Endoscopic Thoracic Sympathectomy Surgery

What is ETS?

For people with excessively sweaty hands or facial blushing, Endoscopic Thoracic Sympathectomy (ETS) is a life-altering procedure that helps them rebuild confidence and enjoy their lives again. The sweat glands responsible for perspiration are controlled by the sympathetic nerves. Over-activity of the sympathetic nerves results in excessive sweating. If these nerves are ablated or destroyed, the sweat glands will cease to function. The sweat glands in the hands, armpits, face and scalp are supplied by sympathetic nerves that originate from within the chest cavity.

The sympathetic chain from where the nerves originate can be identified clearly in the chest using a mini-scope referred to as a thoracoscope. Hence, the term thoracoscopic sympathectomy (or ETS) refers to the operation performed for hyperhidrosis and facial blushing

What Happens During ETS?

ETS surgery is performed in a hospital under general anaesthesia. Two tiny incisions are made in the armpit, and 5mm ports inserted. The breathing of the lung is suspended temporarily, allowing the sympathetic nerve to be accurately identified. The relevant ganglia or nerve cell bodies are ablated, thereby drying the hands, armpits or face as required. Blood oxygen levels are continuously monitored and there is never any danger. A special endo-tracheal or breathing tube is inserted by the anaesthetist to facilitate this process. Ablation of the relevant section of the sympathetic chain can be achieved in a variety of ways, though my preference is to use diathermy or electrocautery. The small incisions are closed with a solitary stitch, and a water-proof dressing is applied. Patients are generally discharged the following morning, and most recover completely within a week.

Post-operative care

As ETS is performed using minimally invasive techniques, recovery from the operation is usually rapid. Expect some initial chest discomfort, but this is readily brought under control with conventional pain relief. Most patients are reasonably comfortable within six hours of the procedure, though my preference is to keep patients in hospital overnight. Routine observations are undertaken by the nursing staff post-operatively. Pain relief is available to maintain comfort, and a normal diet is resumed within four hours of the operation. It is not uncommon to experience some pain between the shoulder blades 2 to 3 days after the procedure, made worse by coughing and sneezing. This usually responds to anti-inflammatories such as Nurofen.

Potential complications of ETS surgery

As with all surgical procedures, individual reactions to the operation varies. Our aim at North Western Vascular is to inform you of complications that may arise, even though the majority of patients do not experience them.

Rebound Hyperhidrosis

Rebound hyperhidrosis is the most feared complication. It involves an increase in sweating in areas of the body not affected by the sympathectomy, such as the lower torso, front or back. It occurs in as many as 30 – 40% of patients, but for most of these patients, it is not troublesome and settles spontaneously. However, in 2% of patients, rebound sweating can be severe, occurring spontaneously on the lower torso. Indeed, in rare cases, some patients may even regret they had the operation. Rebound hyperhidrosis, if it occurs, cannot be reversed with further surgery. In most patients but not all, rebound sweating gradually settles with time.

Pneumothorax or air around the lung may occur, but is rarely of any significance, and settles by itself. If the pneumothorax is large, it can cause breathlessness. Rarely, this may involve inserting a tube into the chest to alleviate the problem. This does not delay discharge as the tube is generally removed the following day, allowing discharge to proceed.

Horner’s Syndrome

Horner’s syndrome is a complication which can occur if the sympathetic nerve supply to the eye is ablated. This results in drooping of the eyelid (ptosis) and constriction of the pupil. Fortunately, this is exceedingly rare, occurring in less than one in 1000 cases.
Sharp chest pain, worse with coughing or sneezing, occurs 3 to 4 days after ETS and is due to inflammation of the lining of the lung (pleura). It may be perceived as a pulled muscle between the shoulder blades and is usually controlled with anti-inflammatories.

Dry Hands

Although this is the aim for many patients, those undergoing sympathectomy for other causes such as facial blushing or axillary hyperhidrosis may need to be warned of this. The problem of dry hands is generally easily remedied with hand creams and moisturisers.
Gustatory sweating or facial sweating following meals, particularly spicy foods, occurs to some extent in 5 to 10% of patients.
Bradycardia or slowing of the pulse may occur but is rarely of any clinical significance. ETS has no impact on exercise tolerance.

Dr Roger Bell at North Western Vascular specialises in performing ETS surgery. ETS is performed in a private hospital with an overnight stay. Surgery offers immediate and permanent relief from hyperhidrosis or Facial Blushing, and in many cases, can be a new beginning for sufferers.

At what hospital can Dr Roger Bell perform ETS surgery?

  • John Fawkner Hospital, 275 Moreland Road, Coburg 3058
  • Cabrini Hospital, 183 Wattletree Road, Malvern 3144
  • Jessie McPherson Hospital, 246 Clayton Road, Clayton 3168

Take the first step towards having dry hands. Make an appointment with Dr Bell to discuss your symptoms and how ETS can stop your hands from sweating.


