Modified Endoscopic Lumbar Sympathectomy for Plantar Hyperhidrosis

Abstract

Objective:

To demonstrate a novel supine retroperitoneoscopic technique for bilateral endoscopic lumbar sympathectomy in the treatment of refractory plantar hyperhidrosis, allowing bilateral access without patient repositioning or entry into the peritoneal cavity.

Materials and Methods:

A 22-year-old male presented with a 2-year history of severe bilateral plantar hyperhidrosis causing difficulty wearing footwear and significant social discomfort. Conservative treatments, including topical aluminum chloride and iontophoresis, failed to provide durable relief. Clinical assessment confirmed severe plantar hyperhidrosis with a Hyperhidrosis Disease Severity Scale score of 4 and a Dermatology Life Quality Index score of 15. The procedure is performed under general anesthesia with the patient in the supine position. A 2-cm incision is made at the level of the umbilicus along the mid-axillary line. After splitting the abdominal wall muscles, the retroperitoneal space was developed by blunt finger dissection. A balloon dissector was introduced and inflated with approximately 450–500 mL of air to create the retroperitoneal working space. Two additional 5-mm working ports were inserted under direct guidance to establish a triangular port configuration. Carbon dioxide insufflation is maintained at 20 mmHg. The psoas muscle is used as the primary anatomical landmark. The lumbar sympathetic chain is now identified along the medial border of the psoas muscle within the prevertebral space. On the right side, the chain lies posterior to the ureter and inferior vena cava, while on the left side, it is located posterior and lateral to the infrarenal aorta. The sympathetic chain was carefully dissected and clipped at the L3–L4 level using titanium clips. The same procedure is subsequently performed on the contralateral side without repositioning the patient. Clip placement is confirmed under C-arm guidance.

Results:

The procedure was completed successfully without intraoperative complications. The patient experienced immediate cessation of plantar sweating in the early postoperative period. There were no neurological deficits, vascular complications, or compensatory hyperhidrosis. The patient is mobilized early and discharged within 24 h. At 36 months’ follow-up, the patient remained asymptomatic with sustained anhidrosis and significant improvement in quality of life.

Conclusion:

Supine retroperitoneoscopic lumbar sympathectomy provides a safe and effective minimally invasive option for the treatment of refractory plantar hyperhidrosis.

Patient consent statement:

Written informed consent was obtained from the patient for publication of this case demonstration as a video.

Consent was obtained for video recording and publication prior to the procedure.

Source of work:

Clinical practice.

No funding was received for this article.

The authors declare no conflicts of interest.

Runtime of video: 6 min 30 sec.