The Flank Incision and Exposure of the Kidney 2

THE FLANK INCISION AND EXPOSURE OF THE KIDNEY 2

Good flank exposure of the kid- perpendicular to the operating ney can be achieved by many sur- table and thus allows the operat- gical approaches. In general, the ing table to be rolled from side to kidney lies higher than expected side for improved exposure of the from the radiologic studies, with anterior or posterior kidney. the left kidney slightly higher Although the anterior superior than the right kidney. Except for iliac spine is positioned at the flex- lower pole renal biopsy, most op- ion of the table, when the table is erations require good exposure of fully flexed, the final position of the renal pelvis and the renal the body will cause the entire pedicle and thus call for either a pelvis to be slightly below the supra–twelfth-rib incision or a apex of the flexion and the ribs to twelfth-rib rib resection. In the fol- be slightly above, which creates lowing discussion of these two tension in the area of the lower approaches, important anatomic considerations for all flank expo- Flank Position sures are highlighted. FIG. 2-1. The flexion of the oper- Tension placed on Anterior Superior iliac spine ating table should be in line with ribs and skin in line with flexion of table the anterior superior iliac spine of the pelvis. This spine is a constant landmark that the surgeon can palpate in both thin and obese patients. After the patient is positioned on the side, the kidney rest can be elevated and the operating table flexed. It is important to monitor Axillary Pad the patient’s vital signs because the vena cava can be compressed Flexion of during this maneuver. We prefer lower Leg that the patient is in a straight lateral position 90 degrees to the table as opposed to an angled position; the straight lateral position can be angled by simple rotation of the operating table from side to side. The surgeon should apply 5- inch–wide adhesive tape horizon- tally across at the level of the iliac spine and around the operating table to secure and maintain the patient in this flank position. The taping stabilizes patient position 2-1 Anterior Superior iliac spine

31 32 Critical Operative Maneuvers in Urologic Surgery

External oblique muscle ribs and flank. The surgeon border of the rectus abdominis Eleventh should palpate the region be- muscle to beyond the posterior rib 1 tween the eleventh and twelfth axillary line. This incision is es- ribs and between the ribs and the sentially slightly superior to the Twelfth iliac spine when the operating twelfth rib.1 Anterior and medial rib table is adequately flexed to en- to the rib, the external oblique (1), Lumbar sure that this tension has been internal oblique (2), and transver- dorsal maintained. sus abdominis (3) muscles are se- fascia The lower leg is flexed to 90 de- quentially divided. Transversus grees at the knee to prevent the Although it is not always pos- abdominis 3 body from rolling from side to sible, the surgeon should attempt muscle side, but the upper leg is kept to preserve the intercostal nerve to Internal straight to maintain the tension of prevent the “frog belly” protru- oblique 2 Flank the incision site; pillows are placed sion of the abdomen after surgery. muscle incision between the legs as support. The intercostal nerve can be freed An axillary pad is placed under from the muscles and can be Rectus abdominis muscle the lower dependent arm to pre- pushed medially and laterally to vent any neural compression. The the incision during the operation. 2-2 upper arm should be placed on an Once the internal oblique mus- airplane rest for stabilization. cle is divided, the dense lumbar dorsal fascia, which lies anterior and medial to the tips of the EXPOSURE eleventh and twelfth ribs, can be For any flank exposure of the identified. kidney, the surgeon must release FIG. 2-3. By opening this fascial three components holding the ribs landmark, the surgeon can enter together: the retroperitoneal space and mo- 1 Intercostal muscles bilize the peritoneum anteriorly. 2 Diaphragmatic attachments FIG. 2-4. The surgeon inserts the to the ribs and retroperito- left index and middle fingers and neum bluntly spreads the fingers be- 3 Internal intercostal mem- neath the transversus abdominis brane holding the proximal muscle to establish a dissection ribs together plane between the anterior peritoneum and the muscle. The Supra–Twelfth-Rib Incision transversus abdominis muscle is FIG. 2-2. The surgeon makes the then divided to the lateral margin incision extending from the lateral of the rectus fascia.

