ETS surgery: discouraged and obsolete techniques

The following methods of interruption have to be considered obsolete and should be avoided.

Rib-oriented double or triple interruption of the sympathetic chain

This original technique is still in use in different hospitals, but it carries higher risks, has no rational advantage over less invasive approaches and should therefore be abandoned:

• For facial hyperhidrosis and facial blushing, a single interruption is sufficient to cut the headwards directed nervous signals, to be executed at the lower border of the 2nd rib. Using coagulating current on the front face of the 2nd rib implies a 3-5% risk of damage to the lower part of a low reaching stellate ganglion, especially if electrocautery is used improperly. In addition, the useless interruption of T3 will only add to the risk of increasing side effects, especially bradycardia.
• For palmar hyperhidrosis, no interruption should occur above the 3rd rib. In order to avoid damage to the T2 ganglion, the cut (or clip) should be placed at the lower margin of the 3rd rib.

Fig 1: Rib-oriented electrocoagulation of the sympathetic chain on 2nd and 3rd rib, here also extended to the 4th.

Fig 2: Highly questionable: deep coagulation down to the periostium of the rib, extending laterally to encompass the Kuntz nerves.

Fig 3: Extensive coagulation around the 2nd rib, quite dangerous regarding the integrity of the stellate ganglion (especially in case of lower placement of the ganglion).