Outpatient Microthoracoscopic Sympathectomy for Palmar Hyperhidrosis

Background: Sympathectomy for palmar hyperhidrosis has been performed for more than 80 years with excellent long-term results. However, several issues are still unresolved: best surgical approach, which level and the number of levels of the sympathetic chain should be divided and the safety of an outpatient procedure. Methods: We reviewed the records of 205 patients who underwent sympathectomy for hyperhidrosis at our institution from April 2002 through March 2005. Fifty consecutive patients (24%) underwent an outpatient microthoracoscopic sympathectomy of a single level (T2) for palmar hyperhidrosis. Operative reports, medical records, and clinical charts were reviewed to determine the success of a single level sympathectomy, the incidence of postoperative compensatory hyperhidrosis, and the safety of an outpatient sympathectomy procedure. Results: There were 41 women (82%) and 9 men. Median age was 22 years (range, 14 to 62). The surgical technique consisted of single-lumen endotracheal tube general anesthesia, single bilateral access incisions (4 mm), 3-mm, 30-degree thoracoscope, temporary CO₂ insufflation, electrocautery nerve division, and no chest drainage. Median operating time was 22 minutes (range, 14 to 50). Sympathectomy consisted of dividing the sympathetic chain at the T2 level and any accessory nerves present. Anatomically, 19 patients (38%) had accessory nerves, right sided in 11, left sided in 5, and bilateral in 3. Two patients (4%) had a chest tube (10F) placed at the time of sympathectomy because of required lysis of apical pleural adhesions. No patient had postoperative bleeding or a wound infection. All patients were discharged the day of surgery. Median follow-up was 15 months (range, 1 to 36). Compensatory hyperhidrosis developed in 6 patients (12%), in 4 with rest and in 2 during exercise, all within 4 weeks. Successful sympathectomy was achieved in 99% of palmar surfaces without recurrence. A single patient experienced persistent sweating of the left hand. Reoperation was successful by dividing level T3. Conclusions: Single level (T2) microthoracoscopic sympathectomy for palmar hyperhidrosis has a high success rate with a low incidence of compensatory hyperhidrosis. This minimally invasive procedure can be performed safely as an outpatient and should be the preferred treatment for medical refractory palmar hyperhidrosis.