In 2006 I started my general surgery residency in the ancient Surgery Department of “Centro Hospitalar de Coimbra (Hospital dos Covões)”, nowadays incorporated in “Centro Hospitalar e Universitário de Coimbra”. Many years before retroperitoneoscopic lumbar sympathectomy was already being perform in the treatment of two main diseases: chronic lower limb ischemia and plantar hyperhidrosis.
For lower limb ischaemia, retroperitoneoscopic lumbar sympathectomy is a last resource option, and only applied for patients with chronic ischaemia > grade III. This procedure has no positive impact in claudication. The indication to perform this technique in that setting is still not unanimous because outcomes cannot be predicted, although in some patients it can preserve the limb and decrease pain. Since the use of retroperitoneoscopy, lumbar sympathectomy became a minimally invasive technique with a low rate of complications. Because of the important clinical results it can provide, its use should be considered in a patient with critical ischemia with high risk of amputation.
The decrease in morbidity following the first retroperitoneoscopic lumbar sympathectomy lead to an increasing acceptance of this minimally invasive technique.
For plantar hyperhidrosis it is also a valid and good option, offering long-term results in contrast to medical treatments, which only provide a temporary relief. Hyperhidrosis is a clinical condition with a negative impact in patients’ social relationships and mental status. It is believed to occur because of an overactivity of eccrine glands, with excessive sweating from soles of the feet. It usually starts in childhood or adolescence, and affects about 0,6% to 1% of population. There are several medical treatments available including periodic plantar injections of botulinum toxin (not in my feet!) with temporary results only. However, cure can only be achieved with bilateral retroperitoneoscopic lumbar sympathectomy. (Use link at the end to assist our video in YouTube). Lumbar sympathectomy for hyperhidrosis was first performed in 1920, but did not gain popularity because of the large incisions, with important postoperative complications, needed to treat a benign disease. However, the decrease in morbidity following the first retroperitoneoscopic lumbar sympathectomy performed in 1973 by Wittmoser, lead to an increasing acceptance of this minimally invasive technique to treat hyperhidrosis.
The procedure aims at removing the sympathetic chain from the upper border of L3 to the lower border of L4, including lumbar sympathetic ganglia (about 4-5 cm of sympathetic chain). Oral diet can be initiated in the afternoon, and patient can be discharge home in postoperative day one. It has a low rate of complications, but surgeons must not forget they are working near important and vital structures: inferior vena cava in right lumbar sympathectomy; abdominal aorta in left lumbar sympathectomy; iliac vessels; urether. Although rare after lumbar sympathectomy, compensatory hyperhidrosis is a possibility. Even though, patients who report this side effect (essentially after thoracic sympathectomy) state it is easier to tolerate and are happy with the results.
Cure of hyperhidrosis can only be achieved with bilateral retroperitoneoscopic lumbar sympathectomy.
Jani Kalpesh from India published in Journal of American College of Surgeons the results of 14 procedures performed in seven patients suffering from plantar hyperhidrosis. He reports a mean operation time of 34 minutes for unilateral retroperitoneoscopic lumbar sympathectomy. All patients reported immediate decrease of sweating. Compensatory hyperhidrosis occurred in none of the 7 patients, and erectile disfunction was not a postoperative problem in any of the males.
According to Kalpesh, the main issue of this technique is the level where the sympathetic chain is sectioned. Since sympathetic fibres arising from the sympathetic chain bellow the upper border of L3 supply the eccrine glands of the feet, this is the correct level to cut. He also states that preserving the first lumbar sympathetic ganglia located above L3 is crucial to avoid ejaculatory complications, since at least one upper lumbar ganglia must be preserved. The removal of a small segment can result in failure because regeneration can occur. Additionally, failure to achieve anhidrosis can result from collateral nerve tracts or “crossover innervation” (unilateral procedure).
So, retroperitoneoscopic lumbar sympathectomy is the only definitive treatment for hyperhidrosis, has good results with a low rate of complications, and patients can be discharge home in the day after. Anhidrosis usually occur 30 minutes after surgery, and patients are happy with the results even if compensatory hyperhidrosis arise.
“By making general practioners and physicians aware of this therapeutic option, permanent cure can be offered to sufferers of this unfortunate affliction.”
Jani Kalpesh
My colleagues and me are still performing this technique, and a video of retroperitoneoscopic lumbar sympathectomy performed for lower limb ischaemic is available in YouTube.
Link to PubMed:
Link to assist video in YouTube (technique starts at 3:15 min):
by Dr. Carlos Eduardo Costa Almeida
General Surgeon