Editing Open Kidney Surgery (section)

==== Flank subcostal (sub 12th rib) ====
* '''Main disadvantage'''
** '''Poor access to the renal hilum'''
* '''Useful in'''
*# '''Lower renal pole'''
*# '''Ureteropelvic junction'''
*# '''Proximal ureter'''
* '''Avoid in'''
*# '''Large renal masses'''
*# '''Partial nephrectomy'''
* '''Surgical description'''
** '''Skin incision'''
*** '''Begins at the costovertebral angle, approximately at the lateral border of the sacrospinalis muscle just inferior to the 12th rib.'''
*** '''Continuing onto the anterior abdominal wall a fingerbreadth below and parallel to the 12th rib.'''
**** '''To avoid the subcostal nerve, the incision can be curved gently downward at the midaxillary line.'''
**** INSERT FIGURE
** Continue dissection through the subcutaneous tissue to expose '''the fascia of the latissimus dorsi and external oblique muscles'''. Use electrocautery to incise the muscles in the line of the incision, starting with the latissimus dorsi posteriorly. '''The posterior inferior serratus muscles''', which insert into the lower four ribs, are also encountered in the posterior portion of the wound and transected. In the anterior aspect of the wound the '''external oblique muscle is divided'''. These maneuvers expose the '''fused lumbodorsal fascia, which gives rise to the internal oblique and transversus abdominis muscles.'''
** '''Divide the lumbodorsal fascia and internal oblique muscle are divided''' (Fig. 60-6).
** '''The subcostal nerve should be identified between the internal oblique and transversus abdominis muscles and spared'''
** '''By using two fingers inserted into an opening created in the lumbodorsal fascia at the tip of the 12th rib, the peritoneum is swept medially as the transversus abdominis is split digitally.'''