ORI GI N AL ARTI CLE
Re t r ope r it on e a l e n doscopic lu m ba r sy m pa t h e ct om y
W a n de r Edu a r do Sa r din h aI; Jose M a n oe l da Silv a Silv e st r eI; Fe r n a n do Th om a z in h oI I; Rodr igo Gom e s d e Oliv e ir aI I; D om in gos d e M or a is Filh oI
IPhy sician. Pr ofessor , Univ er sidade Est adual de Londr ina, Londr ina, PR, Br azil.
I IResident , Vascular Sur ger y Ser v ice, Depar t m ent of Sur gical Clinic, Hospit al Univ er sit ár io Est adual
do Nor t e do Par aná ( HURNP) , Univ er sidade Est adual de Londr ina, Londr ina, PR, Br azil.
Cor r espondence
J Vasc Br as. 2007; 6( 4) : 339- 43.
RESU M O
Con t e x t o: A sim pat ect om ia ainda encont r a indicação no t r at am ent o de v ár ias doenças, t ais com o
a insuficiência ar t er ial per ifér ica cr ônica at er oscler ót ica gr au I V ( Font aine) sem condições de
r ev ascular ização, úlcer as hiper t ensiv as e o fenôm eno de Ray naud acom panhado de lesões t r óficas. A cir ur gia clássica é r ealizada at r av és do acesso r et r oper it oneal, m as t am bém pode ser r ealizada por m eio de t écnicas m inim am ent e inv asiv as.
Obj e t iv o: Est e t r abalho t em o obj et iv o de m ost r ar os r esult ados da sim pat ect om ia lom bar por
pneum or et r oper it onioscopia.
M é t odos: Tr int a e um pacient es for am subm et idos a sim pat ect om ia lom bar por
pneum or et r oper it onioscopia ( 22 hom ens e nov e m ulher es) , com m édia de idade de 48 anos ( 41-70) . Vint e er am pacient es com insuficiência ar t er ial per ifér ica cr ônica, sem possibilidade de r ev ascular ização, t odos com lesões ( necr oses ou úlcer as) ; set e pacient es er am por t ador es de t r om boangeit e oblit er ant e; t r ês t inham úlcer a hiper t ensiv a; e um apr esent av a fenôm eno de Ray naud secundár io. As cir ur gias for am r ealizadas por pneum or et r oper it oneoscopia, sendo feit a a ex ér ese do segundo ao quar t o gânglio da cadeia lom bar .
Re su lt a dos: Não houv e com plicações int r a- oper at ór ias, hav endo necessidade de apenas um a
conv er são par a cir ur gia conv encional por dificuldade t écnica. A dur ação m édia do pr ocedim ent o foi de 103 m inut os e o t em po m édio de int er nação foi de 2 dias.
Con clu sã o: A sim pat ect om ia pode ser r ealizada por pneum or et r oper it onioscopia com as v ant agens
de um a cir ur gia m inim am ent e inv asiv a.
ABSTRACT
Ba ck gr ou n d: Sy m pat hect om y can st ill be per for m ed in t he t r eat m ent of m any diseases, such as
chr onic at her oscler ot ic per ipher al ar t er ial disease st age I V w it hout condit ions of r ev ascular izat ion, hy per t ensiv e ulcer and necr osis associat ed w it h Ray naud phenom enon. The classical t r eat m ent is per for m ed t hr ough r et r oper it oneal access, but can also be per for m ed t hr ough m inim ally inv asiv e t echniques.
Obj e ct iv e : This st udy aim s at ev aluat ing r esult s of r et r oper it oneal endoscopic lum bar
sy m pat hect om y .
M e t h ods: Thir t y - one pat ient s w er e subm it t ed t o r et r oper it oneal endoscopic lum bar
sy m pat hect om y ( 22 m ales and nine fem ales) , m ean age of 48 y ear s ( 41- 70) . Tw ent y pat ient s had chr onic per ipher al ar t er ial disease, w it h no possibilit y of r ev ascular izat ion, all pr esent ing w it h necr osis or ulcer ; sev en pat ient s had t hr om boangiit is oblit er ans, t hr ee had hy per t ensiv e ulcer , and one pat ient had secondar y Ray naud phenom enon. Sur gical pr ocedur es w er e per for m ed by
r et r oper it oneal endoscopic access, besides ex cision of ganglia L2- L4 of t he lum bar sy m pat het ic chain.
Re su lt s: Ther e w er e no int r aoper at iv e com plicat ions, only t he need of conv er t ing t o open sur ger y
due t o t echnical difficult ies. Mean oper at iv e t im e w as 103 m inut es and m ean hospit al st ay w as 2 days.
