Operative Urology 1st Edition

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Preface

More than 125 years have passed since the basic cal operations including newer approaches such as
contributions of John Hunter, Crawford Long, and Lord laparoscopic and minimally invasive surgery. The
Lister transformed surgery into a sound science as well various chapters have been organized according to spe-
as a delicate art. Several great surgeons in later decades cific diseases or clinical problems. This enables the
established basic principles of management that remain reader interested in a particular surgical problem, such
valid to this day. As more knowledge was gained, as kidney cancer or bladder cancer, to find all the
surgical specialties and subspecialties evolved and grew. relevant approaches and information within a single
This has been particularly true in urology, where the chapter or section of the book.
surgical approach to many problems has changed This book reflects the philosophy of the Cleveland
significantly in recent years. Clinic Glickman Urological Institute that urology is a
The Cleveland Clinic Glickman Urological Institute broad surgical discipline that encompasses all opera-
houses more than 50 full-time urological clinicians and tions that relate centrally or peripherally to the geni-
surgeons with in-depth expertise in both general urology tourinary tract and male reproductive organs. We hope
and every urological subspecialty area. Operative that our efforts have yielded a comprehensive and prac-
Urology at the Cleveland Clinic encompasses the entire tical reference source for practitioners and residents
field of urological surgery and is authored exclusively that will ultimately improve the care of patients with
by our distinguished faculty. This compendium provides urological surgical problems.
detailed step-by-step well-illustrated descriptions of all A full text version of the book is available on DVD
commonly performed inpatient and outpatient urologi- and sold separately (ISBN 1-59745-371-4).
Andrew C. Novick, MD
For the editors

v
Acknowledgments

This monumental work was created through the dili- Illustrations Department have created a work of art over
gence and creativity of some of the most accomplished and above its scientific merit. More importantly, they
experts in the field of urology. First and foremost are the have interpreted clinician’s words and photographs into
authors whose dedication both to the science and to this an almost life-like instrument of surgical learning.
book allowed us to assemble one of the most complete Finally, Marge O’Malley and the administrative and sec-
surgical urology atlases ever published, and certainly retarial staff of the Glickman Urological Institute de-
the largest ever published by a single institution. Sec- voted endless hours to this project, allowing its smooth,
ond, the talented artists of the Cleveland Clinic Medical timely publication.

vii
Contents

PREFACE ......................................................................................................... V

CONTRIBUTORS ........................................................................................... xiii

