Review Note

SS_TS 1.14 Outline the anaesthetic management of the following procedures: 

 Thoracoscopic sympathectomy (also refer to the Vascular surgery and interventional radiology specialised study unit)

• Usually young and healthy patients
• Cardiovascular evaluation for angina or prolonged QT syndrome. 
• Patients should be warned about the rare possibility of conversion to an open procedure. 
• Blood group should be ascertained and a sample saved

• Monitoring
• Standard monitoring
• A-line in those with impaired cardiovascular function
• During periods of lung deflation consider more frequent inflation of BP cuff
• Airway:
• Single lumen tube sufficient
• Some centres use proseal LMA
• Can use DLT and deflate surgical side, must check position with fiberoptic scope
• Breathing:
• Standard ventilation for access, may need periods of lung deflation or low volume ventilation at certain periods
• Circulation:
• One large-bore IVL usually sufficient
• Analgesia:
• The surgeon should instil intrathoracic local anaesthetic under direct vision onto the cut edges of the pleura and also infiltrate the port sites. Longer-acting agents such as bupivacaine (0.25–0.5%, 2 mg/kg ) provide extended pain relief. 
•  Multi-modal, often paracetamol + ibuprofen pre-op
• Positioning:
• Brachial plexus injuries reported, careful positioning or arms
• From memory usually supine with arms abducted for surgical access
• Surgical technique:
• Ports + camera - convert to thoracotomy if needed
• 10-15mins per side, often bilateral
• Insufflate small volumes of carbon dioxide continuously into the thorax in order to visualize the sympathetic chain. The insufflation pressure limit should be set at 5–10 mm Hg and flow rates minimized to prevent overenthusiastic carbon dioxide administration causing a tension capnothorax which may be associated with a catastrophic fall in cardiac output
• Beware:
• Hypoxia if one lung ventilation
• Cardiovascular collapse related to insufflation
• Reinflate lung under direct (surgical) vision

• Pain as above + opioids as needed