Upper thoracic sympathetic surgery. Open surgical techniques.

Four open surgical approaches have been used to perform upper thoracic sympathectomy. The posterior approach requires access through the posterior muscles of the back, and rib transection. It is a painful operation that has been practically abandoned in favor of the other techniques. The anterior transthoracic approach consists of a formal thoracotomy and never gained popularity. The supraclavicular approach involves dissection of several important anatomical structures. It requires excellent surgical dexterity, but ensures the easiest postoperative recovery. The last approach involves a small transaxillary thoracotomy. Technically, it is the easier procedure. Both the supraclavicular and the transaxillary approaches were widely used until the advent of thoracoscopic surgery. The results (rate of success, recurrences, and sequelae) were similar for all techniques, depending on the procedure performed on the sympathetic chain, not on the access route. Open approaches for upper dorsal sympathectomy are not used any more except in the very rare cases in which thoracoscopy is unfeasible.