A 34 years male Asian presented from skin department as referral case of bilateral increase in sweating both arms from axilla to palms. He was symptomatic for the last three years and was having different treatment from general OPD and Skin Department in the form of astringent local applications and oral medications. He was clerk by profession and had to use frequent cleaning of sweat during his work that was embaressing and was causing jeopardy to his job. He had no associated clinical features of vasospatic conditions. His base line investigations were normal, additional thyroid function and glucose profile was normal. His chest X-ray was normal with no apparent clinical or radiological evidence of lung parenchymal pathology which would hinder thoracocscopic dissection and approach. He went bilateral thoracoscopic surgical sympathectomy first on right side then on left all procedure was performed in modified decubitans position with patient slightly forward approx 15 degree beyond perpendicular. This allowed the ipsilateral lung to fall away from the posterior located sympathetic chain, first in right position under general anesthesia with double-lumen endotracheal intubation so that the lung on the operative side can be deflated. To enhance exposure of the posterior mediastinum an anterior rotation was given. The pleural space was then inspected using a zero degree 5-mm endoscope fifth intercostals space in midaxillary line. This was supplemented by two 5mm working trocars in third intercoastal space, one anterior and posteriorly. The rib spaces and corresponding segment of the sympathetic chain were then visualized (fig. 1) by an area of bright yellow fat and the overlying parietal pleura incised. Using monopolar cautery the sympathetic ganglia at T2, T3 are isolated and individually excised. Dissection was not carried above the upper border of second rib to preserve 5th stellate ganglion (fig. 2). Finally the bodies of the second and third ribs are horizontally with cautery from the costovertebral angle laterally for 3 to 4 cm, this divided the accessory fibers. Hemostasis was then obtained and chest tube 28 Fr was passed through the axillary port of the endoscope. The procedure was then repeated on the left side. Lung was fully expanded and underwaterseal was finally checked again. A chest roentgenogram was then obtained postoperatively to confirm adequate expansion of the lungs. The patient was then observed for Homer syndrome. Lung was expanded chest tube was removed very next day with full radiological and clinical expansion. Patient was discharged next days.He had complete recovery of symptoms post operatively.
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