Lumbar and thoracic sympathectomy. Operation sympathectomy - what is it, patient reviews, types Lumbar sympathectomy or dripping once a year

UDC 616-072.1:616.832.14

L.E. Gylykov, B.Ch. Damdinov, B.A. Donirov

Videoendoscopy for lumbar sympathectomy

Republican Clinical Hospital named after. N.A. Semashko (Ulan-Ude)

The results of using videoendoscopic lumbar sympathectomy indicate its high effectiveness, and. low morbidity. The duration of surgical intervention and postoperative rehabilitation of patients is reduced, and the likelihood of complications is reduced. This intervention is preferable compared to traditional operations, especially in patients with severe concomitant pathology. It may be recommended as well. as an independent method of treatment, etc. as an addition to reconstructive operations on vessels below the inguinal fold.

Keywords: videoendoscopy, lumbar sympathectomy

videoendoscopy at lumbar sympathectomy

L.E. Gilikov, B.Ch. Damdinov, B.A. Donirov

Republican Clinical Hospital named after N.A. Semashko (Ulan-Ude)

The results of using videoendoscopic lumbar sympathectomy test to its high efficacy and low traumaticity. Duration of surgical intervention and postoperative rehabilitation, and also the probability of complications are reduced. This intervention is preferable in comparison with traditional surgeries especially in patients with severe concomitant diseases. It may be recommended, as an independent method, of treatment and. as an addition. to reconstructive surgeries on vessels lower inguinal fold.

Key words: videoendoscopy, lumbar sympathectomy

introduction

In the last decade, endoscopic operations have become increasingly widespread in operative surgery of many specialties. This is due to the improvement of endoscopic surgical techniques, which have shown their advantages in various areas, providing patients with greater comfort, best results and even a reduction in the number of complications. However, in vascular surgery, especially in operations on the aorta, which usually require more free access, there are some concerns about switching to this method. And yet, one of the niches for the use of endoscopic operations in angiology is the performance of video endoscopic sympathectomies.

Ganglion sympathectomy is one of the most famous and widespread surgical interventions for the treatment of patients with occlusive vascular lesions lower limbs, introduced by Diez in 1924. It is believed that ganglion sympathectomy most completely and lastingly eliminates vasospasm, eliminates or significantly reduces associated pain, thus affecting the main pathological links of obliterating diseases of the main and peripheral arteries (OZMPA). The effectiveness of desympathization increases when it is combined with other pathogenetically based operations.

However, traditional approaches to the thoracic and lumbar sympathetic trunks are highly traumatic (the need for thoracotomy during thoracic sympathectomy, intersection of the major

muscle groups when performing extraperitoneal access for lumbar sympathectomy). Thus, it is initially possible to predict various intra- and postoperative complications: wound suppuration, pneumo- and hemothorax, damage to vessels in the retroperitoneal space, the development of persistent intestinal paresis, retroperitoneal hematomas, intersection of the ureter, etc. The relevance of this problem is high for the elderly and old age with significant concomitant pathology.

Therefore, the use of minimally invasive surgery, which includes videoendoscopic sympathectomy, may be an alternative method surgical treatment patients with acute urolithiasis.

material and methods

For the treatment of occlusive arterial diseases upper limbs Thoracoscopic thoracic sympathectomy has been successfully used in our department since 1996. Considering the significant therapeutic and economic effect of this operation, we began to more actively implement the tactics of using endoscopic operations on the lumbar sympathetic trunk. Since 1999, endoscopic lumbar sympathectomy has been considered for all patients referred to our department for lower extremity urolithiasis. Indications for surgery were the presence in patients of obliterating endarteritis and obliterating atherosclerosis of the vessels of the lower extremities with a distal level of damage. When selecting

patients for surgery were guided by the following criteria: the presence of a distal level of damage to the arteries of the lower extremities and a positive test with vasodilators during rheovasography. To objectify the degree of disturbance of the blood supply to the lower extremities, rheovasography and Doppler ultrasound of the vessels were used, and, if necessary, X-ray contrast examination of the vessels was performed. The degree of ischemia of the lower extremities was determined according to the Fontan classification as modified by A.V. Pokrovsky. Patients who met the selection criteria were offered endoscopic surgery. After receiving an explanation, patients gave informed consent. Video endoscopic lumbar sympathectomy was performed using endoscopic devices from Richard Wolf and Karl Shtorz.

TECHNIQUE OF VIDEOENDOSCOPIC LUMBAR SYMPATECTOMY

Videoendoscopic lumbar sympathectomy was performed under general anesthesia with the patient positioned on the healthy side using a bolster. In the lumbar region, along the mid-axillary line, using a 10-mm thoracoport with optics under eye control, a cavity was created in the retroperitoneal space under gas pressure of up to 15 mm Hg. Art. Two 5-mm thoracoports were inserted into the formed cavity along the anterior axillary line, and then, using conventional clamps, blunt access was made towards the spine and, accordingly, to the lumbar sympathetic ganglia. Ganglia at the L2 - L4 level were isolated and dissected, after which hemostasis was checked, followed by removal of gas, removal of instruments and application of skin sutures.