PART I: THE KIDNEY AND ADRENAL

1. SURGICAL INCISIONS .............................................................................. 3

J. Stephen Jones

2. ADRENAL DISEASE: OPEN SURGERY ....................................................... 17

Andrew C. Novick

3. LAPAROSCOPIC ADRENALECTOMY ........................................................ 23

Mihir M. Desai and Inderbir S. Gill

4. RENAL MALIGNANCY: OPEN SURGERY .................................................. 31

Andrew C. Novick

5. LAPAROSCOPIC SURGERY FOR RENAL CELL CARCINOMA ................... 51

Inderbir S. Gill

6. RENAL CALCULUS DISEASE ...................................................................... 65

Stevan B. Streem and J. Stephen Jones

7. RENAL VASCULAR DISEASE ...................................................................... 89

Andrew C. Novick

8. SURGICAL TECHNIQUE OF CADAVER DONOR NEPHRECTOMY .......... 103

Venkatesh Krishnamurthi

9. OPEN DONOR NEPHRECTOMY ............................................................... 111

David A. Goldfarb

10. LIVING LAPAROSCOPIC DONOR NEPHRECTOMY ............................... 117

Alireza Moinzadeh and Inderbir S. Gill

ix
x CONTENTS

11. RENAL TRANSPLANTATION ................................................................... 121

David A. Goldfarb, Stuart M. Flechner, and Charles S. Modlin

12. RENAL TRAUMA ...................................................................................... 133

J. Stephen Jones

PART II: THE RETROPERITONEUM

13. NERVE-SPARING RETROPERITONEAL LYMPHADENECTOMY .............. 139

Eric A. Klein

14. URETEROLYSIS ........................................................................................ 149

Lawrence M. Wyner

15. PANCREAS TRANSPLANTATION ............................................................ 153

Venkatesh Krishnamurthi

16. URETEROPELVIC JUNCTION OBSTRUCTION ....................................... 161

Stevan B. Streem and Jonathan H. Ross

17. LAPAROSCOPIC PYELOPLASTY .............................................................. 177

Anup P. Ramani and Inderbir S. Gill

18. UROTHELIAL TUMORS OF THE RENAL PELVIS AND URETER:

ENDOUROLOGICAL MANAGEMENT .................................................. 185
Stevan B. Streem

19. MANAGEMENT OF THE EN BLOC

C DISTAL URETER
AND BLADDER CUFF DURING RETROPERITONEOSCOPIC
RADICAL NEPHROURETERECTOMY ................................................... 195
Osamu Ukimura and Inderbir S. Gill

20. URETERAL DISORDERS IN CHILDREN ................................................... 199

Jonathan H. Ross and Robert Kay

21. IATROGENIC AND TRAUMATIC URETERAL INJURY............................. 215

Bashir R. Sankari

22. URETERAL CALCULI ................................................................................ 223

Stevan B. Streem

PART III: THE BLADDER (MALIGNANT)

23. OFFICE PROCEDURES ............................................................................. 231

J. Stephen Jones

24. RADICAL CYSTECTOMY AND ORTHOTOPIC DIVERSION

IN MEN AND WOMEN......................................................................... 243
Eric A. Klein
CONTENTS xi

25. LAPAROSCOPIC RADICAL CYSTECTOMY

WITH INTRACORPOREAL URINARY DIVERSION .............................. 255
Jihad H. Kaouk and Inderbir S. Gill

PART IV: THE BLADDER (BENIGN)

26. BLADDER AUGMENTATION WITH OR WITHOUT

URINARY DIVERSION .......................................................................... 263
Raymond R. Rackley, Joseph Abdelmalak, and Jonathan H. Ross

27. VAGINAL SLING SURGERY FOR STRESS URINARY

INCONTINENCE ................................................................................... 273
Sandip P. Vasavada, Raymond R. Rackley, and Firouz Daneshgari

28. TRANSVAGINAL CLOSURE OF BLADDER NECK .................................... 285

Sandip P. Vasavada, Raymond R. Rackley, Howard Goldman,
and Firouz Daneshgari

29. URETHRAL DIVERTICULA ....................................................................... 289

Sandip P. Vasavada, Raymond R. Rackley, Howard Goldman,
and Firouz Daneshgari

30. REPAIR OF ANTERIOR VAGINAL WALL PROLAPSE ............................... 295

Sandip P. Vasavada, Raymond R. Rackley, Howard Goldman,
and Firouz Daneshgari

31. REPAIR OF BLADDER FISTULAE ............................................................. 299

Mark J. Noble, Sandip P. Vasavada, and Ian C. Lavery

PART V: THE PROSTATE

32. OPEN BENIGN PROSTATECTOMY ......................................................... 315

Charles S. Modlin

33. BENIGN PROSTATIC HYPERPLASIA MINIMALLY INVASIVE

AND ENDOSCOPIC MANAGEMENT ................................................... 323
James C. Ulchaker and Elroy D. Kursh

34. RADICAL RETROPUBIC PROSTATECTOMY............................................ 327

Eric A. Klein

35. LAPAROSCOPIC RADICAL PROSTATECTOMY ....................................... 341

Massimiliano Spaliviero and Inderbir S. Gill

36. LAPAROSCOPIC ROBOTIC-ASSISTED RADICAL

PROSTATECTOMY ................................................................................ 355
Sidney C. Abreu and Inderbir S. Gill

