Bilateral Retroperitoneoscopic Lumbar Sympathectomy by Unilateral Access for Plantar Hyperhidrosis in Women

Introduction

Primary focal hyperhidrosis is a disorder of excessive, bilateral, and relatively symmetric sweating occurring in the axillae, palms, soles, or craniofacial region. ¹ The condition can have a deeply detrimental effect on a patient's quality of life, resulting in dramatic impairments of daily activities, psychological behaviour, social interactions and occupational activities.^1–3 Hyperhidrosis adversely affects one's ability to perform in the workplace, be in public, meet people, and develop personal relationships. ¹ A recent, large epidemiological survey of 150,000 households in the United States has revealed that focal hyperhidrosis is present in 2.8% of the general population. ³ The condition affects both men and women equally, and its prevalence was found to be the highest among people 25–64 years in age. The average age of onset is 25 years but depends primarily on the body area affected. Palmar and axillary hyperhidrosis have the earliest average onset, at 13 and 19 years, respectively. ³ Armpits are affected in 51% of patients, feet in 29%, palms in 25%, and the face in 20%.^3,4

The pathophysiology of focal primary hyperhidrosis is poorly understood, but it is believed to be associated with overstimulation via an autonomic pathway. Either thermal stimuli or higher cortical stimuli can activate autonomics that affect sweat of the axillae, face, palms, or soles. The pattern of stimulation can be peculiar to an individual's inherited dysfunction of the autonomic system. ¹ There is a wide range of nonsurgical and surgical treatments available for patients with focal hyperhidrosis. These treatment modalities vary in their therapeutic efficacy, duration of effect, side effects, and cost, as well as in the scientific evidence of their efficacy.

Nonsurgical therapies include topical treatments (e.g., aluminum salts and aluminum chloride solutions), iontophoresis, botulinum toxin A, systemic treatments (e.g., anticholinergic agents, amitriptyline, clonazepan, beta-blockers, calcium-channel blockers, gabapentin, and indomethacin), and alternative treatments (e.g., biofeedback training, hypnosis, and different types of relaxation techniques). ⁵ Surgical treatments include endoscopic thoracic and lumbar sympathectomy and should be reserved for patients for whom other treatments have been ineffective and who appreciate the risks associated with the procedure and potential complications. ⁵ They destroy the sympathetic ganglia by excision, clamping, transection, or ablation with cautery or laser. Several retrospective studies and uncontrolled clinical trials have demonstrated that endoscopic thoracic sympathectomy is effective in eliminating axillary, palmar, and facial hyperhidrosis in 68–100% of cases.^6,7 Approximately 50% of patients with palmoplantar hyperhidrosis who undergo endoscopic thoracic sympathectomy for excessive palmar sweating also have a reduction in plantar hyperhidrosis.^8,9 The main limitation of this procedure is a high incidence of mild to severe compensatory hyperhidrosis, usually involving the trunk and lower limbs, in up to 86% of patients. ¹⁰ Studies on lumbar sympathectomy for plantar hyperhidrosis are scarce. Some researchers do not recommend it because of associated sexual dysfunction. ¹ On the other hand, Loureiro et al. ¹¹ evaluated 15 women submitted to endoscopic retroperitoneal lumbar sympathectomy and observed that the procedure is safe in women, with very few and tolerable side effects. It decreased plantar sudoresis and improved the quality of life of patients with plantar hyperhidrosis. The advantage of the endoscopic approach to lumbar sympathectomy is the significantly better cosmetic result than the open method, which is particularly important in young patients suffering from hyperhidrosis. ¹² In 2007, Segers et al. ¹³ described 1 case of unilateral laparoscopic retroperitoneal approach to perform bilateral lumbar sympathectomy in a 43-year-old man with distal arterial occlusive disease. The scope of this article is to report our initial experience on bilateral retroperitoneoscopic lumbar sympathectomy (BRLS) by unilateral access technique for the treatment of plantar hyperhidrosis.

