Anterior transperitoneal operative approach to the kidney

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MOST surgeons by tradition have exposed the kidney through a standard flank incision, resecting a rib or opening the chest when wider exposure was needed. The rationale of the retroperitoneal approach was sound, since many operations resulted in prolonged drainage of infected urine. However, with the advent of vascular surgery, it became apparent that adequate exposure of the renal vessels was often not possible through conventional flank incisions. Furthermore, the establishment of retroperitoneal drainage was not only unnecessary, but actually undesirable in revascularization procedures. As a result, the transabdominal transperitoneal approach to the kidney became popular.1–3 With greater experience, this approach has become the procedure of choice in an increasing range of clinical conditions requiring surgical treatment.

This report represents in detail the merits of the anterior approach to the kidney, and outlines both the advantages and the limitations in specific clinical conditions.

The incision

The kidney can be exposed through one of many different anterior incisions. When exposure of only the renal vessels or pelvis is necessary, especially in slender patients, a standard subcostal incision usually is adequate. In obese patients, or when maximum exposure of the great vessels or of both kidneys is required, a bilateral subcostal incision4, 5 will give excellent exposure (Fig. 1A). If there is a large tumor of the kidney or adrenal gland, the incision may be extended to include most of the eleventh rib, with the patient in a slightly oblique position, as recommended by Stewart and Meaney6 (Fig. 1B). A vertical midline . . .



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