37. RADICAL PERINEAL PROSTATECTOMY ................................................. 363

Craig D. Zippe
xii CONTENTS

38. PROSTATE CANCER: BRACHYTHERAPY ................................................. 373

James C. Ulchaker and Jay P. Ciezki

PART VI: THE PENIS AND URETHRA

39. SURGICAL ANATOMY OF THE PENIS .................................................... 377

Kenneth W. Angermeier

40. ANTERIOR URETHRAL STRICTURE ......................................................... 385

Kenneth W. Angermeier

41. HYPOSPADIAS REPAIR ............................................................................ 405

Jonathan H. Ross

42. MALIGNANCIES OF THE PENIS AND URETHRA .................................... 415

Mark J. Noble

43. SURGERY FOR POSTERIOR URETHRAL VALVES .................................... 431

Jonathan H. Ross and Robert Kay

44. ARTIFICIAL URINARY SPHINCTER IMPLANTATION ............................. 435

Drogo K. Montague and Kenneth W. Angermeier

PART VII: THE GENITALIA

45. SURGERY FOR MALE INFERTILITY ......................................................... 443

Anthony J. Thomas, Jr.

46. PENILE PROSTHESIS IMPLANTATION .................................................... 477

Drogo K. Montague and Kenneth W. Angermeier

47. PRIAPISM ................................................................................................. 489

J. Stephen Jones, Drogo K. Montague

48. PEYRONIE’S DISEASE AND CONGENITAL PENILE CURVATURE .......... 493

Kenneth W. Angermeier

49. INGUINAL SURGERY IN CHILDREN ...................................................... 509

Jonathan H. Ross and Inderbir S. Gill

50. ADULT SCROTAL SURGERY.................................................................... 523

Gerard A. DeOreo and J. Stephen Jones

INDEX ............................................................................................................ 543

Contributors

JOSEPH ABDELMALAK, MD • Research Fellow, Section JIHAD H. KAOUK, MD • Section of Laparoscopic and Robotic
of Voiding Dysfunction and Female Urology, Glickman Surgery, Glickman Urological Institute, Cleveland Clinic
Urological Institute, Cleveland Clinic Foundation, Foundation, Cleveland, OH
Cleveland, OH ROBERT KAY, MD • Chief of Staff, Cleveland Clinic
SIDNEY C. ABREU, MD • Section of Laparoscopic and Robotic Foundation, Cleveland, OH
Surgery, Glickman Urological Institute, Cleveland Clinic ERIC A. KLEIN, MD • Head, Section of Urologic Oncology
Foundation, Cleveland, OH and Professor of Surgery, Glickman Urological Institute,
KENNETH W. ANGERMEIER, MD • Section of Prosthetic Cleveland Clinic Foundation, Cleveland, OH
Surgery and Genitourethral Reconstruction, Glickman VENKATESH KRISHNAMURTHI, MD • Director, Kidney/Pancreas
Urological Institute, Cleveland Clinic Foundation, Transplantation, Section of Renal Transplantation, Glickman
Cleveland, OH Urological Institute, Cleveland Clinic Foundation, Cleveland,
JAY P. CIEZKI, MD • Staff Physician, Department of Radiation OH
Oncology, Cleveland Clinic Foundation, Cleveland, OH ELROY D. KURSH, MD • Professor of Surgery, Glickman
FIROUZ DANESHGARI, MD • Co-Director, Center for Female Urological Institute, Cleveland Clinic Foundation,
Pelvic Medicine and Reconstructive Surgery, Glickman Cleveland, OH
Urological Institute, Cleveland Clinic Foundation, IAN C. LAVERY, MD, FACS • Vice-Chairman, Department
Cleveland, OH of Colorectal Surgery, Cleveland Clinic Foundation,
GERARD A. DEOREO, JR., MD • Glickman Urological Cleveland, OH
Institute, Cleveland Clinic Foundation, Euclid, OH CHARLES S. MODLIN, MD • Co-Director, Minority
MIHIR M. DESAI, MD • Section of Endourology and Stone Men’s Health Center, Renal Transplant Surgeon, Section
Disease, Section of Laparoscopic and Robotic Surgery, of Renal Transplantation, Glickman Urological Institute,
Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland Clinic Foundation, Cleveland, OH
Cleveland, OH ALIREZA MOINZADEH, MD • Fellow, Section of Laparoscopic
STUART M. FLECHNER, MD • Director, Clinical Research, and Robotic Surgery, Glickman Urological Institute,
Section of Renal Transplantation, Professor of Surgery, Cleveland Clinic Foundation, Cleveland, OH
Glickman Urological Institute, Cleveland Clinic DROGO K. MONTAGUE, MD • Head, Section of Prosthetic
Foundation, Cleveland, OH Surgery and Genitourethral Reconstruction, Professor
INDERBIR S. GILL, MD, MCh • Head, Section of Laparoscopic of Surgery, Glickman Urological Institute, Cleveland
and Robotic Surgery, Glickman Urological Institute, Clinic Foundation, Cleveland, OH
Cleveland Clinic Foundation, Cleveland, OH MARK J. NOBLE, MD • Staff Urologist, Glickman Urological
DAVID A. GOLDFARB, MD • Head, Section of Renal Institute, Cleveland Clinic Foundation, Cleveland, OH
Transplantation, Cleveland Clinic Foundation, Cleveland, ANDREW C. NOVICK, MD • Chairman, Glickman Urological
OH Institute, Cleveland Clinic Foundation, Associate Dean
HOWARD GOLDMAN, MD • Section of Voiding Dysfunction for Faculty Affairs, Professor of Surgery, Cleveland Clinic
and Female Urology, Glickman Urological Institute, Lerner College of Medicine at Case Western Reserve
Cleveland Clinic Foundation, Cleveland, OH University, Cleveland, OH
J. STEPHEN JONES, MD • Vice-Chairman, Glickman Urological RAYMOND R. RACKLEY, MD • Co-Head, Section of Voiding
Institute, Cleveland Clinic Foundation and Associate Professor Dysfunction and Female Urology, Glickman Urological
of Surgery (Urology), Cleveland Clinic Lerner College Institute, Director, Urothelial Biology Laboratory,
of Medicine at Case Western Reserve University, Lerner Research Institute, Cleveland Clinic Foundation,
Cleveland, OH Cleveland, OH

