Microsurgical robotic suturing of sural nerve graft for sympathetic nerve reconstruction: a technical feasibility study

Background: Endoscopic thoracic sympathectomy (ETS) may provide a permanent surgical cure for primary palmar hyperhidrosis. Unfortunately, some patients can experience intensive post-operative compensatory sweating (CS) that ultimately impairs quality of life. Sympathetic nerve reconstruction (SNR) may be used to counteract severe post-operative CS through the restoration of sympathetic pathways. In this case series, we describe the technical feasibility of a robot-assisted micro-peripheral nerve reconstruction method for achieving SNR in patients with post-operative CS. Methods: Between January 2017 and May 2019, seven cases with severe post-operative CS underwent robot-assisted SNR using a sural nerve graft. We report the pre-operative assessment, the surgical technique, and the clinical outcomes of the study patients. Results: The study sample consisted of five men and two women (median age: 41 years). Primary hyperhidrosis affected the face in one case and the palms in six patients. The median time between ETS and SNR was 20 years. All robotic surgery procedures were successfully accomplished, and neither conversion to open surgery nor the creation of additional ports were required. Sural nerve grafts (median length: 8 cm) were used in all cases, and the median operating time was 10.5 h. There was no operative mortality, with the median length of post-operative hospital stay being 4 days. One patient developed a post-operative pneumothorax—which was treated conservatively. Conclusions: Our case series demonstrates the safety and clinical feasibility of microsurgical robot-assisted sural nerve grafting for achieving SNR in patients with post-operative CS.