CPT® Code 32664

A thoracic sympathectomy is a surgical procedure performed through thoracoscopy, which is also known as video-assisted thoracoscopic surgery (VATS). This minimally invasive technique allows surgeons to access the thoracic cavity with reduced trauma compared to traditional open surgery. During the procedure, the patient is positioned in a semi-Fowler's position, which involves sitting up slightly with the arms positioned away from the body. A roll is placed behind the shoulder to facilitate access to the upper sympathetic chain, which is a network of nerves located in the thoracic region. To perform the surgery, one-lung ventilation is utilized, allowing the contralateral lung to collapse. This collapse is essential as it creates more space within the thoracic cavity, enabling the surgeon to visualize and operate on the sympathetic chain effectively. The procedure involves making one or two small incisions in the chest wall through which a thoracoscope is inserted. The thoracoscope is equipped with a camera and light source, providing a clear view of the sympathetic chain located beneath the parietal pleura, which is the outer membrane covering the lungs. The sympathetic chain runs vertically along the necks of the ribs in the upper vertebral region. The surgeon then uses hook cautery to divide the sympathetic chain, which may involve cutting and coagulating the nerve fibers. In some cases, a segment of the chain may be excised entirely. The goal of the procedure is to obliterate the ganglia by completely severing the sympathetic chain, which can alleviate conditions such as hyperhidrosis, thoracic outlet syndrome, reflex sympathetic dystrophy, and chronic pancreatic pain. After the sympathetic chain is transected, the pleura is carefully divided laterally to the chain, and any aberrant nerve bundles are identified and severed to prevent unintended nerve regeneration. The ends of the sympathetic nerve bundles are cauterized to further inhibit regrowth. The specific level at which the sympathetic chain is transected depends on the condition being treated; for instance, levels T2-T5 are targeted for hyperhidrosis, T1-T3 for thoracic outlet syndrome and reflex sympathetic dystrophy, and T4-T10 for chronic pancreatic pain. Once the procedure is completed, a chest tube is placed to facilitate drainage, and the subcutaneous tissue is closed. The lungs are then expanded, the chest tube is removed, and a subcuticular suture is applied to finalize the surgical site. If necessary, the procedure may be repeated on the opposite side to achieve bilateral results.