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Page 16 of 19 Gharagozloo et al. Mini-invasive Surg 2020;4:48 I http://dx.doi.org/10.20517/2574-1225.2020.35

of debilitating compensatory hyperhidrosis. Greater understanding of the anatomy and physiology of the
sympathetic chain, and advances in minimally invasive surgical techniques and instruments have clarified
many of the controversies. Selective division of the preganglionic and postganglionic sympathetic fibers
from T2-T4 without interruption of the sympathetic chain has been associated with the greatest rate of
anhidrosis and the lowest rates of compensatory hyperhidrosis. In more recent studies, there are indications
that a bilateral staged approach may be preferable to bilateral simultaneous approach to selective dorsal
sympathectomy for hyperhidrosis.

Although the results of bilateral staged robotic selective dorsal sympathectomy appear to be superior to
that of previous procedures, many surgeons question the cost-effectiveness of the robotic procedure. The
comparison of the hospital cost and clinical effectiveness of sympathectomy by video-assisted surgery
(VATS) (thoracoscopic) or robotics has not been performed. However, a number of studies have studied
the hospital cost and clinical effectiveness of robotic versus thoracoscopic and open lobectomy. Nishimura
[72]
reviewed the literature for the cost of robotic lobectomy . Nine of the 18 published articles compared the
cost of robotic lobectomy with VATS alone. All of these studies found a significantly higher total cost in
the robotic group when compared to VATS. The intraoperative costs or charges were significantly higher
[73]
in the robotic group. Interestingly, Kneuertz et al. performed a propensity score-weighted comparison
of the cost and perioperative outcomes of the three approaches to lobectomy for a 5-year period at a
[73]
tertiary referral center . The propensity score comparison showed no statistical difference for the direct
hospital cost between the three groups (robotic $17,223, VATS $17,260 and open $18,075). In this study,
postoperative complications and prolonged hospital stay added considerable hospital expenses. They
concluded that the cost of robotic procedures needs to be placed in the context of the surgical outcomes.
Specifically, in terms of the comparison of the cost of robotic versus VATS selective sympathectomy for
hyperhidrosis, the increased cost of robotic instrumentation needs to be viewed within the perspective of
the rate of anhidrosis and compensatory hyperhidrosis.

Finally, many experienced surgeons can perform a VATs sympathectomy in one hour or less, with two
5-mm ports and usually in the outpatient setting. Comparison of this approach to staged robotic selective
staged sympathectomy needs to be viewed in the context of the rates of anhidrosis and perhaps most
importantly the rate of compensatory hyperhidrosis, and viewed both from the perspective of the patient
and that of the surgeon. Clearly the answer will be provided by a well-designed, prospective randomized
approach which will compare the VATS to the robotic approach with very rigorous definition of anhidrosis
and compensatory hyperhidrosis with inclusion of cost and quality of life considerations.

DECLARATIONS
Authors’ contributions
Both authors contributed equally to the preparation of the manuscript.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Both authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.