Primary hyperhidrosis affects between 1 and 3% of the population. It is a problem of sympathetic deregulation which is characterized by profuse sweating on the palmar surface of the hands, armpits, groin and feet. The therapeutic options for the management of hyperhidrosis have traditionally been non-operative. However, there are several studies demonstrating that primary hyperhidrosis is best treated by endoscopic thoracic sympathectomy.This article presents a review of existing approaches and techniques of thoracoscopic sympathectomy for treatment of hyperhidrosis as well as the author's summary and preferences.Thoracoscopic sympathectomy is now the standard procedure chosen for the treatment of severe hyperhidrosis. It is safe and successful in almost 98% of cases and only 1-2% of patients experience recurrence. All patients develop some degree of compensatory sweating after surgery. In most this is mild and tolerable; however, in 3-5% of patients it is severe and intolerable. The patients should be made aware that the most satisfied patients are those with preoperative palmar or palmar- axillary hyperhidrosis.The best segment interrupted for the treatment of primary hyperhidrosis, is still controversial. The recent body of literature suggests that the highest success rates occur when interruption is performed at the top of R3 or the top of R4 for palmar hyperhidrosis. R4 may offer a lower incidence of compensatory hyperhidrosis but moister hands. For palmar and axillary and only axillary hyperhidrosis interruptions at R4 and R5 are recommended. The top of R3 is best for craniofacial hyperhidrosis.