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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 11 of 19

Figure 7. Selective dorsal sympathectomy as depicted by division of both the RCA and RCG from T2 to T4. The sympathetic chain is left
intact. RCA: rami communicantes albi; RCG: rami communicantes grisei; G: sympathetic ganglion

[20]
2.5% . Furthermore, with this technique, they did not report any patients with Horner’s syndrome.
Finally, this technique has resulted in the lowest reported rate of compensatory hyperhidrosis (16%).
However, subsequent studies with longer follow-up, showed that the results for reduction of perspiration
were transient and that the long-term compensatory hyperhidrosis rate with this technique was 60%-70%
and was comparable to other techniques. It has been suggested that the lack of sustained results with this
technique was the result of poor visualization of the rami and incomplete ramicotomy as the preganglionic
rami were left intact.

Using robotic technology and taking advantage of the 3-dimensional high-resolution magnified view and
improved instrument maneuverability in the confined space, Coveliers and colleagues reported a series
of patients who underwent simultaneous bilateral selective dorsal sympathectomy. In these patients, the
preganglionic and postganglionic rami as well the communicating rami posterior to the sympathetic chain
were divided and the sympathetic chain was left intact [Figure 7]. These authors used anhidrosis rather
than reduction of perspiration as an endpoint. After two years follow-up, there was a 96% rate of anhidrosis
and a 7.2% rate of compensatory sweating [68,69] .

As compensatory hyperhidrosis after sympathectomy is believed to result from redirection of sympathetic
activity to other parts of the body, and has been shown to be related to the extent of sympathectomy,
[70]
Gharagozloo et al. hypothesized that staged bilateral robotic sympathectomy of one upper extremity
[70]
followed by the other may result in even lower levels of compensatory hyperhidrosis. Gharagozloo et al.
studied robotic staged bilateral selective sympathectomy (RSS) directed at the division of the preganglionic
and postganglionic rami without interruption of the sympathetic chain. During RSS, the preganglionic and
postganglionic sympathetic fibers and communicating rami to intercostal nerves 2, 3, and 4 were divided.
The sympathetic chain was left intact [Figure 7]. Anhidrosis was used as an endpoint and was seen in 98%
of patients. In turn, compensatory hyperhidrosis was defined rigorously as “any new sweating”. At a mean
follow up of 28 ± 6 months, 46/47 (98%) patients were free of sustained compensatory hyperhidrosis.