Lumbar Sympathectomy

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Hyperhidrosis and Facial Blushing


- Hyperreactivity of the Sympathetic Nervous System -



Lumbar Sympathectomy


Principles and Methods

In order to stop the nervous impulses to the sweat glands of the feet, the sympathetic chain has to be interrupted at the level of the lumbar ganglia (nerve nodes). The nerve runs along the major vessels (to the left of the aorta and to the right of the inferior vena cava, respectively) in front of the lumbar spine.

In the past, the approach to this awkwardly located nerve required relatively wide incisions and a long recovery. In recent years, a minimally invasive approach has been developed. It requires only 3 small stab incisions in either flank

and a 24 hours hospital stay. With the introduction of this much more precise and less traumatic method, the risk for complications like bleeding, collateral damage and retrograde ejaculation (in the male patient) has been reduced.


Due to the very hidden position of the lumbar sympathetic chain, adjacent to the spine and enclosed in a confined space between the large vessels (aorta on the left side, the inferior vena cava on the right) and the psoas muscle, usually covered by these structures, the access may result relatively complex and sometimes quite awkward. Not infrequently the anatomy varies quite significantly and requires an individualized approach. In rare cases, the nervous chain is not accessible at all, due to adhesions, eg after previous surgery or inflammatory processes.

A sequence of intraoperative images are shown in the following page: Key elements of the operation

Side effects and complications

The majority of patients, after undergoing thoracic sympathectomies for palmar or facial hyperhidrosis, experiences at least some degree of compensatory sweating on the trunc. Lumbar sympathectomy may cause some compensatory sweating as well, but it is usually less pronounced (and almost absent if the patient has had previous thoracic sympathectomy). Often, the microcirculation in the feet increases, leading to a sensation of warm and dry feet. In the male, retrograde ejaculation 1 had been a real risk in the era of open surgery. With endoscopic surgery targeting the lower lumbar chain, it has become a rare and, usually, transitory symptom.



In a minority of cases, access to the nerve may be precluded by a anatomical particularities, difficult to penentrate tissues due to fibrous reaction after inflammatory processes or previous surgery, blurred vision due to local bleeding etc. As in other endoscopic procedures, technical difficulties may require aborting the procedure or converting it to open surgery.

Results

As soon as the sympathetic chain has been interrupted at the level of the 3rd or 4th lumbar ganglion, the feet will be dry, with an immediate success rate of close to 99%

Cosmetic result

Long term results are not far from that figure, though in many patients a slight transpiration may reappear after several months. Rarely, sweating may evolve to a more pronounced degree, but never comparable to the former state. Generally, this phaenomenon is due to the fact that the nervous system "learns" to send the signals along alternative pathways which in most cases are quantitatively insufficient to lead again to a state of hyperhidrosis. However, regrowth (partial or complete) of the nerve is impossible, especially if a segment has been resected.

Availability

Unfortunately, lumbar endoscopic (retroperitoneoscopic) sympathectomy is a relatively complex procedure (mostly carried out in 2 separate sessions) and therefore so far only available in few specialized units in the world. As with other types of hyperhidrosis, all other available treatment solutions should be tried before considering surgery.

In Merano, the procedure is performed at the S. Anna's Clinic, almost always in one single session for both sides. Hospital stay is 24 hours.

For further information contact the surgeons directly:
  Dr. Ivo Tarfusser, MD
    ph: +39-335-241686
    email: summit@parsec.it
  Dr. Alberto Giudiceandrea, MD
    ph: +39-333-3740186
    email: agiudi@yahoo.com


1) Retrograde ejaculation: the sperm does not exit the urethra but flows back into the bladder, to be voided with the urine.