiently distressing to warrant thoracotomy. The endoscopic technique seems to offer satisfactory operating conditions to both these groups. The operation is of short duration, can be performed even under local anesthesia, and the recovery time is far shorter than with any other approach to the nerves in the thorax. Various thoracic conditions have been subjected by others to sympathetic or parasympathetic endoscopic surgery.14 Among them is angina pectoris. Cardiac pain can be successfully treated by injection of the stellate ganglia with absolute alcohol and resection or destruction by cautery of the upper five thoracic ganglia as described by Raney. Swetlow in 1925 was the first to treat cardiac pain with paravertebral injections of alcohol. The complications, such as severe alcoholic neuritis or even hemiplegia, caused by the unpredictable location of the needle tip, have made this treatment rather objectionable. Other objections to the treatment of patients with angina pectoris by means of sympathetic interruptions are of a medical nature. Other conditions which are frequently subjected to sympathectomy, such as hyperhidrosis, causalgia, Raynaud's phenomenon, pancreatic pain and essential hypertension, might lend themselves to the endoscopic approach. COMMENT
Endoscopic operations on the thoracic autonomic nervous system should be of great value to both the physician and the patient. Major
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advantages are shortness of the procedure, minor operative trauma, low incidence of complications, and minimal period of recovery after the operation. These few points alone speak well for adopting the procedure. The advantages of the thoracic endoscopic approach just mentioned would permit many more patients and diseases to be treated by surgical means than would otherwise be considered advisable. The physician who contemplates using the endoscope should keep in mind that it is definitely necessary to practice on animals. In inexperienced hands, complications of endoscopy could be frequent. SUMMARY
The technique of endoscopic operations on the thoracic sympathetic ganglia and rami and on the vagus nerve has been presented. Advantages of the endoscopic approach over the routinely used surgical techniques for operating on the autonomic nerves in the chest are the minimal operative trauma, the shortness of the procedure, and the brief period for postoperative recovery. A wider range of indications for sympathectomy and vagotomy can be expected under these circumstances. Although our experience with this procedure is limited to its use in animals as yet, we anticipate trials in man because of the extensive experience and good results of others. REFERENCES 1. Bernheim, B. M.: Organoscopy: Cystoscopy of the Abdominal Cavity. Ann. Surg. 53: 764-767 (June) 1911. 2. Goetz, R. H. and Marr, J. A. S.: Importance of Second Thoracic Ganglion for Sympathetic Supply of Upper Extremities, With Description of 2 New Approaches for Its Removal in Cases of Vascular Disease: Preliminary Report. Clin. Proc., Cape Town, 3: 102-114 (Mar.) 1944. 3. Herve, R.: De l'excision galvanique des brides pleurales au coura du traitement par Ie pneumothorax. Gaz. d. prato Lille 21: 221, 1914. 4. Hughes, John: Endothoracic Sympathectomy. Proc. Roy. Soc. Med. 35: 585-586 (July) 1942. 5. Jacobaeus, H. C.: tJber die Moglichkeit die Zystoskopie bei Untersuchung seroser Hohlungen anzuwenden. Miinchen. med. Wchnschr. 2: 2090-2092 (Oct.) 1910. 6. Jacobaeus, H. C.: Uber Laparo- und Thorakoskopie. Beitr. Klin. Tuberk 25: 185-354, 1912. 7. Jacobaeus, H. C.: Endopleurale Operationen unter der Leitung des Thorakoskops. Beitr. Klin. Tuberk. 35: 1-35, 1916. 8. Jacobaeus, H. C.: Die Thorakoskopie und ihre praktische Bedeutung. Ergebn. gas. Med. 7: 112-166, 1925. 9. Jacobsson, M. D.: Ett fOrsok att avbranna adherenser vid pneumothoraxbehandling under rontgengenomlysning. Hygiea 76: 961-966, 1914. 10. Kelling, Georg: Ueber Oesophagoskopie, Gastroskopie und Kolioskopie. Mlinchen. med. Wchnschr. 49: 21-24 (Jan. 7) 1902. 11. Kremer, Wilhelm: Die LQsung von Verwachsungen im kiinstlichen Pneumothorax. Stuttgart, Georg Thieme, pp. 467-528, 1938. 12. Kuntz, Albert:IThelAutonomic Nervous System. 4th Ed. Philadelphia, Lea & Febiger, 1953, 605 pp. 13. Kux, E.: Thorakoskopische Eingriffe am Nervensystem. Stuttgart, Georg Thieme, 1954, 130 pp.
