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Gharagozloo et al. Mini-invasive Surg 2020;4:48 I http://dx.doi.org/10.20517/2574-1225.2020.35 Page 7 of 19

Posterior thoracic approach: The classic posterior thoracic approach was popularized by Adson and
[15]
modified by White . This approach required partial rib resection and resulted in prolonged painful
recovery.

[46]
Cervical supraclavicular approach: Telford devised a supraclavicular approach . Although this approach
obviated the pain associated with the rib resection, it was technically demanding and associated with
complications. The transcervical route requires attention to the highly complex anatomy of the cervical
region, and the complications are associated with injury to these structures. The advantages of this approach
include the ability to perform a bilateral sympathectomy in one sitting, minimal pain, and good cosmetic
results. With this approach, due to the inability to reach the lower portion of the sympathetic chain, the T4
ganglion cannot be excised. Therefore, this approach is not as efficacious for patients experiencing axillary
hyperhidrosis.

[27]
Transthoracic approach: Goetz, Marr, and Palumbo advocated an anterolateral transthoracic approach .
Although this approach provided the best exposure and the most accurate sympathectomy possible, this
technique did not gain popularity due to the significant morbidity associated with a thoracotomy.

[47]
Transaxillary approach: In 1954, Atkins described a transaxillary approach which became popular and
is even used in some centers today. As has been noted, this technique suffers from the shortcoming of pain
and lack of visualization through a very small transaxillary incision.

Thoracoscopic approach: The thoracoscopic approach to dorsal sympathectomy was used as far back as
the 1940s. With the advent of advances in optics, lighting, and video endoscopic instrumentation, video-
assisted thoracic surgery became the standard approach to dorsal sympathectomy [48,49] . Presently, there are
four video-assisted approaches to enable dorsal thoracic sympathectomy.

Classic resection: This technique (ganglionectomy) [Figures 2 and 3] involves the resection of the entire
sympathetic chain including the T2, T3, and T4 sympathetic ganglia with the intervening RI.

Clipping of the sympathetic chain: Proponents of this technique have emphasized the potential reversibility
of the removal of the clip. However, clip removal has not been necessarily associated with recovery
of sympathetic function . Furthermore, some authors have postulated that clips may contribute to
[50]
postoperative neuralgia [27,51] .

Thermal ablation of the dorsal sympathetic ganglion: This technique which can be accomplished using
conventional electrocautery, diathermy with monopolar precise coagulation, or radiofrequency ablation has
[51]
become the most commonly used technique . The proponents of this technique have emphasized the ease
of use, shorter operative times, the ability to perform bilateral sympathectomy, and the minimally invasive
nature of the procedure. However, in a meta-analysis of published studies of thoracoscopic sympathectomy
for hyperhidrosis, Hashmonai et al. , showed that resection achieved superior results. It is due to the
[51]
complex nature of the resection even with modern conventional video-assisted thoracic surgical techniques
that the majority of surgeons choose thermal ablation of the sympathetic chain.

In 2011, the Society of Thoracic Surgeons expert consensus report for the treatment of hyperhidrosis was
[52]
published . This report was based on 1,097 published articles in the world’s literature on hyperhidrosis
from 1991 to 2009. These studies suggested that primary hyperhidrosis of the extremities, axillae or face
is best treated by endoscopic thoracic sympathectomy. Interruption of the sympathetic chain could be
achieved either by electrocautery or clipping. This report emphasized the need for the adoption of an
international nomenclature that would refer to the rib levels (R) instead of the vertebral level at which