For the period 1999 - 2003. In the Department of Vascular Surgery of the Republican Clinical Hospital in Ulan-Ude, more than 20 video-endoscopic lumbar sympathectomies were performed on patients with obliterating diseases of the lower extremities. We studied the last 11 patients operated on using this technique, two of them on both sides (group 1). For comparison, we took a group of patients operated on during the same period using the traditional open technique, totaling 20 people (group 2). The average age of patients in group 1 was 53 (46 - 60) years, the average age of patients in group 2 was 54.5 (41 -65) years, that is, no significant difference in age was detected (p = 0.74). Patients in both compared groups had grade 11B ischemia.

RESULTS

Length of intervention time open method lumbar sympathectomy was 45 (35 - 50) minutes. After the introduction of the video endoscopic method of lumbar sympathectomy, the duration of the operation was

35 (20 - 45) minutes, but these differences are not significant (p = 0.12).

During surgical intervention in group 1, two complications were recorded - pneumoperitoneum, which was subsequently eliminated endoscopically, and intestinal paresis, which occurred after bilateral desympatization. In other cases, postoperative observation showed a significant reduction in pain associated with the operation, adequate restoration of intestinal transit, and rapid general recovery. In group 2, 6 complications were recorded, of which there was 1 postoperative wound suppuration, 4 postoperative intestinal paresis, 1 hematoma and 1 bleeding. However, there were no significant differences in the presence of complications in the 1st and 2nd compared groups (p = 0.25).

Due to the low traumatic nature of video-endoscopic surgery, patients were able to move freely on the second day and continue drug and physiotherapeutic treatment. The postoperative bed-day in the 1st group was 4 (4 - 4) days, in the 2nd group - 10 (8-14) days. The difference turned out to be statistically significant (p = 0.000007), which proves the pronounced economic effect of videoendoscopic sympathectomy.

DISCUSSION

Videoendoscopic manipulations in the retroperitoneal space are understandably accompanied by significant technical difficulties. To prevent complications during and after surgery, clear visualization of the main anatomical structures is of great importance. To reduce the risk of injury to the great vessels, as well as the parietal peritoneum and ureter during lumbar sympathectomy, care must be taken when creating a cavity in the retroperitoneal space and mobilizing the sympathetic trunk, as well as ensuring full visualization of the working part of endoscopic instruments when performing electrocoagulation, excluding the possibility of contact with adjacent organs. Therefore, the qualifications and experience of the operating endoscopic surgeon are of great importance.

The immediate results of lumbar endoscopic sympathectomy are very encouraging. In almost all patients with acute urolithiasis in the postoperative period, clear positive dynamics are observed, manifested in an increase in skin temperature, the disappearance of dyshidrosis, and a change in skin color. This proves its high efficiency, comparable to that of traditional access. In addition, after endoscopic lumbar sympathectomy, reconstructive operations on the arteries below the inguinal fold can be successfully performed with restoration of the main blood flow. There is no doubt that all patients after desympatization should be under long-term regular observation with anti-relapse measures.

courses of drug treatment. The nature of the course and prognosis of obliterating arterial diseases, as well as the timely and adequate choice of treatment tactics, largely depend on these factors.

Thus, the results of using video-endoscopic lumbar sympathectomy indicate its high efficiency and low morbidity. The duration of surgical intervention and postoperative rehabilitation of patients is reduced, and the likelihood of complications is reduced. This intervention is preferable to traditional operations, especially in patients with severe concomitant pathology. It can be recommended both as an independent method of treatment and as an addition to reconstructive operations on the vessels below the inguinal fold. Good immediate and, in most cases, long-term results are the basis for the wider use of these operations in the complex treatment of patients with obliterating diseases of the vessels of the extremities of various etiologies.

literature

1. Gaibov A^. The role of ganglion sympathectomy in the treatment of obliterating diseases of the vessels of the lower extremities In K.K. Gaibov, D.D. Sultanov, M.Sh. Bakhrudzinov UU Angiology and vascular surgery. - 2001. - T. 7, No. 1. - P. 70 - 74.

2. Kokhan E.P. Lumbar sympathectomy in the treatment of vascular diseases (history, problems, prospects) In E.P. Kokhan, V.E. Kokhan, O.V. Pin chuk. - M., 1997. - 125 p.

3. Kokhan E.P. Removal of intrathoracic sympathetic ganglia in the treatment of Raynaud's disease U E.P. Kokhan, O.V. Pinchuk, A^. Fomenko UU Endoscopic surgery. - 1997. - No. 1. - P. 3 - 5.

There are times when hyperhidrosis cannot be treated with external means and medicines.

The only method of elimination increased sweating What remains is sympathectomy - the operation of cutting the trunk of the sympathetic nerve.

The sympathetic nervous system is responsible for the active functioning of the sweat glands. Its peripheral part (sympathetic trunk) is located on the surface of the spine, along its entire length. Nerve fibers extend from the trunk, innervating various organs and glands, including sweat glands.

