The history and development of sympathetic trunk reconstruction: a 40-year journey from open surgery to...

Endoscopic thoracic sympathectomy (ETS) is widely used to treat primary hyperhidrosis; however, compensatory sweating (CS) has emerged as a significant complication. Various surgical approaches for managing CS have evolved over the past 4 decades, yet their development and outcomes remain poorly documented. This study aims to examine the historical evolution and advances in techniques for reconstruction of the thoracic sympathetic trunk. A review was conducted using PubMed, Embase, and the Cochrane library, focusing on currently published studies related to the reversal surgery of thoracic sympathectomy. Eligible studies included animal model and clinical studies, and a comprehensive comparison was conducted among different surgical techniques, clinical results, and complications. Twenty-three studies (3 experimental models and 20 clinical reports; 192 cases) demonstrated three distinct eras: open thoracotomy (1980-2003), video-assisted thoracoscopic surgery (2003-2015), and robotic-assisted reconstruction (2016-present). Different techniques showed varying success rates: unclipping (0-89%), direct reconstruction with nerve grafting (36.8-100%), and intercostal nerve bypass (0-93.4%). Among the documented cases, the reported CS improvement rates were highest for direct sympathetic trunk reconstruction with free nerve grafting. Complications were generally mild, including temporary chest wall neuralgia (2.6%), bleeding (1%), and Horner syndrome/temporary blepharoptosis (1.5%). This first comprehensive review demonstrates that sympathetic trunk reconstruction has evolved from an experimental procedure to a viable option for severe CS. Although robotic assistance has enhanced surgical precision, successful outcomes depend primarily on fundamental microsurgical principles, particularly precise nerve coaptation and the proper identification of healthy nerve stumps.