Editing Open Kidney Surgery (section)

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

* Advantages[https://link.springer.com/chapter/10.1007/978-1-84628-763-3_17]
**Excellent access to the upper pole and adrenal gland
**Good exposure to renal hilum
**Lower risk of pleurotomy and pneumothorax compared to standard flank incision
*'''Disadvantages[https://www.us.elsevierhealth.com/hinmans-atlas-of-urologic-surgery-revised-reprint-9780323655651.html]'''
** Limited visibility, best reserved for small renal tumors or benign conditions
*** Better anterior access may be gained from extending incision to other approaches such as the hockey-stick, extended subcostal or bilateral subcostal (Chevron)
**Prolonged ileus or delayed small bowel obstruction secondary to adhesion formation from manipulation of the bowel[https://link.springer.com/chapter/10.1007/978-1-84628-763-3_17]
*'''Step-by-step[https://www.us.elsevierhealth.com/hinmans-atlas-of-urologic-surgery-revised-reprint-9780323655651.html]'''
**See [https://www.youtube.com/watch?v=mjPuC-In9OY video]
**Left side is extraperitoneal approach while right side is transperitoneal approach??
***Spleen and peritoneal contents can be readily mobilized anteriorly on left side??
***Liver limits ability to mobilize peritoneum off Gerota fascia on right side??
**'''Position'''
***Supine with table slightly flexed at the patient's waist (anterior superior iliac spine at the level of the kidney rest)
****A small roll can be placed behind the patient on the operative side, rotating the patient slightly.[https://link.springer.com/chapter/10.1007/978-1-84628-763-3_17]
***If preferred, the shoulder can be turned 30-40 degrees and the ipsilateral arm placed over the head on support
**'''Incision'''
***Medial extent: midline anteriorly (through the ipsilateral rectus), one third of the distance from the xiphoid to the umbilicus
***Lateral extent: at the tip of the 11th rib near the anterior axillary line
****If the exposure is inadequate, further exposure can be gained by extending the incision 
*****Medially and incising the opposite rectus sheath slightly (extended subcostal)
*****Converting it to a hockey-stick
*****Converting it to a full bilateral subcostal (Chevron)
*****Posteriorly as a flank incision
***Two fingerbreadths from the costal margin[https://link.springer.com/chapter/10.1007/978-1-84628-763-3_17]
***Use cautery/scalpel to incise along length of incision
***After incision of the Scarpa fascia, use cautery to dissect through external oblique muscle (and overlying fascia) and anterior rectus sheath.
****Excellent hemostasis is essential to prevent delayed bleeding and hematoma formation. 
***Use cautery to dissect through internal oblique muscle (and overlying fascia) and rectus muscles.
****Rectus muscle may be divided with electrocautery, making sure to control the superior epigastric artery
***Digitally separate the fibers of the transversus abdominis, starting as far laterally as possible, where the peritoneum is less adherent
**'''Left side: extraperitoneal approach'''
***'''Enter extra-peritoneal space'''
****Divide the left side of the anterior rectus sheath and the external oblique muscles for a short distance
****Divide the internal oblique muscles
****Digitally separate the fibers of the transversus abdominis, starting as far laterally as possible, where the peritoneum is less adherent
****Incise the transversalis fascia
***'''Develop extra-peritoneal space'''
****Displace peritoneum. Free the peritoneum off above and below the incision. Sweep the peritoneum bluntly off the abdominal wall laterally and inferiorly to the iliac crest. Continue posteriorly to the lateral edge of the psoas muscle in the extraperitoneal space and bluntly strip the peritoneum from the underlying muscle layer. Sharp dissection with scissors may be required.
****To develop the plane between the peritoneum and the anterior leaf of Gerota fascia, incise the transversalis fascia just outside the reflection of the peritoneum laterally. This should be a filmly, fibroareolar tissue in an avascular plane, and the gonadal and ureter should remain posteriorly
***'''Identify, divide and ligate renal vessels'''
****Renal vessels may be encountered at the level of the aorta
***'''Mobilize kidney'''
****Gerota fascia is divided above the kidney, carefully mobilizing it off of the lower edge of the pancreas
****Lower limit of Gerota is divided above the common iliac artery, and the ureter and gonadal vessels are divided
****The remaining posterior and medial attachments are divided, and the kidney is removed with Gerota fascia
***'''Deliver specimen'''
***'''Closure:''' two-layers
****First-layer: internal oblique
****Second-layer: external oblique and rectus fascia
**'''Right side: transperitoneal approach'''
***'''Enter peritoneal space'''
****Use Debakey forceps to lift up on peritoneum and enter peritoneum with Metzenbaum scissors. Place finger inside and extend incision over finger.
*****Divide the peritoneum in an area free of underlying bowel or the the midline and extend to expose the liver, ascending colon, and greater omentum covering the transverse colon
****The ligamentum teres is doubly ligated and incised to allow for maximal exposure.
****The peritoneum is visually and manually examined to evaluate for metastatic disease. The retroperitoneum and perinephric space are entered by mobilizing the colon with incision of the white line of Toldt while retracting the colon medially. The assistant utilizes a handheld Richardson retractor to lift the anterior abdominal wall improving access to the White line. 
