has been indicated for hyperhidrosis (excessive sweating) since 1920, when Kotzareff showed it would cause anhidrosis (total inability to sweat) from the nipple line upwards. A lumbar sympathectomy was also developed and used to treat excessive sweating of the feet and other ailments, and typically resulted in impotence and retrograde ejaculation in men. Lumbar sympathectomy is still being offered as a treatment for plantar hyperhidrosis, or as a treatment for patients who have a bad outcome (extreme 'compensatory sweating') after thoracic sympathectomy for palmar hyperhidrosis or blushing; however, extensive sympathectomy risks hypotension. Endoscopic sympathectomy itself is relatively easy to perform; however, accessing the nerve tissue in the chest cavity by conventional surgical methods was difficult, painful, and spawned several different approaches in the past. The posterior approach was developed in 1908, and required resection (sawing off) of ribs. A supraclavicular (above the collar-bone) approach was developed in 1935, which was less painful than the posterior, but was more prone to damaging delicate nerves and blood vessels. Because of these difficulties, and because of disabling sequelae associated with sympathetic denervation, conventional or "open" sympathectomy was never a popular procedure, although it continued to be practiced for hyperhidrosis, Raynaud's disease, and various psychiatric disorders. With the brief popularization of lobotomy in the 1940s, sympathectomy fell out of favor as a form of psychosurgery. The endoscopic version of thoracic sympathectomy was pioneered by Goren Claes and Christer Drott in Sweden in the late 1980s. The development of endoscopic "minimally invasive" surgical techniques has decreased the recovery time from the surgery and increased its availability. Today, ETS surgery is practiced in many countries throughout the world predominantly by vascular surgeons. See also Harlequin syndrome References British Journal of Surgery 2004; 91: 264–269 Endoscopy Neurosurgical procedures Thoracic surgical procedures