The most commonly employed surgical approach for a sympathectomy for the upper extremity or for relief of angina pectoris with or without coronary insufficiency is the posterior extrapleural operation of the Smith-wick type, or its modification. For sympathetic denervation of the upper extremity by this technique, a resection of a short posterior section of the third rib was accomplished with the patient in a face-down position. A portion of the second and third intercostal nerves was resected, the rami communicantes or the sympathetic chain at these levels were divided, and the sympathetic chain was likewise divided below the third sympathetic ganglion, whereas, the denervation of the heart required a more extensive resection of the upper sympathetic chain.This former posterior approach had its many pitfalls and limitations, which were mainly technical. The degree and type of exposure were usually inadequate, imposing many obstacles, particularly of performance of an operation
PALUMBO LT. Anterior Transthoracic Approach for Upper Thoracic Sympathectomy. AMA Arch Surg. 1956;72(4):659–666. doi:10.1001/archsurg.1956.01270220107014
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