Editing Open Kidney Surgery (section)

==== <span style="color:#ff0000">Anterior midline</span> ====

*'''Advantages''' (in addition to above)
*#Less painful than flank or transverse abdominal incisions that require division of major muscle groups
*'''Disadvantages[https://www.us.elsevierhealth.com/hinmans-atlas-of-urologic-surgery-revised-reprint-9780323655651.html]'''
*#Limited exposure to the kidneys because of the renal hilum is at the upper limit of the incision
*#Overlying colon, liver, and spleen must be mobilized widely
*#Risk of late bowel obstruction and incisional hernia
*'''Indications'''
*# '''Renal trauma'''
*#* Permits exploration for associated intraperitoneal injuries.
*# '''Bilateral renal procedures'''
*#* Both ureters must be accessed (e.g. retroperitoneal fibrosis)
*# Renovascular surgery
*# Reconstructive procedures, including ileal ureteral replacement
*#Horseshoe kidney
* '''Step-by-step[https://www.us.elsevierhealth.com/hinmans-atlas-of-urologic-surgery-revised-reprint-9780323655651.html]'''
**'''Position:''' supine, with the table extended at the patient's waist
**'''Incision:''' midline, from the xiphoid to just below the umbilicus
**'''Enter peritoneal cavity:''' divide the subcutaneous tissue down to the level of the fascia and identify the linea alba. Incise the linea alba to expose the preperitoneal fat covering the peritoneum. Grasp of the preperitoneal fat, ensuring that bowel is not taken with it, and sharply cut through the peritoneum layer. The remainder of the posterior rectus fascia and peritoneum may be opened, taking care to avoid any potential adhesions between the bowel and the anterior abdominal wall.
**'''Identify renal vessels:''' expose the posterior peritoneum by displacing the patient’s small bowel contents to the right and the descending colon to the left. 
***'''Make an incision in the posterior peritoneum over the aorta, between the fourth portion of the duodenum and the inferior mesenteric vein (IMV).''' 
****This area is devoid of vessels arising off of the anterior aorta as long as one stays above the takeoff of the inferior mesenteric artery (IMA).
***'''Continue dividing superiorly over the aorta up to the left renal vein.''' 
****The renal vein is dissected above and below with care taken not to injure the superior mesenteric artery (SMA); '''the SMA should be''' '''on the anterior surface of the aorta and is usually 1 to 2 cm cephalad to the left renal vein.''' 
***The left and right renal arteries are usually encountered coursing directly lateral off the aorta posterior to the left renal vein though multiple arteries may arise anywhere from above the level of the SMA down to the common iliac arteries
**Approach to kidneys:
***Incise along the lateral edge of the colon on the avascular line of Toldt, continuing up around the hepatic flexure (right) or splenocolic ligament (left).
****On the right side, the second portion of the duodenum is encountered after medialization of the colon. The duodenum is then medialized (Kocher maneuver) over the aorta, which exposed the anterior aspect of the IVC
****On the left side, the upper limit of Gerota fascia must be separated from the lower edge of the pancreatic tail and splenic hilum.
***After abdominal contents are mobilized off Gerota fascia, a self-retaining retractor can be placed to keep the intestines out of the way for the remainder of the surgery.
**Closure
***One-layer closure