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14. MacCarty, C. S.: Surgery of the Sympathetic Nervous System. J.-Lancet 69: 377-384 (Nov.) 1949. 15. Maurer, Gustav: Thorakoskopie und Kaustik. Neue Wege und Ziele. Beitr. Klin. Tuberk. 69: 246-264, 1928. 16. Raney, R. B.: A Hitherto Undescribed Surgical Procedure Relieving Attacks of Angina Pectoris: Anatomic and Physiologic Basis. J.A.M.A. 113: 16191623 (Oct. 28) 1939. 17. Raney, R. B.: Personal communication to the authors. 18. Swetlow, G. 1.: Alcohol Injections into Nerve Tissues for the Relief of Pain. Am. J. M. Sc. 171: 397-407 (Mar.) 1926. 19. Unverricht, W.: Die Thorakoskopie als Hilfsmittel fUr die endopleurale galvanokaustische Durchtrennung von Pleurastragen, sowie ftil' eine neue Lokalisationsmethode extrapleural anzugreifender Adhasionen. Ztschr. Tuberk. 36: 267-288, 1922. 20. Van Pernis, P. A.: Variations of the Thoracic Duct. Surgery 26: 806-809 (Nov.) 1949. Mayo Clinic Rochester, Minnesota
THE endoscopic approach for diagnostic or therapeutic purposes in various body cavities has proved its value over many years. At the turn of the century endoscopy was still limited to the treatment of certain conditions of the urinary bladder. As early as 1902, however, Kelling reported that the abdominal cavity of dogs could be inspected without any hazard, and he predicted the future application of endoscopic examinations to man. In 1910 Jacobaeus published a paper in which he pointed out the possibilities of inspecting serous cavities in man by means of a cystoscope. He successfully performed laparoscopy and thoracoscopy, and considered endoscopic inspection of the pericardium. Bernheim in America reported on the diagnostic value of cystoscopy of the abdominal cavity in 1911. Laparoscopy was the center of interest at that time. Soon thoracoscopy became an important aid in the diagnosis of certain diseases of the lung and in the differential diagnosis of pleurisy. The superior visual conditions in the chest as compared with those in the abdomen, and the greater danger of diagnostic thoracic surgical exploration for undetermined surgical disease have made thoracic endoscopy especially helpful. Endoscopic intrapleural pneumolysis (endoscopic cutting of intrapleural adhesions) to make collapse therapy practicable for some patients with pulmonary tuberculosis without the trauma of thoracotomy was tried by Herve and J acobsson and perfected by Jacobaeus, Unverricht, Maurer and Kremer. All these early reports included good anatomic descriptions of the ... Research Fellow, Minnesota Heart Association 1956 and 1957; Fellow in Surgery, Mayo Foundation, Graduate School, University of Minnesota; Rochester, Minnesota.
** Consultant, Section of Neurologic Surgery, Mayo Clinic; Associate Professor of Neurologic Surgery, Mayo Foundation, Graduate School, University of Minnesota; Rochester, Minnesota. t Consultant, Section of Physiology, Mayo Clinic; Professor of Physiology, Mayo Foundation, Graduate School, University of Minnesota; Rochester, Minnesota. 1403
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Herbert A. Roedling, Collin S. MacCarty, Grace M. Roth
subpleural vascular system, the ribs and other structures. None of the investigators, however, seems to have given attention to the autonomic nervous system, that is, the vagus nerve and the thoracic sympathetic chain. In the early 1940's Hughes, Goetz and Marr, and Kux independently reported on the possibility of using an endoscopic approach for operations on the sympathetic chain in the chest. Hughes, in England, resected successfully the stellate ganglion and the greater splanchnic nerve in four cases. Goetz and Marr used the operation in order to resect the second thoracic ganglion in peripheral vascular disease of the upper extremity. Kux was using endoscopic intrapleural pneumolysis at the beginning of World War II and by this method was able to see the thoracic sympathetic chain and to resect segments in a limited number of cases. In 1947 he began to use thoracoscopy extensively, and in 1954 he published a book on this subject. 13 At that time he had utilized this convenient way of operating on the thoracic autonomic nervous system in 1104 patients. In 1956 we started to use this type of surgical procedure on animals. In this paper we shall discuss the pertinent anatomy and the technical aspects and possibilities of endoscopic surgery on the autonomic nervous system in man. ANATOMY
Thoracic SYIIlpathetic Nerves
The thoracic portion of the sympathetic chain is located along the ventrolateral aspects of the vertebral column and is covered only by the thin transparent parietal pleura, thus making resection or injection from within the thoracic cavity an easy and logical procedure (Fig. 404, A). The thoracic portion of the sympathetic chain includes usually 10 or 11 ganglia. These ganglia vary greatly in size and form. Their usual arrangement is segmental. The first of these ganglia is often fused with the inferior cervical ganglion and is then called the "stellate ganglion." The stellate ganglion, particularly the portion that is the inferior cervical ganglion, is located laterally and ventrally to the vertebral artery; however, some rami are located dorsal to this artery, which makes resection of this portioll of the sympathetic chain hazardous. The sympathetic nerve supply of the upper extremity is segmental in its distribution. The preganglionic fibers arise in the second to tenth thoracic spinal segments. They ascend without synapse in the sympathetic trunk. They then form synapses with the postganglionic fibers in the first thoracic ganglion and inferior cervical ganglion (stellate ganglion). Only a few synapses occur with the middle cervical ganglion. The postganglionic fibers, the majority of which are in the stellate ganglion, join the roots of the brachial plexus.
