b. Patient Preparation. The position of the patient on the operating table will
depend on the type of lesion, the position of the kidney, and the surgical approach
selected. The most common position for kidney operations is the lateral when a lumbar,
transpleural, or extra-pleural transthoracic approach is to be used. A supine or a
modified Trendelenburg position is employed when an abdominal approach is to be
c. Approaches to the Kidney.
(1) Lumbar or simple flank incision. This incision begins at the
costovertebral angle and parallels the twelfth rib. It extends, forward and downward
between the iliac crest and the thorax.
(2) Nagamatsu incision. This is a modification of the simple flank incision
and is made over the eleventh and twelfth ribs, removing a section of each.
(3) Thoracoabdominal incision. The tenth and eleventh ribs are removed,
and the chest cavity is opened, collapsing the lung. Rib spreaders and approximators
and chest drainage are required. When the lumbar, Nagamatsu, or thoracoabdominal
approach is used, the patient is placed in a lateral position.
(4) Transperitoneal and retroperitoneal incisions. The patient is placed in a
supine position. A vertical incision is made in the epigastric and umbilical region on the
affected side. This approach is used for a large kidney tumor or when the kidney and
ureter are extensively involved in the surgery.
d. Operative Approach (Lumbar Approach).
(1) The incision is carried through the skin, fat, and fascia. Bleeding vessels
are clamped with hemostats and ligated.
(2) The external oblique, the latissimus dorsi, and the internal oblique
muscles are exposed. The required portions of the dorsi, external oblique, posterior
inferior serratus, and internal oblique muscles are split or divided and retracted with a
dull rake or Richardson right-angled retractors. Bleeding is controlled. The
transversalis fascia is cut with scissors. Then the iliohypogastric and ilioinguinal nerves
are identified and retracted. The sacrospinal muscle is retracted. The deep lumbar
fascia is separated. The quadratus lumborum muscle may be divided.
(3) The pleura, peritoneum, and twelfth thoracic artery and nerve are
identified and retracted. Laparotomy pads and Deaver retractors are placed to protect
the adjacent structure and afford exposure.
(4) If necessary, a rib or ribs (twelfth, eleventh, or tenth) may be resected to
give access to the kidney. The periosteum is stripped with an Alexander costal
periosteotome and Doyen rib raspatory.