Con clu sion : Sy m pat hect om y can be per for m ed by r et r oper it oneal endoscopy using t he
adv ant ages of a m inim ally inv asiv e sur ger y .
Ke y w or ds: Lum bar sy m pat hect om y , r et r oper it oneal endoscopy .
I n t r odu ct ion
Since it s fir st use in 1920, by Adson & Br ow n1 in t he USA and Diez2 in Sout h Am er ica, sy m pat hect om y is st ill used for t he t r eat m ent of som e diseases.
Sy m pat hect om y changes v asom ot or t one, causing im pr ov em ent in sk in m icr ocir culat ion. The phy siopat hological bases of sy m pat hect om y ar e: 1) im m ediat e par aly t ic v asodilat at ion; 2) hem om et ak inesis phenom enon; 3) dev elopm ent of collat er al cir culat ion.3 The pr ocedur e can be indicat ed in cases of at her oscler ot ic chr onic per ipher al ar t er ial insufficiency w it h im possibilit y of r ev ascular izat ion, in t hr om boangiit is oblit er ans and in v asospast ic ischem ic m anifest at ions associat ed w it h funct ional ar t er iopat hies.4 I t can also be indicat ed for hy per hidr osis and r eflex
sy m pat het ic dy st r ophy .5
The conv ent ional t echnique of lum bar sy m pat hect om y by r et r oper it oneal access m ay pr esent som e inconv eniences inher ent t o any sur gical pr ocedur e, such as ex t ensiv e dissect ion, painful incision and com plicat ions such as sur gical w ound infect ion, hem at om a, bleeding, post oper at iv e par aly t ic ileus if t her e is inadv er t ent per for at ion of t he per it oneum and incisional her nia. How ev er , it s adv ant age is pr ov iding w ide access t o t he r et r oper it oneal cav it y , allow ing m or e facilit y of sy m pat het ic chain ex cision and cont r ol of bleeding m or e efficient ly and appr opr iat ely .
M e t h od
From October 2003 to February 2007, 31 patients were submitted to RELS. Of these, 22 were male and nine were female (Table 1), mean age of 48 years (41-70). A total of 34 sympathectomies were performed, three bilateral – two patients with thromboangiitis obliterans and one patient with chronic peripheral arterial insufficiency (CPAI). The patients submitted to bilateral RELS needed that procedure at different moments, because the lesions were manifested at different times.
There were no diabetic patients. All 20 patients with atherosclerotic CPAI had trophic lesions (necrotic ulcers or gangrene). Of these, 11 had ulcers and nine had toe gangrene. All seven
patients with thromboangiitis obliterans, diagnosed by Shionoya criteria,5 had ischemic ulcers or
gangrene, and three of them had been previously submitted to contralateral lumbar
sympathectomy by conventional open access, and two had been previously submitted to cervical-thoracic sympathectomy due to finger gangrene. As to the three patients who had hypertensive ulcer, none of them had a satisfactory response with clinical treatment. One female patient had toe gangrene in the lower limb due to Raynaud phenomenon associated with mixed disease of the connective tissue. In our sample, three patients had body mass index (BMI) > 31. Presence of obesity brought technical difficulties in the access, in creation of retroperitoneal cavity and in identification of sympathetic chain due to higher presence of fat in that space.
Su r gica l pr oce du r e
int r oduce t he t r ocar . The sit e of t hose incisions is r epr esent ed in Figur e 2. The fir st 2- 3 cm incision is locat ed in t he ant er ior ax illar y line, half w ay t hr ough t he coast al r idge and t he iliac cr est , by w hich a 10- m m cam er a w as int r oduced. Thr ough t his fir st ent r y , a blunt dissect ion w as init ially per for m ed, pr ogr essing t hr ough t he aponeur ot ic m uscle unt il r eaching t he per it oneum . At t hat m om ent , a finger dissect ion w as per for m ed, r eflect ing t he per it oneum m edially unt il r eaching t he r et r oper it oneal fat ; nex t , t he 10- m m t r ocar is inser t ed t o cr eat e space, r eflect ing t he per it oneum m edially . Then, bot h incision ex t r em it ies w er e sut ur ed at t he fascia t o av oid leak age of car bon gas, w hich w ill be insufflat ed w it h 12- 14 m m Hg pr essur e.
