Palmar hyperidrosis is excessive sweating beyond physiological needs in the palm without recognized etiology. Although a benign disease, it is annoying to most patients. Currently the best treatment for this condition is upper thoracic 
sympathectomy via many different approaches. The video-thoracoscopic approach has been recommended as a minimally invasive procedure and universally accepted as an effective and enduring treatment for primary hyperidrosis. However, the simultaneous ganglionectomy for bilateral cases has been reported to be associated with a troublesome compensatory hyperidrosis in between 22% and 81% of patients. In this prospective study, 2-months interval of sequential ganglionectomy was carried out in 30 consecutive children between 4 and 16 years of age (group A); whereas simultaneous bilateral sympathectomy was done in 18 patients (group B) Unilateral sympathectomy was accomplished generally within 7 minutes. 
All patients but 4 were discharged after an overnight stay. None of the patients required conversion to open sympathectomy. 
Horner's syndrome did not occur in any case. Compensatory hyperidrosis did not develop in any of the patients of group A but in all patients of group B, moreover this technique was proved to be useful in up to 60% of patients associated with plantar hyperidrosis.
Conclusion : 1- Based on the accumulated experiences, it is justified to recommend early surgery even in the preschool age 2- Sequential ganglionectomy should be the standard practice in the management of primary hyperidrosis 3- The mechanism of improvement in plantar hyperidrosis following sequential sympathectomy still needs to be clarified in a larger study