xiii
xiv CONTRIBUTORS

ANUP P. RAMANI, MD • Fellow, Section of Laparoscopic OSAMU UKIMURA, MD • Fellow, Section of Laparscopic
and Robotic Surgery, Glickman Urological Institute, and Robotic Surgery, Glickman Urological Institute,
Cleveland Clinic Foundation, Cleveland, OH Cleveland Clinic Foundation, Cleveland, OH
JONATHAN H. ROSS, MD • Head, Section of Pediatric Urology, JAMES C. ULCHAKER, MD, FACS • Section of Urologic
The Children's Hospital at the Cleveland Clinic Foundation, Oncology/Prostate Center, Glickman Urological
Cleveland, OH Institute, Cleveland Clinic Foundation,
BASHIR R. SANKARI, MD, FACS • Staff, Glickman Urological Cleveland, OH
Institute, Cleveland Clinic Foundation, Charleston, WV SANDIP P. VASAVADA, MD • Co-Head, Section
MASSIMILIANO SPALIVIERO, MD • Fellow, Section of of Voiding Dysfunction and Female Urology, Glickman
Laparoscopic and Robotic Surgery, Glickman Urological Urological Institute, Cleveland Clinic Foundation,
Institute, Cleveland Clinic Foundation, Cleveland, OH Cleveland, OH
STEVAN B. STREEM, MD • Head, Section of Stone Disease LAWRENCE M. WYNER, MD • Staff, Glickman Urological
and Endourology, Glickman Urological Institute, Institute, Cleveland Clinic Foundation,
Cleveland Clinic Foundation, Cleveland, OH Charleston, WV
ANTHONY J. THOMAS, JR., MD • Head, Section CRAIG D. ZIPPE, MD • Co-Director, Prostate Center,
of Male Infertility, Glickman Urological Institute, Glickman Urological Institute, Cleveland Clinic
Cleveland Clinic Foundation, Cleveland, OH Foundation, Cleveland, OH
I The Kidney and Adrenal
1 Surgical Incisions
/ Stephen Jones

