Bilateral VATS Sympathectomy for Ventricular Tachycardia Electrical Storm

This video demonstrates a bilateral thoracoscopic sympathectomy using a modified supine, steep reverse Trendelenburg position to enhance exposure and improve intraoperative safety. The supine positioning facilitates immediate access for cardiopulmonary resuscitation, while the reverse Trendelenburg position lowers the thoracic cavity, improving visualization of the sympathetic chain. 
 
The left side was dissected first due to its higher procedural yield in the event of early termination. Access was achieved with the Optiview technique. The sympathetic chain was dissected between the stellate ganglion superiorly and the fourth rib inferiorly, followed by the placement of a Blake drain and lung re-expansion. 
 
On the right side, identical exposure and dissection were performed, with the additional identification and division of Kuntz’s fibers just superior to the second rib to prevent aberrant conduction between T2 and the brachial plexus. Drains were removed the same day, and the patient experienced no complications. 
 
This video highlights three key technical points:  

1. Modified patient positioning to optimize exposure and safety 
2. Systematic identification of anatomic boundaries for precise sympathectomy 
3. Targeted division of Kuntz’s fibers to ensure complete denervation and reduce the risk of recurrence 

References

1. Chihara RK, Chan EY, Meisenbach LM, Kim MP. Surgical Cardiac Sympathetic Denervation for Ventricular Arrhythmias: A Systematic Review. Methodist Debakey Cardiovasc J. 2021 Apr 5;17(1):24-35. doi: 10.14797/QIQG9041. Epub 2021 Mar 25. PMID: 34104317; PMCID: PMC8158456.
2. Vaseghi M, Gima J, Kanaan C, Ajijola OA, Marmureanu A, Mahajan A, Shivkumar K. Cardiac sympathetic denervation in patients with refractory ventricular arrhythmias or electrical storm: intermediate and long-term follow-up. Heart Rhythm. 2014 Mar;11(3):360-6. doi: 10.1016/j.hrthm.2013.11.028. Epub 2013 Nov 28. PMID: 24291775; PMCID: PMC4253031. Thoracoscopic and Anatomic Landmarks of Kuntz's Nerve: Implications for Sympathetic Surgery. Marhold, Franz et al. The Annals of Thoracic Surgery, Volume 86, Issue 5, 1653 – 1658
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4. Yun, Steven, et al. Westmead Eye Manual, edited by Adrian Fung, Richard Parker, Ben Sim, Dominic McCall, and Steven Yun, Royal Australian and New Zealand College of Ophthalmologists, 2021, www.westmeadeye.com/07-neuro-ophthalmology/08-horners-syndrome/.

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