Historically, palmar hyperhidrosis was treated with transection of the sympathetic chain at R2 and R3, with the addition of R4 if axillary hyperhidrosis was also present. More recent beliefs are that palmar hyperhidrosis can be effectively treated by limiting disruption to a single level, at either R3 or R4, in an effort to minimize side effects and to improve overall quality of life for these patients. Studies have shown that interruption of the sympathetic chain at R4 alone is associated with the lowest incidence of compensatory hyperhidrosis (CH) , the fewest regions/sites of CH, and the lowest frequency of excessively dry hands [24, 25]. Multivariate analysis revealed the most important variable influencing patient satisfaction was palmar over-dryness [25]. The satisfaction rate overall was higher in those with slightly moister hands (more common in the R4 group) as opposed to those with excessively dry hands and significantly higher rates of CH (more commonly in R3 group) [24]. Perhaps more importantly, none of the patients undergoing disruption at the R4 level regretted having the operation [25]. Expert consensus reports that two interruptions in the sympathetic chain at R3 and R4 provide the driest hands at the expense of a higher risk of CH. However, the panel’s recommendation is for an R3 interruption alone, but goes on to state that R4 interruption is an acceptable alternative in order to limit CH [13]. With this in mind, the options of both an R3 or a R4 disruption can be discussed with parents to allow them to make an educated decision, informing them that an R3 interruption alone tends to provide dry hands, though sometimes overly dry, with an increased risk of CH, whereas an R4 interruption alone has a lower rate of CH but the possibility of continuing to have slightly moister hands than the normal child.

For patients with palmar and plantar hyperhidrosis , expert consensus recommends either R4 interruption alone or R4 and R5 interruptions. To yield the driest feet, this panel endorses two interruptions at R4 and R5. However, disruption at R4 alone may reduce the incidence of CH while still providing satisfactory results [13].

In patients with axillary, palmar-axillary, or palmar-axillary-plantar hyperhidrosis , the optimal operation is an interruption at both R4 and R5 [13]. As with palmar hyperhidrosis , some surgeons favor a single level of interruption, at either R4 [26] or R5 [27], for axillary hyperhidrosis. One study demonstrated a 0 % incidence of CH after R5 interruption with no patient regretting having undergone this procedure [27]. Consent requires a careful discussion of the risks and benefits of the varying levels of interruption and the consequences of aggressive or conservative procedures.

ETS can also be used for patients with severe craniofacial hyperhidrosis and must be distinguished from facial blushing as results for this latter condition are less impressive. Expert consensus recommends R3 interruption alone to reduce the risk of CH and Horner’s, which are more common with R2 interruption or R2 and R3 interruptions [13, 27].

Thoracoscopic sympathectomy is performed under general anesthesia. A single-lumen endotracheal tube (SLT) is sufficient in most cases; however, some surgeons prefer a double-lumen endotracheal tube (DLT) . There are pros and cons to both types of tubes. Single-lung isolation is the main advantage offered by a DLT, which decreases motion within the operative field. However, with the use of CO₂ insufflation, positioning, and intermittent breath holding, the lung rarely obscures the surgeon’s view to any significant degree. Some authors have employed bronchial blockers successfully. Furthermore, pediatric airway anatomy may only permit the use of the smaller diameter SLT. Larger diameter tubes may increase the likelihood of a sore throat and transient hoarseness in the immediate postoperative period. In general, a DLT is technically more challenging to place, and proper placement should be confirmed both clinically and bronchoscopically. Ultimately, the decision on the type of endotracheal tube depends on individual preference, age of the child, and discussion between the surgeon and anesthesiologist.

The patient lies supine in a semi-Fowler position with the head of the bed elevated at 30–45° (Fig. 9.2). This allows gravity to help retract the upper lobes out of the intended operative field and helps to decompress some of the smaller veins coursing near the rib heads. Rotation of the bed toward the contralateral side can also facilitate in this endeavor. Both arms are abducted to 90 degrees and secured to arm boards so as to expose the axillae. The elbows should be padded to avoid postoperative ulnar neuralgia. A roll is placed behind the shoulders to improve access to the upper sympathetic chain. The supine position provides more than adequate exposure and requires no delay for repositioning and re-preparing the opposite chest. Alternatively, some authors prefer a lateral decubitus position with the operating table extended to widen the intercostal spaces. An axillary roll is placed, and the ipsilateral arm is secured to an elevated arm board at a gentle angle. For this positioning, the surgeon stands ventral to the patient with the assistant and video monitor on the opposite side.

This procedure requires an operating theater capable of accommodating standard endoscopic equipment. Basic instruments include a 3-mm rigid thoracoscope (either 0- or 30-degree angled lens), a 3-mm hook electrocautery, a 3-mm endoscopic blunt-tipped curved scissors (mini-Metzenbaum-type) with a monopolar cautery attachment, a 3-mm endoscopic curved dissector, and three 3-mm blunt-tipped trocars. In the unusual event that any significant bleeding is encountered, a suction/irrigation system should be readily available but not opened on the sterile field. Depending on the surgeon’s preference for performing interruption of the sympathetic chain, an endoscopic clip applier or the Harmonic scalpel (Ethicon Endo-Surgery, Inc., Cincinnati, OH) can serve as alternatives to hook electrocautery. However, clip appliers and alternate energy devices are not required and may increase the cost of the case.

In the recovery room, a routine upright chest radiograph is performed to ensure complete lung re-expansion and exclude a significant residual pneumothorax, which is unlikely. However, small apical pneumothoraces that do not require chest tubes are not uncommon. The carbon dioxide within the chest is typically reabsorbed within 3 h. Most patients tolerate this procedure without issue and are discharged home later that same day on an oral pain regimen. We ask patients to limit their activity for 48 h postoperatively and then to gradually increase to regular activity within a week of surgery.

When opening the parietal pleura or dividing the sympathetic chain, the surgeon should avoid the underlying periosteum because damaging it may cause severe sunburn-like pain in the postoperative period [29]. To protect the stellate ganglion from harm, do not carry out any dissection above the superior border of the second rib. Reduce the settings as well as the use of electrocautery during this procedure whenever possible. Also, sharp division or clipping of the sympathetic chain obviates the potential for inadvertent injury to the stellate ganglion due to spread of an electrical current. When dividing the chain sharply, it is important to separate the ends of the nerve adequately using the “tuck” technique described above.

Anatomical variation of the sympathetic chain can increase the likelihood of operative failure or complications. In the child with palmar hyperhidrosis , some authors advocate division of the pleura overlying the bodies of ribs 2 and 3 at least 2 cm lateral to the chain, and any accessory fibers of Kuntz are severed as they are encountered [32–34]. Occasionally, the sympathetic chain may run medial to the rib heads and can increase the probability of an aortic injury in the left chest if caution is not exercised [34]. The surgeon should be aware of the location of the subclavian vessels, azygos vein, hemiazygos vein, thoracic aorta, vagus nerve, and phrenic nerve and take caution to protect them from harm throughout the operation. This procedure usually involves a rather bloodless dissection, but significant bleeding can result from avulsion of intercostal veins draining directly to the azygos vein [20]. Thus, it may be necessary to cauterize or clip some of these vessels while attempting to expose the sympathetic chain. An azygos lobe is an infrequent anatomical variation consisting of an accessory pulmonary lobe at the apex of the lung, which when present may make it difficult or even impossible to accomplish a thoracoscopic sympathectomy [35, 36].