Editing Open Kidney Surgery (section)

== Approaches to Open Kidney Surgery ==

=== Classification ===

# '''Flank''' (see [https://i2.wp.com/abdominalkey.com/wp-content/uploads/2020/01/f008-005-9780128016480.jpg?w=960 Figure])
##'''11th/12th rib supracostal'''
##'''11th rib transcostal'''
##'''Thoracoabdominal'''
##Anterior 11th rib exposure
##Flank subcostal
##Foley muscle splitting
# '''Anterior''' (see [https://i1.wp.com/abdominalkey.com/wp-content/uploads/2020/01/f008-004-9780128016480.jpg?w=960 Figure])
##'''Midline'''
##'''Subcostal''' (and extended subcostal)
##'''Bilateral subcostal (Chevron)'''
##'''Modified thoracoabdominal (hockey-stick)'''
##Transverse
##Paramedian
#'''Dorsal lumbotomy'''

=== Factors to consider ===

# Size of tumor
# Presence of thrombus
# Prior surgical history
# Patient body habitus

=== Flank approaches ===

* '''Advantages[https://www.us.elsevierhealth.com/hinmans-atlas-of-urologic-surgery-revised-reprint-9780323655651.html]'''
**'''Avoids entry into peritoneal cavity, minimizing bowel complications'''
**Direct access to kidney
*Disadvantages[https://www.us.elsevierhealth.com/hinmans-atlas-of-urologic-surgery-revised-reprint-9780323655651.html]
**Lateral incisions necessitate division of large muscle
**Risk of pleural injury
**Risk injuring intercostal nerves
**Risks of postoperative flank bulge, hernia, and significant pain
*Useful in[https://www.us.elsevierhealth.com/hinmans-atlas-of-urologic-surgery-revised-reprint-9780323655651.html]
**Partial nephrectomies
**Repair of ureteropelvic junction obstruction
**Open stone surgeries
**Drainage of renal or perirenal abscesses
*'''Avoid in'''
** '''Patients with pre-existing cardiopulmonary deficits'''
*** Exaggerated lateral decubitus positioning may compromise pulmonary function and venous return to the heart.
*'''Position: ipsilateral lateral decubitus position'''
**After induction of anesthesia, insertion of an endotracheal tube, and introduction of a Foley catheter, the patient is moved on the table so that the ASIS is below the break of the table.
***In the classical flank position, the dependent 12th rib is directly over the kidney rest. Some surgeons do not use kidney rest.
**The patient is then positioned in ipsilateral lateral decubitus. 
**The head is supported to avoid excess flexion at the cervical spine. 
**The patient’s back is supported by a rolled blanket or surgical beanbag. 
**To preserve stability and prevent forward roll, the dependent leg is flexed at the hip and knee and the top leg is kept straight. Two pillows should be placed between the legs, and both ankles should be padded.
**An axillary roll is deployed just caudal to the axilla and above the nipple line to prevent compression or injury of the brachial plexus. 
**Any other pressure points are padded. 
**The nondependent arm should be placed on a padded Mayo stand so that the arm is horizontal with slight forward rotation at the shoulder. 
**The table is flexed between the iliac crest and costal margin until the flank muscles are under stretch. 
***Optional: kidney rest is elevated in conjunction with table flexion.
**The bed is placed in Trendelenburg position so that the flank is rendered parallel to the floor. 
**The patient is secured to the mobile part of the operating table with 2-inch-wide adhesive tape at the shoulder and the hip, which fixes the patient in place while allowing adjustment of flexion. Care should be taken to leave enough space for the self-retaining retractor.

