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Objective This study aime to investigate the clinical status of opioid free with spontaneous breathing anesthesia in the treatment of palmar hyperhidrosis through thoracic sympathectomy under thoracoscopy. Methods A total of 93 patients with palmar hyperhidrosis who underwent elective surgery with general anesthesia were randomly divided into control group (group C) and observation group (group O). In group C, patients were treated with propofol, sufentanil, and cisatracurium. In group O, patients were anesthetized with propofol, dexmedetomidine, and thoracic paravertebral block. The changes of vital signs and blood gas indicators between two groups before anesthesia (T1), at the time of skin incision (T2), after surgery (T3), and leaving the operating room (T4) were observed. The visual analog scale (VAS) of patients immediately after awakening (P1), leaving the operating room (P2), 2 hours (P3), 6 hours (P4), and 24 hours after surgery (P5) were recorded. The occurrence of perioperative anesthesia related complications, postoperative recovery time and patients' satisfaction were also observed. Results There was no case of surgical interruption due to anesthesia or anesthesia methods changing during the perioperative period. And no significant difference in the changes of sedation and pain index was observed between two groups (P > 0.05). However, in group O, the VAS scores were higher at P1 and P4 (P > 0.05), PH was lower, PCO2 and BG were higher at T2 (P < 0.05), and the incidence of perioperative hypertension and tachycardia was higher (P < 0.05). There were no statistically significant difference in postoperative recovery time and patient's satisfaction between these two groups (P > 0.05). Conclusion The implementation of opioid free with spontaneous breathing anesthesia strategy in day surgery for palmar hyperhidrosis is safe and feasible but the application of this strategy has no significant advantages in clinical practice of day surgery. [ABSTRACT FROM AUTHOR]