Divided transversus abdominis muscle Lumbar dorsal fascia opened Peritoneum 2-3 2-4 reflected medially Chapter 2 The Flank Incision and Exposure of the Kidney 33

FIG. 2-5. The two large muscles, the latissimus dorsi and the serratus posterior, are partially divided to expose the posterior part of the ribs and the intercostal muscles. One common error is to fail to Pleural cavity complete the posterior dissection Eleventh rib despite an excellent anterior dissection. Twelfth rib FIGS. 2-6 AND 2-7. The surgeon uses Latissimus a sponge stick bluntly and gently dorsi muscle Lumbar dorsal fascia to sweep the posterior Gerota’s Serratus posterior muscle fascia medially off the psoas and quadratus lumborum muscles (1 Cut edge of latissimus in Fig. 2-6). The kidney and peri- dorsi muscle toneum are rolled medially by Iliac crest this maneuver, exposing the pos- 2-5 terior surface of the kidney and its pedicle in Gerota’s fascial compartment.

Entry into Retroperitoneum

1 Proper entry for vascular isolation External oblique muscle Internal oblique muscle Peritoneum Transversus abdominis muscle Latissimus dorsi muscle Quadratus lumborum Rectus abdominis muscle muscle Serratus posterior muscle Psoas muscle Kidney with Peritoneum Sacrospinalis muscle Gerota's fascia Latissimus dorsi muscle

Serratus posterior muscle 2-6

Psoas muscle Kidney

Peritoneum 2-7 reflected medially 34 Critical Operative Maneuvers in Urologic Surgery

Diaphragmatic Attachments Intercostal Attachments FIGS. 2-8 AND 2-9. With outward FIG. 2-10. With the same traction traction of the free end of the applied outward and downward twelfth rib, the surgeon uses the on the distal tip of the twelfth rib, right index finger and gently the intercostal muscles are now pushes proximally against the gently divided from the superior inner aspect of the twelfth rib, margin of the rib, beginning at the thereby separating strands of the distal tip of the rib and extending diaphragmatic muscles from the to the proximal region, avoiding rib. This maneuver exposes the in- injury to the pleura. ner aspect of the rib completely The surgeon can divide the and gives the surgeon a clear view muscle directly above the rib Diaphragmatic of the diaphragmatic muscles’ at- without injury to the vasculature attachments to ribs tachments to the rib and retroper- and nerves, which are located im- itoneum. These diaphragmatic at- mediately below the rib. Crus of tachments are then divided. FIG. 2-11. The surgeon’s right in- diaphragm Using the index ﬁnger, the sur- dex finger pushes gently against 2-8 geon must apply pressure against the most proximal inner aspect the rib rather than on diaphrag- of the twelfth rib until the junction matic muscles or the adjacent of the vertebral body is felt. The pleura. This maneuver, in essence, surgeon can now palpate the in- separates the pleura from the rib. ternal intercostal membrane and eleventh rib above. The intercostal Pleura membrane is a thin, dense band of tissue holding the two ribs to- Lung gether. Only this dense membrane Diaphragmatic attachments is divided; the tissue deeper to this membrane is left intact. When Rib dividing this membrane, the surgeon can feel the release of tension. The Finochetto retractor with two dry laparotomy pads can be Diaphragmatic attachments placed on either side of the ribs and opened slowly for full expo- Plane of dissection sure of the kidney. This same exposure can be applied to the eleventh rib if necessary. Twelfth-Rib Rib Resection 2-9 FIG. 2-12. Using periosteal elevators such as Doyen periosteal elevators, the surgeon ﬁrst cleans and frees the rib from its intercostal attachments with periosteal eleva- Latissimus tors in opposing directions as illus- dorsi muscle 11 trated. The Doyen elevators curl around the bony rib and essen- tially release the periosteum and its diaphragmatic attachments.

