Surgical Sympathectomy from an anesthesia point-of-view.

1. z
Surgical
Sympathectomy
Chris Nunley BSN, RN, SRNA

2. z
Outline
Procedure
definition
Procedure
overview
Preoperative
planning
Intraoperative
planning
Postoperative
complications
Anesthetic
plans for
procedure
Questions

3. z
What is Surgical Sympathectomy?
 There are 2 main types of surgical sympathectomy procedures.
 Thoracoscopic Sympathectomy is used in the treatment of
Hyperhidrosis and is an outpatient procedure.
 Lumbar Sympathectomy is used in the treatment of causalgia,
inoperable lower limb ischemia with rest pain or gangrene, and
some symptomatic vasospastic disorders.

4. z
Lumbar Sympathectomy
 Causalgia responds well to lumbar sympathectomy, especially if
done early in the clinical course.
 Has been shown to increase collateral blood flow and local skin
blood flow.
 Scleroderma that may result in an impending amputation may
benefit from sympathectomy and improve wound healing.

5. z
Procedure Overview
 Involves the division of
preganglionic fibers along their
segmental origins and resection of
corresponding relay ganglia.
 Sympathetic chain is dissected
free from surrounding tissue then
clipped proximally and distally and
finally resected.
 For most clinical indications an L2
and L3 ganglionectomy will
provide sufficient sympathectomy
to the lower extremity.

6. z
Surgical Approach
 3 different approaches the surgeon can use.
 Anterolateral Retroperitoneal approach- most commonly used
approach.
 Posterior approach- used less often due to significant postop
muscle spasms.
 Anterior/Transperitoneal approach- usually performed with an
abdominal aortic or intraperitoneal procedure.
 These can be done open, laparoscopic, or percutaneous. No
studies have shown one is better then the other.

7. z
Positioning
 Anterolateral
Retroperitoneal
approach- Supine with
flank slightly raised
 Posterior approach-
Prone
 Anterior/Transperitoneal
approach- Supine

8. z
Preoperative Considerations
 Respiratory- Patients with vascular disorders
most often have a history of smoking and COPD
so preop evaluation of pulmonary function,
including CXR, PFT’s, and ABG’s, may be
beneficial.
 Cardiovascular- This patient population can
have an increased incidence of CAD and HTN.
Tests such as ECG or Echo may be needed.
 Neurologic- A thorough neuro exam is required
to assess for neurological deficits that can occur
postoperatively.
 Renal- Due to this patient population’s history
they may be at risk for renal artery disease and
renal insufficiency. Checking BUN, Cr,
electrolytes, and UA may be beneficial.
 Hematologic- This patient population may be
taking anticoagulant or antiplatelet
medications. Tests such as Hct, Hgb, PT,
PTT, INR may be beneficial.
 Endocrine- This patient population may have
an increased incidence of DM. Precaution
should be taken due to possibility of delayed
gastric emptying and hypo/hyperglycemia.

9. z
Intraoperative Considerations
 Procedure can be accomplished with either regional or general anesthesia.
 Muscle relaxation is not required for the entire procedure.
 Antibiotics: Cefazolin 2g IV or 3g if >120 kg.
 Surgical time: 2-4 hours
 EBL: 50-100 ml
 BSS is 3-5 ml/kg/h
 All pressure points padded.
 Check eyes especially if using prone position.

10. z
Postoperative Complications
 Postsympathectomy Neuralgia
 Sexual derangement that can result in Retrograde Ejaculation.
This most often occurs with bilateral L1 sympathectomy.
 Wound hematoma
 Wound infection
 Paraspinous muscle spasms

11. z
Anesthetic
Plans

12. z
Plan A (General)
Preop
• 2 mg Versed
Induction
• Fentanyl 50
mcg
• Lidocaine 80 mg
• Propofol 150 mg
• Succinylcholine
100 mg
Maintenance
• Zofran 4 mg
• Decadron 4 mg
• Fentanyl 50
mcg
• Acetaminophen
1 g
• Sevoflurane
titrated to 1
MAC
• N2O/O2 70:30
mix or as
tolerated
Emergence
• O2 100%
• Sevoflurane off
• Patient should
be
spontaneously
breathing
• Precedex 1
mcg/kg
• Suction
thoroughly and
extubate
Postop Pain
• Dilaudid 1mg
• Toradol 30 mg

13. z
Plan B (TIVA)
Preop
• Versed 2 mg
Induction
• Fentanyl 100
mcg
• Lidocaine 80 mg
• Propofol 150 mg
• Succinylcholine
100 mg
Maintenance
• Remifentanil 0.1-
0.35 mcg/kg/min
• Propofol 60-90
mcg/kg/min
• Zofran 4 mg
• Decadron 4 mg
• Acetaminophen 1
g
Emergence
• O2 100%
• Remifentanil
• Reduce to 0.05-
0.1 mcg/kg/min
10 min. before
end
• Turn infusion off
5 min. before
end
• Propofol
• Reduce to 20-
40 mcg/kg/min
10 min. before
end
• Turn infusion off
3 min. before
end
• Precedex 1
mcg/kg
• Suction
thoroughly and
extubate
Postop Pain
• Dilaudid 1 mg
• Toradol 30 mg

14. z
Question 1
 Sufficient sympathectomy will be provided to the lower
extremities with ganglionectomy of?
A. C1 and C2
B. T3 and T4
C. L2 and L3
D. L3 and L4

15. z
And the answer is……
C

16. z
Question 2
 Lumbar Sympathectomy is used in the treatment of? (Select 2)
A. Causalgia
B. Acne
C. Scleroderma
D. Conjunctivitis
E. Chest pain

17. z
And the answer is……
A and C

18. z
Question 3
 What are 2 postop complications that can occur with Lumbar
Sympathectomy?
A. Blindness
B. Postsympathectomy neuralgia
C. Liver failure
D. Sexual derangement
E. PTSD

19. z
And the answer is……
B and D

20. z
Question 4
 The patient can be positioned in ____ or ____ depending on the
surgical approach?
A. Supine or Lateral
B. Prone or Supine
C. Lateral or Prone
D. Lithotomy or Lateral

21. z
And the answer is……
B

22. z
Question 5
 The EBL for a Lumbar Sympathectomy is?
A. 10-30 ml
B. 25-50 ml
C. 50-100 ml
D. 100-200 ml

23. z
And the answer is……
C

24. z
References
 Jaffe, R. A., Schmiesing, C. A., & Golianu, B.
(2020). Anesthesiologist's Manual of Surgical Procedures.
Lippincott Williams & Wilkins.
 Nagelhout, J. J., & Elisha, S. (n.d.). Nurse Anesthesia, 6th ed.
Elsevier, 2018.
 Karanth, V. K., Karanth, T. K., & Karanth, L. (2016, December
13). Lumbar sympathectomy techniques for critical lower limb
ischaemia due to non-reconstructable peripheral arterial
disease. The Cochrane database of systematic reviews.
Retrieved April 10, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6463847/