The sympathectomy method is based on clamping or complete destruction of the branches of the sympathetic trunk, which are responsible for the innervation of the sweat glands of the axillary region, palms, and, less commonly, feet.

In this case, sweating in the problem area stops completely. Despite all its effectiveness, the operation has many disadvantages, due to which it is used only for severe hyperhidrosis that is not amenable to other treatment.

Having understood what sympathectomy is, it is worth learning in more detail about who is prescribed this type of surgical intervention. It has few indications, and they are all associated with excessive activity of the sympathetic nervous system.

The operation is performed in following cases:

  • primary, not associated with other diseases;
  • Raynaud's disease - damage to the small vessels of the hands, manifested by spasm of the fingers, swelling, cyanosis and the formation of trophic ulcers;
  • Blushing syndrome - intense redness of the face that occurs with any manifestation of emotion;
  • Sudeck's syndrome is a post-traumatic pain syndrome with severe trophic disorders of the limbs.

Before a sympathectomy, a thorough examination of the patient is carried out in order to confirm its necessity and identify any deviations in health that may affect the course of the operation and the course of the postoperative period.

The operation to cut the branches of the sympathetic trunk has many risks:

  • According to reviews from patients with sympathectomy, sweating in other places increases after surgery. This phenomenon is called compensatory hyperhidrosis. It occurs due to the fact that when the sweat glands in one area stop working, in order to maintain normal thermoregulation processes, increased fluid removal from the glands of other parts of the body is required. This effect develops in 5% of those undergoing surgery.
  • The occurrence of relapses. If the volume of the operation is incomplete, it is possible to restore the nerve fibers of the sympathetic trunk, which leads to the absence of the desired effect.
  • Damage to the intrathoracic sympathetic node. Accompanied by Horner's syndrome, manifested in unilateral disruption of the innervation of the eye muscles: drooping upper eyelid, unusually small pupil, recession eyeball.
  • Entry of air or blood between the layers of the pleura (pneumothorax/hemothorax) due to incorrect actions of the surgeon during sympathectomy.
  • Pain syndrome after surgery. Normally it lasts no more than a few days.
  • Harlequin syndrome. Unilateral redness of the skin and sweating, which occurs due to incomplete destruction of nerve fibers.
  • Side effects general anesthesia: nausea, headaches, allergic reaction, pain, pulmonary infections.

Based on the degree of destruction of the branches of the sympathetic trunk, the following types of sympathectomy operations are distinguished:

  • Reversible. A clamping clip is applied to the nerve fibers, disrupting the conduction of impulses to the sweat glands. This type of intervention is convenient because if compensatory hyperhidrosis develops in other parts of the body, the clip can be removed and side effects eliminated. This is possible in the first three months after surgery, after which the nerve is damaged irreversibly. Sometimes the clip does not always completely compress the nerve and the operation does not bring the desired effect.
  • Irreversible. The nerve is cut, which does not give it the opportunity to recover. Sweating in the operated area disappears forever; there is no opportunity for nerve regeneration with the development of compensatory hyperhidrosis.

The methods of performing the operation also differ:

  • Open sympathectomy. An incision is made along the back of the chest between the ribs, through which access to the desired nerve is achieved. It is crossed or clamped with a clip. This method outdated and practically not carried out - it is extremely traumatic, the postoperative rehabilitation period is long, and a deep scar remains at the incision site.
  • Percutaneous method. An electrode is inserted through a small incision under X-ray control to burn out the nerve. A catheter is also inserted, through which a chemical cauterizing substance is supplied to the nerve. The method is labor-intensive, there is a high probability of injury to the pleura, neighboring nerves and vessels. Not widely used.
  • Endoscopic sympathectomy. Special endoscopic instruments and a mini-camera are introduced through punctures in the skin, which allows the surgeon to control all his actions. The sympathetic nerve is cut or pinched in the desired location. With this type of surgical intervention, the risks of erroneous injury to other nerves and neighboring tissues are minimal. The postoperative period is easy and quick, the scars on the skin are almost invisible.

Depending on the location of the problem area increased sweating, surgical access can be lumbar (sweating feet) and thoracic (hyperhidrosis of the face, armpits, palms, upper half of the body).

Lumbar sympathectomy is rarely performed, especially in men, because of the possible damage to the nerves leading to the genitals and the development of impotence.

After endoscopic intervention, hospital stay lasts no more than a few days. According to reviews from patients with sympathectomy, the effect develops immediately after surgery.

Recovery period does not require special appointments, the main thing is to carefully monitor your well-being. In order for the rehabilitation to be successful, it is necessary to remember that if severe sweating occurs in other parts of the body or if there is no effect from the operation, it is necessary to urgently contact a surgeon.

26.05.2017

You will learn what a sympathectomy is, when it is performed, and the difference between endoscopic thoracic and thoracoscopic methods of surgery. We will also consider prices and reviews for such treatment.

Among other things, I will tell you for what diseases such an operation is performed, what are the indications and contraindications. Let’s briefly touch on the progress of the operation and possible risks to the patient’s health.

What is sympathectomy

- This surgery by blocking nerves in the sympathetic nervous system.

