Midline extraperitoneal approach to upper urinary tract surgery: Anatomical basis of surgical technique

Abstract

To overcome the disadvantages inherent in the standard surgical approach to the kidney, we introduced a novel surgical technique via a midline extraperitoneal approach. The surgical technique is not substantially different from that of the standard midline transperitoneal approach, except no entry is made into the peritoneal cavity. Although the peritoneum itself is extremely thin and fragile, the peritoneum together with underlying subperitoneal fascia can be dissected readily as a substantial layer, if the proper plane is dissected. Further medial mobilization of the peritoneal sac en bloc by pursuing the fusion fascia plane allows full exposure of the kidney, ureter and great vessels. This approach was adopted for consecutive 51 patients during a 10-month period in 2003. All operations, including 33 radical nephrectomies and 11 nephroureterectomies were completed successfully without significant technical difficulties and differences in operation time and estimated blood loss compared to the transperitoneal approach. No intra-or perioperative complication occurred. All patients did seem to have a much more comfortable postoperative period with minor pain and few abdominal complaint, and the clinical impression was that they resumed the physical activity and oral intake earlier than those after the transperitoneal approach (P = 0.056). There are no operation-related problems such as intra-abdominal adhesion or abdominal muscle weakness resulting in some deformity at 2-year or more follow up. This approach combines the advantages of the transperitoneal midline and extraperitoneal flank approach. Its use will undoubtedly reduce the complications inherent in the transperitoneal approach or the flank approach.

Midline extraperitoneal approach for bilateral widespread retroperitoneal abscess originating from anorectal infection

“…We used the totally extraperitoneal approach through a single midline vertical incision in the lower abdomen. This anterior retroperitoneal approach is typically used for lumbar spine procedures [16] and also for reconstruction of the abdominal aorta and iliac arteries [17] , repair of obturator hernia [18] , retroperitoneal lymph node dissection [19] , and urinary tract surgery [20] . In our case, the anterior midline approach enabled us to drain and irrigate extensively the bilateral retroperitoneal abscess without intra-abdominal manipulation.…”

Midline extraperitoneal approach to retroperitoneal pathology ‐ broadening the horizons

“…In 2006, the first published series of 51 nephrectomies out of Japan applied this approach. 4 They reported no intra-or peri-operative complications. Furthermore, patients where a midline EP method was used resumed physical activity and oral intake 10% earlier than those after the TP approach (P = 0.056).…”

“…Extraperitoneal flank incision overcomes the risks associated with entering the abdominal cavity however conveys a higher incidence of pneumothorax, injury to the subcostal nerves and flank muscles. Resulting denervation of the ipsilateral abdominal wall leads to deformity with patients reporting persistent discomfort and resultant numbness in the corresponding region 4 . Additionally, this unilateral approach compromises exposure of the contralateral retroperitoneum often required in inferior vena cava thrombectomy and RPLND or the ability to extend the dissection cranially or caudally based on intraoperative findings.…”

“…Although a midline EP approach has been utilized for RPLND and sympathectomy, it is not routinely employed for all retroperitoneal surgery. In 2006, the first published series of 51 nephrectomies out of Japan applied this approach 4 . They reported no intra‐ or peri‐operative complications.…”

“…Resulting denervation of the ipsilateral abdominal wall leads to deformity with patients reporting persistent discomfort and resultant numbness in the corresponding region. 4 Additionally, this unilateral approach compromises exposure of the contralateral retroperitoneum often required in inferior vena cava thrombectomy and RPLND or the ability to extend the dissection cranially or caudally based on intraoperative findings. The midline EP approach avoids the disadvantages of the transperitoneal and the flank entries whilst maintaining the advantages of both.…”