****After mobilization of the colon, a self-retaining Buchwalter retractor is placed
***'''Identify, divide and ligate renal vessels'''
****Renal vessels may be approached through the posterior peritoneum as described for above midline transperitoneal 
*****Alternatively, incise along the lateral border of the hepatic flexure and mobilize the right colon and duodenum medially to expose the kidney
***'''Mobilize kidney'''
****'''Medialize the colon:''' Incise the posterior parietal peritoneum on the line of Toldt from the common iliac artery to the hepatic flexure. Develop the anterior pararenal space by dissecting in the plane anterior renal fascia and the mesentery of the ascending colon
*****This step may be difficult if large or inflammatory masses as the anterior pararenal space may be obliterated by tumor or occupied by numerous large collateral vessels
*****Important to stay out of the ascending mesocolon because injury to the right colic or ileocolic arteries (and their branches) can devitalize this segment of the colon
****Mobilize the hepatic flexure of the colon using sharp and blunt dissection to minimize the risk of hepatic capsular tear and to improve visualization of the upper pole and adrenal gland. The hepatorenal ligament is also incised to allow the upper pole of the kidney to fall away from the liver. The Falciform ligament is also incised to allow the liver to be retracted without injury.
****'''Medialize the duodenum''' (Kocher maneuver): The second part of the duodenum may be closely connected to the medial part of the tumor, and  is useful for mobilizing it farther medially and away from the mass.
*****The duodenum is fragile and is in danger of injury, with necrosis and perforation as a consequence. Avoid using electrocautery around the duodenum, but, if necessary, light bipolar coagulation can safely achieve hemostasis
****'''Identify IVC:''' Incise the anterior renal fascia on the medial aspect of the kidney and identify the IVC
****'''Identify renal vein:''' dissect anteriorly on the IVC, both cranially and caudally, until the left renal vein, right renal veins, and right gonadal vein are identified. Dissect the right renal vein and place a vessel loop around it so that it can be gently and atraumatically retracted
****'''Palpate the renal vein and IVC for evidence of tumor thrombus'''
****'''Identify and ligate renal artery:''' The right renal artery is usually located deep and superior to the right renal vein on the lateral side of the IVC. If possible, dissect around the right renal artery using a right angle clamp. Stay close to the vessel and spread the perivascular tissue using the right angle clamp or Metzenbaum scissors. Use 2-0 silk ties or a vascular staple load to ligate the renal artery.
*****If the right renal artery is hard to isolate because tumor is encroaching medially on the renal hilum or because troublesome hilar bleeding is occurring, identify the artery in the interaortocaval region and control it with either a 2-0 silk or vascular staple load. This provides much better exposure to the right renal artery lateral to the IVC, which can then be ligated and divided.
*****In the interaortocaval region, watch for lumbar veins that come into the renal vein or vena cava at this level. When you encounter them, do not secure them with clips that may become displaced or preclude the ability to use a stapler, but pass a 0 silk suture on a right angle clamp and tie it.
****'''Bluntly develop the posterior pararenal space.''' Normally, this is easily done by gently sliding the left hand underneath the kidney while retaining contact with the fascia of the muscles of the posterior abdominal wall. Small vessels in the posterior pararenal space that perforate through the posterior renal fascia should be clipped or cauterized as this plane is gently developed.
****Occasionally, the renal tumor will invade the psoas muscle posteriorly, making the posterior dissection difficulty. In these circumstances, ensure that the renal pedicle is adequately controlled before dissected the tumor away from the muscle sharply.
****'''Bluntly dissect the inferior pole of the kidney''' (with its investing fat and renal fascia).
****'''Identify and ligate the ureter.''' Doubly ligate it with 2-0 silk or large clip and then divide it, or take it with an additional staple load.
****'''Identify the gonadal vein''' and protect it by gently pushing it medially. 
*****This vein is friable, and its avulsion from the IVC is a common cause of hemorrhage during nephrectomy
****Dissect the inferomedial kidney away from the IVC until it is free up to the renal hilum superiorly.
****With the exception of the upper pole, the entire kidney with the perirenal fat and renal fascia intact should now be mobilized
****'''Dissect the upper pole of the kidney.''' Grasp the kidney with the left hand and gently pull it caudally into the wound to expose the upper pole attachments, working laterally to medially, free the kidney from its cranial attachments.
****'''Consider adrenalectomy vs. adrenal-sparing.''' 
*****If adrenalectomy is indicated, remove the gland en bloc with the kidney, within the renal fascia.
*****If the adrenal can be spared, dissect it off the anterior, superior, and medial surface of the kidney
******The cranial connections to the adrenal gland must be divided carefully step by step between clips or by using a join vessel sealing and dividing device or stapler. Clip the small vessels and especially the lymphatics.
******If the adrenal gland is injured, oversew the edge with 4-0 monocryl on a tapered half-circle SH needle.
******Beware of the short right adrenal vein that typically enters the IVC posterolaterally, high in the retroperitoneum, near the hepatic veins. If avulsed, this small vein can lead to significant hemorrhage before it is controlled.
****'''Deliver specimen'''
****'''Closure'''
*****looped 0-PDS to reapproximate the rectus and internal oblique muscles. The external oblique fascia is reapproximated using interrupted 0-Vicryl sutures. The incision is infiltrated with 0.5% Marcaine and the skin is closed with subcuticular closure or staples.