As a rule, it is carried out in two main cases:

  1. For (excessive sweating)
  2. For atherosclerosis of the lower extremities (done to increase blood flow)

Below we will look at these two main tasks in more detail.

Endoscopic sympathectomy for hyperhidrosis

Endoscopic sympathectomy is an operation that is used in extreme cases of palmar hyperhidrosis and stress-induced redness of the face.


The operation itself has been proposed for a long time. Back at the end of the 19th century. However, at that time it was used for a wide range of indications and not always effectively.

The first uses against hyperhidrosis were carried out in the 20s of the last century. However, sympathectomy began to be widely used only with the introduction of thoracoscopic techniques.

In the beginning there were primitive thoracoscopes with no serious optical effort. However, with the use of modern endoscopic equipment, such operations have become much easier, safer and without complications.

Currently, thin endoscopes, good magnifying optics and excellent instruments are used during surgery. All this makes the operation the safest in qualified hands.

Operation requirements

Modern performance of sympathectomy surgery is based on several positions:

  1. It should be performed by a thoracic surgeon. Despite what other surgeons who undertake this operation may say, there is a potential risk of complications. In this case, only the experience of a thoracic surgeon can save the patient from very serious problems.
  2. The operation must be performed in the presence of a qualified anesthesiological team. Although the operation is quite fast. However, during its implementation, certain changes in the rhythm of cardiac activity and a decrease in oxygen consumption are possible. The anesthesiologist must be prepared for such turns in advance.
  3. The operating room should be equipped with good endoscopic equipment. Since the operation is performed on very small structures, clear visibility and excellent magnification are necessary.

How is thoracic sympathectomy performed?

Endoscopic thoracic sympathectomy ( also called chest) is performed under general anesthesia and on both sides. Sometimes the patient is told that we will perform the operation on one side. Then you will stay with the drainer for 2-3 days and then we will discharge you. And after some time ( 1 – 6 months) let's do the operation.


Now, if you were told this, then I would warn you against having surgery in such clinics. Because they clearly do not have modern knowledge in this field of surgery.

Sympathectomy can always be performed in one stage. The only exceptions can be very rare cases, which we will discuss below.

In general, the operation begins with the introduction of chest(into the pleural cavity) carbon dioxide. Due to this, the lung collapses and moves away from the top of the pleural cavity. As a result, the nerve is exposed. It needs to be examined, selected and then either intersected, or a section of it removed, or clipped.

In good clinics they generally prefer riveting. Then the patient still has the possibility of nerve recovery after removal of the clip.

The need for such precautions is due to the fact that one of the undesirable side effects of sympathectomy is the risk of developing severe sweating of the torso. The so-called compensatory hyperhidrosis.

With palmar hyperhidrosis, it does not bother you as often. However, in at least 4% of patients operated on for palmar hyperhidrosis, it causes very heavy sweating torso. She creates more more problems patients than with sweaty palms.

After completing the operation on one side, the surgeon straightens the lung and leaves no drainage ( tubes in the pleural cavity) except in certain cases. For example, if there are adhesions in the pleural cavity.

By the way, the presence of adhesions is another reason why the operation should be performed by a thoracic surgeon. Only he will be able to adequately assess the condition of the lungs and the possibility of performing surgery on another lung without harming the patient’s health.

Thoracic sympathectomy on the other side is performed in exactly the same way. A peculiarity may be that when performing the second stage, the anesthesiologist may note a slight decrease in blood oxygen saturation. But this is then very quickly compensated for.

During this second stage, there is also a decrease in heart rate, which is a direct consequence of the sympathectomy.

Postoperative period

In the postoperative period, patients require rest and control X-ray studies. In some cases, ultrasonic testing may be used.

Immediately after surgery, you may experience fairly intense pain in the chest area and between the shoulder blades. This is a direct consequence of the entry of the troacans between the ribs.

But the very next day the severity of the pain decreases significantly. In general, patients leave without the need to take pain medications. And within 3 - 4 days the pain usually goes away completely.

The incisions in endoscopic sympathectomy are minimal. Therefore, after the stitches are removed and after 2-3 months, they turn white and become almost invisible.

Sympathectomy for facial redness

Facial redness techniques may be considered as other indications for sympathectomy. In this case, the operation is carried out according to several other requirements. It is performed higher in an area that is more risky for an inexperienced surgeon.

This operation is more responsible. Therefore, before conducting it, be sure to find out the reputation of this clinic and its doctors.

It is after this operation that complications occur in the form of Horner's syndrome. A very clear selection of patients is also necessary, since the risk of severe compensatory hyperhidrosis is significantly higher than with surgery against palmar hyperhidrosis.

Severe compensatory hyperhidrosis occurs in almost 9% of patients.

Sympathectomy for both palmar hyperhidrosis and stress facial flushing is a last resort treatment. In any case, you need to try all the possibilities for conservative therapy to avoid surgery.

But if the need for such an operation continues, then it is better to contact clinics that already have significant experience in carrying out this treatment. There must also be a surgeon who will be prepared for all potential problems encountered during the operation.

What are the dangers of thoracoscopic sympathectomy?

