Pitfalls in thoracoscopic sympathectomy: mechanisms for failure.

The technical ease of thoracoscopic sympathectomy has established this as the procedure of choice for upper-limb sympathectomy. Notwithstanding the invariable success of this procedure, those rare instances of unsuccessful sympathectomy are disconcerting to the surgeon. Unsuccessful sympathectomy manifests as persistent or recurrent sympathetic activity after a seemingly successful procedure. The causes of this phenomenon include misinterpretation of the sympathetic chain at thoracoscopy, regeneration of the sympathetic chain, and alternate neural pathways via the nerve of Kuntz. With the large numbers of sympathectomies being undertaken, the few instances of unsuccessful sympathectomy have prompted a review of this subject. Although alternate neural pathways may have little significance when a T2 ganglionectomy is undertaken, anatomic misinterpretation of the sympathetic chain is an important yet under-recognized cause of an unsuccessful sympathectomy. Sympathetic nerve regeneration remains extremely uncommon. Persistent and recurrent sympathetic activity may be successfully managed by resympathectomy performed thoracoscopically.