Thoracoscopic and Anatomic Landmarks of Kuntzʹs Nerve: Implications for Sympathetic Surgery

Background Kuntzʹs nerves (KN) have been blamed for surgical failures of endothoracic sympathectomy. The prevalence of these fibers, however, varies between the surgical (about 10%) and anatomic literature (about 80%). This clinically orientated cadaveric study was conducted to explain this discrepancy, to reveal possible reasons for the low thoracoscopic detection rate, and to define anatomic structures as possible landmarks of KNs. Methods Video-assisted thoracoscopy was performed in 33 thoracic cavities of fresh human cadavers within 48 hours postmortem, followed by anatomic dissection of the first intercostal space. Kuntzʹs nerves and concomitant blood vessels were of special interest. Statistical analysis included frequencies and χ2 tests. Results Kuntzʹs nerves were identified in 12.1% by thoracoscopy, whereas anatomic dissection revealed KNs in 66.7% (p = 0.003). Subpleural veins (mean diameter, 2.2 ± 0.9 mm) parallel to KNs were found in 81.8%. No collateral arteries were identified. Diameters of KNs were 1.4 ± 0.7 mm; distances between the first thoracic ganglion and the middle of KNs were 9.7 ± 3.0 mm. Thoracoscopic recognition of these Kuntz veins was higher than that of KNs (62.5% vs 18.2%, p < 0.005). Conclusions The low thoracoscopic detection rate of KNs may be due to the low color contrast of these small fibers. They have, however, most frequently concomitant subpleural veins that are easier to detect. These veins may serve as orientation landmarks of KNs and thus contribute to a more complete denervation improving the outcome of thoracoscopic sympathectomies.