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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 lat- eral position 90 degrees to the table as opposed to an angled po- sition; 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 peri- toneum 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. 11 12 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 serra- tus 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 dis- section. 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 11 12 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 sur- geon can feel the release of ten- sion. 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 ap- plied to the eleventh rib if neces- sary. Twelfth-Rib Rib Resection 2-9 FIG. 2-12. Using periosteal eleva- tors such as Doyen periosteal ele- vators, the surgeon first cleans and frees the rib from its intercostal at- tachments 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.
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