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Good flank exposure of the kid- perpendicular to the operating
ney can be achieved by many sur- table and thus allows the operat-
gical approaches. In general, the ing table to be rolled from side to
kidney lies higher than expected side for improved exposure of the
from the radiologic studies, with anterior or posterior kidney.
the left kidney slightly higher Although the anterior superior
than the right kidney. Except for iliac spine is positioned at the flex-
lower pole renal biopsy, most op- ion of the table, when the table is
erations require good exposure of fully flexed, the final position of
the renal pelvis and the renal the body will cause the entire
pedicle and thus call for either a pelvis to be slightly below the
supra–twelfth-rib incision or a apex of the flexion and the ribs to
twelfth-rib rib resection. In the fol- be slightly above, which creates
lowing discussion of these two tension in the area of the lower
approaches, important anatomic
considerations for all flank expo- Flank Position
sures are highlighted.
FIG. 2-1. The flexion of the oper- Tension placed on Anterior Superior iliac spine
ating table should be in line with ribs and skin in line with flexion of table
the anterior superior iliac spine of
the pelvis. This spine is a constant
landmark that the surgeon can
palpate in both thin and obese
After the patient is positioned
on the side, the kidney rest can be
elevated and the operating table
flexed. It is important to monitor Axillary Pad
the patient’s vital signs because
the vena cava can be compressed Flexion of
during this maneuver. We prefer lower Leg
that the patient is in a straight lat-
eral position 90 degrees to the
table as opposed to an angled po-
sition; the straight lateral position
can be angled by simple rotation
of the operating table from side to
side. The surgeon should apply 5-
inch–wide adhesive tape horizon-
tally across at the level of the iliac
spine and around the operating
table to secure and maintain the
patient in this flank position. The
2-1 Anterior Superior iliac spine
taping stabilizes patient position

32 Critical Operative Maneuvers in Urologic Surgery

External oblique muscle ribs and flank. The surgeon border of the rectus abdominis
Eleventh should palpate the region be- muscle to beyond the posterior
rib 1 tween the eleventh and twelfth axillary line. This incision is es-
ribs and between the ribs and the sentially slightly superior to the
Twelfth iliac spine when the operating twelfth rib.1 Anterior and medial
rib table is adequately flexed to en- to the rib, the external oblique (1),
Lumbar sure that this tension has been internal oblique (2), and transver-
dorsal maintained. sus abdominis (3) muscles are se-
fascia The lower leg is flexed to 90 de- quentially divided.
Transversus grees at the knee to prevent the Although it is not always pos-
abdominis 3 body from rolling from side to sible, the surgeon should attempt
side, but the upper leg is kept to preserve the intercostal nerve to
Internal straight to maintain the tension of prevent the “frog belly” protru-
oblique Flank the incision site; pillows are placed sion of the abdomen after surgery.
muscle 2 incision between the legs as support. The intercostal nerve can be freed
An axillary pad is placed under from the muscles and can be
Rectus abdominis muscle the lower dependent arm to pre- pushed medially and laterally to
vent any neural compression. The the incision during the operation.
upper arm should be placed on an Once the internal oblique mus-
airplane rest for stabilization. cle is divided, the dense lumbar
dorsal fascia, which lies anterior
and medial to the tips of the
EXPOSURE eleventh and twelfth ribs, can be
For any flank exposure of the identified.
kidney, the surgeon must release FIG. 2-3. By opening this fascial
three components holding the ribs landmark, the surgeon can enter
together: the retroperitoneal space and mo-
1 Intercostal muscles bilize the peritoneum anteriorly.
2 Diaphragmatic attachments FIG. 2-4. The surgeon inserts the
to the ribs and retroperito- left index and middle fingers and
neum bluntly spreads the fingers be-
3 Internal intercostal mem- neath the transversus abdominis
brane holding the proximal muscle to establish a dissection
ribs together plane between the anterior peri-
toneum and the muscle. The
Supra–Twelfth-Rib Incision transversus abdominis muscle is
FIG. 2-2. The surgeon makes the then divided to the lateral margin
incision extending from the lateral of the rectus fascia.



