Finding the Optimal Level and Method for Thoracoscopic Treatment of Primary Palmar Hyperhidrosis

Shadi Hamouri, Hanan Hammouri, Hamzah Daradkeh, Abdel Rahman Al manasra, Nabil Al-zoubi, Nathan Michael Novotny


Background: The standard treatment of primary palmar hyperhidrosis had been thoracoscopic R2
sympathectomy, yet this sympathectomy level has been associated with serious unwanted side effects.
Therefore, some recent experiences have recommended R2-sparing R3 or R4 thoracoscopic
sympathectomy with less side effects, particularly compensatory hyperhidrosis (CH). The aim of this
study is to compare the effect of R2-sparing thoracoscopic sympathectomy at R3 vs R4 levels in the
treatment of palmar hyperhidrosis.
Materials and Methods: Medical records of all patients were retrospectively reviewed between
January 2010 and January 2017. Patients were assessed at 1 week, 1 month, and 6 months or more for
success of the procedure, side effects, such as compensatory hyperhidrosis (CH), pneumothorax,
Horner’s syndrome, and brachial plexus injuries were recorded. Patient satisfaction was assessed.
Results: Seventy-nine patients were operated on for palmar hyperhidrosis. At 6 months follow up, all
patients reported complete disappearance of the symptoms with dry hands after surgery except three
patients in R4 group who have a mild sweating. No failure or worsening of the symptoms developed.
Any immediate post-operative complications disappeared within 4 weeks. Ten patients in the R3 group
developed some degree of CH (48%) compared to11 patients in the R4 group (19%) (p =0.014). At a
follow up period of R3 (78±7.6) and R4 (37±15), a telephone interview was conducted using a
questionnaire and revealed that the rate of CH and palmar over dryness was significantly lower in the
R4 group than in the R3 group (pP =0 .001, 0.004, respectively). No patient developed recurrence.
Conclusion: Both R3 and R4 thoracoscopic sympathectomies are effective with a high success rate and
minimally invasive methods for the treatment of palmar hyperhidrosis. R4 appeared to be a better
technique with significantly less compensatory hyperhidrosis and over dryness of the palms. With the
removal of a segment of the sympathetic chain, there were no recurrences in either group.


Primary Palmar hyperhidrosis, Sympathecotomy, Compensatory Hyperhidrosis, Videoassisted thoracoscopic surgery.

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