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Visceral sensory fibers from the heart travel over the middle and inferior cardiac nerves and upper five thoracic sympathetic ganglia. The superior cardiac nerve does not seem to carry visceral afferent fibers from the heart. Because of this anatomic structure, destruction of the stellate ganglion by injection of alcohol eliminates the afferent portion of the cardiac nerves, but it does not interfere with the direct supply in the upper thoracic cardiac nerves. Therefore, to obtain best relief from cardiac pain the upper five thoracic sympathetic ganglia through which most of the visceral sensory fibers from the heart run should be destroyed or resected in addition to the stellate ganglion. 14 The splanchnic nerves carry mostly visceral afferent fibers and preganglionic visceral efferent fibers. The greater splanchnic nerve is formed by fusion of many rami arising from the main sympathetic chain between the fifth and tenth thoracic ganglia. It descends into the posterior mediastinum. Occasionally a ganglion is present in the course of the nerve. The lesser splanchnic nerve originates by the union of some rami from the ninth and tenth sympathetic thoracic ganglia. Finally, the least splanchnic nerve originates from the last thoracic and first lumbar ganglia, or even from the lesser splanchnic nerve, and fuses with the other splanchnic nerves in the celiac plexus subdiaphragmatically.12 Vagus Nerve
The right and the left vagus nerves enter the thorax in close relationship to the carotid arteries. The left vagus runs with the aorta and esophagus distally and is located laterally and finally anteriorly to the esophagus. The right vagus, however, swings in the mid chest region to the posterior lateral aspect of the esophagus. The close relationship of the lower part of the right vagus and the thoracic duct should be pointed out. Thoracic Duct
Van Pernis dissected 1081 cadavers in a study of the variations of the thoracic duct. In performing splanchnicectomy in the right lower part of the chest of a patient in the fasting state the invisible thoracic duct is of importance to the surgeon. The cisterna chyli usually is located at the level of the second lumbar vertebra; however, in 33 per cent of persons it is located at the level of the first lumbar vertebra, and in 10 per cent at the level of the twelfth thoracic vertebra. Below the eighth thoracic vertebra the duct is always single. The average diameter is 2 to 4 rom. Topographically the duct is usually medial to the azygos vein and lateral to the aorta, and together with these vessels it passes through the diaphragm. PRELIMINARY ARTIFICIAL PNEUMOTHORAX
In order to make thoracoscopy possible, especially in the therapeutic aspect of operating on the autonomic nervous system, it is necessary to
•
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Herbert A. Roedling, Collin S. MacCarty, Grace M. Roth
Fig. 403. The thoracic endoscope with its various parts.
