Sympathectomy divides or clips part of the sympathetic nerve chain that runs along either side of the spine, in order to interrupt the signal that over-activates sweat glands or blood vessels in a defined area. It is usually performed endoscopically through the chest for severe sweating of the palms and armpits, and through a lower back route in selected cases involving the feet and the peripheral circulation. The operation is considered for people with severe primary hyperhidrosis that disrupts work, study and social life, after the less invasive options have been exhausted: medical-strength topical antiperspirants, iontophoresis, botulinum toxin injections and oral medication. It may also be considered for severe facial flushing, for chronic limb ischaemia that cannot be corrected by vascular means, and for certain chronic nerve pain syndromes. Before any decision, secondary causes of sweating must be excluded: an overactive thyroid, infection, diabetes, certain medicines, menopausal change, and blood and lymphatic diseases. Sweating that involves the whole body, or occurs at night with fever or weight loss, calls for a diagnostic search rather than surgery. The plan is made by a team that includes a thoracic or neurological surgeon, a dermatologist and a physician, and candidacy is determined by clinical examination and tests, not by reading a page. The limits are the most important part of this page. The operation does not treat generalised whole-body sweating, nor sweating that is secondary to another cause, and the effect of the chest route on sweating of the feet is limited. Most importantly, **compensatory sweating** on the back, abdomen and thighs is common afterwards and in some patients is more troublesome than the original complaint. It is usually permanent, because dividing the nerve cannot be reversed; clipping is sometimes offered as a less final option, but with no guarantee of a return to the previous state. For these reasons the procedure is a last step rather than a first one. Surgery is performed under general anaesthesia with temporary deflation of the lung for the chest route, through small ports. A chest X-ray afterwards confirms that the lung has re-expanded, and discharge is usually rapid.
Procedure steps
- 1
Excluding secondary causes and documenting severity
Thyroid function, blood sugar and other tests are performed as the case requires, every medicine the patient takes is reviewed, and the impact of the sweating on work, study and daily life is documented, because that documentation is what justifies an irreversible procedure.
- 2
Trying the less invasive options first
Medical topical antiperspirants, iontophoresis, botulinum toxin injections and oral medication are exhausted under dermatological supervision and the outcome of each is recorded. Surgery is only considered after these have failed or could not be tolerated.
- 3
Explicit counselling about compensatory sweating
Before consent the patient is told that sweating may shift to the back, abdomen and thighs, that this is common, usually permanent and not easily reversed, and that it can be more troublesome than the original complaint. This conversation is a mandatory part of the decision, not a formality.
- 4
Endoscopic surgery through small ports
Under general anaesthesia the lung on one side is temporarily deflated and the endoscope is introduced through one or two small ports. The sympathetic chain is identified over the rib necks, only the agreed level is divided or clipped, and the lung is re-expanded before moving to the other side.
- 5
Confirming lung expansion and short observation
The ports are closed and a chest X-ray confirms lung expansion with no air in the pleural space. Breathing, pain, eyelid position and pupil size are monitored for some hours, and the patient is discharged the same day or after one night.
Before the procedure
Complete the tests requested to exclude secondary causes of sweating before your date, and do not skip this stage even if it takes time. Tell the team about all your medicines and supplements, especially blood thinners, anticoagulants, heart and asthma treatments, and stop nothing on your own. Report any lung disease, asthma or recent chest infection, and any previous chest surgery, because adhesions change the operative plan. Stop smoking as far as you can, since it increases lung problems after temporary deflation. Ask for the issue of compensatory sweating to be explained to you in writing, and ask about anything you have not understood before you sign. Follow the fasting time before anaesthesia, and arrange someone to accompany, drive and help you for the first two days.
After the procedure
Expect chest or shoulder pain in the first days, which is common after endoscopic surgery. Take painkillers as prescribed, breathe deeply and perform the breathing exercises you were taught to avoid lung collapse. Keep the wounds clean and dry, and avoid lifting, vigorous sport and air travel until your doctor allows it. Note that dryness of the palms may appear quickly, while your body needs weeks for the new sweating pattern to settle; do not judge the final result before then. **Seek emergency care immediately** for **shortness of breath or sharp chest pain that worsens on breathing in**, which may indicate air in the pleural space; fever with wound discharge or redness; **coughing up blood**; severe persistent chest or arm pain with numbness; **a drooping eyelid with a small pupil and dryness of one side of the face**, which needs assessment; or marked palpitations or dizziness on standing. Contact your doctor if **compensatory sweating** is disrupting your life, so the available options can be discussed.
Expected duration
Usually 45 to 90 minutes for both sides, with discharge the same day or after one night.
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