Editing Open Kidney Surgery (section)

==== 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