- Preoperative preparation
- Consent for risks including bleeding, nerve injury, ejaculatory dysfunction (in males), or bowel/bladder dysfunction
- Anaesthesia and positioning
- General anaesthesia
- Patient positioned in supine or modified lateral position depending on surgeon preference
- Foley catheter inserted
- Incision and exposure (retroperitoneal approach)
- Make a flank or lower midline/paramedian incision, depending on laterality and exposure needed
- Retract or divide abdominal wall musculature
- Enter the retroperitoneal space via blunt dissection intially in the preperitoneal space
- Mobilise peritoneal contents medially to expose the psoas muscle and lumbar vertebral bodies
- Sweep ureter forward with peritoneum
- Follow anterior surface of psoas onto vertebral bodies
- More difficult on right due to IVC
- Identifying the lumbar sympathetic chain
- The chain lies along the anterolateral surface of the lumbar vertebral bodies
- It is a whitish cord with segmental ganglia—most commonly found at L2–L4
- Take care to avoid lumbar arteries and veins, ureter, and genitofemoral nerve
- Dissection and excision
- For unilateral sympathectomy: dissect and excise or divide the sympathetic trunk and ganglia from L2 to L4
- In males, avoid damage to L1 ganglion, which may affect ejaculation
- Ensure adequate haemostasis, as small lumbar vessels may be troublesome
- Preserve adjacent structures
- Closure
- Confirm haemostasis
- Reapproximate peritoneum if opened
- Close muscular and fascial layers in standard fashion
- Skin closed with absorbable or interrupted sutures
- Postoperative care
- Monitor for hypotension, lower limb temperature changes, urinary retention
- Watch for complications like bleeding, nerve injury, or sexual dysfunction
- Mobilise early and resume diet as tolerated
- Complications
- Retrograde ejaculation (L1) and impotence
- Ureteric damage
- Regeneration
- Pain recurrence
- Post sympathectomy neuralgia
- Hypotension