- This traditional method manipulations with the sympathetic nerve trunk. That is, the skin and muscles in the neck area are cut, which gives very extensive access to the nerve.

It is precisely because of the extensive surgical access that problems may arise after this method of operation. For example, there may be heavy bleeding. Therefore, never agree to this method of performing an operation!

The endoscopic option is safer and does not leave noticeable scars. For comparison, this method makes an incision of less than one centimeter. We also use more modern equipment, which reduces health risks.

is a palliative method of treating diseases of the blood supply to the extremities, accompanied by ischemia, intermittent claudication and trophic disorders. The method allows you to improve blood circulation without interfering with the main vessels.

Lumbar sympathectomy for atherosclerosis of the lower extremities

Diseases:

  • Atherosclerosis of the lower extremities
  • Trophic ulcers of the legs
  • Diabetic macroangiopathy
  • Endarteritis, etc.

Sympathectomy itself implies the exclusion of the nerve nodes responsible for the narrowing of peripheral vessels from the normal functioning.

Previously, such interventions were part of arterial interventions or were performed independently. For this purpose, open surgery methods were used, and the access itself was performed under general anesthesia.

Considering that the sympathetic nodes lie on the anterior surface of the spine, the surgeon had to go quite deep. As a result, there were complications from anesthesia, surgical access, from a long hospital stay, and so on.

Today, a modified sympathectomy technique is used for atherosclerosis of the lower extremities. It is carried out under the control of a computed tomograph.

Doctors precisely and very accurately puncture the area of ​​the node. Next, a neurolytic drug is directly administered, which completely disables the node from normal functioning.

Administration of a neurolytic drug

The consequence of this procedure is to disable the constricting effect on the vessels. As a result, the vessels dilate and fill with blood.

We see the first effects in the first 30 minutes. The legs begin to warm up, the pain syndrome decreases, and the blood supply to the extremities improves.

Indications for sympathectomy surgery

Indications for sympathectomy surgery are some diseases of the arteries and some diseases of the veins with trophic changes.

First of all, this technique is used for patients who cannot undergo open bypass surgery or arterial replacement.

The fact is that the method refers to indirect vascularization and the main arteries are not involved in this situation.

What are the risks?

The sympathetic node is located in close proximity to large vessels such as the aorta and inferior vena cava. Therefore, this method of treatment is accompanied by bleeding risks.

The next contraindication is injury nerve root . It all depends on accuracy. If a nerve root is damaged, sensitivity may be lost. As a rule, pain syndromes do not occur.

In case of adequate therapy, such symptoms are relieved within 2 - 3 months, as a rule, without side effects.

Also, given that various drugs are used in this procedure, anaphylactic reactions. Mainly for local anesthetics. Can develop and individual reactions on iodine and iodine-containing preparations used during the procedure.

Also to side effects risks may include damage around underlying organs such as renal pelvis, ureters and so on. Infection also applies to risks. Therefore, the procedure requires execution under aseptic conditions.

Risks also include pneumothorax. Occurs when there is work on high-lying sympathetic nodes. Or it occurs in the case of significant spinal deformities such as scoliosis, spinal hernia, and so on.

In some cases there is neuralgia along the nerve root and neuropathies may occur along the anterolateral surface of the thigh. This phenomenon goes away on its own within 2 to 3 months.

In the case of a complete block of sympathetic nodes on both sides, men may experience symptoms dry orgasm and ejaculation disorders.

Contraindications for sympathectomy

Who can we not perform sympathectomy on and what are the contraindications? If the patient has foci of chronic infections(infected gangrene or ulcers), then due to the risks of spreading infections, such a procedure is very dangerous.

If the patient had stroke or heart attack over the next three months, there is a risk of relapse. In this case, the person is first taken to rehabilitation and only after that this procedure is carried out.

If the patient has claustrophobia, then he must be immediately warned that a long stay in a confined space is required. Therefore, given the possibility panic attacks, not every doctor will be able to admit such patients to treatment.

In patients with heart failure 3 degrees may be decompensation of cardiac activity. Therefore, doctors will not perform surgery for this type of pathology.

There is also a ban in case of manifestation allergic reactions on medications used during the procedure.

It is also contraindicated if you are taking medications anticoagulant series. For example, Fraxiparin, Clexane, Warfarin, Xarelto, Prodaxa, etc. After all, then the procedure will be associated with significant bleeding and the formation of hematomas.

Advantages of sympathectomy for atherosclerosis of the lower extremities

Let's look at the advantages of sympathectomy for atherosclerosis of the lower extremities. In normal clinics, this method is considered minimally invasive. Therefore, it has a fairly large number of advantages over open surgery.

Firstly, there is a lack of extensive surgical access. Accordingly, the number of infections that are predicted for the patient is significantly less. There is also no anesthesia and its risks. The procedure itself is performed under local anesthesia.

Considering that there is no anesthesia and large surgical access, the number of complications is reduced tenfold. The mortality rate of this procedure is very low. As a rule, this is less than 1%. Patients tolerate this operation very well.

