Sympathectomy

Sympathectomy is a surgical procedure that involves the cutting off or clamping of some nerves from the sympathetic nervous system.

Sympathetic nervous system is a part of the autonomic nervous system - a system which controls the functions of our internal organs like the stomach and heart. The sympathetic nervous system is responsible for the stress response of our body. Every time we get stressed, it is this system that causes increased heart rate, production of energy and sweating. 

Sympathectomy is usually done to treat a condition called hyperhidrosis.

Everybody sweats more when they feel nervous or exercise, but people with hyperhidrosis sweat excessively for no particular reason. Hyperhidrosis occurs when sympathetic nerves cannot regulate sweating in some areas of the body. Hyperhidrosis can interfere with day-to-day social and professional activities like driving, writing, and holding objects, and at times, it may be embarrassing.

Using a roll-on antiperspirant, medicines or a procedure called electrolysis may sometimes help with excessive sweating; however, in severe cases, such treatments may not be able to control the sweating. If the hyperhidrosis is persistent or becomes difficult to manage, then doctors suggest surgical treatment such as sympathectomy.

The procedure is called endoscopic thoracic sympathectomy, cervical sympathectomy or endoscopic lumbar sympathectomy depending on what part of the nerve is treated. Typically, the brain sends signals to parts of the body via the nerves, causing sweating. After sympathectomy, the signals passing from the brain to the body part are blocked, which controls the sweating.

Sympathectomy may also be done for facial blushing, conditions that cause chronic pain and Raynaud’s phenomenon.

Sympathectomy may be recommended if a person has:

• Excessive sweating on the face, hands, underarms and feet
• Facial blushing
• Conditions that may cause chronic pain
• Raynaud phenomenon, which causes sensitivity to cold temperatures

Sympathectomy may not be advised in the following individuals, as the surgery may not have the desired results:

• Overweight or obese individuals with a body mass index >28 as they are at risk of severe excessive (compensatory) sweating
• Individuals undergoing treatment for psychiatric conditions or those with neurologic illnesses as the medications for these conditions can cause increased sweating.

The following steps will be taken before the surgery:

• You will be asked to sign a consent form, which gives the doctor approval to perform the procedure.
• You will be asked to not eat or drink after midnight before the surgery.
• Your doctor will conduct a physical examination, including blood and diagnostic tests and also check your medical history to ensure that you are fit for the surgery.
• You should make sure that you have someone to drive you home after the surgery and stay with you overnight.
• You should stop smoking at least 4 weeks before the surgery to ensure timely recovery. If you continue to smoke, the surgery may need to be cancelled.
• Inform your healthcare provider about all medicines, including prescribed or non-prescribed medicines or any supplements that you take.
• You may have to discontinue a few medicines such as blood thinners (e.g., Coumadin and Plavix) before the surgery. However, do not stop any medication on your own.
• You should not consume any non-steroidal anti-inflammatory medicines such as ibuprofen, Motrin or Aleve or aspirin-containing medicines up to 1 week prior to your surgery.
• Inform your healthcare provider if you are sensitive or allergic to any medicines, latex, iodine, tape, contrast dyes and anaesthetic agents.
• Also, tell the doctor if you are pregnant or you suspect you are pregnant.

Endoscopic thoracic sympathectomy is a minimally invasive procedure that has good success rates and is safe and effective for hyperhidrosis.

• Once you arrive at the hospital and complete the formalities, you will be asked to change into a hospital gown. Usually, the procedure takes around 1 to 2 hours, and you may be allowed to go home the same day.
• You will be given anaesthesia that will put you to sleep so that you don’t feel any pain during the entire procedure.
• The anesthesiologist will insert a tube into your airways through your mouth to your lungs (trachea). This tube will help you breathe during the surgery.
• The surgeon will then make two to three small cuts below your underarm on one side of the chest.
• To get a better view of the nerve inside the chest, your lung will be deflated. 
• After this, the surgeon will move aside your lung and will insert a small video camera and other surgical tools inside the various incisions on your chest. Using the camera, the surgeon will guide the tools and divide the affected nerves.
• The specific bundles of nerve cells, called ganglions, responsible for sweating will be removed.
• Once the procedure is completed, the surgeon will remove the camera and other tools.
• Your lung will be re-expanded, and your skin will be closed with dissolvable sutures.
• To help your lungs regain their function properly, the surgeon may leave in a small (4 mm) tube on either side of your chest for a few hours after the operation. 

