Position the patient with legs spread and torso elevated at approximately 40% (semi-Fowler’s position) as shown in Figure 35.1. This position allows the operating surgeon to stand comfortably between the legs and gives excellent access to both left and right sympathetic chains. After air enters the pleural space, gravity will cause the lungs to fall down, exposing the upper sympathetic chains under the parietal pleura.

Starting on one side, introduce the thoracoscope at the 3 to 4 interspace in the anterior axillary line. If an operating thoracoscope is available, only a single port is required. Alternatively, two ports are used and a nonoperating angled thoracoscope suffices.

The cervical sympathetic chains pass deep into the subclavian vessels to enter the chest by running over the first rib just lateral to the vertebral bodies. Commonly, the lower cervical and first thoracic sympathetic ganglia fuse to form the cervicothoracic, or stellate, ganglion. As in the rest of the sympathetic chain, the thoracic sympathetic chain is marked by a series of ganglia, which are visible as swellings under the parietal pleura. The ganglia correspond approximately to the thoracic nerves but often coalesce so that the total number is fewer than 12.

When there is a separate first thoracic ganglion, it is larger than the rest of the ganglia in the chain and roughly crescent-shaped. The second and subsequent ganglia are found at the cranial border of the next lower thoracic vertebral body. The lowest thoracic ganglion is commonly larger and contains a coalescence of the 11th and 12th nerves.