Evolution of Robotic-Assisted Sympathetic Trunk Reconstruction: Technical Innovation and Clinical Experience

Abstract

Endoscopic thoracic sympathectomy, while effective for palmar hyperhidrosis, results in devastating compensatory sweating and autonomic dysfunction affecting >80% of patients. We present our institutional evolution of robotic-assisted sympathetic trunk reconstruction (STR) for post-sympathectomy complications. Our prospective series of 23 patients underwent robotic STR with free nerve grafting (mean follow-up: 2 years). Six-month outcomes demonstrated significant improvement: Chest severity 9.4 ± 0.9 to 6.0 ± 2.4 (p < 0.001), back severity 9.3 ± 0.8 to 6.1 ± 2.6 (p < 0.001), with sustained gains at 2 years. To minimize donor site morbidity, we progressively transitioned to free intercostal nerve autografts, followed by vascularized intercostal nerve (vICN) grafting beginning January 2025. Vascularized grafts maintained immediate perfusion, enabling continuous Schwann cell proliferation and accelerated recovery. A propensity score-matched analysis of vICN versus free intercostal grafts achieved 100% technical success with no vascular complications. Six-month vICN recipients demonstrated continuous improvement without temporary worsening observed in controls. Recently, single-port robotic systems substantially reduced postoperative chest wall morbidity. These innovations demonstrate that precisely executed microsurgical technique, enabled by robotic precision and interdisciplinary expertise, offers viable treatment for carefully selected patients with intolerable post-sympathectomy complications.

Keywords

sympathetic trunk reconstruction - Single Port Robotic System - vascularized intercostal nerve

Publication History

Article published online:
30 January 2026

• References

• 1 Cerfolio RJ, De Campos JR, Bryant AS. et al. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 2011; 91 (05) 1642-1648
• 2 Rojas D, Duggan SM, Mauduit M. et al. Impact of robotic-assisted and video-assisted sympathetic nerve reconstruction on quality of life for severe compensatory hyperhidrosis after thoracic sympathectomy. Interdiscip Cardiovasc Thorac Surg 2023; 36 (06) ivad106
• 3 Sung CW-H, Chen LW-Y, Lee C-H. et al. The systemic adverse effects of endoscopic thoracic sympathectomy are underrecognized: A questionnaire-based study. BMC Plast Reconstr Surg 2025; 1: 7
• 4 Rantanen T, Telaranta T. Long-term effect of endoscopic sympathetic nerve reconstruction for side effects after endoscopic sympathectomy. Thorac Cardiovasc Surg 2017; 65 (06) 484-490
• 5 Gebitekin C, Melek H, Cetinkaya G. et al. Intercostal nerve reconstruction for severe compensatory hyperhidrosis: The Gebitekin technique. Ann Thorac Surg 2021; 111 (06) e443-e446
• 6 Chen LW, Chao YK, Wong AW. et al. The history and development of sympathetic trunk reconstruction: A 40-year journey from open surgery to robotic-assisted microsurgery. J Robot Surg 2025; 19 (01) 337
• 7 Connery CP. Reconstruction of the sympathetic chain. Thorac Surg Clin 2016; 26 (04) 427-434
• 8 Chen LW, Goh M, Goh R. et al. Robotic-assisted peripheral nerve surgery: A systematic review. J Reconstr Microsurg 2021; 37 (06) 503-513
• 9 Chang TN, Daniel BW, Hsu AT. et al. Reversal of thoracic sympathectomy through robot-assisted microsurgical sympathetic trunk reconstruction with sural nerve graft and additional end-to-side coaptation of the intercostal nerves: A case report. Microsurgery 2021; 41 (08) 772-776
• 10 Chang TN, Chen LW, Lee CP, Chang KH, Chuang DC, Chao YK. Microsurgical robotic suturing of sural nerve graft for sympathetic nerve reconstruction: A technical feasibility study. J Thorac Dis 2020; 12 (02) 97-104
• 11 Chen LW, Chang TN, Lee CP. et al. Robotic sympathetic trunk reconstruction for compensatory sweating after thoracic sympathectomy. JTCVS Tech 2023; 21: 251-258
• 12 Chang TN, Lu JC, Sung CW. et al. Elongation of intercostal nerve cutaneous branches for breast and nipple neurotization during breast reconstruction after mastectomy for breast cancer: Case-control study. Br J Surg 2024; 111 (02) znae005
• 13 Santoro M, Piacentini R, Perna A. et al. Resveratrol corrects aberrant splicing of RYR1 pre-mRNA and Ca²⁺ signal in myotonic dystrophy type 1 myotubes. Neural Regen Res 2020; 15 (09) 1757-1766
• 14 Broeren BO, Duraku LS, Hundepool CA. et al. Nerve recovery from treatment with a vascularized nerve graft compared to an autologous non-vascularized nerve graft in animal models: A systematic review and meta-analysis. PLoS ONE 2021; 16 (12) e0252250
• 15 Toia F, Matta D, De Michele F, Pirrello R, Cordova A. Animal models of vascularized nerve grafts: A systematic review. Neural Regen Res 2023; 18 (12) 2615-2618
• 16 Chen LW, Chao YK, Lee CP. et al. First-in-human application of robotic vascularized intercostal nerve grafts for thoracic sympathetic trunk reconstruction: A technical innovation. BMC Surg 2025; 25 (01) 496