Vessels and nerves

12 Intercostal muscles Serratus posterior muscle 2-10 Chapter 2 The Flank Incision and Exposure of the Kidney 35

Internal intercostal membrane and costotransverse ligament Eleventh rib

A Intercostal nerve (ventral Internal intercostal membrane ramus of thoracic nerve) Scapula Internal intercostal membrane Infraspinatus muscle over external intercostal muscle Subscapularis muscle Serratus anterior muscle

B Innermost intercostal muscle B © Copyright 1995. CIBA-GEIGY Corporation. Reprinted with Internal intercostal muscle permission from Atlas of Human External intercostal muscle Anatomy illustrated by Frank Netter, M.D. All rights reserved.

2-11

External oblique muscle Rectus abdominis muscle

Doyen periosteal elevators

Rib

Nerve and vasculature

2-12 36 Critical Operative Maneuvers in Urologic Surgery

Since the rib is resected at its fingers to separate the two layers, proximal end with rongeurs, there first the renal vein and then the is no need to divide the intercostal renal pelvis can be identified membrane as is performed in the medially. supra–twelfth-rib incision. With the patient in the full After the rib is resected, the flank position for right-side dis- surgeon uses blunt dissection to section to expose the kidney, the reestablish the plane between the surgeon will not see the duode- quadratus lumborum and psoas num as clearly as when the pa- muscles on one side and the pos- tient is in the supine position terior Gerota’s fascia and kidney (Kocher maneuver, see p. 12). As on the other side as described pre- the separation of the peritoneum Adrenal gland viously. and the Gerota’s fascia is completed, the duodenum will be just anterior to the vena cava. SIMPLE NEPHRECTOMY AND FIG. 2-15. From the anterior as- RECONSTRUCTIVE RENAL SURGERY pect of the kidney, the surgeon FIG. 2-13. The surgeon divides the can usually identify all venous Division of most lateral posterior aspect of the structures, renal vein, adrenal Gerota's Gerota’s fascia to expose the lat- vein, gonadal vein, and lumbar fascia for eral surface of the kidney. vein. access to Dissection between the Ge- At times it may be necessary to kidney rota’s fascia and the kidney medi- free the entire posterior Gerota’s ally on both sides provides excel- fascia from the posterior muscles Kidney lent exposure of the kidney, renal to isolate the renal artery located pelvis, and renal pedicle. slightly inferior to and behind the 2-13 renal vein. The renal artery is always li- RADICAL NEPHRECTOMY IN FLANK gated and/or divided before the POSITION FOR SMALL RENAL renal vein is. Two ties (0 silk) are CANCERS IN LOWER HALF OF placed proximally and one distally. KIDNEY Superiorly, the surgeon follows FIG. 2-14. The dissection pre- the Gerota’s fascia and proceeds serves the integrity of the Gerota’s beyond the adrenal gland. While fascia and includes the adrenal cautiously using gentle down- gland (1). ward traction with the left index The surgeon separates the pos- and middle fingers on either side terior Gerota’s fascia from the of the adrenal gland, the surgeon psoas muscle (2). can clip and divide the attach- The surgeon then identifies the ments superiorly with the right upper ureter and places a vessel hand. If the adrenal vein has not loop for traction. Often the go- been identified yet, it will usually 1 nadal vein is next to the ureter lie on the medial aspect of the and can be divided on the right adrenal gland (for right-sided side. nephrectomy). The most difficult maneuver of 2 the operation is to separate the RENAL AND ADRENAL 3 posterior peritoneum from the anterior Gerota’s fascia (3). The as- VASCULATURE sistant holds the peritoneum up On the right side, the adrenal, re- while the surgeon uses the fingers nal, and gonadal veins branch di- to gently tease a dissection plane rectly from the vena cava, whereas between the two. The reflection of on the left side, the adrenal, acces- the posterior peritoneum can of- sory lumbar, and gonadal vessels ten be seen and used as a guide. join the renal vein. 2-14 As the surgeon gently uses the On the right side, the adrenal Chapter 2 The Flank Incision and Exposure of the Kidney 37

