Thoracoscopic Sympathectomy

What is thoracoscopic sympathectomy

Patients with primary hyperhidrosis have the option of undergoing a surgical procedure called thoracoscopic sympathectomy. The operation is also known as endoscopic thoracic sympathectomy or minimally invasive thoracic sympathectomy.

The sweat glands are stimulated by nerve fibers that arise from the spinal cord and run along each side of the spine in what is called the sympathetic chain. The thoracoscopic sympathectomy interrupts the sympathetic chain, preventing the nerve signals that originate in the spine from reaching and stimulating the sweat glands. This sympathetic chain is interrupted by cutting it, which is an irreversible procedure.

The sweat glands in each area of the body are controlled by nerves that arise at a specific level of the spine; therefore, the sympathetic chain must be interrupted only at the specific level that controls the affected areas. For primary hyperhidrosis of the hands, the sympathetic chain is interrupted at the level of the third to fourth rib.

Pablo Laje, MD, a pediatric general surgeon at The Children’s Hospital of Philadelphia, offers surgery to children and teenagers who have primary focal hyperhidrosis of the hands, alone or in combination with armpits and/or feet. Patients whose hands are not involved are not candidates for the operation.

What to expect during surgery

The operation is performed in the operating room, under general anesthesia. Two tiny incisions are made in each armpit, which results in minimal postoperative pain and almost invisible scars. One of the incisions is used to place a very thin thoracoscope (similar to a small TV camera) and the other incision is used for the surgical instruments.

The operation takes approximately one hour for both sides. No drains or chest tubes are used, and the incisions don’t require any stitches that will need to be removed. The patient generally goes home the morning after the operation.

Outcomes

The operation is very effective in stopping hyperhidrosis of the hands, with consistent success rates above 95 percent. Patients who also have axillary (armpit) or plantar (foot) hyperhidrosis often experience improvement in these areas as well. The operation is more effective in children and adolescents than in adults.

Less than 1 percent of patients experience complications during or after the operation. Potential complications include pneumothorax, hemothorax, surgical site infection and Horner’s syndrome. Horner’s syndrome is a partial drooping of the eyelid and constriction of the pupil. It occurs when the sympathetic chain is interrupted at an inappropriately high level. The incidence of Horner’s syndrome is very low (less than 1 percent), and in most cases is temporary.

Compensatory sweating is a relatively common side effect (not a complication) of the thoracoscopic sympathectomy. Compensatory sweating is characterized by excessive sweating in areas of the body that were not affected prior to the operation, and the cause is unknown. The chest, the back and the thighs are the areas that can be affected by compensatory sweating. Compensatory sweating is much less common in children and teenagers than in adults. In most cases the compensatory sweating is mild or moderate, and very rarely is severe enough to cause as much discomfort as the previous sweating of the hands.

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