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Palmar Hyperhidrosis (Sweaty Palms)

From the early days of the surgical treatment for palmar hyperhidrosis (hand sweating) there was tremendous progress from different open approaches (large incisions) to modern day endoscopic approaches (minimally invasive). Since the late 1980’s there was great progress made with regard to the optic surgical instruments which enabled surgeons to perform surgeries through small incisions, on an outpatient basis with a very speedy recovery. The same happened with thoracic sympathectomy and here not only the technical issues improved but also our understanding of what should be done to those patients.

Initial indications to perform endoscopic thoracic sympathectomy (ETS) were changed over the years once more information and follow-up on patients was gained. Not only the indications were changed but also what level of sympathectomy should be applied to the patients. The final and the most correct approach is still being debated among world specialists even though the success rate is extremely high. The question of compensatory sweating was not totally solved but other than that the operation has a proven success rate of 98 to 99%.

When excessive armpit sweating is associated with excessive hand sweating this can be also treated with ETS but with a somewhat lesser degree of success, around 85%.

The most effective and proven (98%+) treatments for hyperhidrosis are surgical. Surgical treatment depends on the area of sweating. For excessive hand sweating the most common surgery is Endoscopic Thoracic Sympathectomy(ETS). For excessive foot sweating the most effective surgery is Endoscopic Lumbar Sympathectomy. For excessive armpit sweating the most effective surgery is Axillary Suction Curettage. For a combination of excessive sweating a different surgical approach may be taken depending on the type of level of sweating.

Combination of Hand and Foot Sweating

In most of the cases patients have sweaty hands and sweaty feet. In the majority of the patients sweaty hands are of a greater concern. This is why, when it comes to surgery, the ETS procedure is the first to be performed with some degree improvement of the feet. If that level of improvement is not enough then later on the ELS surgical procedure can be performed.

For those who have mild hand sweating and severe foot sweating

In these cases, with the above mentioned presentation, performing the ELS procedure as the first operation can be justified. That being said one must bear in mind that these type of cases are less frequent than the usual cases of severe hands and feet sweating. The fact that those patients have sweaty hands and sweaty feet indicates that they are a carrier of the hyperhidrosis gene. It necessitates a very thorough discussion between the patient and the hyperhidrosis surgeon.

Technical Details of the Surgery

The ETS procedure is done under general anesthesia. The technique that Dr. Reisfeld uses is intubation with a single lumen endotracheal tube which prevents the need for collapsing the lung. Once the patient is asleep through a small needle some air is introduced into the chest cavity pushing the lung away from the site where the operation is going to be performed.Then the video equipment is inserted and another small trocal is used to perform the surgery with the clamping method. With the clamping method there are a few clamps that are placed onto the sympathetic chain. These clamps are non toxic. They are made from titanium which is an inert material. Why more than one? The clip is very small and has a width of about 1.5mm so order to encompass a segment of the sympathetic chain at least 2 clips are applied at each segment. This is to ensure a total cessation of the nerve signals. In a regular case where no armpit sweating is involved there are 2 clips applied to level 3 (rib level # 3) and 2 clips on level 4. In cases of excessive armpit sweating 2 clips are applied at level 5. So in total, on either side, the patient can have either 4 of 6 clips. The clips are so small they will not activate any alarms in the airport security lines.

The two cuts on either side of the chest cavity are about 1cm in size. Once one side is completed the air is taken out and the same is repeated on the other side. The patients are then moved to the recovery room, chest X Rays are taken, and about 2 hours after the beginning of the operation the patients are ready to leave. There will be some pain which is controlled with oral medications. This pain becomes mild within 24 hours and then eventually dissipates.

What to expect after the surgery

Patients can walk around the same day. Eating can be resumed very quickly to a normal diet. A shower can be taken the next day and the level of physical activity will be basically judged by the patient. Generally speaking resumption of totally normal activity is to be anticipated within a few days. Dissolving sutures are used to close the skin and there is no need to remove those.

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