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Yu Chap 02 (31-38)
Yu Chap 02 (31-38)
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 Flank the incision site; pillows are placed sion of the abdomen after surgery.
muscle 2 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
11
12
Psoas
muscle
Kidney
Peritoneum
2-7 reflected medially
34 Critical Operative Maneuvers in Urologic Surgery
12 Intercostal muscles
Serratus
posterior muscle
2-10
Chapter 2 The Flank Incision and Exposure of the Kidney 35
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 com-
pleted, 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
posterior peritoneum from the an- RENAL AND ADRENAL
3 VASCULATURE
terior Gerota’s fascia (3). The as-
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
artery renal
A
vein
Right Left renal vein
renal vein Lumbar vein B
K E Y P O T E N T I A L
P O I N T S P R O B L E M S
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.