Editing Open Kidney Surgery (section)

==== Anterior 11th Rib Exposure[https://link.springer.com/chapter/10.1007/978-1-84628-763-3_17] ====

* Extraperitoneal approach
* Advantages
** Smaller incision than flank incision
** Obviates need for rib removal
** Minimizes risk of pneumothorax
** Less pain than with a standard flank or transperitoneal incision
* Disadvantages
** Inability to examine intraperitoneal contents
** Slightly decreased exposure of hilum (compared to transperitoneal approach)
* Useful in
** Partial nephrectomy
** Small to moderate tumors that require radical nephrectomy and are not amenable to laparoscopic nephrectomy
* Position
** Semiflank torque position with the operative side and torso rotated medially 45° off the table, while the hips and lower extremities remain in a supine position
** The anterior superior iliac spine is placed just below the inferior aspect of the kidney rest. This allows for maximal exposure in the operative area after the table is maximally flexed and the kidney rest is elevated. The table is placed into a mild Trendelenburg position to keep the patient parallel to the floor. An axillary roll is placed as well as a posterior role to maintain the flank position. All extremities and pressure points are carefully padded and protected. The upper extremity, ipsilateral to the tumor, is placed onto a padded aeroplane arm board. The contralateral upper extremity is placed on a standard arm board. The patient is secured into position with the use of wide adhesive tape. The operative area is shaved and prepared with the agent of choice.
* Incision
** Plan incision along a straight line from the tip of rib 11 toward a mark 1 cm above the umbilicus
*** Length of the incision is tailored individually for the patient’s body habitus and size of tumor
* Step by step
** The ribs are palpated and identified. A marking pen is used to outline ribs 10, 11, and 12. A straight incision is made. Dissection is carried through the external oblique and internal oblique muscles laterally. The medial extent of the incision extends to the lateral aspect of the ipsilateral rectus muscle (Fig. 8a-1C and D). Should a larger incision be necessary, the rectus fascia can be opened and rectus muscle divided also
** The transversus abdominis muscle overlies the peritoneum and must be opened while the peritoneum is dissected off posteriorly to remain extraperitoneal. The cut edges of the internal oblique muscle are grasped with Alice clamps at the lateral edge of the incision and the transversus abdominis fascia is dissected off the posterior abdominal wall both inferiorly and superiorly. A handheld Richardson retractor allows for elevation of the anterior abdominal wall as a sponge stick or Kittner is utilized for mobilization of the peritoneum (Fig. 8a-1E and F). The transversus is incised taking care to not open the peritoneum. A self-retaining Buchwalter retractor is utilized to maintain exposure. Moistened laparotomy sponges are used to protect soft tissues from retractor damage. Blunt dissection is used to mobilize the peritoneum medially off of Gerota’s fascia. With adequate mobilization, the renal hilum becomes visible. Additional retractors are carefully placed to hold the peritoneum medially (Fig. 8a-1G). In right neprectomy, the second portion of the duodenum can be visualized and retracted medially. Closure is performed with Looped 0-PDS suture to reapproximate the internal oblique and rectus muscles. Inter�rupted 0 Vicryl sutures are used to reapproximate the external oblique fascia. Marcaine (0.5%) is infiltrated into the muscle, subcutaneous tissues, and along rib 11 medially for postop�erative analgesia. The skin can be closed with subcuticular closure or staples.