Sympathectomy (e.g. ETS): when nothing else works

Blocking, transecting, or destroying parts of the sympathetic nerve trunk: nerve surgery

If nothing else has worked, the only remaining option is to block, cut off, or destroy the nerves responsible for the sweating.

A last resort

If all other treatments have failed, the last resort is to block, sever, or destroy the nerve trunk responsible for the sweating. There are different procedures for this. Due to the many potential side effects, surgical procedures on the sympathetic nerve should only be performed when all other treatment options have failed.

What is the sympathetic nerve trunk?

The sympathetic nerve trunk is part of the autonomic nervous system along with its counterpart, the parasympathetic. The sympathetic nerves affects the smooth muscles, blood vessels, and glands. In contrast to the voluntary contractions of skeletal muscles, the regulation of the sympathetic nervous system cannot be consciously controlled by humans. One effect of the sympathetic nerve is the increase in sweat gland secretion.

The nerve cell clusters (ganglia) of the sympathetic nerve adjacent to the spine are interconnected and together form the sympathetic trunk. The nerve signals responsible for sweating on the head, hands, and underarms are transmitted in the thoracic part of the sympathetic nerve, while the signals for the feet are transmitted in the lumbar section of the sympathetic nerve.

Sympathectomy applications

Indications include primary (focal) hyperhidrosis on the hands, feet, underarm, or face/head. The surgical procedures can also be applied to morbid blushes (facial blushing, erythrophobia).


If you are looking for information on surgical procedures against excessive sweating, you will quickly be confronted with many abbreviations and technical terms which we will briefly explain to you below. All surgical procedures have a common goal: to disrupt the transmission of signals via the sympathetic nerve. There are two options: Blocking the nerve by clipping, severing, or destroying the ganglia. All surgical procedures can be performed endoscopically, which means they are minimally invasive. An open sympathectomy, with the patient’s chest open, is no longer performed.

Endoscopic sympathetic block (ESB)

The endoscopic sympathetic block (ESB) is an operation that blocks the ganglia of the sympathetic nerve. ESB is performed either at the thorax for the treatment of hyperhidrosis on the hands, armpits, head, or face, or in the lumbar region for the feet.

One or more titanium clips are used to constrict the sympathetic nerve. ESB is also sometimes called endoscopic transthoracic sympathetic clipping (ETSC). In contrast to ETS or ELS (described below), the nerve ganglia are not severed or destroyed, but are merely clamped to prevent the transmission of nerve impulses. Nevertheless, ESB/ETSC is only conditionally reversible for a short period of time. Often, after a procedure, the function of the nerve cannot be completely restored.

Transection or destruction of the sympathetic ganglia by endoscopy (ETS and ELS)

In a so-called endoscopic transthoracic sympathectomy (ETS), the ganglia at the level of the thorax are surgically transected (cut) or destroyed. Nerves can be destroyed using electrically generated heat or by injecting chemicals. The transection of the nerve is done with an ultrasound. This can be used to treat hyperhidrosis in the area of the head, hands and, with restrictions, the armpits.

In case of plantar hyperhidrosis, an endoscopic lumbar sympathectomy (ELS) is necessary. ELS uses endoscopic technique to reach the sympathetic ganglia in the lumbar region. The procedure is used to treat hyperhidrosis of the feet. The surgical options are the same as for ETS.


After endoscopic sympathetic surgery, general complications such as bleeding, injury to neighbouring structures, nerve damage, infection, healing disorders, thrombosis, and embolisms may occur.

Specific risks of ESB, ETS, and ELS are injury to adjacent organs, blood vessels and nerves, pneumothorax, pleurisy, and other complications resulting from damage to nearby ganglia.

In addition, all surgical procedures on the sympathetic nervous system are a major intervention in the autonomic nervous system of a patient, which can have physical as well as psychological consequences. On the physical level, risks include compensatory sweating, sweating while eating, or Horner’s syndrome. Negative psychological consequences can include depression and the loss of strong emotions.

Compensatory sweating after surgery

Compensatory sweating is a very common complication after operations on the sympathetic nerve. Excessive sweating is completely prevented by disrupting the transmission of nerve signals to the treated areas (hand, face, armpits, or feet), which affects the body’s natural ability to regulate its temperature. The actual amount of sweat remains the same. As a result, there is often a shift of sweat production to other parts of the body. Typically, excessive sweating then occurs especially in the groin and pubic region, on the torso, on the legs, and in the lumbar region and buttocks.

How much does such an operation cost?

The cost of a treatment is usually in the mid four-digit range.

Will health insurance pay for this surgery?

Whether statutory health insurance will cover the treatment is uncertain. We recommend asking your insurance company before beginning treatment. After evidence of its medical necessity has been submitted, the costs will be reimbursed on a case-by-case basis.

Benefits and risks of sympathectomy compared to HIDREX iontophoresis treatment

Even if the excessive sweating in the treatment area can be stopped permanently by the surgical procedure, the procedure should only be considered in exceptional cases. The operation can involve numerous risks and side effects such as compensatory sweating. An intervention in the autonomic nervous system is irreversible. In contrast, non-invasive iontophoresis therapy is free from negative long-term effects, although it may cause temporary irritation or redness in the treatment area.


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