Retroperitoneoscopic Lumbar Sympathectomy - Treatment of Plantar Hyperhidrosis

Retroperitoneoscopy

Lumbar Sympathectomy:

The lumbar sympathectomy was initially utilized for the treatment of ischemic and painful disorders of the lower limbs. This treatment, which was popular among vascular surgeons, remained unchanged for several decades. Its use slowly decreased after 1960, when arterial reconstruction techniques were introduced. It is still useful for some patients with vascular diseases; however, it is particularly useful in the treatment of plantar hyperhidrosis.

Primary hyperhidrosis is the most frequent indication for sympathectomies, both lumbar and thoracic. This disease affects about 1% of the population and is characterized by excessive sweating in specific regions of the body such as the hands, face, scalp, axilla and feet. The endoscopic thoracic sympathectomy (ETS) is indicated for the treatment of palmar, axillary and craniofacial hyperhidrosis. The results of plantar excessive perspiration, however, are less expressive. Many patients with Primary hyperhidrosis who have undergone ETS still continue to experience excessive sweating of the feet after surgery.

The endoscopic retroperitoneal lumbar sympathectomy (ERLS) is efficient in the treatment of PHH isolated from or associated with other affected areas that persisted after ETS. It is believed, however, that there could be a worsening of compensatory sweating (CS), when adding the effects of ETS to the lumbar regions of the same patient. It is highly probable that suppression of one more segment of the sympathetic chain could actually increase CS. This is one of the principal doubts concerning lumbar sympathectomy.

Hyperhidrosis, or excessive sweating, is a physiological disorder that affects 1-3% of the population. It can occur in areas of the body that possess a concentrated amount of sweat glands, for example, the hands, axillae, and feet. Many conservative modalities of treatment are available for this condition such as topical aluminum chloride solutions, oral anticholinergic medications, iontophoresis machines, and even botulinum toxin injections. However, there are a multitude of hyperhidrosis patients who do not appropriately respond to conservative management and a more advanced approach is indicated.

Sympathectomy is a surgical option that arose in 1920 to treat patients with occlusive vascular issues such as Buerger disease, Reynaud’s disease, and other myriad medical conditions including hyperhidrosis. Over the years, the technique of the sympathectomy has evolved greatly. Endoscopic thoracic sympathectomy (ETS) has been performed for several years, and is now a documented safe and effective method for eradicating palmar hyperhidrosis and, in about 15% of cases, plantar hyperhidrosis yet, up until very recently, there was no cure for plantar hyperhidrosis. A similar procedure, lumbar sympathectomy, emerged in the early 1950s, but with it came potential adverse effects involving neuralgia and even sexual dysfunction in men. As with thoracic sympathectomy, compensatory sweating usually in the legs, abdomen, or back is also a common adverse result with lumbar sympathectomy. Lumbar sympathectomy has been performed more commonly in the last decade for plantar hyperhidrosis as more experience was gained to minimize adverse effects. Lumbar sympathectomy entails either clamping or resecting the sympathetic ganglia between the levels of L2-L4 causing nerve disruption to ensue cessation of plantar sweat. Most surgeons completely resect the lumbar sympathetic ganglia, but a conversation with Raphael Reisfeld, MD, FACS (November 2011) of Los Angeles confirmed he is currently the only surgeon in the world to use the “clamping method”in lumbar sympathectomy. The “clamping method” entails 3-4 5mm titanium clips on each side of the sympathetic chain as opposed to complete resection. The purpose of this study is to provide a systematic review of the evidence thus far, for providers and patients considering lumbar sympathectomy for plantar hyperhidrosis. Plantar hyperhidrosis, though not life-threatening, is nonetheless an extremely debilitating disorder both psychosocially and medically. It can negatively affect marital or other intimate relationships, prevent participation in barefoot activities, ruin shoes, and cause skin infections as well as lesions.

