RETROPERITONEAL APPROACH TO THE LUMBAR SPINE

DR. ASHISH AGARWAL.DR.NITIN PAIKRAO.

DEPT. OF ORTHOPAEDICSB.Y.L.NAIR CH. HOSPITAL

INDICATIONS FOR RETROPERITONEAL

APPROCH

l 1.SPINAL DECOMPRESSION.

2.LUMBAR SPINE FUSION.

3. PSOAS ABSCESS DRAINAGE.

4.OPEN BIOPSY OF VERTEBRAL BODY

5. SYMPATHECTOMY

POSITION OF PATIENT

1. Left semilateral position with 45 degree tilt

to horizontal with patient facing away from

surgeon.

2. Supine position with table tilted to 45

degree.

.

Figure 6-31 Place the patient in the semilateral position for the

anterolateral (retroperitoneal) approach to the lumbar

POSITION OF PATIENT FOR RETROPERITONEAL APPROCH

midline.

INCISION

• AN OBLIQUE FLANK INCISION FROM THE

POSTERIOR HALF OF THE 12TH RIB TO

MIDWAY BETWEEN THE UMBILICUS AND THE

PUBIC SYMPHYSIS .

posteriorly.

INCISION FOR RETROPERITONEL APPROCH

Figure 6-33 Make an oblique flank incision extending down from the

posterior half of the 12th rib toward the rectus abdominis muscle

SUPERFICIAL SURGICAL DISSECTION

• DIVIDE THE APONEUROSIS OF THIS MUSCLE IN THE LINE OF ITS FIBERS, WHICH IS IN LINE WITH THE SKIN INCISION.

• THE EXTERNAL OBLIQUE MUSCLE SHOULD BE SPLITTED IN THE LINE OF ITS FIBERS I.E. LIKE HANDS IN POCKETS.

Figure 6-34 Incise the external oblique muscle and aponeurosis in line

with its fibers and in line with the skin incision

EXTERNAL OBLIQUE MUSCLE FIBRES ARE SPLITTED ALONG DIRECTION OF ITS MUSCLE FIBRES

it.

.

SUPERFICIAL SURGICAL DISSECTION

.

• DIVIDE THE INTERNAL OBLIQUE MUSCLE IN LINE WITH THE SKIN INCISION AND PERPENDICULAR TO THE LINE OF ITS MUSCULAR FIBERS. THIS DIVISION CAUSES PARTIAL DENERVATION, BUT IF THE MUSCLE IS CLOSED PROPERLY, POSTOPERATIVE HERNIAS CAN BE AVOIDED .

.FIGURE 6-35 DIVIDE THE INTERNAL OBLIQUE IN LINE WITH THE SKIN

INCISION AND PERPENDICULAR TO THE LINE OF ITS MUSCULAR FIBERS.

.

DISSECTION OF INTERNAL OBLIQUE MUSCLE

.

UNDER THE INTERNAL OBLIQUE MUSCLE

LIES THE TRANSVERSUS ABDOMINIS

MUSCLE. IT SHOULD BE DIVIDED IN LINE

WITH THE SKIN INCISION TO EXPOSE THE

RETROPERITONEAL SPACE .

.

.

Figure 6-36 Divide the underlying

transversus abdominis muscle in line

with the skin incision.

DO NOT CUT TRANSVERSALIS FASCIA

ASIT FORMS PROTECTIVE LAYER

OVER THE PERITONEUM

.IN THE ANTERIOR PART OF THE WOUND, IDENTIFY THE PERITONEUM AND ITS CONTENTS. POSTERIORLY, IDENTIFY THE RETROPERITONEAL FAT.

.

• Using SPONGE ON SPONGE HOLDER, develop a plane between the retroperitoneal fat and the fascia that overlies the psoas muscle .

• Place a Dever retractor over the peritoneal contents and retract them to the right upper quadrant. The ureter, which is attached loosely to the peritoneum, is carried forward with it.

video

video

.

PERITONEUM WITH ITS CONTENT IS PUSHED ANTERIORLY TO EXPOSE THE LUMBAR SPINE AND MAJOR VESSELS.

video

.• IDENTIFY THE PSOAS FASCIA, BUT DO

NOT ENTER THE MUSCLE.

• FOLLOW THE SURFACE OF THE PSOAS

MEDIALLY TO REACH THE

ANTERIOLATERAL SURFACE OF THE

VERTEBRAL BODIES.

. LEVEL CONFIRMATION

• PLACE A NEEDLE INTO THE

INVOLVED LUMBAR VERTEBRA AND

TAKE A RADIOGRAPH TO IDENTIFY

THE EXACT LOCATION.

.• THE AORTA AND VENA CAVA EFFECTIVELY ARE

TIED TO THE WAIST OF THE VERTEBRAL BODIES

BY THE LUMBAR SEGMENTAL ARTERIES AND

VEINS.

• THESE SMALLER VESSELS MUST BE LOCATED

INDIVIDUALLY ON THE INVOLVED VERTEBRAE

AND TIED SO THAT THE AORTA AND VENA CAVA

CAN BE MOBILIZED AND THE ANTERIOR PART OF

THE VERTEBRAL BODY REACHED

IDENTIFY SEGMENTAL VESSEL

TWO LAYERS OF PREVERTEBRAL FASCIA

SEGMENTAL VESSELS IN BETWEEN

INFILTRATE

PREVERTEBRAL

FASCIA

video

INCISE

• 11 NO BLADE

• OUTER LAYER OF PREVERTEBRAL FASCIA

DISSECTION OF SEGMENTAL VESSELS

• HOLD OUTER LAYER OF PREVERTEBRALFASCIA WITH KOCHERS

• DISSECTION WITH PEANUT• IDENTIFY THE VESSELS• LIGATE THE VESSELS• COAGULATE• CUT BETWEEN THE LIGATURE.

SUBPERIOSTEAL DISSECTION

• INCISE THE DEEPER LAYER OF PREVERTEBRAL FASCIA

• INCISE PERIOSTEUM• SUBPERIOSTEAL ELEVATION TILL ANT.SURFACE OF BODY• ROLLER PACK AND PENCIL PERIOSTEM• LESS CHANCES OF DAMAGING MAJOR VESSELS• MINIMISE BLOOD LOSS

.ELEVATE PSOASIDENTIFY POSTERIOR MARGIN OF VERTEBRAL BODYIDENTIFY PEDICLEIDENTIFY NEURAL FORAMINADECOMPRESS CORDIDENTIFY EXISTING NERVE ROOTUSE BIPOLAR NEAR NEURAL STRUCTURES

CAVEAT…………• The ureter is attached loosely to the peritoneum. If

doubt , it should be stroked gently to produce peristalsis.

• The sympathetic chain is found between the vertebral bodies and the psoas muscle laterally,

• The genitofemoral nerve lies on the anterior aspect of the psoas muscle.

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FRACTUREL2 VERTEBRA

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EXPANDIBLECAGES

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L3 FRACTURE

L3 FRACTURE

L1 FRACTURE

L1 FRACTURE

Drawbacks of Retroperitoneal Approch :

1. Restricted exposure to L 5-S1 disc

space.

2. Extensive dissection of soft tissue

3. Technically difficult

.

THANK YOU !!!