Retroperitoneoscopic lumbar sympathectomy for buerger's disease: a novel technique

The conventional lumbar sympathectomy procedure through the extraperitoneal route requires a muscle cutting-splitting incision, which leads to significant postoperative pain and prolonged convalescence. With increasing experience in retroperitoneoscopic procedures, we did a pilot study to explore the role of retroperitoneoscopy in lumbar sympathectomy. We describe herein our technique used for the surgery.

The patient was placed in a lateral position. A 15-mm incision was made just below the 12th rib, and retroperitoneal space was created using blunt finger dissection. A custom-made, large balloon was inserted and inflated with the equivalent of 750 mL to 1000 mL of saline. The second 10-mm port was placed in line with the first port above the iliac crest. The third and fourth 5-mm ports were placed anterior to the first 2 ports. Peritoneum was retracted anteriorly. The medial border of the psoas muscle was used as a landmark and a chain identified immediately medial to it. Lumbar vessels were ligated on the right side. The first to fourth lumbar sympathetic ganglia were removed with the intervening chain. The port sites were closed without a drain.

We attempted and successfully completed this procedure in 8 patients; 6 on the left side and 2 on the right side. The average operating time was 38 minutes. The mean hospital stay was 1.5 days. All patients had symptomatic pain relief and clinical improvement.

Retroperitoneoscopic lumbar sympathectomy is a safe and effective procedure. It has a short convalescent time and minimal morbidity; hence, it is a viable alternative for the open procedure.