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Page 2 of 10 Gharagozloo. Mini-invasive Surg 2020;4:14 I http://dx.doi.org/10.20517/2574-1225.2019.55

Keywords: Robotic, sympathectomy, hyperhidrosis, minimally invasive, selective sympathectomy

INTRODUCTION
Surgery on the sympathetic nervous system is characterized by the evolution of indications and techniques
which have correlated with the evolution and greater understanding of the physiology and anatomy of this
complex part of the nervous system [1-20] .

Presently, hyperhidrosis is the most important established indication for sympathectomy. Historically,
surgical sympathectomy for hyperhidrosis has been associated with three areas of controversy: (1) the
surgical approach; (2) the technique of sympathectomy; and (3) the extent of sympathectomy.

Many surgical approaches have been described: (1) the posterior thoracic approach; (2) cervical
supraclavicular approach; (3) transthoracic approach; (4) trans-axillary approach; (5) thoracoscopic
approach; and (6) robotic thoracoscopic approach. Sympathectomy can be accomplished by:
ganglionectomy, clipping, or ablation of the dorsal sympathetic chain.

The extent of sympathectomy correlates with the incidence of complications. Clearly, more limited
sympathectomy has been associated with lower rates of compensatory hyperhidrosis. Although there is no
definite consensus, it has been suggested that highest success rates occur when interruption is performed
for T3 and T4 for palmar hyperhidrosis. T4 and T5 interruption is recommended for palmar and axillary,
palmar, axillary, and pedal hyperhidrosis. T3 interruption has been recommended for craniofacial
[21]
hyperhidrosis .
Selective postganglionic sympathectomy represents a more directed approach to sympathetic denervation
[22]
of the upper extremity . In this procedure, the sympathetic trunk and ganglia are left intact and only
the postganglionic rami, which accompany the intercostal nerves 2, 3, and 4 to the upper extremity, are
divided selectively. Friedel et al. reported a success rate of up to 95% and a compensatory hyperhidrosis
[23]
rate of 2.5% after performing selective postganglionic sympathectomy or ramicotomy. Recently, Coveliers
and colleagues reported a series of patients who underwent robotic simultaneous bilateral selective dorsal
postganglionic ramicotomy using a surgical robot [24,25] . Although postganglionic ramicotomy has been
used for more than 20 years, most surgeons have abandoned the technique because studies have found a
significantly higher recurrence rate in comparison with sympathectomy [26-29] . It has been suggested that
the historic results with ramicotomy may have been in part due to the limitations of the visualization and
instrument technology, and the fact that the preganglionic fibers were left intact.

Given the theoretical advantage of reducing compensatory sweating by limiting the extent of
sympathectomy, we have reasoned that the division of both the preganglionic and postganglionic rami
communicantes from the sympathetic trunk to the upper extremity without targeting the trunk itself may
be a more effective technique for “selective sympathectomy”.

This paper outlines the technique of robotic selective sympathectomy (RSS) and the early results.

METHODS
Technique
A left-sided double lumen tube is used and the lung on the side of the procedure is isolated. The patient is
placed in a lateral decubitus position.