Cr eat ion of a space in t he r et r oper it oneal cav it y , by inflat ing t he gas, and w it h t he aid of a cam er a t hat pr ov ides dir ect and safer v isualizat ion, allow s int r oduct ion of t he second and t hir d por t als. The second 10- m m por t al is placed ar ound 2- 4 cm lat er ally t o t he r ect us abdom inis sheat h, dist ally t o t he cam er a por t al. The t hir d por t al, m easur ing 5 m m , is placed in t he sam e r efer ence as t he second, but in pr ox im al posit ion. These t w o lat t er por t als ar e used as w or k inst r um ent s ( dissect ion and gr asping) . A four t h por t al is oft en needed t o place a t hir d w or k inst r um ent ( liv er r et r act or ) , w hich w ill r et r act t he psoas m uscle super ior ly , since it fr equent ly cov er s t he sy m pat het ic chain, m ak ing v isualizat ion difficult .
m edially t o it and using a cur ve dissect ion and gr asping for ceps, being car eful not t o dam age adj acent st r uct ur es, such as ur et er , lum ber ar t er ies and v eins ( Figur e 3) . The sy m pat het ic chain r uns t hr ough t he dihedr al angle for m ed by t he psoas m uscle and v er t ebr al bodies. Pr oper
dissect ion should be per for m ed t o ex pose t he dist al segm ent of t he lum bar sy m pat het ic t r unk t o ident ify t he L4 ganglion. Fr om t hat point , 3- 4 cm of t he chain is r esect ed pr ox im ally . At t he end of t he pr ocedur e, hom eost asis and fascia sy nt hesis ar e r ev iew ed.
Re su lt s
Thir t y - one pat ient s w er e subm it t ed t o RELS, w it h a t ot al of 34 pr ocedur es per for m ed by r et r oper it oneal endoscopy ( 12 pr ocedur es t o t he r ight , 19 t o t he left and t hr ee bilat er al
pr ocedur es) . All pr ocedur es w er e successfully per for m ed; how ev er , due t o t echnical difficult ies, it w as necessar y t o conv er t t o conv ent ional open sur ger y in one pat ient . That pat ient w as obese, w it h a lar ge am ount of r et r oper it oneal fat , r equir ing ex t ensiv e dissect ion and being difficult t o pr oper ly ident ify t he st r uct ur es, w hich m ade t he pr ocedur e t echnically difficult . Aft er conv er sion t o
conv ent ional open sur ger y , t he r et r oper it oneal fat , w hich had been dissect ed, w as r em ov ed and t her e w as no difficult y in ident ify ing t he sy m pat het ic chain.
Ther e w as per for at ion of t he per it oneum in four cases. The r et r oper it oneal cav it y cr eat ed by t he car bon gas is sm all and t he per it oneal opening m ak es t he insufflat ed gas in t he r et r oper it oneal cavit y also pass t o t he per it oneal cav it y . This r esult s in a r educt ion in t he space cr eat ed by t he pneum or et r oper it oneum , m ak ing t he pr ocedur e longer due t o t he difficult y in per for m ing it in an ev en sm aller space. How ev er , it is not necessar y t o per for m conv er sion t o conv ent ional sur ger y due t o per it oneal per for at ion.
One month after the surgery, none of the patients complained about neuralgia and only one patient had hypoesthesia in the inguinal region. There was no sexual dysfunction in men, even in those who were submitted to bilateral RELS.
Of the patients with CPAI without conditions of revascularization, nine had gangrene restricted to toes and 11 had ischemic ulcers. Of the nine patients with toe gangrene, seven had healing after debridement. Of the two patients with more extensive lesions, one was submitted to
transmetatarsal amputation and one to transtibial amputation due to extensive lesion infection. The 11 patients with ulcers had lesion healing during the 6-month follow-up.
Of the seven patients with thromboangiitis obliterans, six had toe gangrene and one had ischemic ulcer. They all had good response with healing and improvement in pain pattern. The patients with hypertensive ulcer had good response, with lesion healing.
The patient with Reynaud syndrome, after sympathectomy, was submitted to toe amputation of the affected limb and progressed with complete healing.
D iscu ssion
Indication of lumbar sympathectomy has been reduced due to success of distal revascularizations and new drugs. However, a considerable number of patients cannot be submitted to arterial reconstruction or has trophic lesions associated with vasospastic phenomena that do not respond
to pharmacological therapy. The Tr ansAt lant ic I nt er- Societ y Consensus(2000)6established the
indications for lumbar sympathectomy: 1 – main: selected patients with distal occlusive disease that cannot be submitted to surgery and thromboangiitis obliterans. Surgery impossibility mainly depends on lack of distal drainage; 2 – sympathectomy is indicated in patients whose ankle-brachial index is higher than 0.3; that tissue necrosis is limited to toes and absence of neuropathy (diabetes). Conventional lumbar sympathectomy, with risks inherent to any open surgery, remains as standard surgery for these patients. All patients in this series had ankle-brachial index higher than 0.3.