The purpose of any surgical incision is facilitation of vascular grafts, or abdominal mesh) must be carefully
the planned operation with the least possible morbidity. considered prior to violating these structures.
As most urological operations can be performed via many Body habitus often influences choice of incision. The
different approaches, the surgeon must combine under- dictum, "No one is fat in the flank," results from the
standing of all alternatives with the flexibility to choose observation that a large pannus will fall forward when
the incision most appropriate to each clinical situation. the patient is placed in the standard flank position. There-
The selection may make the difference between an easy fore, nephrectomy on a morbidly obese patient can be
or difficult operation, which will affect the experience of easier to perform via a flank incision than it would be
both the patient and surgeon. through a subcostal. Open nephroureterectomy tradition-
ally requires both a flank and a lower abdominal incision.
GENERAL CONSIDERATIONS However, a single extended subcostal extraperitoneal
flank incision may allow complete removal of the kidney,
Urological organs can be approached via multiple routes. entire ureter, and bladder cuff in a thin woman with a
For example, the kidney can be accessed through transab- short waist and wide pelvis. This can save time and avoid
dominal incisions (subcostal, midline, paramedian), flank potential wound contamination during patient reposition-
incisions (through or between the beds of the lowest three ing and draping.
ribs, or lumbodorsal), a combination of the two (thoracoab- Severe kyphosis or scoliosis may make surgical
dominal), or laparoscopically. The surgeon should choose approaches more or less difficult. Whereas left scoliosis
based on operation-specific and patient-specific factors. might make left flank incision difficult, the right side
Operation-specific issues depend on the surgical goals. might actually be easier than usual owing to the splaying
Larger incisions, especially those that allow access to the of the ribs away from the iliac crest.
entire coelom, give more exposure at the cost of additional Concurrent pathology may affect the decision. If a patient
morbidity and cosmetic impact. Whereas one might priori- has gallbladder disease and a large right renal cancer, both
tize wide exposure and choose a thoracoabdominal incision organs may be removed through a subcostal incision. A
for a large renal mass with caval involvement, an extraperi- flank incision followed by laparoscopic cholecystectomy
toneal flank incision gives adequate exposure with less may be chosen if the pathology is in the contralateral kidney.
morbidity for pyeloplasty or routine nephrectomy. Excessive incisional length increases the discomfort
Avoidance of involving additional body cavities, par- and cosmetic impact, whereas an undersized incision may
ticularly if infection is present, may play a role in decision make an otherwise easy operation a struggle. Matching
making. For example, extraperitoneal flank incision for an the skin incision to the fascial opening assures the scar is
infected renal calculus or abscess minimizes the risk of only as long as required, but fascial closure is not compro-
contaminating the peritoneal cavity or thorax. mised on either end.
Patient-specific cosmetic or anatomical considerations Utilizing the entire incision also requires appropriate
are often overlooked. Some patients may resist surgery if retraction. The Buchwalter retractor is useful in most
they perceive disfigurement. Other patient-specific factors flank and abdominal incisions, as it gives a fixed exposure
to be considered include scarring or adhesions from radia- and does not tire like a surgical assistant. Alternatively,
tion or previous surgery. Abdominal access in a patient with other self-retaining retractors like the Finochietto or
a stoma or neobladder may require creatively avoiding a Balfour work well for oppositional retraction but do not
midline incision. Artificial material (e.g., urinary prostheses. offer multidirectional retraction.

