Eur J Plast Surg (2006) 29: 73–78
A. G. N. Robertson
A. M. Russell
A. J. B. Kirk
Endoscopic thoracic sympathectomy: a review
Received: 22 March 2005 / Accepted: 17 January 2006 / Published online: 25 May 2006
# Springer-Verlag 2006
Abstract Hyperhydrosis and craniofacial blushing are
common conditions, both being mediated by excess
sympathetic activity. These conditions may be socially
disabling and cosmetically unacceptable to a patient.
Endoscopic thoracic sympathectomy (ETS) has been
developed as an effective and safe method of dealing
with these patients and is now an established part of our
surgical repertoire. This paper describes the technique and
development of ETS and discusses alternative strategies.
Keywords Endoscopic thoracic sympathectomy
Hyperhydrosis is a common condition affecting 1% of the
population [1, 33]. It is mediated by excess sympathetic
activity. Craniofacial blushing, another clinical phenome-
non, is also caused by sympathetic overactivity. Both of
these conditions can be socially disabling and cosmetically
unacceptable to the patient. Surgical approaches to sym-
pathectomy have been well documented since the 1920s
but were associated with significant morbidity. Endoscopic
thoracic sympathectomy (ETS) has been developed as an
effective and safe method of dealing with these patients and
is now an established part of our surgical repertoire. As
there are variations in practices in ETS, we feel it
appropriate to review this very useful procedure.
Dorsal sympathectomy was initially documented as useful in
the treatment of primary hyperhydrosis by Kotzareff 
using a supraclavicular approach in 1920. Thoracotomy or
trans-axillary approaches to the sympathetic trunk have been
described. As these open approaches often caused significant
morbidity , a thoracoscopic approach was advocated and
first performed by Hughes in 1942 . Kux  was also
an advocate of the thoracoscopic approach and, by 1951, he
had performed more than 500 thoracoscopic sympathec-
tomies, predominantly for peptic ulcer disease.
In the 1990s, the production of sophisticated imaging
equipment allowed the development of video-assisted
thoracoscopic surgery (VATS) within the discipline of
thoracic surgery. Major advances in minimally invasive
surgery had already taken place in the fields of laparo-
scopic gynaecology and laparoscopic general surgery.
The increase in popularity of VATS led to a resurgence
of interest in sympathectomy. Endoscopic thoracic sym-
pathectomy for hyperhydrosis has, thus, been developed.
The experience with ETS for hyperhydrosis has led to the
expanding indication of the technique for craniofacial
blushing and social phobia .
The thoracic sympathetic trunk lies along the head of the
ribs, immediately behind the costal parietal pleura in
endothoracic fascia. There are normally 10–11 ganglia in
the thorax. These are segmentally arranged, and the
posterior intercostal arteries and veins, in general, pass
posteriorly to the trunk [4, 23].
In 70–80% of people, the inferior cervical ganglion fuses
with the first thoracic ganglion to become the stellate
(cervicothoracic) ganglion. This ganglion lies posterior to
the lung apex .
The Nerve of Kuntz is an inconsistent communicating
ramus between T2–T1 occurring in 10% of patients. Lying
on the neck of the ribs, it carries post-ganglionic branches
An editor’s comment on this paper is available at http://dx.doi.
A. G. N. Robertson
A. M. Russell
A. J. B. Kirk (*)
Department of Cardiothoracic Surgery, Western Infirmary,
Glasgow G11 6NT, Scotland