Robotic Hyperhidrosis Surgery and ETS Reversal

Hyperhidrosis surgery, for excessive sweating of the hands, armpits or feet, gives immediate and permanent results, but it should be offered only to patients with severe disease who have exhausted every non-surgical treatment. Dr. Shaiwal Khandelwal, Director - Thoracic Surgery, Max Hospital, Gurugram, India, performs it robotically to identify the nerve levels precisely, and he reverses the side effects of earlier sympathectomies with robotic sympathetic nerve reconstruction.

Hyperhidrosis is, in his words, very close to his heart. This article covers who should have surgery, why the traditional operation causes side effects, how he has modified it and how he repairs the damage when a previous operation has gone wrong. The full range of his thoracic work is summarised in the complete guide to thoracic surgery from basics to robotics, and the wider specialty is on the thoracic surgery hub.

What hyperhidrosis is and who it affects

Primary hyperhidrosis is sweating far beyond what the body needs to regulate its temperature, typically affecting the palms, the armpits (axillae) and the soles of the feet. Dr. Khandelwal puts its prevalence at around 2 to 4% of the population across the world.

The people affected are young, and their quality of life is very poor. They suffer a great deal, and, as he puts it, the real problem is that nobody really understands what they are going through.

Who should have hyperhidrosis surgery

Surgery is a very good option for:

• Palmar hyperhidrosis (the hands).
• Axillary hyperhidrosis (the armpits).
• Palmoplantar hyperhidrosis (the hands and feet).
• Palmar-axillary hyperhidrosis (the hands and armpits).

He usually does not operate on craniofacial hyperhidrosis, sweating of the head and face.

Exhaust non-surgical treatment first

Surgery must not be offered to every patient. Dr. Khandelwal insists on a detailed assessment, and the patient should already have exhausted all non-surgical treatments: oral medication and local treatments such as creams and botulinum toxin injections. Only for high-grade hyperhidrosis, where the hands are literally dripping, should surgery be offered. Patients with mild to moderate hyperhidrosis should be advised to continue with lifestyle modification and local treatment.

Two standard elements of that assessment frame the decision. First, secondary hyperhidrosis, sweating caused by another condition such as an overactive thyroid, an infection or a medication, has to be excluded, because it is treated by addressing the cause rather than the nerves. Second, severity is commonly graded on the Hyperhidrosis Disease Severity Scale, a four-point patient-reported scale on which grades 3 and 4 (sweating that is barely tolerable or intolerable and frequently or always interferes with daily activities) define severe disease.

Balancing dry hands against side effects

The reason for this caution is that every form of sympathetic surgery has some side effects. The decision is a trade-off between the benefit of dry hands and the cost of those side effects, and only a patient whose sweating is genuinely severe will accept them. His aim is to minimise the side effects; no technique can make them zero. When surgery is chosen, its results are immediate and permanent.

A rare cardiac indication

The same operation on the sympathetic chain has one very rare indication outside sweating: refractory ventricular tachycardia, a dangerous heart rhythm that persists despite medication. Interrupting the sympathetic nerve supply to the heart (cardiac sympathetic denervation) reduces the drive behind these arrhythmias.

ETS side effects: how sympathectomy works and why it can go wrong

The sympathetic chain is a pair of nerve trunks running down either side of the spine inside the chest, with a ganglion (a cluster of nerve cell bodies) at each rib level. These nerves drive sweating. Endoscopic thoracic sympathectomy (ETS) interrupts the chain through small incisions so that the signal to the sweat glands of the hands and armpits stops.

In the older way of doing ETS, patients had dry hands immediately, but at times they developed many side effects:

• Severe compensatory sweating over the back and chest: the body sweats heavily elsewhere instead.
• Gustatory sweating: embarrassing sweating, with the face turning red, whenever the patient eats something spicy.
• Thermoregulatory disorder: difficulty controlling body temperature.
• Neurological and mood symptoms: mental confusion, poor concentration, low energy levels and emotionlessness.
• Cold hands and excessively dry hands.

Compensatory sweating is the most common side effect of sympathectomy reported in the medical literature, and it tends to be more severe the higher and more extensive the interruption of the chain.

The cause: the wrong level, or too much

In Dr. Khandelwal's analysis, the side effects come from doing the operation at the wrong place. The rib level may be wrongly identified, the sympathectomy may be performed at a higher level than intended, or too much of the chain may be divided. The most common reason is anatomical variation, which leads the surgeon to divide the chain at a higher level than planned. ETS performed the traditional way, he warns, invites a lot of problems.

Robotic hyperhidrosis surgery: the modified technique

Dr. Khandelwal has modified the operation and now performs it robotically. The central difficulty is identifying the ganglia, which is very difficult by VATS; the magnified robotic view allows each ganglion to be identified properly.

He combines a ganglionectomy, the removal of a sympathetic ganglion, with a ramicotomy. A ramicotomy divides only the small connecting branches (rami) that link the chain to the nerves, rather than cutting across the whole chain at a high level. In his operation, he first identifies the fourth thoracic ganglion, then works on the sympathetic chain close to the third ganglion and performs a grey ramicotomy of the third ganglion.

This technique, he reports, is giving him very good results. The side effects are very much less frequent in his patients, and acceptance by patients is very good.

Reversing a previous ETS: robotic sympathetic nerve reconstruction

Because the traditional operation can go wrong, Dr. Khandelwal receives referrals from all over of patients who have had ETS at other centres and are now living with these troublesome symptoms. To reverse the side effects, he performs robotic sympathetic nerve reconstruction.

How the reconstruction is done

1. The proximal and distal cut ends of the sympathetic chain are identified.
2. A segment of the patient's own intercostal nerve, the nerve that runs beneath each rib, is harvested as a graft to bridge the gap.
3. The nerve ends are reconnected with interrupted sutures of 8-0 nylon, a very fine microsurgical suture.

In his view, this kind of nerve repair inside the chest is possible only with the robotic system.

Outcomes of sympathetic nerve reconstruction

The quality of life of these patients has really improved after reconstruction. They report a significant improvement after around eight to nine months. Repaired nerves regenerate slowly, which is why the benefit takes months rather than weeks to appear.

When to refer for hyperhidrosis surgery or ETS reversal

Refer for hyperhidrosis surgery only when sweating is severe and non-surgical treatment has failed, and refer for reconstruction when a previous ETS has left troublesome side effects. For a referring doctor, the practical message is in the sequence. Treat mild and moderate hyperhidrosis with lifestyle measures, medication, creams and botulinum toxin. Reserve surgery for severe, refractory disease in a patient who understands the trade-off. And when surgery is chosen, the level and extent of the nerve interruption decide whether the patient gets dry hands alone or dry hands with lasting side effects.

For a patient who has already had ETS and is living with compensatory sweating or the other symptoms above, robotic reconstruction offers a way to reverse them. The robotic platform that makes this possible is the same one Dr. Khandelwal uses near the nerves and major vessels of the mediastinum, described in lung cancer and mediastinal surgery by VATS and robotics. His detailed answer to a doctor's question on patient selection and technique is on the Live Discussion page.