Chemical sympathectomy,7,8 through radiologically-guided percutaneous injections of phenol or
alcohol, shows some success in a few series, but in others9it shows inconstant results, especially
regarding duration of sympathetic blockade.
Use of laparoscopic techniques in sympathectomy shows the advantages of minimally invasive surgery and makes the procedure feasible and efficacious.
Some authors use laparoscopic sympathectomy using the transperitoneal access10 with excellent
outcomes; however, we prefer the pneumoretroperitoneum technique due to lower clinical
repercussions of an intra-abdominal hypertension. Beglaibter et al.11described their technique for
RELS with excellent outcomes. The retroperitoneal endoscopic technique was described by Gaur12
in 1992, but there are other variations, such as use of balloon placed through a small incision in
the retroperitoneal space.13
Use of a fourth portal was necessary in 12 surgeries. That instrument, which is a liver retractor, was crucial for continuing the surgical procedure in these cases, since it allows raising the psoas muscle, or perhaps retracting the peritoneal sac. Besides some advantages and difficulties previously mentioned, such as difficulty in obese patients and long learning curve,
videolaparoscopy has restricted indications in vascular surgery (opposed to digestive surgery) and small cavity for the procedure. We believe that RELS using video is a safe and technically
accessible surgery for experienced surgeons in videolaparoscopy. The excellent clinical outcomes are compared to conventional open surgery, with the advantages of a minimally invasive surgery.
Re fe r e n ce s
1. Adson AW, Brown GE. Treatment of Raynaud’s disease by lumbar ramisection and
ganglionectomy and perivascular sympathetic neurectomy of the common iliac arteries. JAMA 1925;84:1908-10.
2. Diez J. Un nuevo metodo de simpatectomia perif‚rica para el tratamiento de las afecciones trƒficas y gangrenosas de los miembros. La disociacƒn fascicular. Bol Soc Cir Buenos Aires. 1924;8:792-4.
3. Puech-Le„o P. Cirurgia do sistema nervoso simp…tico: bases t‚cnicas. In: Goffi FS, editor. T‚cnica cir†rgica: bases anat‡micas, fisiopatolƒgicas e t‚cnicas da cirurgia. 4a ed. S„o Paulo: Atheneu; 1996. p. 200-3.
4. Kauffman P. Simpatectomias. In: Raia AA, Zerbini EJ, editores. Clˆnica cir†rgica Alˆpio Corr‰a Neto. 4a ed. S„o Paulo: Sarvier; 1994. p. 84-101.
5. Shionoya S. Diagnostic criteria of Buerger’s disease. Int J Cardiol 1998;66(Suppl 1):S243-5.
6. Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg. 2000;31(1 Pt 2):S1-S296.
7. Cross FW, Cotton LT. Chemical lumbar sympathectomy for ischemic rest pain. A randomized, prospective controlled clinical trial. Am J Surg. 1985;150:341-5.
8. Yoshida WB, Lem‡nica L, Rollo HA, et al. Bloqueio simp…tico lombar com fenol nas oclusŠes arteriais cr‡nicas de membros inferiores. Cir Vasc Angiol. 1994;10:20-4.
9. Redman DR, Robinson PN, Al-Kutoubi MA. Computerised Tomography guided lumbar sympathectomy. Anaesthesia. 1986;41:39-41.
10. Kathouda N, Wattanasirichaigoon S, Tang E, Yassini P, Ngaorungsri U. Laparoscopic lumbar sympathectomy. Surg Endosc. 1997;11:257-60.
11. Beglaibter N, Berlatzky Y, Zamir O, Spira RM, Freund HR. Retroperitoneoscopic lumbar sympathectomy. J Vasc Surg. 2002;35:815-7.
12. Gaur DD. Laparoscopic operative retroperitoneoscopy: use of a new device. J Urol. 1992;148:1137-9.
Cor r e spon de n ce :
Wander Eduardo Sardinha
Rua Borba Gato, 1079 - Jardim Ipiranga CEP 86010-630 – Londrina, PR, Brazil Tel.: (43) 3322.1411, (43) 9911.3015 Email: wandersardinha@uol.com.br
Study presented at the 36th Brazilian Congress of Angiology and Vascular Surgery.
