Anterolateral retroperitoneal approach

Indications

  • Access to L1 to Sacrum
  • Drainage of psoas abscess
  • Spinal fusion
    • Approach from Left because Aorta is harder to damage than IVC

Position

  • Semi lateral position at 45° facing away from surgeon
    • Sandbags under hips & shoulder
    • Allows peritoneal contents to fall away from incision
    • Tilt table

Landmarks

  • 12th rib
  • pubic symphysis
  • lateral border of rectus abdominis
    • 5cm lateral to midline

Incision

  • oblique flank incision extending from
  • Start: posterior half of the 12th rib towards the lateral border of rectus abdominis
  • End: Halfway between umbilicus & pubic symphysis

Internervous Plane

  • No true plane
    • External oblique, Internal oblique & Transversus abdominis are innervated segmentally

Superficial Dissection

  • Fat
  • Aponeurosis of external oblique muscle
  • Incise
    • External oblique
    • Internal oblique
    • Transversus abdominus
  • Exposes retroperitoneal space
  • Blunt finger dissection with finger
    • Develop plane between retroperitoneal fat & fascia overlying psoas muscle
  • Gently mobilise peritoneal cavity & retract medially using Dever retractor

Deep Dissection

  • identify Psoas fascia
    • genitofemoral nerve
    • segmental lumbar branches of aorta
    • sympathetic chain
  • Psoas Abcess
    • Locate abscess & drain
  • Fusion
    • Ligate & tie segmental lumbar branches of aorta & IVC

Dangers

  • Nerves
    • Sympathetic chain
    • Genitofemoral nerve
  • Vessels
    • Segmental lumbar arteries & veins
    • Vena Cava
    • Aorta
  • Ureter