Global Journal of Medical Research, I: Surgeries and Cardiovascular System, Volume 22 Issue 2

straight direction from the umbilicus. The anatomy must be confirmed because there may be anatomical variations or umbilical deviation due to previous abdominal surgery. The surgery is performed under general anesthesia with the patient in the supine position. A thermometer is placed on each plantar foot surface of the patient. Before anesthetic induction, the temperature of the feet is approximately 25 º C, while after anesthesia, it rises to 32 º C on average. Pneumoperitoneum with carbon dioxide and pressure of 12 mm of mercury is established and four 5- mm trocars are inserted. The video camera is introduced through the first one placed in the umbilicus. The dissection forceps are introduced through the suprapubic area and right-and left-iliac fossa trocars (Figure 3). The patient is placed in the Trendelenburg position, exposing the root of the mesentery, which is at the level of the L3 vertebral body. Under the direct view of the endoscope and with the aid of dissection forceps, a small opening of the posterior peritoneum is made close to the third portion of the duodenum after cranial mobilization of the mesentery and intestines (Figure 4). With the forceps inserted through the umbilical trocar, a lumbar spine projection is made to identify the L3-L4 vertebrae using a C-arm radioscopy to help locate the level of the vertebrae. Thus, consequently, locating the sympathetic chain, which allows for the approach to the sympathetic plexuses on the right and left sides. Subsequently, the vena cava is bluntly dissected and medially displaced so that the sympathetic chain, usually found behind the vein, can be visualized. The level of the sympathetic resection is confirmed with intraoperative radioscopy at L3-L4 on the right. Thus, the section of the sympathetic chain is carried out. Similarly, the para-aortic lymph nodes are dissected in order that the rigth sympathetic chain is reached (Figure 7 and 8). Under intraoperative radioscopy, the rigth sympathetic chain is sectioned after its level is confirmed at L3-L4. The opening that gives access to the retroperitoneum, which is soon after closed, can be seen in Figure 9. When the sympathetic section is performed, there is an increase of approximately 2 ºC in temperature and significant vasodilation of the lower limbs. Thus, the section of the sympathetic chain can be confirmed. The surgery lasts approximately one hour and does not require a hospital stay longer than 24 hours. Prophylactic antibiotics are used in surgery and common analgesics are given to the patient postoperatively. After the removal of the stitches, which usually takes 10 days, the patient can resume normal activities. Figure 10 shows the excellent aesthetic result achieved after the procedure. IV. R esults The cases of 16 patients who underwent laparoscopic superselective transperitoneal lumbar sympathectomy were analyzed. Most of them were women (n=12) and had a higher education degree. Ages ranged from 19 to 36 years, with a mean of 28.3±4.5 years. Three women had already undergone surgical treatment of plantar hyperhidrosis. Before the procedure, patients mentioned wearing from one to four pairs of socks per day. Women reported wearing two or three different pairs (mean 2.8±1.1), while men, one or two (mean 1.6±0.5; p = 0.039). Fifty patients were treated over 18 years; however, only 16 were contacted. These underwent the procedure from 1 to 15 years ago. In a telephone interview, 15 patients reported improvement in both feet, while 1 patient described seeing improvement in only one foot and undergoing a second surgery. Patient satisfaction with the treatment was assessed using a five-point Likert scale in which 1 would be dissatisfied; 2, somewhat satisfied; 3, satisfied; 4, very satisfied; and 5, extremely satisfied. Two patients reported being somewhat satisfied (2 points); two were satisfied (3 points); and the other 14were very or extremely satisfied (4 and 5 points). Among both men and women, 75% of patients declared being very or extremely satisfied. There was no association between the degree of satisfaction and the number of pairs of socks changed before treatment (p=0.78). Three patients reported improvement in sweating, in addition to the feet, in another region of the body. Most patients (n=13) developed compensatory sweating with the most affected region being the trunk, but with less intense sweating. There were no surgical complications in the case series reported in this study; however, one case required reintervention because the first procedure failed to control the symptoms on one side. V. D iscussion This study presented cases of plantar hyperhidrosis treated with the laparoscopic superselective transperitoneal lumbar sympathectomy technique and the vast majority of patients were satisfied with the treatment. The extraperitoneal lumbar sympathectomy is a technique little used because of the difficulty of its performance and the lack of trained surgeons. Despite the clear improvement in the quality of life of treated patients 6 , the number of patients with the pathology who have delayed surgical treatment is still difficult to assess. As it is performed with a commonly used positioning, the technique described allows for accessing the retroperitoneal space through anterior approaches to the spine, thus, facilitating the procedure. 50 Year 2022 Global Journal of Medical Research Volume XXII Issue II Version I ( DD ) I © 2022 Global Journals Laparoscopic Superselective Transperitoneal Lumbar Sympathectomy for Treating Plantar Hyperhidrosis