Minimally Invasive Sympathicotomy for the Treatment of Hyperhidrosis: After 20 Years of Practice, What Have We Learned?

INTRODUCTION: Hyperhidrosis is a frequent disorder with an estimated prevalence of 3% in the general population. This condition carries relevant impairments in social relationships for patients. Hyperhidrosis can affect different anatomical areas with palmar region being the most disturbing for everyday activities and social relevance. Several conservative and topical treatments are available for the patients, but their efficacy is often limited and temporary. Video-assisted thoracoscopic sympathicotomy of T2 and T3 ganglia with a minimally invasive technique represent a definitive treatment for palmar and axillary hyperhidrosis.1,2 MATERIALS AND METHODS: This minimally invasive approach for thoracoscopic sympathicotomy was first described by Raposio et al3 2 decades ago. This single-entry thoracoscopic procedure is carried out with a specifically modified endoscope equipped with optic fiber and a wire loop for electrocautery at its distal end. Since 1997, 781 patients have been treated at our department and 1,562 sympathicotomies have been performed. RESULTS: Out of 781 patients, 734 reported complete resolution of palmar hyperhidrosis. In 47 subjects, the procedure could not be completed due to the presence of anatomical anomalies. We have also observed a 44% incidence rate of vascular structures overlying sympathetic ganglia, lung adherence, and retropleural fat that complicated the surgical procedures. In 6 patients, symptoms relapsed after the procedure, most likely due to accessory sympathetic pathways. Of these, 2 underwent revision surgeries and were successfully treated. Only 2 patients complained of generalized compensatory hyperhidrosis. No major complication was observed. Surgeries were performed as 1-day surgery procedure. Mean operative time was 45 minutes. CONCLUSIONS: Video-assisted thoracoscopic sympathicotomy represents a definitive treatment for palmar and axillary hyperhidrosis, and it should be considered when conservative options failed to relieve the symptoms. This minimally invasive approach provides effective resolution for this disorder with minimal postoperative complication rate. However, the relatively high rate of vascular structures overlying sympathetic ganglia, lung adherence, and retropleural fat can potentially complicate the procedure, thus preventing less-experienced surgeons from obtaining positive surgical outcomes. REFERENCES: 1. Raposio E, Caruana G. Video-assisted thoracoscopic sympaticotomies for the treatment of palmar and axillary hyperhidrosis. In: Raposio E, ed. Atlas of Endoscopic Plastic Surgery. 1st ed. New York, N.Y.: Springer; 2015:81–89. 2. Raposio E, Caruana G. Video-assisted thoracic sympathicotomy for the treatment of palmar and axillary hyperhidrosis: a 17-year experience. Surg Laparosc Endosc Percutan Tech. 2015;25:417–419. 3. Raposio E, Filippi F, Nordstrom RE, et al. Endoscopic transthoracic dorsal sympathectomy for the treatment of upper extremity hyperhidrosis: a new minimally invasive approach. Plast Reconstr Surg. 1998;102:1629–1632.