Materials and Methods

The sample consisted of female patients who presented with plantar hyperhidrosis at the time of surgery and received BRLS by the unilateral access technique at our hospital. The following criteria were used for establishing the diagnosis of plantar hyperhidrosis ¹ :

Focal, visible, and excessive sweating of at least 6 months in duration without apparent cause with at least two of the following characteristics:

All patients had already been submitted to a previous thoracic sympathectomy with no improvement of the plantar hyperhidrosis (Table 1). We did not include any men in our series due to the risk of developing postoperative sexual dysfunction. ¹ All patients received and signed an informed consent before the procedure.

Surgical Technique

Under general anesthesia and with endotracheal intubation, the patient was positioned in right lateral decubitus position with a pillow between her knees. The skin was incised longitudinally for 2–3 cm at the tip of the 12th left costal arch in the left posterior axillary line. After blunt dissection of the subcutaneous tissue, the left lumbar muscle and its fascia were identified and retracted. The retroperitoneum was reached and the initial dissection was performed digitally. A 10-mm trocar was placed, and the retroperitoneal space was achieved by using carbon-dioxide (CO₂) gas and the 30-degree endoscope. Two additional trocars were placed: a 5-mm trocar at the tip of the left anterosuperior iliac spine and a 10-mm trocar at the left costal border in the left anterior axillary line.

The first landmark identified was the left psoas muscle (Fig. 1A). In a medial direction, the left genitofemoral nerve was identified above the psoas tendon (Fig. 1A). Then, the left ureter was located and retracted superiorly attached to the peritoneum (Fig. 1B). Following this, the lumbar sympathetic trunk was identified medially to the muscle and bordering the left side of the lumbar spine (Fig. 1C and 1D). The nerve was covered by a capsule formed by the psoas muscle insertion at the lumbar spine. The capsule was opened, and the trunk and its ganglia were revealed. After careful dissection, the nerve was clipped (Fig. 2A) and resected (Fig. 2B), including the second and third lumbar ganglia. The length of the removed chain was standardized to 4 cm.

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FIG. 1.

(A) Identification of the psoas muscle and the genitofemoral nerve on the left side. (B) The ureter is displaced superiorly attached to the peritoneum. (C) Identification of the lumbar spine and the left nerve bordering the spine. (D) Dissection of the left nerve and its ganglia.

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FIG. 2.

(A) Clipping the left sympathetic nerve. (B) Resection of a 4-cm segment of the nerve. (C) Dissection between the aorta and the lumbar spine. (D) Dissection between the vena cava and the lumbar spine, ligating lumbar veins, when necessary.

Dissection continued over the lumbar spine, retracting the aorta (Fig. 2C) and the vena cava superiorly (Figs. 2D and 3A). In this step of the procedure, lumbar veins were ligated by using LT300 titanium clips, when necessary (Fig. 2D). The right nerve was identified at the right edge of the lumbar spine (Fig. 3B). The same procedure was performed for the right nerve. It was dissected, clipped (Fig. 3C), and sectioned (Fig. 3D).

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FIG. 3.

(A) Superior retraction of the vena cava. (B) Identification of the right nerve. (C) Placement of titanium clips at the right nerve. (D) Resection of the nerve.

The operative field was checked for any bleeding, and the retropneumoperitoneum was evacuated. Single sutures were put in the fascia and in the subcutaneous tissue. A cosmetic subcuticular suture was used in the skin. Patients were discharged from the hospital on postoperative day 1 and were reevaluated after 1 week and 1 month. During these consultations, they were interviewed and examined, in an attempt to identify their impression of the surgery, its results, and the development of any side effects.

Results

All BRLS were performed successfully by the same surgeon with the same technique from January through March 2009. Mean operative time and mean estimated blood loss were 59 minutes and 54 cc, respectively. We had no intraoperative complications. Patients received their first meal 6 hours after the procedure and were discharged home 12.8 hours after surgery (Table 2).

Immediate warming of the feet was observed at the end of all procedures. On follow-up consultations, all patients referred a complete resolution of the plantar hyperhidrosis, and only 1 patient complained about a new onset of compensative hyperhidrosis. That patient who presented compensative hyperhidrosis on the back and at the inguinal region due to the thoracic sympathectomy did not report improvement of the symptoms, but she did not observe any worsening of of symptoms as well (Table 3).

