BACKGROUND: Video-assisted retroperitoneoscopy is a relatively new surgical technique for performing lumbar sympathectomies and is used increasingly for the treatment of primary plantar hyperhidrosis. In this paper, we report on our clinical experience with this procedure. METHODS: Between December 2004 and August 2011, 306 retroperitoneoscopic lumbar sympathectomies have been performed on 154 patients with severe refractory plantar hyperhidrosis. The perioperative course as well as the postoperative results were analysed in a retrospective analysis. RESULTS: All 306 lumbar sympathectomies were performed in retroperitoneoscopic technique and in none of the cases a conversion to open surgery was necessary. Mortality was zero, and there were no serious intraoperative complications. In approx. 25% of the patients, the surgery was classified as technically difficult for a number of reasons. Postoperative complications occurred in 4 patients (2.6%) in the form of an abdominal wall haematoma, pneumonia, pulmonary embolism and a thrombosis of the right iliac vein. In all patients, the hyperhidrosis was eliminated immediately after surgery. 121 patients (79%) underwent follow-up controls 24 months after surgery on average. Three patients (2.5%) suffered a hyperhidrosis relapse. Adverse events occurred in form of compensatory sweating in 63 patients (52%) and in form of post-sympathectomy neuralgia in 47 patients (39%). Three men developed a temporary ejaculation disorder. CONCLUSIONS: Lumbar sympathectomy can be performed safely and effectively with retroperitoneoscopic surgical technique. Morbidity is low and the procedure is suited very well for the treatment of plantar hyperhidrosis. Since this surgery may be technically difficult because of the anatomic particularities of the retroperitoneum, high expertise with endoscopic surgical techniques is required.