Thoracoscopic Sympathectomy for Hyperhidrosis

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Excessive sweating, known as hyperhidrosis, can be treated by destroying nerves to permanently interrupt the brain signal that causes sweating. There are two sympathetic trunks of nerves that run alongside the spine. Sympathectomy involves cutting and sealing (known as cauterizing) a portion of the sympathetic chain that controls sweating.

The basic operation goes back to 1920 but was very risky. Not until the 1980s, with the pioneering of endoscopic thoracic sympathectomy, followed by the advent of minimally invasive techniques, did the operation become widely done. Previously a major incision had to be made to reach the sympathetic chain. Now, with minimally invasive surgery, the procedure is done with several tiny incisions of less than one inch each. Using a small fiberoptic camera and small surgical instruments that are inserted through the incisions, the surgeon will cauterize a portion of the sympathetic chain. (See Dr. Krasna's Thoracoscopic Sympathectomy article published by the Cardiothoracic Surgery Network, CTS Net)

This procedure is performed most often for excessive sweating of the hands, face and underarms, but is also effective for facial blushing, social phobia, Raynaud’s disease and Reflex Sympathetic Dystrophy.

The Procedure
A sympathectomy is done under general anesthesia. Since the operation is performed through the area just below the underarm, the patient’s arms need to be propped up at a 90 degree angle to the body. First the surgical team deflates the lung to enable the surgeon to access the sympathetic nerve chain. A one inch incision is made under the armpit, usually between the second and third ribs. A videoscope or small camera is inserted through the incision to view the inside of the chest and the sympathetic nerve chain. A cautery device is then lowered through the scope and used to destroy a portion of the sympathetic nerve. The operation usually requires just a one night stay, and the patient can go back to a normal routine or work in a few days.

Benefits and Risks
Sympathectomy offers an option for patients with severe hyperhidrosis for whom medical treatment has failed. It cures excessive sweating of the hands, face, underarms and feet in almost all cases. The surgery is effective immediately.  Patients wake up from surgery and are pleasantly surprised to have warm, dry hands. The procedure has minimal risks, and the benefits generally outweigh the risks for people who suffer from excessive sweating. 

People who are not good candidates for the surgery are those with a prior chest surgery or who have severe heart problems, respiratory disease, an active infection, or a low heart rate.  

The risks include:

• Compensatory Hyperhidrosis: The most common side effect, this may occurs either temporarily or permanently to approximately 50 percent of patients. Basically, the body redirects the sweat. Though the patient is cured from excessive sweating of the hands, underarms and/or feet, heavier sweating occurs in some other part of the body, such as the chest, back or legs. However, most patients report that they can cope with this type of sweating and are relieved not to sweat excessively in their hands, face or underarms.
• Gustatory Sweating: This is sweating that increases while a person is eating.
• Horner’s Syndrome: This is a rare side effect that is unlikely to occur when an experienced surgeon performs the sympathectomy. The syndrome is the result of inadvertent damage to the higher nerves, producing decreased facial sweating, drooping of the eyelids and enlarged pupils.
• Pneumothorax: This is a temporary problem of air or gas collecting in the check cavity during surgery. It may cause the lung to collapse, but it corrects spontaneously. It is not a major problem, but the patient would not be able to fly for sometime afterwards.
• Pain: This may result from surgical instruments pressing on nerves along the ribs during the surgery. It is temporary and usually minor.

Rarely, complications of excessive bleeding or injury to surrounding tissues occur.