Divided transversus
abdominis muscle
Lumbar dorsal fascia opened
2-3 2-4 reflected medially
Chapter 2 The Flank Incision and Exposure of the Kidney 33

FIG. 2-5. The two large muscles,

the latissimus dorsi and the serra-
tus posterior, are partially divided
to expose the posterior part of the
ribs and the intercostal muscles.
One common error is to fail to Pleural cavity
complete the posterior dissection Eleventh rib
despite an excellent anterior dis-
Twelfth rib
FIGS. 2-6 AND 2-7. The surgeon uses Latissimus
a sponge stick bluntly and gently dorsi muscle Lumbar dorsal fascia
to sweep the posterior Gerota’s
Serratus posterior muscle
fascia medially off the psoas and
quadratus lumborum muscles (1 Cut edge of latissimus
in Fig. 2-6). The kidney and peri- dorsi muscle
toneum are rolled medially by Iliac crest
this maneuver, exposing the pos- 2-5
terior surface of the kidney and
its pedicle in Gerota’s fascial

Entry into Retroperitoneum

1 Proper entry for vascular isolation

External oblique muscle

Internal oblique muscle Peritoneum
Transversus abdominis
Latissimus dorsi muscle
Quadratus lumborum Rectus abdominis
muscle muscle
Serratus posterior muscle
Psoas muscle Kidney with
Gerota's fascia Peritoneum
Sacrospinalis muscle
Latissimus dorsi muscle

Serratus posterior muscle





2-7 reflected medially
34 Critical Operative Maneuvers in Urologic Surgery

Diaphragmatic Attachments Intercostal Attachments

FIGS. 2-8 AND 2-9. With outward FIG. 2-10. With the same traction
traction of the free end of the applied outward and downward
twelfth rib, the surgeon uses the on the distal tip of the twelfth rib,
right index finger and gently the intercostal muscles are now
pushes proximally against the gently divided from the superior
inner aspect of the twelfth rib, margin of the rib, beginning at the
thereby separating strands of the distal tip of the rib and extending
diaphragmatic muscles from the to the proximal region, avoiding
rib. This maneuver exposes the in- injury to the pleura.
ner aspect of the rib completely The surgeon can divide the
and gives the surgeon a clear view muscle directly above the rib
Diaphragmatic of the diaphragmatic muscles’ at- without injury to the vasculature
attachments to ribs
tachments to the rib and retroper- and nerves, which are located im-
itoneum. These diaphragmatic at- mediately below the rib.
Crus of tachments are then divided. FIG. 2-11. The surgeon’s right in-
diaphragm Using the index finger, the sur- dex finger pushes gently against
2-8 geon must apply pressure against the most proximal inner aspect
the rib rather than on diaphrag- of the twelfth rib until the junction
matic muscles or the adjacent of the vertebral body is felt. The
pleura. This maneuver, in essence, surgeon can now palpate the in-
separates the pleura from the rib. ternal intercostal membrane and
eleventh rib above. The intercostal
Pleura membrane is a thin, dense band of
tissue holding the two ribs to-
Lung gether. Only this dense membrane
Diaphragmatic attachments is divided; the tissue deeper to
this membrane is left intact. When
Rib dividing this membrane, the sur-
geon can feel the release of ten-
sion. The Finochetto retractor with
two dry laparotomy pads can be
attachments placed on either side of the ribs
and opened slowly for full expo-
Plane of dissection
sure of the kidney.
This same exposure can be ap-
plied to the eleventh rib if neces-
Twelfth-Rib Rib Resection
2-9 FIG. 2-12. Using periosteal eleva-
tors such as Doyen periosteal ele-
vators, the surgeon first cleans and
frees the rib from its intercostal at-
tachments with periosteal eleva-
Latissimus tors in opposing directions as illus-
dorsi muscle 11 trated. The Doyen elevators curl
around the bony rib and essen-
tially release the periosteum and
its diaphragmatic attachments.
Vessels and nerves

