Hyperhidrosis – Laparoscopic Lumbar Sympathectomy – a case report

Introduction

Hyperhidrosis is sweating in excess than that is required for normal thermoregulation.  It begins in either childhood or adolescence. Although any site on the body can be affected by hyperhidrosis, the sites most commonly affected are the palms, soles, and axillae. Hyperhidrosis exists in 3 forms: Emotionally induced hyperhidrosis (in which it affects the palms, soles, and axillae,    Localized hyperhidrosis, Generalized hyperhidrosis. Hyperhidrosis often causes great emotional distress and occupational disability for the patient, regardless of the form.It affects both sexes and affects persons of all ages.In a study of 850 patients with palmar, axillary, or facial hyperhidrosis, 62% of patients reported that sweating began since before they could remember; 33%, since puberty; and 5%, during adulthood.

Authors: Dr. R. Padmakumar, Dr. Madhukara Pai, Dr. Arun kumar S, Dr. Farish Shams, Dr. Zuhail Bin Nazar, Dr. Khaleel Abdulkader, Dr. Mabel Pereira, Dr. Anurag verma

Case Report

32-year-old male patient from Lakshadweep had reported to us with complaints from his childhood and was operated on right side retroperitoneoscopic lumbar sympathectomy before one year by same team. His complaints resolved completely on the right side. His symptoms are cold limb, profuse sweating of the left lower limb. When he used casual slippers, his slippers slip off and when he wears shoe, it pours out.

The temperature in lower limb was recorded pre-operatively and found to be very low. (less than 88 F) (Figure 1) Routine blood investigations and anaesthetic check-up was done, he was posted for retroperitoneoscopic lumbar sympathectomy under GA. Patient was operated and L2, L3, L4 ganglions removed. Patient had no issues in immediate post-op. Patients symptoms improved drastically in the post-op period. His temperature improved to 97.6 F and his limb became pinkish and was not having the issues of sweating. Patient was discharged on POD-2. (Figure 2)

Hyperhidrosis, temperature recording
Figure 1: Showing the temperature recording of left lower limb as low, also feet looks pale compared to right foot showing 97.1 and is pinkish.
Laparoscopic Lumbar sympathectomy post op temperature recording
Figure 2: Post op limb temperature is 97.6 and pinkish compared to previously operated side.

Discussion

Anatomy

The sympathetic trunk lies lateral to the vertebral bodies for the whole length of the vertebral column. It communicates with the anterior rami of spinal nerves via rami communicants. The sympathetic trunk permits preganglionic fibres of the sympathetic nervous system to ascend to spinal levels superior to T1 and descend to spinal levels inferior to L2/3.

The superior end of it is continued upward through the carotid canal into the skull, and forms a plexus on the internal carotid artery; the inferior part travels in front of the coccyx, where it converges with the other trunk at a structure known as the ganglion impar.

Along the length of the sympathetic trunk are sympathetic ganglia known as paravertebral ganglia.The sympathetic trunk is a fundamental part of the sympathetic nervous system, and part of the autonomic nervous system. It allows nerve fibres to travel to spinal nerves that are superior and inferior to the one in which they originated. Also, number of nerves, such as most of the splanchnic nerves, arise directly from the trunks.

Pathophysiology

Hyperhidrosis may be idiopathic or secondary to other diseases, metabolic disorders, febrile illnesses, or medication use. Generalized hyperhidrosis may be secondary to numerous conditions including the following: Neurologic or neoplastic diseases, spontaneous periodic hypothermia and hyperhidrosis. Localized unilateral or segmental hyperhidrosis is rare and of unknown origin. The condition usually presents on the forearm or forehead in otherwise healthy individuals, without evidence of the typical triggering factors found in essential hyperhidrosis. Localized hyperhidrosis may also be associatedwith the following: gustatory stimuli, eccrine nevus.

Diagnosis/Evaluation

Diagnostic criteria favouring primary hyperhidrosis include excessive sweating of 6 months or more in duration, with 4 or more of the following:

  1. Primarily involving eccrine-dense sites (axillae/palms/soles/craniofacial).
  2. Bilateral and symmetric
  3. Absent nocturnally
  4. Episodes at least weekly

Visible signs of hyperhidrosis are clear.

