Editing Open Kidney Surgery (section)

==== Bilateral subcostal (Chevron) ====

* '''Composed of bilateral anterior subcostal incisions'''

===== Advantages =====
*Provides access to both sides of the retroperitoneum

===== Disadvantages =====
*Limited exposure to lower abdomen and pelvis

===== Useful in =====
* '''Renovascular surgery'''
* '''Radical nephrectomy with inferior vena cava (IVC) tumor thrombectomy or tumor extension into liver, spleen, or pancreas.'''
** Outstanding exposure of the renal pedicles and great vessels.
**For kidney tumors with extensive thrombus requiring access to the chest, a cephalad median sternotomy extension can be made (Mercedes incision) providing full access to the heart
*Bilateral renal tumors
*Bilateral nephrectomies for large polycystic kidneys

===== Technique =====
* '''Position: supine with abdomen hyperextended over a break'''
* [https://upload.wikimedia.org/wikipedia/commons/2/27/Incisions_of_the_torso.svg '''See Figure: Incision L''']
* '''[https://youtu.be/tTT7uKdpaHI?si=9K0-zQ6VDYUy8liZ See Video]'''
*'''Skin incision'''
** '''Begins at the tip of the 11th rib'''
** '''Continues approximately two fingerbreadths below and parallel to the costal margin, curves superiorly in the midline, travels parallel to the contralateral costal margin, and terminates at the tip of the contralateral 11th rib.'''
*'''Divide anterior abdominal wall muscles'''
**Divide both sides of the anterior rectus sheath
**Insert a finger under the rectus muscle and divide it with cautery, taking care to control the epigastric artery
***The superior epigastric artery runs along the deep surface of the rectus abdominis[https://en.wikipedia.org/wiki/Superior_epigastric_artery]
**Divide the external and internal oblique muscles and split the fibers of the transversus abdominis muscle
*'''Enter peritoneum'''
**Incise the transversalis fascia and peritoneum
**Complete the incision against one or two fingers inside the abdomen
**Divide the falciform of the liver between two clamps, ligating each end or using a vessel-sealing device
**Exposure of the kidneys and retroperitoneum on the right and left sides is identical to that described earlier (midline transperitoneal incision)
*'''Closure'''
**Straighten the table
**Place a holding sure in to approximate the linea alba in the midline, which is tied after fascia closure is completed
**The incision may be closed in a single layer, including the anterior and posterior rectus sheaths, or multiple layers incorporating the peritoneum and posterior rectus fascia in one layer and the internal and external oblique fascial layers laterally with addition of the anterior rectus sheath medially