==== 11th/12th rib supracostal ====

* '''Can be used above the 11th or 12th ribs'''
**'''May be challenging to mobilize pleura without injury with approach above 11th rib''' 
*Advantages
** Easier than flank 11th transcostal incision and may provide equal exposure
*'''Surgical description'''
** See [https://www.youtube.com/watch?v=9DzxdniYrms video]
**'''Incision'''
*** Begin at the lateral border of the sacrospinalis muscle/posterior axillary line, at the superior aspect of the 12th or 11th rib
**** The level of the incision is determined by the patient’s anatomy, the location of the lesion, and the planned procedure.
*****Using cross-sectional imaging, a horizontal line drawn from the kidney over to the lateral edge of the rib marks the highest level that is easily accessed from that level of flank incision[https://www.us.elsevierhealth.com/hinmans-atlas-of-urologic-surgery-revised-reprint-9780323655651.html]
*** Continuing anteriorly until the lateral border of the ipsilateral rectus abdominis muscle.
****If the incision is to be extended anteriorly, the patient may be rocked back 30 degrees with a rolled towel providing support behind the back.
** '''Enter retroperitoneum'''
***Continue dissection through the subcutaneous tissue at the superior aspect of the rib to expose the latissimus dorsi posteriorly and external oblique muscles anteriorly (see [https://ars.els-cdn.com/content/image/3-s2.0-B9780128026533000609-f11-08-9780128026533.jpg Figure]).
***In the posterior aspect of the incision, divide the latissimus dorsi to expose the posterior inferior serratus muscles (see [https://basicmedicalkey.com/wp-content/uploads/2016/06/f028-002-9780323077798.jpg Figure]). Then, divide the posterior inferior serratus muscles to expose the intercostal muscles (see [https://mblexguide.com/wp-content/uploads/2022/08/Muscles-of-posterior-torso.jpg Figure]).
***Anteriorly, divide the external oblique muscles to expose the internal oblique muscles. Then, divide the internal oblique muscles to expose the transversus abdominis muscle. As the 11th intercostal neurovascular bundle is encountered between the internal oblique and transversus abdominis, it is freed up and reflected superiorly. The transversus abdominis muscle fibers are separated in line with their fibers, while sweeping the peritoneum medially and inferiorly.
***The intercostal muscles above the 12th rib are carefully incised off the top edge of the rib beginning at its tip using cautery and proceeding posteriorly. The corresponding intercostal nerve is identified and spared. To avoid the neurovascular bundle, the intercostal muscles are divided in close proximity to the superior aspect of the rib.
***Lifting the tip of the rib, the attachments of the diaphragm are teased off of the underside of the upper edge of the rib with scissors, watching for the edge of the pleura, which is usually encountered a few centimeters back from the tip of the rib.
***The edge of the pleura is mobilized off the rib and is reflected superiorly while the intercostal nerve remains safe below the 11th rib
***Run the pad of the left index finger back along the top edge of the rib until it meets the sharp edge of the costovertebral ligament. Insert slightly opened heavy curved scissors, curve down, and hug the top of the rib with the blades to divide the ligament sharply, avoiding the intercostal bundle that lies below the upper (11th) rib.
***The lower rib can pivot down on its costovertebral joint and be retracted inferiorly to be held out of the way with a selfretaining retractor.
***Divide the lumbodorsal fascia at the tip of the rib to avoid both peritoneum and pleura (see [https://abdominalkey.com/wp-content/uploads/2016/06/B9781416069119000013_f001-007-9781416069119.jpg Figure]).
***Reflect the peritoneal envelope medially.
***
** '''Setup self-retaining retractor''' (e.g., Finochietto, Bookwalter, or Omni-Tract)
***Protect the ribs with moist sponges
**'''Develop pararenal space'''
***Bluntly develop the pararenal space
***Gently push the peritoneum anteromedially with a moist sponge stick to further develop the anterior pararenal space medially.
**'''Identify and ligate renal vessels'''
***'''Identify renal vein:''' for left-sided nephrectomy, open the anterior renal fascia overlying the aorta and dissect superiorly until the left renal vein is found. Using right angle dissection, place a vessel loop around the left renal vein for retraction. Palpate the vein for evidence of tumor thrombus. Dissect and mobilize the left renal vein while ligating its lumbar, adrenal, and gonadal branches with 3-0 silk. These branches of the left renal vein, particularly the lumbar branch, are common sources of operative hemorrhage during left nephrectomy.
***'''Identify renal artery:''' identify the left renal artery as it comes off the lateral surface of the aorta deep to the left renal vein, doubly ligate it with 2-0 silk, and then divide or take with a vascular staple load. With the left renal artery controlled, the left renal vein should decompress. If it remains engorged, the possibility of an accessory renal artery needs to be considered, and the lateral aorta should be further dissected before ligating the vein. Otherwise, the vein can be safely ligated with 2-0 silk and divided or taken with the vascular staple load.
**'''Completely mobilize the kidney''' outside of the renal fascia: start with the posterior pararenal space. Progress inferiorly and identify then divide the ureter while mobilizing the lower pole.
**'''Adrenalectomy/spare adrenal:''' pull the upper pole into the wound and dissect the adrenal gland off the superoanteromedial kidney, progressing laterally to medially. Alternatively, if adrenalectomy is indicated, identify and ligate the left middle adrenal artery on the lateral surface of the aorta. Proceed from the superolateral surface of the renal fascia medially, progressively clipping and dividing the attachments and blood supply to the left  adrenal gland.
**'''Closure:''' Partially straighten the table, just enough to allow the edges of the wound to come together. If a drain is required, it is placed through a stab incision well below the 12th rib. A running or interrupted suture closure of the external and internal oblique fascial layers may be made with heavy absorbable or permanent suture in one or two layers, with care taken to avoid the intercostal neurovascular bundle below the rib

