Editing Open Kidney Surgery (section)

=== 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.