If direct visualization of the affected areas by hyperhidrosis is desired, the iodine starch test may be used. This test requires spraying of the affected area with a mixture of 0.5-1 g of iodine crystals and 500 g of soluble starch. Areas that produce sweat turn black. If generalised hyperhidrosis is noted one must search for underlying causes by doingThyroid Function Test,Blood glucose,Urine catecholamines, Uric acid levels, Purified Protein Derivative, and Chest x-ray to rule out Tuberculosis.

Hyperhidrosis Management

There are two options:

  1. Medical management
  2. Surgical management

Medical management

Hyperhidrosis treatment is challenging for both the patient and the physician. Both topical and systemic medications have been used.

Topical agents for hyperhidrosis therapy include topical anticholinergics, boric acid, 2-5% tannic acid solutions, resorcinol, potassium permanganate, formaldehyde, glutaraldehyde, and methenamine.Systemic agents used to treat hyperhidrosis include anticholinergic medicationssuch as propantheline bromide, glycopyrrolate, oxybutyninandbenztropine.Theyare effective because the preglandular neurotransmitter for sweat secretion is acetylcholine (although the sympathetic nervous system innervates the eccrine sweat glands).

Other treatment options for hyperhidrosis include iontophoresis and botulinum toxin injections. Botulinum toxin injections are effective because of their anticholinergic effects at the neuromuscular junction and in the postganglionic sympathetic cholinergic nerves in the sweat glands.Radiofrequency ablation and use of microneedle radiofrequency therapy for axillary hyperhidrosis has been recommended.

Surgical management

 Sympathectomy has been used as a permanent effective treatment since 1920. Usually, it is reserved for the final treatment option.Sympathectomy involves the surgical destruction of the ganglia responsible for hyperhidrosis. 

Lumbar sympathectomy is an effective treatment for lower limb hyperhidrosis. There are two approaches: open and minimal access approach.

In case of minimal access surgery there are transperitoneal and retroperitoneoscopic approach.

Retroperitoneoscopic approach:

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

Hyperhidrosis - Lumbar sympathectomy port placement
Figure 4: Port placement
Intra-op picture showing sympathetic chain
Figure 5: Intra-op picture showing sympathetic chain

Conclusion

Retroperitoneoscopic approach is better than open, as there is no cutting of muscles, also the blood loss is less, the patient has less post-op pain, also chance of wound infection are less comparatively.The patient goes home early, and goes to work the next day. Its comparatively safer than transperitoneal as the chance of bowel injury, infection is less as we are in the retroperitoneal space. Approaching sympathetic chainis also relatively easier for surgeon in case of retroperitoneoscopy.

References

  1. Altman RS, Schwartz RA. Emotionally induced hyperhidrosis. Cutis. 2002 May. 69(5):336-8. [Medline].
  2. Ruchinskas R. Hyperhidrosis and anxiety: chicken or egg?. Dermatology. 2007. 214(3):195-6. [Medline].
  3. Drott C, Gothberg G, Claes G. Endoscopic transthoracic sympathectomy: an efficient and safe method for the treatment of hyperhidrosis. J Am AcadDermatol. 1995 Jul. 33(1):78-81. [Medline].
  4.  Mader S. S. (2000): Human biology. McGraw-Hill, New York, ISBN 0-07-290584-0ISBN 0-07-117940-2.
  5. Pritchard T. E., Alloway D. (1999): Medical neuroscience. Hayes Barton Press, ISBN 978-1-593772000:https://books.google.com/books/about/Medical_neuroscience.html?id=m7Y80PcFHtsC
  6. Rodrigues Masruha M, Lin J, Arita JH, DE Castro Neto EF, Scerni DA, Cavalheiro EA, et al. Spontaneous periodic hypothermia and hyperhidrosis: a possibly novel cerebral neurotransmitter disorder. Dev Med Child Neurol. 2010 Dec 17. [Medline].
  7. Mehta S, Ralot T, Masatkar V, Agarwal N, Rana A. A curious case of hourly attacks of disabling episodic spontaneous hypothermia with hyperhidrosis. Indian J DermatolVenereolLeprol. 2015 Mar-Apr. 81(2):185-6. [Medline].

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