What is the success rate following sympathectomy?
The success rate varies according to the condition for which the sympathectomy is being performed. In those that have the procedure for sweaty hands, the success rate (ie achieve dry hands) is very close to 100%. It is important to emphasize the benefit is permanent. Some patients (less than 5%) might experience a bout of hand sweating in the first week, but this is not an indication of a poor response and is never sustained. For patients undergoing a sympathectomy for facial blushing, over 90% will no longer blush after sympathectomy. The response for blushing of the neck and upper chest is a little less predictable. For axillary hyperhidrosis, the success rate is about 70%. This is because the sympathetic nerve supply to the axillary sweat glands, can sometimes arise form ganglia (nerve cell bodies) well down and relatively inaccessible on the sympathetic chain. For that reason, I have abandoned sympathectomy for patients with axillary sweating as miraDry is a much better option for this.
The main complication is rebound sweating or compensatory hyperhidrosis. In response to ablation of the sympathetic chain, the brain sends signals to the sympathetic nerves below to work a little harder. Indeed 30 -40% of patients experience at least some degree of rebound sweating. Fortunately, in most, it is very mild and of no concern. However, in one in 50 patients, the rebound can be quite severe, causing spontaneous sweating on the torso, back or front. I have had patients who regret they had the procedure because of this complication, and everyone is warned of this. Horner’s syndrome which results in a droopy eyelid and constricted pupil, will occur if the Stellate ganglion is ablated. This occurs rarely, one in 1000 cases, usually due to misinterpretation of the anatomy by the surgeon. I believe this is far more likely to occur if the operator is inexperienced. Gustatory sweating, which is facial sweating following eating, particularly in response to spicy foods is a form of rebound occurring in 5% of patients. Chest complications such as pneumothorax or chest infections are very rare, but can occur. It is however quite common to experience heaviness in the chest and sharp pain often at the back, particularly with coughing and sneezing, referred to as pleuritic pain in the first week. Some patients (less than 5%) notice a marked difference in temperature between the upper torso and lower torso. In rare cases, it can become somewhat disconcerting.
Most patients stay overnight and are discharged the following morning. If the procedure is performed early in the day, I am happy for patients to go home the same day, as long as a responsible adult is at home to care for the patient.
I recommend a week off work, especially if the work is of a physical nature. Sharp chest and back pain is common in the first week, and often requires anti-inflammatory medications such as Nurofen to control the pain. Having said that, a number of patients return to work earlier and seem to manage quite all right.
Particularly for my interstate patients, this is often asked. All patients have a post-operative X-ray to exclude a pneumothorax (residual air in the chest cavity). This is rarely of any consequence and settles spontaneously but I caution patients against flying until the pneumothorax has resolved completely. Without a pneumothorax, I usually recommend 4 to 5 days before flying.
Bad rebound, which fortunately is very uncommon (about one in 50 cases) is the complication I fear most for my patients, as it is out of my control. In most cases, the rebound sweating does decrease with time, but this cannot be guaranteed for all. From a practical viewpoint, there is no surgical option for rebound sweating. Certain medications with anti-cholinergic properties (eg Ditropan) can be helpful in this setting.
There are many ways of performing a sympathectomy, including cutting the nerve, clamping the nerve, excising the nerve or ablating the nerve. I choose to ablate (by electro-cautery) the ganglia, which are the nerve cell bodies from where the nerves are derived. This guarantees that the objective of the procedure (ie dry hands or eliminate blushing) is far more likely to be achieved. I am not a proponent of clamping the nerve, as this results in an incomplete sympathectomy and does not result in a reversal of rebound sweating with the removal of the clamps.
John Fawkner Hospital – 275 Moreland Road Coburg Jessie McPherson Private Hospital (Monash Medical Centre) – 246 Clayton Road Clayton Cabrini Hospital Malvern – 183 Wattletree Road Malvern All hospitals have state of the Art facilities with first class nursing care.
It is not uncommon for patients to have a combination of sweaty hands and sweaty feet. It is more frequent for the hands to be more problematic, though this is not always the case. However, almost invariably I recommend treating the hands first, as this is more often the more troublesome, but also that in two-thirds of patients, there is a significant improvement in the feet following a thoracic sympathectomy.
Absolutely. A lumbar sympathectomy (performed laparoscopically or by an open procedure) will interrupt the sympathetic nerve supply to the lower limbs, thereby cutting off the nerve supply to the sweat glands in the feet. Performed as an open procedure, it involves incisions on each side of the abdomen in order to approach the sympathetic chain. The operation takes approximately one hour, is performed under general anaesthesia, requires 2 to 3 days in hospital, and a 3 to 4 week recovery. The success rate is very high (greater than 95%), and complications are rare.