Editing Open Kidney Surgery (section)

==== Modified thoracoabdominal (hockey-stick) ====

* Extraperitoneal approach
** Transverse portion of the incision facilitates development of the extraperitoneal space
* Position
** Begin with patient supine with table flexed at the waist
** Place the patient in the modified flank position with the ipsilateral arm suspended over the chest and a roll beneath to elevate the ipsilateral side slightly
* Incision
** May be extended inferiorly all the way to the pubic bone or laterally over the rib case as a thoracoabdominal incision
** Divide the subcutaneous tissues and anterior rectus fascia in line with the incision
** Divide the body of the rectus muscle at the upper edge of the incision
** Divide the external oblique, internal oblique, and transversalis muscle near the costal margin
** Enter retroperitoneum, lateral to the peritoneal reflection
** The peritoneum can be swept off the anterior abdominal muscles medially before the posterior rectus fascia is opened
** The abdominal wall flap can then be retracted inferiorly with a towel clamp
** The peritoneal envelope is them mobilized laterally back to the psoas while superiorly the peritoneum is mobilized off the diaphragm
** The plane between the peritoneum and the anterior leaf of Gerota fascia is most easily identified near the lower pole and is developed by incising the thin fascial layer that envelops them together
** The remainder of the avascular plane is developed bluntly using fingers or a Kittner, reflecting the entire peritoneal envelope medially
** The kidney, ureters, and gonadal vessels with Gerota fascia remain atop the psoas muscle
** A self-retraining retractor such as a Bookwalter allows the peritoneum to be kept medially out of the way
** Closure
*** The transverse portion of the incision is closed in two layers, with care taken to keep the corner properly aligned