==== Thoracoabdominal approach ====

* '''Useful in (4):'''
*# '''Large renal masses'''
*# '''Suprarenal or upper pole masses (for right-sided tumours, can push liver into chest)'''
*# '''Renal tumors with venous extension'''
*# '''Tumors involving adjacent structures.'''
* '''Surgical description'''
** '''Position: similar to flank approach (see above); the pelvis is rotated to a more horizontal position than for the flank incisions, at an angle of approximately 45 degrees.'''
** '''Skin incision'''
*** '''Begins at the lateral aspect of the sacrospinalis muscle over the 10th or 11th rib'''
**** Depending on the location of the tumor, access is gained through the 8th, 9th, 10th, or 11th intercostal spaces.
*** '''Can continue and can travel as far as the contralateral rectus abdominis muscle or caudally toward the symphysis pubis.'''
** The internal oblique and transversus abdominis muscles are transected. The underlying peritoneum is opened, and the peritoneal cavity and chest are entered. Staying close to the superior border of the rib, the intercostal muscles are divided, which exposes the underlying pleura and diaphragm.
** The pleura is opened sharply, taking care to avoid the lung. The costovertebral ligament is divided. The diaphragm is opened from its thoracic surface. Starting anteriorly and proceeding posteriorly, the diaphragm is opened in a curvilinear fashion staying about two fingerbreadths from the chest wall to avoid injuring the more central phrenic nerve.
** The liver or spleen is gently retracted upward. Additional hepatic mobility can be obtained by dividing the coronary ligament and the right triangular ligament of the liver.
** '''For right-sided tumors''', the kidney and great vessels are approached by mobilizing the colon medially and mobilizing the duodenum medially (kocherizing).
** '''For leftt-sided tumors,''' the kidney and great vessels are approached by mobilizing the colon and the tail of the pancreas.

==== Flank subcostal (sub 12th rib) ====
* '''Main disadvantage'''
** '''Poor access to the renal hilum'''
* '''Useful in'''
*# '''Lower renal pole'''
*# '''Ureteropelvic junction'''
*# '''Proximal ureter'''
* '''Avoid in'''
*# '''Large renal masses'''
*# '''Partial nephrectomy'''
* '''Surgical description'''
** '''Skin incision'''
*** '''Begins at the costovertebral angle, approximately at the lateral border of the sacrospinalis muscle just inferior to the 12th rib.'''
*** '''Continuing onto the anterior abdominal wall a fingerbreadth below and parallel to the 12th rib.'''
**** '''To avoid the subcostal nerve, the incision can be curved gently downward at the midaxillary line.'''
**** INSERT FIGURE
** Continue dissection through the subcutaneous tissue to expose '''the fascia of the latissimus dorsi and external oblique muscles'''. Use electrocautery to incise the muscles in the line of the incision, starting with the latissimus dorsi posteriorly. '''The posterior inferior serratus muscles''', which insert into the lower four ribs, are also encountered in the posterior portion of the wound and transected. In the anterior aspect of the wound the '''external oblique muscle is divided'''. These maneuvers expose the '''fused lumbodorsal fascia, which gives rise to the internal oblique and transversus abdominis muscles.'''
** '''Divide the lumbodorsal fascia and internal oblique muscle are divided''' (Fig. 60-6).
** '''The subcostal nerve should be identified between the internal oblique and transversus abdominis muscles and spared'''
** '''By using two fingers inserted into an opening created in the lumbodorsal fascia at the tip of the 12th rib, the peritoneum is swept medially as the transversus abdominis is split digitally.'''

==== 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.

=== Anterior approaches ===

* '''Advantages[https://www.us.elsevierhealth.com/hinmans-atlas-of-urologic-surgery-revised-reprint-9780323655651.html]'''
#Familiar to most surgeons
#Open and closure are very rapid
#Able to evaluate other intraabdominal organs
#Rapid access to the renal hilum
#Good control of the aorta/IVC if they are injured
#Reduced pain by avoiding muscle division
==== <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

==== <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.

==== 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
* '''Surgical description'''
** Position: supine with abdomen hyperextended over a break
**'''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.'''
*** INSERT FIGURE
**Enter peritoneum
***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
***Divide the external and internal oblique muscles and split the fibers of the transversus abdominis muscle
***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

==== 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

==== 11th rib transcostal ====

* Involves removal of the 11th rib
* Used in
** Simple or partial nephrectomy
** Simple adrenalectomy
* Steo-by-step
** See [https://www.youtube.com/watch?v=qkxcucqbh04 video]

=== Dorsal lumbotomy ===
* '''Useful in'''
*# '''Pediatric patients'''
*# '''Thin adults requiring bilateral nephrectomy'''
* '''Main advantage: low morbidity since no muscle is transected'''.
** Anatomic approach to the kidney, with incision of fascial planes rather than muscle.
* '''Main disadvantage: lack of exposure, particularly to the renal hilum and its vessels'''
* Surgical description
** Position: prone
** Incision: vertical skin incision from the inferior border of the 12th rib to the iliac crest, in line with the lateral border of the sacrospinalis muscle.
** [Further details in Campbell’s]