After the surgery

• You will be moved to the recovery ward and will be kept under observation. The incision (cut) sites will be checked, and after your blood pressure, pulse and breathing rate are stabilized, you will be moved to your hospital room or ward.
• The breathing tubes will be removed, and you will notice that your hands and feet will be warm and dry.
• Typically, most individuals can go home the next day or within 24 hours, but if someone takes time to wake up from the anaesthesia, then they may have to stay overnight.

Two other types of sympathectomy surgeries are done as follows:

Cervical sympathectomy:

This surgery helps reduce sweating in the arms and hands. The sympathetic nerve supply to arms and hands arises from the lower neck and the upper chest. This surgery is done using the keyhole method (laparoscopic). A camera and instruments are inserted through a small incision between two ribs just below the armpit. A second laparoscopic instrument is inserted through another incision and the nerve is destroyed.

Lumbar sympathectomy:

This surgery helps reduce sweating in the feet. The nerves that supply to the sweat glands of the feet are located at the back of the abdomen. As this area is difficult to access, lumbar sympathectomy is done as open surgery with cuts in the side of the abdomen. Nerves on both sides can be cut at the same time during the surgery. Mostly, an overnight stay in the hospital is required for this surgery. The recovery process can take 2-4 weeks.

You may feel pain around the incision site for a week. This usually gets better, and you can take medicines as prescribed by your doctor. Patients may take oral painkillers (acetaminophen) for 7 to 10 days after the operation. You may feel pain in your chest while breathing deeply as your chest may be sore.

Your healthcare practitioner may provide you with a diet plan or ask you to continue with your normal diet. There are no major activity restrictions after this surgery. Therefore, you should be able to resume work within a week.

You should take the following care after the surgery.

• If you have tape on the incision site, leave it on for a week or until it falls off on its own. If you have to apply a bandage because of the fluid seeping out of the wound, change the dressing every day.
• Wash and keep the incisions dry and clean. Avoid soaking in the tub and swimming.
• Generally, it is better to take a shower than a bath to prevent the wound from getting wet. Ask your doctor if it is okay to shower after 1 to 2 days or else don’t take a bath for the first 2 weeks or until your doctor advises it.
• No heavy lifting or vigorous exercises or strenuous activities until the healing process is over. You may walk a little each day as walking boosts blood flow and prevents pneumonia and constipation.
• Resume your activities slowly.
• Your doctor will give instructions about taking medicines. Take pain medicines or antibiotics as directed.

The benefits of sympathectomy are as follows:

• A limited number of cuts on your body
• Reduced pain
• A short hospital stay
• Faster recovery and resuming of regular activities

When to see the doctor?

Call or visit your doctor immediately if:

• You have pain that does not subside even after taking a painkiller.
• You have a fever above 100^oF.
• You have any symptoms of infection such as increased pain, redness or swelling, pus coming out from the incision site, or swollen lymph nodes.
• Your stitches get loose or your cuts open up.
• You have enough bleeding from the site of the incision to soak up a big bandage.

The possible risks associated with sympathectomy are:

• Bleeding
• Pain
• Infection, heart attack or stroke during the surgery
• More sweating in other body parts
• Breathing problems
• Collapsed lung
• Pneumonia

Besides these, other risks include haemothorax (blood collection in the chest), pneumothorax (collection of air in the chest), damage to the nerves or arteries, slow heartbeat and Horner syndrome (nerve injury that causes drooping of the eyelid and decreased sweating on the face.

Your doctor will schedule your follow-up. You may have to visit around 1 week after the surgery and, during the visit, the surgeon will check the incisions and remove the remaining sutures, if any.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.