12 Intercostal muscles
posterior muscle

Chapter 2 The Flank Incision and Exposure of the Kidney 35

Internal intercostal membrane

and costotransverse ligament

Intercostal nerve (ventral Internal intercostal membrane
ramus of thoracic nerve) Scapula
Internal intercostal membrane Infraspinatus muscle
over external intercostal muscle Subscapularis

B Innermost
intercostal muscle
B © Copyright 1995. CIBA-GEIGY
Corporation. Reprinted with Internal intercostal muscle
permission from Atlas of Human
External intercostal muscle
Anatomy illustrated by Frank
Netter, M.D. All rights reserved.


oblique muscle
Rectus abdominis muscle

Doyen periosteal


Nerve and

36 Critical Operative Maneuvers in Urologic Surgery

Since the rib is resected at its fingers to separate the two layers,
proximal end with rongeurs, there first the renal vein and then the
is no need to divide the intercostal renal pelvis can be identified
membrane as is performed in the medially.
supra–twelfth-rib incision. With the patient in the full
After the rib is resected, the flank position for right-side dis-
surgeon uses blunt dissection to section to expose the kidney, the
reestablish the plane between the surgeon will not see the duode-
quadratus lumborum and psoas num as clearly as when the pa-
muscles on one side and the pos- tient is in the supine position
terior Gerota’s fascia and kidney (Kocher maneuver, see p. 12). As
on the other side as described pre- the separation of the peritoneum
Adrenal gland viously. and the Gerota’s fascia is com-
pleted, the duodenum will be just
anterior to the vena cava.
SIMPLE NEPHRECTOMY AND FIG. 2-15. From the anterior as-
RECONSTRUCTIVE RENAL SURGERY pect of the kidney, the surgeon
FIG. 2-13. The surgeon divides the can usually identify all venous
Division of most lateral posterior aspect of the structures, renal vein, adrenal
Gerota's Gerota’s fascia to expose the lat- vein, gonadal vein, and lumbar
fascia for eral surface of the kidney. vein.
access to Dissection between the Ge- At times it may be necessary to
kidney rota’s fascia and the kidney medi- free the entire posterior Gerota’s
ally on both sides provides excel- fascia from the posterior muscles
Kidney lent exposure of the kidney, renal to isolate the renal artery located
pelvis, and renal pedicle. slightly inferior to and behind the
2-13 renal vein.
The renal artery is always li-
RADICAL NEPHRECTOMY IN FLANK gated and/or divided before the
POSITION FOR SMALL RENAL renal vein is. Two ties (0 silk) are
CANCERS IN LOWER HALF OF placed proximally and one distally.
KIDNEY Superiorly, the surgeon follows
FIG. 2-14. The dissection pre- the Gerota’s fascia and proceeds
serves the integrity of the Gerota’s beyond the adrenal gland. While
fascia and includes the adrenal cautiously using gentle down-
gland (1). ward traction with the left index
The surgeon separates the pos- and middle fingers on either side
terior Gerota’s fascia from the of the adrenal gland, the surgeon
psoas muscle (2). can clip and divide the attach-
The surgeon then identifies the ments superiorly with the right
upper ureter and places a vessel hand. If the adrenal vein has not
loop for traction. Often the go- been identified yet, it will usually
1 nadal vein is next to the ureter lie on the medial aspect of the
and can be divided on the right adrenal gland (for right-sided
side. nephrectomy).
The most difficult maneuver of
the operation is to separate the
posterior peritoneum from the an- RENAL AND ADRENAL
terior Gerota’s fascia (3). The as-
sistant holds the peritoneum up On the right side, the adrenal, re-
while the surgeon uses the fingers nal, and gonadal veins branch di-
to gently tease a dissection plane rectly from the vena cava, whereas
between the two. The reflection of on the left side, the adrenal, acces-
the posterior peritoneum can of- sory lumbar, and gonadal vessels
ten be seen and used as a guide. join the renal vein.
2-14 As the surgeon gently uses the On the right side, the adrenal
Chapter 2 The Flank Incision and Exposure of the Kidney 37

adrenal Left adrenal Right
vein vein adrenal
vein Left
Right Left renal adrenal
renal artery Right vein
artery renal
Right Left renal vein
renal vein Lumbar vein B