Discussion

The performance of sympathectomy leads to an alteration of the vasomotor tonus, providing the improvement of the microcirculation on the skin. Pathophysiologic explanations of this process include: immediate paralytic vasodilation, phenomena of hemometacinesis, and development of collateral circulation. ¹⁴ The procedure can be indicated in cases of chronic peripheral arterial insufficiency with an impossibility of revasculation, in thromboangiitis obliterans, and in vasoespastic ischemic disorders associated with functional arteriopathies. It can also be indicative of hyperhidrosis and sympathetic reflex dystrophy. The endoscopic thoracic sympathectomy is indicated for the treatment of palmar, axillary, and craniofacial hyperhidrosis. ¹¹ The results of plantar excessive perspiration, however, are less expressive (improved in up to 58% of cases). ¹⁵ Many patients with plantar hyperhidrosis who have undergone endoscopic thoracic sympathectomy still continue to experience excessive sweating of the feet after surgery.

The retroperitoneal lumbar sympathectomy is efficient in the treatment of plantar hyperhidrosis isolated from, or associated with, other affected areas that persist after endoscopic thoracic sympathectomy.^16,17 The conventional approach to lumbar sympathectomy, by open retroperitoneal access, can present some inconvenience inherent to any surgical procedure, such as extensive dissection, painful incision, and complications, such as surgical-site infection, hematoma, bleeding, postoperative ileus (if there is perforation of the peritoneum), and incisional hernia. However, it sustains some advantages, such as wide access to the retroperitoneal cavity, allowing easier resection of the sympathetic trunk and control of any bleeding efficiently and appropriately. ¹⁸

The use of laparoscopic techniques on sympathectomy shows the advantages of minimally invasive surgery and is feasible and efficient. The benefits include less painful postoperative course, faster convalescence, early return to daily activities and to work, and shorter hospitalization. The disadvantages are longer surgical time, mainly in the beginning of the learning curve, and reduced working space, which can make the complete resection of the ganglia (L2–L3) more difficult. ¹⁸ Some researchers perform the laparoscopic lumbar sympathectomy by the transperitoneal approach ¹⁹ with excellent results; others ²⁰ use the retroperitoneoscopic technique with the same favorable outcomes. Here, we described the lumbar sympathectomy by the unilateral retroperitoneoscopic approach, with success in a small group of patients. Our technique is different from Segers et al., ¹³ because they created the pneumoperitoneum by placing the Verres needle at the umbilicus to guide the placement of the retroperitoneal trocars, whereas we used only the retroperitoneal access, thereby avoiding the peritoneal cavity and its potential complications (e.g., postoperative ileus and intraperitoneal organ lesions). This method has the advantages of minimal invasiveness, with short skin incisions just in one side of the body. In that way, we were able to reduce the number of skin incisions to only three. In the study by Loureiro et al. ¹¹ on endoscopic retroperitoneal lumbar sympathectomy in women, despite the minimal cuts, the aesthetic outcome was only considered good for 53% of patients. This fact demonstrates a high degree of aesthetic exigency in this population, making conventional surgery for plantar hyperhidrosis almost unacceptable for these young patients. Hyperhidrosis interferes with patient self-esteem and vanity, which obliges surgeons to search for the best possible cosmetic results in this type of treatment, ¹¹ and the reduction of the number of incisions is a point to be considered. Perioperatively, we were able to have an excellent exposure of the structures. It was straightforward to display the sympathetic trunk as well as to identify the lumbar veins and arteries and avoid lesions to these structures.

Obese patients have more adipose tissue in the retroperitoneum and this can make the dissection of the sympathetic chain more difficult, once the working space obtained by retroperitoneoscopy is smaller than that created by the transperitoneal approach. ¹⁸ It is believed that there could be a worsening of compensatory sweating after the retroperitoneal lumbar sympathectomy, when adding the effects of thoracic sympathectomy to the lumbar regions of the same patient. ²¹ We did not report this worsening phenomenon. Postsympathectomy pain is reported to affect about 35% of patients. It appears between the the 10th and 20th postoperative days^22,23 and diminishes or disappears within a few months. We did not observe this complication in our patients. Injury to the ureter, which is described in the open technique, has not been recorded in the method discussed.^24,25

Conclusions

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