Right adrenal Left adrenal Right vein vein adrenal vein Left Right Left renal adrenal renal artery Right vein renal A artery vein Right Left renal vein renal vein Lumbar vein B Right Left gonadal gonadal vein vein Right Left gonadal renal vein 2-15 vein Left gonadal vein vein can be injured during a radical nephrectomy for large upper pole cancer as previously dis- cussed (see p. 12). FIG. 2-16. On the left side, the loca- tion and vasculature of the adrenal gland is more accessible and eas- Left ier to expose. The most common adrenal vein venous injury involves the acces- Left sory lumbar vein draining into the renal renal vein from a posterior posi- vein tion. Because this vein is located directly behind the renal vein, the surgeon may miss it before divid- Accessory ing the renal pedicle vein (see lumbar p. 20). vein Left gonadal PLEUROTOMY vein Inadvertent pleurotomy is common with flank incisions. The sim- plest method to correct this prob- lem is to insert a chest tube (see p. 23). For a small opening, a red rubber catheter can be placed within 2-16 the pleural cavity, and the open- The surgeon gradually moves ing can be closed with a stitch (2-0 the catheter out while watching chromic). for air bubbles to be expelled. After the surgery is completed When no further air bubbles and the wound is reapproximated come out through the catheter, the around this catheter, the proximal surgeon pulls the catheter out. end of the red rubber catheter is In most cases, the postoperative placed to an underwater seal such chest radiograph shows a small as a medicine cup filled with water. residual defect of 10% pneumo- The anesthesiologist can ex- thorax. This small defect does not pand the lung by inflation and can require treatment but needs only push the air within the cavity out monitoring with serial radio- through the red rubber catheter. graphs. 38 Critical Operative Maneuvers in Urologic Surgery

KEY POTENTIAL POINTS PROBLEMS The patient is positioned with Pleurotomy: Perform postopera- the anterior iliac crest in line with tive closure with the tip of a red the ﬂexion of the table. rubber catheter in the pleural The retroperitoneum space is es- cavity and the open end to an un- tablished ﬁrst. derwater seal to blow out the air in the pleural cavity or place The intercostal muscles, di- chest tube aphragmatic attachments, and intercostal membrane (for supra– Intercostal vasculature and nerve in- twelfth-rib incision) are released. jury: Achieve hemostasis by elec- trocoagulation → perform stitch Note that above the twelfth rib ligation of vasculature not in- the pleura can be easily swept cluding the nerve off, whereas the pleura is more adherent to the ribs above the Inadvertent opening of the posterior eleventh rib. peritoneum: Perform immediate closure because this defect may The Gerota’s fascia is divided to be forgotten subsequently expose the kidney and renal pedicle for reconstructive renal Torn adrenal vein on right side: Ap- surgery. ply hand compression on the vena cava → apply curved Satin- The posterior peritoneum and sky vascular clamp on a cuff of anterior Gerota’s fascia are sepa- the vena cava before repairs if rated to expose the renal pedicle necessary (see p. 59) for a cancer operation. Excessive manipulation of left-sided The right adrenal vein is care- dissection leading to splenic injury fully dissected out for right-sided with hemorrhage suspected based on tumors. For left-sided tumors, the sudden drop in blood pressure: Per- surgeon must watch for the lum- form peritoneotomy → explore bar vein draining into the renal spleen to see if preservation is vein from a posterior position. possible → if not, perform splen- ectomy (see p. 28)

REFERENCE 1 Turner-Warwick RT: The supracostal approach to the renal area, Br J Urol 37:671, 1965.