Classification of Procedures
Retroperitoneal surgery encompasses several main approaches, with the lumbar incision serving as the foundational approach for the majority of them.
- Renal surgery: includes incision of the parenchyma (nephrotomy), opening of the renal pelvis (pyelotomy), creation of an artificial fistula (nephrostomy), and organ suspension for fixation (nephropexy). More radical procedures include partial resection and total organ removal (nephrectomy).
- Vascular procedures: performed for renovascular hypertension or as part of a kidney transplantation.
- Adjacent procedures: operations on the adrenal glands and various segments of the ureters.
Approaches to the Kidney and Upper Third of the Ureter
Surgeons traditionally use two classic incisions to expose the kidney and the proximal ureter.
Fedorov incision (lumbotomy) Begins at the apex of the angle formed by the 12th rib and the lateral margin of m. erector spinae (approximately 7–8 cm from the spinous processes). The line runs obliquely downward toward the umbilicus and ends at the iliac crest, although it can be extended all the way to the umbilicus if necessary.
Layer-by-layer dissection:
- Skin, subcutaneous tissue, and fascia.
- The muscular layer is traversed in three layers. First: m. latissimus dorsi (superiorly) and m. obliquus externus abdominis (inferiorly). Second: m. serratus posterior inferior and m. obliquus internus abdominis. Third: m. transversus abdominis. If necessary, m. rectus abdominis is additionally divided up to the linea alba.
- In the deeper layers, fascia thoracolumbalis and m. quadratus lumborum are incised.
The parietal peritoneum along with adipose tissue is bluntly separated medially and upward. The kidney is palpated through the dense, shiny retrorenal fascia, which is then incised; the adipose capsule is bluntly dissected, and the organ is delivered into the wound.
Bergmann incision Follows the bisector of the angle between the 12th rib and the edge of m. erector spinae. The incision ends two fingerbreadths above the anterior superior iliac spine. Access to the organ is performed similarly to the Fedorov technique. Modifications exist: extending the line downward parallel to the inguinal ligament forms the Israel incision, while extending the line upward to the 11th rib expands the exposure.
Approach to the Lower Third of the Ureter
For procedures on the pelvic ureter up to its entrance into the urinary bladder, the Pirogov incision is optimal.
The incision line begins at the anterior superior iliac spine and runs 4 cm above and strictly parallel to the inguinal ligament. Both oblique abdominal muscles and the transversus abdominis muscle are divided during the approach, reaching the lateral border of the rectus abdominis muscle. An important feature of this technique is that the peritoneum is not opened, but carefully displaced medially and upward, providing a safe pathway to the ureter.
Approaches to the Renal Artery
The most rational approaches to the renal artery are midline laparotomy and thoracophrenolumbotomy. The latter is used to perform endarterectomy, resection of a stenotic vascular segment, or bypass grafting.
The incision for thoracophrenolumbotomy begins at the 10th intercostal space from the mid-axillary line and extends anteriorly toward the anterior midline of the body. After layer-by-layer dissection of the soft tissues down to the retroperitoneal space, a thoracotomy in the 10th intercostal space and a phrenotomy (incision of the diaphragm) are performed.
Key to the approach is the division of the medial part of the diaphragmatic crus. This maneuver allows visualization of the thoracoabdominal aorta, including the celiac trunk, superior mesenteric artery, and both renal arteries.
Working on the right side has an important anatomical feature: the middle segment of the right renal artery is covered by the inferior vena cava, so the vein must be mobilized. The surgeon must also always keep in mind the potential presence of accessory arteries.
Briefly: answers to topical questions
What fasciae surround the kidney in the retroperitoneal space?
Sources mention the following in relation to the kidney and perirenal structures:
- Prerenal fascia (fascia prerenalis).
- Retrorenal fascia (fascia retrorenalis).
- Gerota's fascia, which limits perirenal hemorrhage; tumor extension beyond it is classified as T4.
- Toldt's fascia, located in the retroperitoneal space.
- Lateral conal fascia, thickening of which may be observed in perirenal hemorrhage.
What are the anatomical boundaries of Petit's lumbar triangle?
The anatomical boundaries of Petit's lumbar triangle (Trigonum lumbale) are formed by the margins of the back and abdominal muscles, as well as bony structures.
- Laterally — margins of the latissimus dorsi (m. latissimus dorsi) and external oblique abdominal (m. obliquus externus abdominis) muscles.
- Inferiorly — iliac crest.
- Floor — internal oblique abdominal muscle.
This triangle is formed by the divergence of the margins of these muscles and represents a weak spot in the first muscular layer through which lumbar hernias and abscesses may emerge.
For level memorization: kidney — Fedorov and Bergmann (high), upper ureter — Bergmann (middle), lower ureter — Pirogov (low, near the inguinal ligament).
Class and exam questions
How to distinguish the peritoneum from the renal fascia during Fedorov's approach?
The retrorenal fascia appears as a dense, shiny structure, which visually distinguishes it from the parietal peritoneum in the surgical wound.
What is the key to the approach in thoracophrenolumbotomy?
The main step that opens the view to the aorta and renal arteries is the division of the medial part of the diaphragmatic crus.
Which anatomical structure impedes access to the right renal artery?
The middle segment of the right renal artery is anteriorly covered by the inferior vena cava, so it must be carefully mobilized during surgery.
What else to study on this topic
- Technique of blunt dissection of the renal adipose capsule
- Mobilization of the inferior vena cava during vascular procedures
- Specific surgical tactics for accessory renal arteries
- Midline laparotomy as an alternative approach to renal vessels
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