From: Operative Urology at the Cleveland Clinic

Edited by: A. Novick et al. © Humana Press Inc., Totowa, NJ
4 JONES

the abdominal muscles at the waist demonstrate tension,

bringing them into parallel with the floor. The ribs can be
palpated and marked in all but the most obese patients.
ELEVENTH RIB INCISION (CLASSIC FLANK)
Although a flank incision can be made through or
between the beds of the lowest three ribs, removal of the
11th rib usually offers excellent exposure and minimizes
risk of entering the pleura.
The incision begins posteriorly at the angle of the rib
and may extend as far as the border of the rectus abdomi-
F i g . 1 . 1 ( Fr o n t Vi e w ) nus. The skin and subcutaneous tissues are opened to
expose the latissimus overlying the chosen rib. Transect-
ing the overlying muscle exposes the periosteum, which
can be incised along the length of the rib using the elec-
INCISIONS FOR EXPOSURE OF THE UPPER trocautery or scalpel.
GENITOURINARY ORGANS A periosteal elevator is used to remove the periosteum
to the point where it wraps above and below the rib. Care
Flank Approaches must be taken caudally to stay between rib and perios-
A flank incision offers extraperitoneal access to the teum to avoid injuring the neurovascular bundle running
kidney and adjacent structures. However, access to the along the rib notch.
hilar structures may be limited, especially in the presence The opposite end of the Alexander periostial elevator
of large tumors. Experienced surgeons rarely find this lim- is shaped to allow detachment of the intercostal fibers on
itation bothersome if exploration of other intra-abdominal the upper and lower rib margins. Because of the direc-
structures is not required. tional attachment of the fibers, pulling the instrument “up
Nowhere is proper positioning more important than for on the down side and down on the up side” mobilizes the
flank incisions. This is achieved by placing the patient in rib borders.
the lateral decubitus position after induction of anesthesia. The Doyen rib instrument slides into the plane between
A towel roll or bag of intravenous fluid is placed under the rib and periosteum. The instrument is then pulled in each
axilla to protect against brachial nerve palsy. An electrically direction along the rib to complete the rib dissection. If
controlled surgical bed is helpful, especially during closure the instrument is placed too deeply, bleeding from the
of the incision when a hand crank will likely hit the arm neurovascular bundle and pleural injury are likely.
board. The dependent leg is flexed, with pillows placed A rib cutter divides the rib posteriorly. Rongeur scis-
between the legs to protect pressure points. The upper leg is sors remove any bony spicules. Marrow bleeding is usu-
almost straight, crossing the mid-calf of the lower leg. The ally minimal.
lower arm is placed on an arm board. A double arm board Anteriorly the rib must be separated from the costal
or instrument stand may support the upper arm. margin using electrocautery or heavy scissors.
The patient’s waist should be directly over the kidney Blunt dissection through the remaining fibers in the
rest. Extend the table at the waist only after the kidney anterior rib bed exposes the retroperitoneum. Care is
rest is fully elevated. Correct bed extension occurs when taken to mobilize the pleura for cephalad retraction. If

F i g . 1 . 2 ( B a c k Vi e w )
C H A P T E R 1 / S U R G I CA L I N C I S I O N S 5

Fig. 1.3

entered, the pleura is closed at the end of the procedure SUBCOSTAL FLANK INCISION
after aspirating air from the thorax using a red rubber If there is no need for high exposure, a flank incision
catheter. can be made below the 12th rib. This eliminates the risk of
After bluntly sweeping the peritoneum anteriorly off entering the pleural cavity, but is no less painful than a rib
the abdominal wall, the muscular layers may be divided incision. The incision is especially useful in children.
between fingers using the electrocautery. A formal flank position is used. After marking the tips
of the lower ribs with a surgical pen, it is helpful to draw
the position of the 12th thoracic nerve, also known as the
subcostal nerve. The incision extends from sacrospinalis
muscle posteriorly to the rectus border anteriorly.

