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Primary hyperhidrosis is a distressing condition in which there is excessive sweating of unknown cause. This condition affects 0.6–1% of the population and involves the hands, but frequently also the feet, axillae and, to a lesser extent, face, trunk, and scalp .

Conservative treatment with topical, Botulinum toxin injection or oral anticholinergic agents offers only minimal and temporary relief, and iontophoresis, which induces a nonspecific injury of the epidermis with abnormal keratinization and hyperkeratotic plugging of the orifices of the sweat gland, requires longterm maintenance therapy to prevent recurrence.

Therefore the treatment of choice for palmar hyperhidrosis, that can offer a effective long-term cure is thoracoscopic sympathectomy.

Thoracoscopic sympathectomy was first reported in 1942, and since then advances in endoscopic video technology have been successfully applied. Most authors advise destruction of the 2nd and 3rd thoracic sympathetic ganglia for palmar hyperhidrosis and recommend extending the resection to include the 4th–6th ganglia for axillary hyperhidrosis.

The sympathetic nerve that supply to the upper limb arises from the 2nd to 6th thoracic segments of the spinal cord and enters the corresponding sympathetic ganglia. The sympathetic fibres are distributed to the limb via the somatic nerves arising from spinal segments C5 to T1. It follows that division of the sympathetic trunk as it crosses the neck of the second rib will transect all pre- and postganglionic sympathetic fibres as they ascend to join the brachial plexus. Several surgical techniques have been described, but only in the 1970s sympathectomy for hyperhidrosis became considerably safer with the introduction of the minimally invasive thoracoscopic technique of Kux.

Since then many thoracoscopic methods have been described, with different access sites and different operative approaches (resection of the chains or simple chain division over the ribs, or selective sympathectomy. Video-assisted thoracoscopic (VATS) sympathectomy provides excellent anatomical exposure without the need for morbid incision.

It has been proven safe, reliable, and cost-effective, offering long-term relief of symptoms and a significant reduction in the morbidity associated with open surgery, without affecting its success rate.