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Wednesday, 27 March 2013

Lumbar Sympathectomy

Open Lumbar Sympathectomy
 

      Indications
                TAO- Rest Pain, Non healing superficial ulcers
                Hyperhiderosis
      Anesthesia: Spinal
      Position of the Patient: Lateral/ Kidney position
      Incision- From the tip of 12 rib to lateral border of rectus at the level of umbilicus.

  Steps of Operation
      Step 1. Incision deepened by spltting the muscles
                  Anteriorly
                 External oblique
                 Internal oblique
                Transversus abdominis
                      Posteriorly
                Latissimus dorsi
                Serratus posterior inferior

      Step 2. Peritoneum and the adherent ureter is pushed anteriorly.

      Step 3. Medial to Psoas major, sympathetic ganglia are felt over the vertebral body

      Step 4. L1 Ganglion is identified near the crus of the diaphragm

      Step 5. L 2, L 3 and L 4 Ganglia with intervening fibers are removed by protecting Aorta on left  and IVC on right

      Step 6. Haemostasis achieved and the wound is closed in layers

Structures which can mimic a sympathetic chain
      Ilio inguinal and ilio hypogastric nerves
      Muscle sheath fibers
      Lymphatics with lymph nodes

Complications
Sterility due to Retrograde ejaculation, if L1 ganglia on both sides are removed.

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