collapse the lung on the side of the operation. The only contraindications are extensive pleural adhesions which make preliminary endoscopic intrapleural pneumolysis impossible. Hughes induced unilateral pneumothorax over a period of some days before operation; however, this seems to place an unnecessary strain on the patient. Endoscopy should be performed immediately after induction of the pneumothorax, and roentgenologic examination should always be done after the pneumothorax in order to insure that the lung has collapsed uniformly.13 It is not the purpose of this paper to point out the technical details and safeguards for the induction of artificial pneumothorax. INSTRUMENTS USED FOR THORACOSCOPY
Hughes operated through two cannulas, which is certainly convenient for performing endoscopic intrapleural pneumolysis, because the location of intrapleural adhesions is unpredictable. However, for operations on the thoracic autonomic nervous system, with its known anatomic location, the work is much easier to perform through one cannula. The instrument we use was made in Germany.* All the parts of this instrument are shown in Figure 403. The various parts, such as lampholder, needle for injection of anesthetic agents or for absolute alcohol for sympathetic block, cautery tips and different optical systems, can all be changed through the cannula. THORACOSCOPY
Previously it was pointed out that our experience with endoscopic operations on the thoracic autonomic nervous system is still limited to experimental animals. Although the thoracic sympathetic chain in
* Wolf Endoscopic manufacturers,
Knittlingen-Wurett, Germany.
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monkeys or even dogs shows few anatomic variations in comparison with those in man, the technical difficulties seem to have been overcome by our studies on these animals. The technique of thoracoscopy is essentially the same in animals as in man. After a rather small number of endoscopies on living animals or on animals killed immediately before operation (since the pleura becomes translucent a few hours after death), the surgeon becomes adept at identifying the various structures in the chest wall seen through the endoscope. Study of published reports of procedures performed in man2, 4, 13 indicates that the procedure is about as follows: The site of the thoracentesis should be chosen rather carefully. The site of the thoracentesis and the position of the patient depend on which nerve is to be operated on. The upper part of the thoracic sympathetic chain is best approached by inserting the trocar in the anterior axillary line at the level of the third intercostal space, with the patient in a supine position. An equally satisfactory approach is anteriorly through the second intercostal space, with the patient in a sitting position. The lower thoracic part of the sympathetic chain with the splanchnic branches can be observed through the endoscope when thoracentesis is done in the midaxillary line in the fourth to seventh intercostal space, the patient or the animal lying on the side. The vagus nerves are located close to the aorta, esophagus, azygos vein and vena cava, thus making endoscopic approach possible only if the patient is lying on his stomach so that the collapsed lung moves anteriorly and exposes the nerve. The further posterior the paracentesis is performed, the better the view of the vagus through the endoscope. This posterior approach, however, makes it more difficult to see the vagus and the sympathetic chain simultaneously. A second or even a third thoracentesis for extensive resections is advisable and is not of any disadvantage to the patient. 13 After the patient or the animal is placed in the proper position, exact site of the thoracentesis should be marked on the skin. The operation can be performed under either general or local anesthesia. Since some patients are highly sensitive to pain, general anesthesia might be used for extensive sympathetic resection which is painful. If local anesthesia is used, procaine hydrochloride should be infiltrated into the skin at the site of the thoracentesis and into deeper tissues as far as the pleural surface. Thoracentesis is performed in the specific intercostal space chosen after a small incision (0.5 to 1 cm.) is made in the skin to simplify insertion of the trocar. The trocar is slowly advanced until the pleura is entered. The cannula is cleaned with a sponge tightly affixed to a sponge holder, and thus it is impossible for bits of tissue or blood to obstruct the optical system or the lamp. If the lung has been successfully collapsed, the insertion of the lamp-
Herbert A. Roedling, Collin S. MacCarty, Grace M. Roth A
B
c
D
Fig. 404. A, The thoracic portion of the sympathetic chain, as seen through the covering transparent parietal pleura, is located to the left, that is, lateral to the azygos vein. Intercostal venous branches and two ribs are crossed by the sympathetic trunk (dog). B, Injection of a thoracic sympathetic ganglion. Illustrated is the endoscope with the needle in position for injection (dog). C, In the upper left part and below the center are two circular areas where pleura and sympathetic trunk have been cauterized (dog). D, Extirpation of a thoracic sympathetic segment. Note the nerve twisted around the forceps (dog).