Right Left gonadal

gonadal vein
vein Right Left
gonadal renal
vein vein
vein can be injured during a radi-
cal nephrectomy for large upper
pole cancer as previously dis-
cussed (see p. 12).
FIG. 2-16. On the left side, the loca-
tion and vasculature of the adrenal
gland is more accessible and eas- Left
ier to expose. The most common adrenal
venous injury involves the acces- vein
sory lumbar vein draining into the renal
renal vein from a posterior posi- vein
tion. Because this vein is located
directly behind the renal vein, the
surgeon may miss it before divid- Accessory
ing the renal pedicle vein (see lumbar
p. 20). vein
Inadvertent pleurotomy is com-
mon with flank incisions. The sim-
plest method to correct this prob-
lem is to insert a chest tube (see
p. 23).
For a small opening, a red rub-
ber catheter can be placed within 2-16
the pleural cavity, and the open- The surgeon gradually moves
ing can be closed with a stitch (2-0 the catheter out while watching
chromic). for air bubbles to be expelled.
After the surgery is completed When no further air bubbles
and the wound is reapproximated come out through the catheter, the
around this catheter, the proximal surgeon pulls the catheter out.
end of the red rubber catheter is In most cases, the postoperative
placed to an underwater seal such chest radiograph shows a small
as a medicine cup filled with water. residual defect of 10% pneumo-
The anesthesiologist can ex- thorax. This small defect does not
pand the lung by inflation and can require treatment but needs only
push the air within the cavity out monitoring with serial radio-
through the red rubber catheter. graphs.
38 Critical Operative Maneuvers in Urologic Surgery

 The patient is positioned with  Pleurotomy: Perform postopera-
the anterior iliac crest in line with tive closure with the tip of a red
the flexion of the table. rubber catheter in the pleural
 The retroperitoneum space is es- cavity and the open end to an un-
tablished first. derwater seal to blow out the air
in the pleural cavity or place
 The intercostal muscles, di-
chest tube
aphragmatic attachments, and
intercostal membrane (for supra–  Intercostal vasculature and nerve in-
twelfth-rib incision) are released. jury: Achieve hemostasis by elec-
trocoagulation → perform stitch
 Note that above the twelfth rib
ligation of vasculature not in-
the pleura can be easily swept
cluding the nerve
off, whereas the pleura is more
adherent to the ribs above the  Inadvertent opening of the posterior
eleventh rib. peritoneum: Perform immediate
closure because this defect may
 The Gerota’s fascia is divided to
be forgotten subsequently
expose the kidney and renal
pedicle for reconstructive renal  Torn adrenal vein on right side: Ap-
surgery. ply hand compression on the
vena cava → apply curved Satin-
 The posterior peritoneum and
sky vascular clamp on a cuff of
anterior Gerota’s fascia are sepa-
the vena cava before repairs if
rated to expose the renal pedicle
necessary (see p. 59)
for a cancer operation.
 Excessive manipulation of left-sided
 The right adrenal vein is care-
dissection leading to splenic injury
fully dissected out for right-sided
with hemorrhage suspected based on
tumors. For left-sided tumors, the
sudden drop in blood pressure: Per-
surgeon must watch for the lum-
form peritoneotomy → explore
bar vein draining into the renal
spleen to see if preservation is
vein from a posterior position.
possible → if not, perform splen-
ectomy (see p. 28)

1 Turner-Warwick RT: The supracostal
approach to the renal area, Br J Urol
37:671, 1965.