Bilateral retroperitoneoscopic lumbar sympathectomy by unilateral access for plantar hyperhidrosis in women:

Primary focal hyperhidrosis is a disorder of excessive, bilateral, and relatively symmetric sweating occurring in the axillae, palms, soles, or craniofacial region. Armpits are affected in 51% of patients, feet in 29%, palms in 25%, and the face in 20%. There is a wide range of nonsurgical and surgical treatments available for patients with focal hyperhidrosis. Surgical treatments for plantar hyperhidrosis include thoracic and/or lumbar sympathectomy.

Retroperitoneoscopic lumbar sympathectomy by unilateral access seems to be feasible when performed by a surgeon with experience on advanced laparoscopy. Larger series comparing unilateral to bilateral access are necessary to establish the real benefits and potential disadvantages of this new technique.

Retroperitoneoscopic Lumbar Sympathectomy – Treatment for Buerger's Disease:

Buerger's disease is characterized by peripheral ischemia of an inflammatory nature with a self-limiting course. Shionoya's criteria for the diagnosis of Buerger's disease are smoking history; onset before age 50; infrapopliteal arterial occlusion; either upper limb involvement or phlebitis migrans; absence of atherosclerotic risk factors other than smoking. Buerger's disease is the most common cause of peripheral vascular disease (PVD) in India. The majority of patients present with an advanced stage of ischemia; hence, most of them require surgical intervention in the form of either lumbar sympathectomy, omentopexy, or major or minor amputations.

Recent times have seen rapid development in laparoscopic procedures, so much so, that almost all intraperitoneal procedures are being done by minimally invasive techniques. However, the development of retroperitoneoscopy has been slow compared with that of transperitoneal laparoscopy. This is because of the inability to produce pneumoretroperitoneum with direct introduction of a Veress needle in the retroperitoneum. Introduction of balloon dissection techniques of the retroperitoneum has opened up new horizons in the field of retroperitoneoscopy. Consequently, all the retroperitoneal organs are amenable to retroperitoneoscopic surgery. The improvement in optics and availability of better instruments now provides a bright, high-resolution magnified image so that the anatomy is more visible than in open surgery.

Medline search yielded very few articles related to retroperitoneoscopic lumbar sympathectomy, and therefore the procedure is neither standardized nor widely practiced, which could partly be because of the relative rarity of Buerger's disease in the Western Hemisphere. Because of sufficient experience gained by us in retroperitoneoscopic surgery pertaining to the kidney, ureter, and adrenal gland, our surgical team became quite familiar with anatomic dissection of the retroperitoneum; hence, it was considered appropriate to perform and standardize the procedure of retroperitoneoscopic lumbar sympathectomy.

Though laparoscopy is a familiar procedure, it makes sense that a retroperitoneal organ should be approached by the retroperitoneal route only. It provides the shortest route and direct access to retroperitoneal organs.However, a few basic problems to be dealt with while performing retroperitoneoscopic surgery are the limited working space, the absence of landmarks, and prevention of peritoneal penetration.

No significant complications were encountered in the study. Postoperative pain at the operation site was negligible and so was the need for analgesia. The patients were discharged within 1 to 2 days and returned to work after 1 week. Our patients were from low socioeconomic strata; therefore, the quick return to work was a clear advantage over the longer recuperation time required after open surgery.

Follow-up of the patients ranging from 12 to 19 months has not revealed recurrence of the disease, which proves the efficacy of retroperitoneoscopy as an alternative to conventional procedures.

Conclusion:

Despite limited experience with this procedure, retroperitoneoscopic lumbar sympathectomy is a safe and effective procedure for patients with advanced Buerger's disease requiring lumbar sympathectomy. It has a short convalescent time with minimal morbidity. It appears to be a viable alternative to open procedures. Besides, Retroperitoneoscopic resection of the lower lumbar sympathetic trunk is a safe and effective procedure for obtaining suspension of excessive sweat secretion in patients with plantar hyperhidrosis that cannot be treated with conservative methods.

World Laparoscopy Hospital, Cyber City, DLF Phase II, Gurugram, NCR Delhi, 122 002, India
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