holder and optical systems can be achieved without further difficulties. However, if the instruments are not heated to 37° C. before insertion, vision will be obscured for about one to two minutes because of the higher temperature and humidity in the thoracic cavity. Therefore warming instruments is helpful. For inspection of the thoracic cavity and for localization of the sympathetic chain, vagus nerves or both, a wide-angle optical system
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should be used. Mter all the pertinent anatomic structures have been identified with the aid of this wide-angle lens, this optical system should be exchanged for a.r:egular lens which magnifies when the object to be inspected is only a short distance away. A long needle can be inserted through the endoscope for injection of procaine hydrochloride into the parietal pleura at the site of the operation or for the injection of absolute alcohol into sympathetic ganglia (Fig. 404, B). Cauterization is performed by exchanging the needle, if previously used, for the cautery. After the desired point of interruption of the sympathetic chain or vagus nerve is located, the thin pleura covering the nerve is cauterized with diathermy, and the sympathetic chain or vagus nerve is exposed. With the cautery cold the nerve is underhooked and pulled away from the chest wall, and then is cut with galvanic current. This technique makes injuries to the underlying chest wall and somatic nerves impossible. Mter the sympathetic nerve has been cut, the same procedure should be done at a lower or higher level of the nerve in order to resect the nerve (Fig. 404, C). This segment then can be removed by special forceps which will grip the nerve segment in its center after it is exposed from the covering pleura by cauterization. A twisting motion of the forceps then will remove this loose segment (Fig. 404, D). The length of such a segment should not exceed 8 cm. TECHNICAL DIFFICULTffiS
Bleeding. Although bleeding is seemingly the difficulty most likely to be encountered in endoscopic operations on the thoracic portion of the autonomic nervous system, the large vessels can easily be seen through the endoscope and readily avoided. However, the lower part of the right vagus nerve is close to the azygos vein, and sometimes an injury to this vessel can be avoided only by separating the nerve from the vein by means of injection of a solution of sodium chloride or procaine hydrochloride between the two. 13 As mentioned before, the close relationship of the stellate ganglion to the vertebral artery makes endoscopic resection of this part of the sympathetic chain rather hazardous. However, the results of alcohol injection into the ganglion under direct vision seem to be equal to surgical removal. Hemorrhages from small branches of the intercostal vessels can be controlled at the time of operation by cauterization or injection of locally acting coagulants. It seems also important not to operate on patients with prothrombin deficiency from anticoagulant drugs. Injury of the Thoracic Duct. The close anatomic relationship of the right vagus nerve, the azygos vein, the right splanchnic nerves, and the main lymphatic duct in the right lower part of the thorax has been mentioned. When operations are performed in this region, the surgeon must beware of injuring the thoracic duct, which is invisible in the fasting state.
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Herbert A. Roedling, Collin S. MacCarty, Grace M. Roth
Foreign Bodies. The instruments should always be checked by the surgeon himself. Loose light bulbs could fall into the thoracic cavity. Precautionary Measures. In order to be prepared to treat problems such as large hemorrhages, the operation should be done in the operating room, and instruments for an emergency thoracotomy should always be available. COMPLICATIONS
Infection. Kux, who has the largest series of cases, has never observed postoperative infections. In some cases, a small amount of fluid can be seen postoperatively at the costophrenic angle; this is absorbed within a few days. Adhesions. It is uncommon for adhesions to form between the two layers of the pleura at the site of operation. INDICATIONS
The value of sympathetic or parasympathetic interruptions in the chest is not altered by the endoscopic approach; however, we consider that many thoracic conditions which could be treated by sympathectomy or vagotomy are not so treated because of the major operative trauma inherent in orthodox approaches. For some patients the operative risk is high; others refuse operation because their symptoms do not seem sufficiently distressing to warrant thoracotomy. The endoscopic technique seems to offer satisfactory operating conditions to both these groups. The operation is of short duration, can be performed even under local anesthesia, and the recovery time is far shorter than with any other approach to the nerves in the thorax. Various thoracic conditions have been