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Page 8 of 10 Gharagozloo. Mini-invasive Surg 2020;4:14 I http://dx.doi.org/10.20517/2574-1225.2019.55

Sympathetic Chain

Selective Dorsal Sympathectomy
Transection of T2, T3, T4, PreG, Post G, RCA, RCG

Figure 6. Selective dorsal sympathectomy with division of both preganglionic and postganglionic rami. PreG: Preganglionic; PostG:
postganglionic; RCA: rami communicantes albi; RCG: rami communicantes grisei

Selective sympathectomy is not easily accomplished with conventional video-assisted thoracic surgical
techniques. The improved dexterity and three-dimensional visualization used with robotic technology makes
robotics ideal for selective dorsal thoracic sympathectomy. Using robotic technology and taking advantage
of the three-dimensional high resolution magnified view and improved instrument maneuverability in
the confined space, Coveliers et al. [24,25] reported a series of patients who underwent simultaneous bilateral
selective dorsal postganglionic sympathectomy who after a two-year follow up had a 96% rate of relief of
hyperhidrosis and a 7.2% rate of compensatory sweating.

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”. Furthermore, 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, staged bilateral
robotic sympathectomy of one upper extremity followed by the other may result in even lower levels of
compensatory hyperhidrosis.

In this study, patients with combined axillary and palmar hyperhidrosis underwent RSS in a staged fashion.
The staged approach was chosen to allow for the transient compensatory hyperhidrosis to dissipate before
further interruption of the sympathetic flow. In addition, given the morbidity associated with the robotic
ports, a staged bilateral approach was chosen to obviate bilateral thoracic pain. Presumably due to the use
of three robotic ports, optimal pain management necessitated longer hospital stay.

The use of robotic technology adds more ports and results in greater morbidity, longer operative times,
and greater cost. These shortcomings may be offset by greater accuracy of dissection and lower rates of
compensatory hyperhidrosis.