Fig. 1.4 Fig. 1.5

6 JONES

Fig. 1.6

The skin and subcutaneous tissues are opened to

expose the external abdominal oblique muscle and latis-
simus dorsi. Care must be taken opening the internal
oblique in order to avoid damaging the subcostal nerve,
which lies between the internal abdominal oblique muscle
and the underlying transversalis abdominus.
Careful mobilization of the subcostal nerve and vessels
Fig. 1.8
allows them to be retracted either cephalad or caudad. The
lumbodorsal fascia (the fusion of the internal oblique and
transversalis muscle sheaths posteriorly) is incised to DORSAL LUMBOTOMY
enter the retroperitoneum. Peritoneum is then swept away This incision is used infrequently, but in properly
from the anterior abdominal wall. The transversalis fibers selected thin patients it offers relatively atraumatic access
are separated bluntly. to the ureteropelvic junction (UPJ). The incision is limited

Fig. 1.7 Fig. 1.9

C H A P T E R 1 / S U R G I CA L I N C I S I O N S 7

Fig. 1.12

The incision follows the lateral border of the

Fig. 1.10
paraspinous muscles from the 12th rib to iliac crest.
by the 12th rib superiorly and the iliac crest inferiorly, so Rolled sheets support the shoulders with the patient
there is no option to extend it; therefore, it should be used prone. A small amount of bed extension increases the dis-
only when the access needed is undoubtedly within this tance between the bony limits.
narrow window. After opening the skin and subcutaneous tissues, the
lumbodorsal fascia is identified. The medial aspect is
bordered by the paraspinous muscles and quadratus lum-
borum. The lateral aspect is bordered by the latissimus
dorsi. Dividing the lumbodorsal fascia exposes Gerota’s
fascia. Because the space is small, the incision may be
best visualized with handheld retractors. The UPJ and
upper ureter are easily mobilized through a window in
Gerota’s fascia.

Fig. 1.11 Fig. 1.13

8 JONES

Fig. 1.15

The skin incision is made two fingerbreadths below the

costal margin from the anterior axillary line to slightly
across the midline. The external oblique, internal oblique,
and transversalis muscles are opened laterally. Their fas-
ciae briefly join lateral to the rectus abdominus muscle.
At that point, the rectus fascia splits anteriorly and poste-
riorly. In patients without extensive intra-abdominal scar-
ring, an effective approach is to enter the peritoneal cavity
Fig. 1.14
in the midline portion of the incision under direct visuali-
zation. Properitoneal fat should be swept off the peri-
Anterior Approaches toneum, which is grasped with tissue forceps and held up
Excellent exposure and ready access to the renal hilum to allow the underlying omentum and small bowel to fall
are advantages of intra-abdominal anterior approaches. away prior to cutting between the forceps (inset, Fig. 1.17).
Disadvantages include the higher incidence of ileus and Two fingers are placed under the abdominal wall to pro-
incisional hernia. tect the underlying small bowel. The abdominal wall is then
opened under direct vision, ligating the branches of the supe-
SUBCOSTAL TRANSPERITONEAL INCISION rior epigastric artery. The falciform ligament holds the liga-
The patient is placed in the supine position with the mentum teres, which is the remnant of the umbilical vein. In
bed extended below the lumbar spine. A blanket elevating patients with adhesion of peritoneal contents to the abdomi-
the ipsilateral shoulder enhances lateral extension. The nal wall, the dissection into the abdomen should be done
skin is prepped all the way to the bed. with a combination of blunt and sharp dissection. Lateral

Fig. 1.16
C H A P T E R 1 / S U R G I CA L I N C I S I O N S 9

Fig. 1.17

Fig. 1.19
entry sometimes avoids these adhesions. The incision ends
posterolaterally near the peritoneal reflection of Toldt.
The patient’s waist is positioned over the flexion point
BILATERAL SUBCOSTAL TRANSPERITONEAL INCISION of the surgical bed. Arms may be tucked at the patient’s
Excellent exposure to the upper abdominal cavity and side, but if the dissection is planned beyond the anterior
retroperitoneum is afforded through this incision, other- axillary line, they should be placed on arm boards. Table
wise known as a chevron or “bucket-handle” incision. extension increases exposure as long as caval compres-
sion by stretching is avoided.
As with any bilateral incision, care should be taken to
assure the incision is symmetrical with respect to the mid-
line and to the costal margins. The abdomen is entered in
the same manner as in the unilateral subcostal transperi-
toneal incision.

Fig. 1.18 Fig. 1.20