Editing Open Kidney Surgery (section)

==== 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.