subjected by others to sympathetic or parasympathetic endoscopic surgery.14 Among them is angina pectoris. Cardiac pain can be successfully treated by injection of the stellate ganglia with absolute alcohol and resection or destruction by cautery of the upper five thoracic ganglia as described by Raney. Swetlow in 1925 was the first to treat cardiac pain with paravertebral injections of alcohol. The complications, such as severe alcoholic neuritis or even hemiplegia, caused by the unpredictable location of the needle tip, have made this treatment rather objectionable. Other objections to the treatment of patients with angina pectoris by means of sympathetic interruptions are of a medical nature. Other conditions which are frequently subjected to sympathectomy, such as hyperhidrosis, causalgia, Raynaud's phenomenon, pancreatic pain and essential hypertension, might lend themselves to the endoscopic approach. COMMENT
Endoscopic operations on the thoracic autonomic nervous system should be of great value to both the physician and the patient. Major
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advantages are shortness of the procedure, minor operative trauma, low incidence of complications, and minimal period of recovery after the operation. These few points alone speak well for adopting the procedure. The advantages of the thoracic endoscopic approach just mentioned would permit many more patients and diseases to be treated by surgical means than would otherwise be considered advisable. The physician who contemplates using the endoscope should keep in mind that it is definitely necessary to practice on animals. In inexperienced hands, complications of endoscopy could be frequent. SUMMARY
The technique of endoscopic operations on the thoracic sympathetic ganglia and rami and on the vagus nerve has been presented. Advantages of the endoscopic approach over the routinely used surgical techniques for operating on the autonomic nerves in the chest are the minimal operative trauma, the shortness of the procedure, and the brief period for postoperative recovery. A wider range of indications for sympathectomy and vagotomy can be expected under these circumstances. Although our experience with this procedure is limited to its use in animals as yet, we anticipate trials in man because of the extensive experience and good results of others. REFERENCES 1. Bernheim, B. M.: Organoscopy: Cystoscopy of the Abdominal Cavity. Ann. Surg. 53: 764-767 (June) 1911. 2. Goetz, R. H. and Marr, J. A. S.: Importance of Second Thoracic Ganglion for Sympathetic Supply of Upper Extremities, With Description of 2 New Approaches for Its Removal in Cases of Vascular Disease: Preliminary Report. Clin. Proc., Cape Town, 3: 102-114 (Mar.) 1944. 3. Herve, R.: De l'excision galvanique des brides pleurales au coura du traitement par Ie pneumothorax. Gaz. d. prato Lille 21: 221, 1914. 4. Hughes, John: Endothoracic Sympathectomy. Proc. Roy. Soc. Med. 35: 585-586 (July) 1942. 5. Jacobaeus, H. C.: tJber die Moglichkeit die Zystoskopie bei Untersuchung seroser Hohlungen anzuwenden. Miinchen. med. Wchnschr. 2: 2090-2092 (Oct.) 1910. 6. Jacobaeus, H. C.: Uber Laparo- und Thorakoskopie. Beitr. Klin. Tuberk 25: 185-354, 1912. 7. Jacobaeus, H. C.: Endopleurale Operationen unter der Leitung des Thorakoskops. Beitr. Klin. Tuberk. 35: 1-35, 1916. 8. Jacobaeus, H. C.: Die Thorakoskopie und ihre praktische Bedeutung. Ergebn. gas. Med. 7: 112-166, 1925. 9. Jacobsson, M. D.: Ett fOrsok att avbranna adherenser vid pneumothoraxbehandling under rontgengenomlysning. Hygiea 76: 961-966, 1914. 10. Kelling, Georg: Ueber Oesophagoskopie, Gastroskopie und Kolioskopie. Mlinchen. med. Wchnschr. 49: 21-24 (Jan. 7) 1902. 11. Kremer, Wilhelm: Die LQsung von Verwachsungen im kiinstlichen Pneumothorax. Stuttgart, Georg Thieme, pp. 467-528, 1938. 12. Kuntz, Albert:IThelAutonomic Nervous System. 4th Ed. Philadelphia, Lea & Febiger, 1953, 605 pp. 13. Kux, E.: Thorakoskopische Eingriffe am Nervensystem. Stuttgart, Georg Thieme, 1954, 130 pp.
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14. MacCarty, C. S.: Surgery of the Sympathetic Nervous System. J.-Lancet 69: 377-384 (Nov.) 1949. 15. Maurer, Gustav: Thorakoskopie und Kaustik. Neue Wege und Ziele. Beitr. Klin. Tuberk. 69: 246-264, 1928. 16. Raney, R. B.: A Hitherto Undescribed Surgical Procedure Relieving Attacks of Angina Pectoris: Anatomic and Physiologic Basis. J.A.M.A. 113: 16191623 (Oct. 28) 1939. 17. Raney, R. B.: Personal communication to the authors. 18. Swetlow, G. 1.: Alcohol Injections into Nerve Tissues for the Relief of Pain. Am. J. M. Sc. 171: 397-407 (Mar.) 1926. 19. Unverricht, W.: Die Thorakoskopie als Hilfsmittel fUr die endopleurale galvanokaustische Durchtrennung von Pleurastragen, sowie ftil' eine neue Lokalisationsmethode extrapleural anzugreifender Adhasionen. Ztschr. Tuberk. 36: 267-288, 1922. 20. Van Pernis, P. A.: Variations of the Thoracic Duct. Surgery 26: 806-809 (Nov.) 1949. Mayo Clinic Rochester, Minnesota