Thoracic splanchnic nerves: implications for splanchnic denervation

Abstract

Splanchnic neurectomy is of value in the management of chronic abdominal pain. It is postulated that the inconsistent results of splanchnicectomies may be due to anatomical variations in the pattern of splanchnic nerves. The advent of minimally invasive and video-assisted surgery has rekindled interest in the frequency of variations of the splanchnic nerves. The aims of this study were to investigate the incidence, origin and pattern of the splanchnic nerves in order to establish a predictable pattern of splanchnic neural anatomy that may be of surgical relevance. Six adult and 14 fetal cadavers were dissected (n l 38). The origin of the splanchnic nerve was bilaterally asymmetrical in all cases. The greater splanchnic nerve (GSN) was always present, whereas the lesser splanchnic nerve (LSN) and least splanchnic nerve (lSN) were inconsistent (LSN, 35 of 38 sides (92 %) ; LSN, 21 of 38 sides (55 %). The splanchnic nerves were observed most frequently over the following ranges : GSN, T6-9 : 28 of 38 sides (73 %) ; LSN, when present, T10-11 : (10 of 35 sides (29 %) ; and lSN, T11-12 : 3 of 21 sides (14 %). The number of ganglionic roots of the GSN varied between 3 and 10 (widest T4-11 ; narrowest, T5-7). Intermediate splanchnic ganglia, when present, were observed only on the GSN main trunk with an incidence of 6 of 10 sides (60 %) in the adult and 11 of 28 sides (39 %) in the fetus. The higher incidence of the origin of GSN above T5 has clinical implications, given the widely discussed technique of undertaking splanchnicectomy from the T5 ganglion distally. This approach overlooks important nerve contributions and thereby may compromise clinical outcome. In the light of these variations, a reappraisal of current surgical techniques used in thoracoscopic splanchnicectomy is warranted. The 3 splanchnic nerves of the thoracic sympathetic trunk, arise from the lower 8 ganglia. The greater splanchnic nerve (GSN) is formed by branches of the T5-9 sympathetic ganglia, the lesser splanchnic nerve (LSN) from T10-11 ganglia and the least splanchnic nerve (lSN) from the T12 ganglion. These splanchnic nerves contain, predominantly, visceral efferent fibres, as well as pain conducting visceral afferent fibres (McMinn, 1994).The highest cephalad contribution of the sympathetic chain to the GSN is documented as the T4 or

Thoracic Part of Sympathetic Chain and its Branching Pattern Variations in South Indian Cadavers

“…In the present study the common origin was from the 11 th ganglion in 17 specimens (27%) and from the 12 th ganglion in 7 specimens (11%). Some authors observed in his findings the intermediate splanchnic ganglia (ISG) was observed only on the GSN main trunk with an incidence of 6 out of 10 sides (60%) in the adult cadavers and 11 of 28 sides (39%) in the fetuses [7]. In the present study intermediate splanchnic ganglion was observed in 13 of 62 (21%) sides in adult cadavers on the GSN.…”

“…In the present study in 11 cases 11 ganglia were present bilaterally; an accessory ganglion connecting with the subcostal nerve was present in three cadavers bilaterally and in one cadaver unilaterally. The origin of splanchnic nerves differs considerably with respect to their number, the level at which the thoracic ganglia gives off their fibers to the individual thoracic splanchnic nerves, the presence of the lesser and least nerves and accessory nerve fibers [5][6][7][8]. There were three splanchnic nerves of the thoracic sympathetic trunk; arising from the lower eight ganglia.…”

Variations of Thoracic Splanchnic Nerves and its Clinical Implications

“…A higher origin of the greater splanchnic nerve at the level of T4 has been reported (Kuntz, 1934 andReed, 1951) but in the present study, we report the same at a higher level i.e T3 . To the best of our knowledge, only a single study in the past has reported a higher origin of greater splanchnic nerve at T3 level, but it was not supplemented with necessary histological study (Naidoo et al, 2001). There are past reports of a common trunk for the greater and lesser splanchnic nerves (Naidoo et al) but our study showed a common trunk of greater, lesser and least splanchnic nerves after each of them had originated separately from MSC.…”

“…This operation is used in the treatment of the nagging pain in chronic pancreatitis and pancreatic cancer (Naidoo et al) . The success of the sympathetic denervation procedure depends upon the presence or absence of visible or barely perceptible accessory ganglia and pathways other than those classically described (Naidoo et al;Hoffmann;Kuntz & Alexander, 1950;Ehrlich & Alexander, 1951). The region of second thoracic ganglion is considered as a key ganglion for any sympathectomy (Ramsaroop et al, 2004).…”

Immunohistochemical characteristics of neurons in the ganglia of the greater splanchnic nerve of the pig

“…In addition, the celiac ganglia are functionally related to the splanchnic nerves [4]. The splanchnic nerves contain the visceral efferent fibers but also pain-conducting visceral afferent fibers [5,6] and transmit the majority of nociceptive information www.fhc.viamedica.pl from the viscera. Clinically, splanchnic nerve block may provide relief of pain in a subset of patients who fail to obtain relief from celiac plexus block [7].…”