The procedure itself does not require much preparation, except that doctors ask the patient not to eat in advance. And in case of any manifestations of fear or nervousness, doctors ask that sedatives be taken in advance.

Progress of lumbar sympathectomy surgery

Now let's talk a little about the course of the lumbar sympathectomy operation. Typically, the patient is placed in a supine position into the CT scanner. Next, doctors mark the spinous processes of the lumbar vertebrae, conduct an initial scan and mark the area where the needle and guidewire are inserted.

Lumbar sympathectomy is a surgical treatment for hyperhidrosis, as well as chronic failure arterial blood supply to the lower extremities using resection of the 2nd – 4th ganglia of the lumbar spinal column. Surgical intervention for such diseases is carried out using retroperitoneal access, but the most in an efficient way treatment is the use of lumbar sympathectomy, which improves blood flow.

Indications for surgery

Indications for surgery, in addition to hyperhidrosis, are:

  • development of diabetic angiopathy;
  • obliterating endarthritis;
  • nonspecific arthritis stages 1 and 2;
  • Stage 3 postphlebitic syndrome of deep venous disorders in the lower extremities;
  • obliterating atherosclerosis in the vessels of the lower extremities.

In addition, surgical intervention is possible as an additional method to reconstructive surgical interventions on the aorta and its branches, as well as when chronic disorders arterial blood flow (grades 2 and 3).

Contraindications to the procedure

Before deciding to use surgery, the doctor must assess all possible risks of treatment.

Direct contraindications to the operation are:

  • diabetic diseases of any severity;
  • pathological disturbances in the functioning of the endocrine system;
  • infectious and inflammatory diseases;
  • development of secondary hyperhidrosis;
  • severe pulmonary emphysema and pleurisy;
  • presence in the patient's medical history of surgical intervention on the abdominal organs;
  • symptoms of heart and respiratory failure.

In addition, allergy testing is mandatory to avoid possible complications during an operation to cut (clip) the sympathetic fiber.

Preparatory stage

Particular attention is paid to the preoperative preparation of the patient, which involves undergoing a thorough examination using standard diagnostic methods:

  • collection of urine and blood for clinical analysis;
  • biochemical blood test;
  • determination of the patient’s blood type and blood rhesus;
  • analysis for HIV infection, hepatitis, syphilis, etc.
  • In addition, fluorographic examination is provided, as well as electrocardiogram monitoring.

Progress of surgery

A standard operation requires the mandatory use of epidural anesthesia or intubation anesthesia. The patient is placed in the same position as for retroperitoneal discectomy, then the surgical field is prepared for surgery.

The incision is made parallel to the convergence of the oblique and rectus abdominis muscles, closer to the umbilical cavity. The depth of the cut is 10 mm. This allows you to define 1 port in order to insert the endoscope.

At the initial stage, the surgeon performs digital enucleation of the retroperitoneal space. The fascia is then separated using a balloon dissector. If the cavity formed is large enough, the balloon is removed and a 2nd port for surgical instruments is installed. Sometimes during the operation a retractor is used, which is inserted into the operated cavity after the formation of 1 port.

After opening the tissues of the retroperitoneal space, 2 trocars are additionally introduced, which facilitate the surgeon’s work. Next, the retractor peels away the muscles from the peritoneum and retroperitoneal tissue, which provides access to the ganglia and sympathetic fibers.

On final stage The sympathetic ganglia are separated using a dissector. First, the sympathetic trunk is dissected with its simultaneous elevation above nearby tissues, then the sympathetic trunk branches are dissected, followed by the isolation of the sympathetic ganglia.

Possible complications

During any surgical intervention, various types of complications are possible, including when performing lumbar sympathectomies, which manifest themselves as follows:

  • extremely rarely, bleeding is observed, which can develop as a result of skin damage, large blood vessels and intercostal spaces;
  • if blood or air gets into the pleural area, hemothorax or pneumothorax may develop;
  • if the rules of asepsis are insufficiently observed during the operation, various types of infection are possible;
  • in the postoperative and rehabilitation period, compensatory hyperhidrosis may develop, which can occur with such intensity that removal of the clip is required. This can lead to restoration of the function of the sympathetic trunk and a return to its original state;
  • post-sympathectomy pain symptoms, changes in taste, increased dryness of the skin, neuralgia and ejaculation disorders may develop;
  • when involved in pathological process intrathoracic stellate node may develop Horner's syndrome, which is characterized by ptosis (drooping of the upper eyelid), narrowing of the pupil and retraction of the eyeball.

Most dangerous consequences sympathectomy – sudden stop heart disease and anaphylactic shock.

It is important to note that in some patients, even after surgery, there is no positive effect, and in some cases, symptoms can, on the contrary, intensify, which is explained by the presence of Kunz nerves. However, there are practically no alternative options. Independent restoration of a removed segment of the sympathetic trunk is impossible. Statistics state that the complication occurs in 5% of all identified cases.

It must be taken into account that the number of sympathetic ganglia sometimes does not correspond to the number of vertebrae in the lumbar region. It is often possible for ganglia to merge into one node. Sympathectomy is performed only if other treatment methods are ineffective and is performed taking into account the course of the disease and the individual characteristics of the patient.

