Surgical Management of Hyperhidrosis
By Justin Blasberg, MD
Hyperhidrosis is a condition of excessive sweating that affects approximately 3 percent of the population. Patients may present in early adolescence or during their twenties, and often suffer from symptoms for many years prior to evaluation by a physician. Approximately 50 percent to 60 percent of hyperhidrosis patients have a family history of the disorder.
Hyperhidrosis can occur almost anywhere on the body, and most commonly affects the hands and soles of the feet. Isolated axillary hyperhidrosis or in combination with other sites is also a common presentation. These symptoms can be socially and professionally debilitating.
The majority of patients are appropriately managed by primary care physicians with various non-surgical techniques prior to consideration for invasive treatment. This includes a number of options:
Insurance companies overwhelmingly require multiple attempts at medical management of hyperhidrosis prior to consideration for surgical intervention.
Not all patients will respond to these treatments. For those with severe symptoms or a lack of response with medical therapy, minimally invasive surgical management is the treatment of choice. This technique, known as ETS (endoscopic thoracic sympathectomy), involves removal of portions of the sympathetic chain that causes excessive sweating. The specific levels and degree of resection required is specific to the patient’s symptoms.
National studies have reported the success rates for ETS at 100 percent for hyperhidrosis of the hands, 98 percent for the underarms, and 82 percent for the feet. (Doolagh et al. Thoracoscopic Sympathectomy for Hyperhidrosis: Indications and Results. Ann Thorac Surg. 2004;77:410-414.)
A bilateral ETS takes approximately 40 minutes to perform in total. Following the induction of general anesthesia with an endotracheal tube that allows for individual lung isolation, two 5mm incisions are made in the axilla in the vicinity of the third rib. These incisions are typically made in the inframammary crease and have excellent cosmetic results. The lung on the operative side is deflated and the sympathetic nerve chain is visible by retracting the lung away.
Cautery dissection is utilized to isolate the specific level of interest, typically with a camera in one port and the cautery instrument in the other. This includes removal of the ganglion of interest, the intervening sympathetic chain, and the ventral and dorsal rami.
Once the chain is removed, the instruments are removed and the lung re-inflated. Air is evacuated with a red rubber catheter and the incisions are closed with stitches placed entirely under the skin. No chest tube is required for this procedure. The procedure is then repeated on the other side of the chest as described.
The patient receives a chest X-ray in the recovery room to confirm appropriate inflation of both lungs, and they are discharged home with prn pain control with one-week follow-up. Most patients require pain medication or acetaminophen for seven to 10 days following surgery. There are no activity restrictions after the follow-up visit, and patients can return to work within one week.
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For More Information
The minimally invasive thoracic group at the University of Wisconsin Hospital and Clinics has undergone specialized training and has achieved outstanding results performing ETS. You can learn more about hyperhidrosis and how to refer a patient for treatment at the Thoracic Surgery website.