Introduction: Hyperhidrosis, while not life-threatening, can significantly disrupt daily life. Thoracoscopic
sympathetic chain sectioning is the most effective treatment for children with severe cases. However, compensatory
hyperhidrosis (CH) is a common side effect, affecting 50-90% of patients. The optimal level for sympathetic chain
interruption is debated, aiming to minimize damage to afferent fibers that regulate the sudomotor center. This
study compares outcomes of sympathicotomy performed at the third versus fourth rib (T3 vs. T4).
Patients and methods: This prospective, single-blind, randomized controlled trial included 50 pediatric patients
with primary palmar hyperhidrosis, treated between April 2020 and April 2022. Participants were randomly
assigned to two equal groups. Exclusion criteria comprised mild hyperhidrosis, successful medical treatment,
contraindications for thoracoscopic surgery, and suspected secondary hyperhidrosis. One-year postoperative
follow-up assessed therapeutic success, side effects, over-dry hands, recurrence, and CH. Patient satisfaction was
evaluated using a visual analog scale.
Results: The patients' ages ranged from 5 to 17 years (Mean 11.22 ± 3.31). Symptoms began between ages 4
and 12 (Mean 6.74 ± 2.02). The cohort included 17 males (34%) and 33 females (66%). Group B experienced
more cases of moist hands compared to Group A (16 vs. 2). Over-dry hands were more frequent in Group A (6
cases) than in Group B (1 case). Recurrence occurred in one case in Group A and two cases in Group B. CH was
significantly higher in Group A (56% vs. 16%; p = 0.015), with two severe cases in Group A and none in Group B.
Conclusion: T4 thoracoscopic sympathicotomy offers comparable success to T3, with the added benefits of a
higher incidence of moist hands, reduced CH rates, and improved patient satisfaction.