Patients who experience intolerable adverse effects after endoscopic thoracic sympathectomy performed for primary regional hyperhidrosis are candidates for sympathetic trunk reconstruction (STR). The goal of STR is to regain sympathetic function by restoring the anatomical continuity of the resected trunk. In this chapter, we describe our approach to thoracic STR—which is based on the collaboration between two teams specializing in thoracic surgery and plastic surgery (microsurgery subspecialty). The teams share a robotic platform (da Vinci® surgical system) which is paramount to successful outcomes. The procedure starts with the thoracic surgeon performing pneumolysis followed by the identification of the ruptured sympathetic trunk. Concomitantly, the microsurgeon harvests the left sural nerve as a source for grafting. Upon identification of the sympathetic trunk, the microsurgeon takes over and bridges the sympathetic trunk defect using the sural graft via 8-0 nylon. Additionally, the sural nerve graft is fixed to the involved intercostal nerves with a side-to-side coaptation. The patient is subsequently turned to the right side and the procedure is repeated contralaterally. As of April 2021, our group has performed a total of 33 STRs. Most cases experienced moderate-to-significant clinical improvements at six post-operative months, especially in terms of compensatory sweating and thermoregulation (J Reconstr Microsurg; 37(6):503–513, 2021. 10.1055/s-0040-1722183).