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    Dorsopathies are a group of diseases connective tissue and musculoskeletal system, the main symptom of which is periodic pain in the trunk and limbs. The most common representative of this group is dorsopathy of the lumbosacral spine.

    In general, prediseases are a very common type of pathology, which affects almost every second person, despite the fact that during the course of life it manifests itself in almost everyone. Although episodes of back pain caused by this disease are short-lived, in some patients the disease can become chronic, causing constant pain and long-term disability.

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    The most common risk factors are:

    • hereditary predisposition, which is realized through the characteristics of the human constitution (immunological, hormonal, psychogenic, biochemical, etc.);
    • static and dynamic overloads during work, especially when in uncomfortable positions. In this case, ignorance or failure to follow the simplest ergonomically sound techniques for performing work operations, body positions, etc. may also be reflected;
    • lack of physical activity (regular exercise, sedentary lifestyle), sudden changes in physical activity, occasional serious physical activity in people leading a sedentary lifestyle;
    • poor posture and spinal diseases (kyphoscoliosis, scoliosis, stoop);
    • overweight, frequent colds;
    • bad habits (smoking, alcohol), excessive addiction to spices, pickles, smoked and fried foods.

    Manifestations and types of pain in dorsopathy

    Clinically, osteochondrosis manifests itself in most cases as a reflex syndrome, and occasionally as a compression syndrome. In the vast majority of cases, the lumbosacral spine is affected, which is what causes the “popularity” of this particular type of dorsopathy.

    There are these types of pain:

    • local;
    • projection;
    • radicular (radicular);
    • pain that appears as a result of muscle spasm.

    Local pain is usually constant, diffuse, and is centered in the area of ​​the spinal lesion. Also, the nature of the pain may change with changes in posture or body position.

    Projection pains are of a different nature; they are common. In this case, projection pain is much more diffuse, prone to superficial distribution, but in nature and intensity it is very close to local.

    Radicular pain is shooting in nature. Typically, radicular pain is dull and aching, but it can intensify significantly with movement, causing the pain to become acute. Radicular pain almost always radiates to the extremities. This pain can intensify with movement and with provoking factors, such as coughing, sneezing, and straining.

    Nowadays, great attention is paid to pain syndrome resulting from muscle spasm. In this case, the cause of pain is not only spasm, but also the existence of trigger points and areas of hypertonicity in tense muscles. Moreover, such pain syndrome may not be associated with osteochondrosis at all.

    Characteristic symptoms of the disease

    The most noticeable symptoms of dorsopathy of the lumbosacral spine are pain in lumbar region, feeling of heaviness in the back. At the same time, as we said above, the pain can be of a completely different nature, it can manifest itself when moving, bending or turning, it can be constant, often the pain is “shooting” in nature. Nausea, dizziness, and in some cases tinnitus may also occur.

    Principles of disease diagnosis

    Initially, the doctor collects complaints and general information, as a result of which it is established:

    • localization and irradiation of pain;
    • dependence of pain on movement and body position;
    • Have you ever had injuries or diseases of the spine (benign and malignant tumors etc.);
    • emotional state of the patient.

    In this case, the examination is aimed at identifying infectious processes, the appearance of neoplasms (malignant or benign) and somatic diseases, which can manifest themselves as pain in the spine. During a neurological examination, the emotional state of the patient is assessed and it is determined whether there are paralysis, paresis, loss of reflexes, or sensitivity disorders. Local soreness, range of motion in the limbs, and spinal mobility are also checked.

    After this, additional research, the purpose of which is to clarify the diagnosis:

    • radiography of the spine, which is carried out in several projections;
    • biochemical and general tests blood;
    • computed tomography or magnetic resonance imaging of the spine.

    Based on the results obtained, the doctor can determine accurate diagnosis and prescribe treatment.

    Dorsopathy can occur in one of three forms:

    • acute (up to 3 weeks);
    • sub-acute (3-12 weeks);
    • chronic (over 12 weeks).

    First of all, treatment is designed to reduce or completely remove the pain syndrome that occurs during the disease. The main recommendations at this stage are: limiting physical activity, using non-steroidal anti-inflammatory drugs, muscle relaxants. For chronic pain, the list is expanded rehabilitation programs, dosed and gradually increasing physical motor and physical activity, sleeping on a special orthopedic mattress, training in an individual motor mode, which is selected for a specific patient depending on the indications.

    It is worth noting that the treatment of dorsopathy must be approached comprehensively and cannot be limited to only drug treatment, since in this case the muscular corset of the back will weaken, which will lead to new manifestations of the disease or the appearance of new diseases of the spine. On the other hand, the patient cannot conduct exercise therapy in this condition. The first few days are needed to relieve inflammation and all associated factors, as well as significantly reduce pain.

    Standard treatment regimen for acute back pain

    From days 1 to 3: strict bed rest, pain blockades by the hour, use of muscle relaxants.

    From days 3 to 10: semi-bed rest, hourly painkillers, muscle relaxants, physiotherapy, moderate exercise.

