Lumbar Sympathectomy Surgery
Minimally invasive approaches for Lumbar sympathectomy are increasingly performed in patients with intractable sweating of the feet. Especially in patients in whom the Endoscopic thoracic sympathectomy has failed to relieve the sweating of the feet. Lumbar sympathectomy has mainly been performed in female patients because of the reported incidence of retrograde ejaculation in men. Several recent articles have reported no sexual dysfunction in men undergoing the operation. It has been reported that as long as the sympathectomy is performed below the L2 ganglion, sexual dysfunction did not occur.
We have developed a unique minimally invasive technique to access the Lumbar sympathetic trunk, using a “Tubular Retractor” through a one inch incision in both flanks of the abdomen. This technique has been used extensively in spinal surgery to access the Lumbar spine for Interbody fusion operations.
Through a muscle splitting abdominal wall incision, the Lumbar spine is accessed behind the peritoneal cavity. The tubular retractor is carried into this retroperitoneal space with fluoroscopic guidance and docked on the Psoas muscle, which lies on the side of the Lumbar spine. Using the operating microscope, the edge of this muscle is pulled back to identify the Lumbar sympathetic trunk. The trunk is divided with an ultrasonic instrument (Harmonic Scalpel) or clipped. The sympathetic trunk is cut or clipped over the Lumbar 3rd and 4 the bodies, effectively isolating the L3 and L4 ganglia (L3G, L4G). Foot temperature is monitored over the toes and should see an immediate rise with isolation of the sympathetic trunk. The wound is closed cosmetically with buried sutures. The patient is repositioned for the opposite side and the procedure is repeated. Patients typically stay overnight and are discharged home the next day. Post-operatively patients may experience some soreness in the groins which is transient and abates in a week to ten days. Lumbar sympathectomy affords 95- 97% relief of sweating and relieves the odor associated with the sweating.
This technique is a more direct approach to the Lumbar sympathetic trunk as opposed to the Laparoscopic trans-peritoneal and retroperitoneal approaches; where locating and identifying the sympathetic trunk is tedious. Ability to use the Microscope allows 3-D visualization versus the 2-D visualization with the endoscope, making for a safer more definitive operation.