Thoracic sympathectomy has undergone significant change since its initial description over 100 years ago. Originally described utilizing a posterior approach, the procedure has changed over the years from a supraclavicular approach and transaxillary thoracotomy to multiport thoracoscopy and, most recently, single-port thoracoscopy. Indications for a thoracic sympathectomy include the treatment of reflex sympathetic dystrophy (RSD), Raynaud’s Disease, chronic pancreatic pain, and, most commonly, hyperhidrosis. Hyperhidrosis presents as severe sweating of the face, hands, axillary regions, feet, or any combination of these and is present in at approximately 2% of the population.

The thoracic sympathetic chain exists as a paired group of, up to, 12 interconnected ganglia that correspond to each thoracic nerve. The chains lie in either pleural space on the ventral surface of the ribs just lateral to the costo transverse process articulation (Figs. 33.1 and 33.2). The sympathetic chains take a more lateral position as they travel more inferiorly in the chest. Each ganglion lies below the corresponding named rib thus the stellate, or T1 ganglion, lies just below the first rib and is frequently covered by cervicothoracic fat pad (Fig. 33.3). This anatomy, however, is not always constant and in a minority of patients ganglia may be fused or located at or slightly above their corresponding rib. Attention to anatomy is critical for defining the correct level of the desired sympathectomy. The first rib can always be identified by the subclavian artery that courses over it and by the fact that it lacks a corresponding intercostal muscle on its superior border.

Aside from the main sympathetic chain, smaller accessory nerves of Kuntz can be found in up to 60% of patients (Fig. 33.4). These nerves were originally described as only crossing the second rib but, more recently, they have been shown to crossover any of the first four thoracic ribs. Currently, there is some argument as to the role of the Kuntz nerves in pathologic processes such as hyperhidrosis; however, most thoracic surgeons make an attempt to find and transect these nerves.

Various approaches to division of the sympathetic chain have included resection of the individual ganglia as well as division of the interganglionic nerve trunk. This difference in the technique has led to confusion and misnomers when surgeons discuss the intended procedure in the literature and with patients. To clear this confusion, a consensus has been reached, which considers a sympathectomy, to be excision of a ganglion, or ganglia, over a specific rib or ribs (designated by the letter G/level of treatment). A sympathicotomy, on the other hand, consists of division of the sympathetic chain without removal of ganglia (designated by the letter R/level of treatment). This is the most common practice for conditions such as hyperhidrosis even though most studies improperly call this a sympathectomy. Current nomenclature defines the level of sympathicotomy at the corresponding rib where division of the nerve chain occurs. Thus, an R3 sympathicotomy would be defined as the division of the sympathetic chain over the third rib.