Horner syndrome after sympathectomy in the thoracoscopic era

Horner syndrome after sympathectomy has significantly decreased in current surgical practice. This is predominantly due to refinements in operative techniques, and an improved understanding of the patterns of sympathetic outflow pathways. We present a review of our experience with this disconcerting complication of sympathectomy when undertaken for palmar hyperhidrosis.

Over a 12-year period (1992 to 2004), patients undergoing sympathectomy for palmar hyperhidrosis were prospectively evaluated. In all patients the thoracoscopic approach was attempted bilaterally. The technique entailed the accurate identification of the second thoracic ganglion, followed by its dissection and resection. Excessive manipulation and cautery on the sympathetic chain was avoided.

A total of 1137 procedures were undertaken in 567 patients. In 1 patient (during the early part of the technical experience) a unilateral Horner syndrome was noted on the first postoperative day; this effect was noted to have resolved spontaneously within 6 months. Review at 3 months was possible in 382 patients, either directly or telephonically. In these patients no further case of Horner syndrome was documented.

The key to avoiding the development of a Horner syndrome after sympathectomy entails a thorough appreciation of the appropriate surgical anatomy, avoidance of violent manipulation and traction of the sympathetic chain, and the avoidance of diathermy on the sympathetic chain. The adherence to these principles has consigned Horner syndrome after sympathectomy as an entity of historical interest.