    From 10 to 20 days: moderate regimen with limited activity, painkillers, physical therapy, massage, manual therapy.

    From 20 to 40 days: active regimen, pain relief only when necessary, active physical therapy.

    This scheme is standard, but cannot be used in this form for each specific case. Treatment of dorsopathy must be carried out by a doctor after a full examination, and the form of the disease and its course must be taken into account.

    Treatment of acute dorsopathy

    • bed rest (on a hard surface or a special orthopedic mattress) for 1-3 days;
    • mild dry heat or cold;
    • for a few days - a corset;
    • analgesics;
    • muscle relaxants;
    • local therapy;
    • blockade with local anesthetics - according to doctor’s indications.

    After the process subsides, the patient undergoes physiotherapeutic treatment, massage and manual therapy.

    It should be noted that self-treatment is absolutely unacceptable; the choice of drugs and procedures should be made by a doctor. Even the advice of people who have already recovered and remember their treatment well is not an argument - specific drugs, as well as the course of treatment itself, are determined by the attending physician depending on the patient’s condition, the form and course of the disease.

    Treatment of exacerbation of chronic form

    In this case, the following are assigned:

    • non-steroidal anti-inflammatory drugs;
    • local therapy (blockades, ointments);
    • painkillers;
    • muscle relaxants;
    • chondroprotectors.

    When the exacerbation subsides, non-drug treatment methods are prescribed, increased motor and physical activity, and correction is carried out psychological state, for which group and individual psychotherapy and antidepressants are used. It is also necessary to ensure the formation of a new motor stereotype in the patient.

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    Operations on lumbar sympathetic trunk have been carried out for a long time. The first sympathectomy at the lumbosacral level using an open approach was first performed in 1921 by Diez. The author proposed to treat obliterating diseases of peripheral vessels in this way. In subsequent years, the technique of interventions was gradually improved and operations were used in the treatment of pain syndromes, various vascular diseases and hyperhidrosis of the lower extremities.

    Blood vessel diseases, causing various circulatory disorders in individual parts of the body or throughout the body, are one of the most common reasons for surgical interventions in various parts of the sympathetic nervous system.

    In recent time lumbar sympathectomy has become quite widespread, because sometimes remaining the only method of treating chronic arterial insufficiency of the lower extremities, it leads to improved blood flow and promotes the opening of arteriovenous shunts. Traditional surgical interventions on the lumbar portion of the sympathetic nervous system in this pathology were mainly performed from an extraperitoneal retroperitoneal approach. IN recent years The operation of endoscopic retroperitoneal lumbar sympathectomy is increasingly being used.

    Indications for carrying out of this intervention are (V.S. Savelyev, 1998):
    obliterating endarteritis and nonspecific arteritis of I-II degree;
    diabetic angiopathy;
    obliterating atherosclerosis of the vessels of the lower extremities (as an addition to reconstructive surgery on the aorta and its branches) in chronic arterial insufficiency of II-III degree (according to A.V. Pokrovsky);
    postphlebic syndrome of the deep veins of the lower extremities in stage III of the disease (according to V.S. Savelyev).

    Contraindications and preoperative preparation the same as for retroperitoneal endoscopic discectomy.
    During surgery Intubation anesthesia or high epidural anesthesia is more often used.

    Position of the patient when performing lumbar endoscopic sympathectomy the same as when performing retroperitoneal endoscopic discectomy.
    In the area of ​​​​the convergence of the oblique and rectus abdominis muscles at the level of the navel, a 10 mm long soft tissue incision is made to install the first port through which the endoscope. Initially, digital dissection of the tissues of the retroperitoneal space is performed. Further separation is carried out, most often, using a balloon dissector. After creating the necessary cavity in the retroperitoneal space, the balloon is removed and a second port for instruments is installed. You can use retroperitoneum, which is created after the first port is installed and the endoscope is inserted.

    After preparation of retroperitoneal tissues two more 5 mm trocars for instruments are introduced: one at a distance of 2-3 cm from the crest ilium, the other - 2-3 cm from the costal arch along the axillary line.

    After retractor The peritoneum and retroperitoneal tissue are detached from the muscles, and the ganglia and connective fibers of the sympathetic trunk become visible. It is located: on the left - between the aorta and lumbar muscles, on the right - between the inferior vena cava and the lumbar muscles.

    When approaching sympathetic ganglia They are sequentially isolated, and then, using a dissector, the sympathetic trunk is separated from the underlying tissues and raised. The branches of the sympathetic trunk are crossed with an L-shaped electrode and the sympathetic ganglia are isolated. Typically, 3-4 ganglia are removed to achieve the effect. After their isolation, the retractor is replaced with a clamp, and the dissector with scissors. The ganglia of the sympathetic trunk are divided with scissors without coagulation to prevent the development of pain in the postoperative period.

    Effectiveness of the intervention will be greater when performing a simultaneous bilateral sympathectomy.
    When executing endoscopic retroperitoneal sympathectomy The same complications are possible as with endoscopic retroperitoneal discectomy and spinal stabilization.
    The duration of the operation is 30-60 minutes.

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