Options
Anterior
- thoracotomy
- thoracoabdominal
- abdominal
Posterior
Anterior Approaches
C2 - T2
- anterior cervical approach
- may have to split manubrium / sternotomy for lowest levels
T3 - T7
- thoracotomy
- patient on side left side up to avoid veins
- always easier to mobilise aorta
- scapular in the way of the ribs
- release scapula and lift away from ribs
- go through bed of appropriate rib
- usually rib 2 above vertebra
- have to deflate lung with double lumen ETT
- divide segmental artery away from foramen
- identify discs (hills) and vertebral bodies (valleys)
T7 - T12
- thoracotomy
- patient on side
- bed of rib 2 above vertebra
- can usually push lung out of way without deflation
T12 - L1
- thoracoabdominal
- patient on side
- through bed of 10th rib
- diaphragm attaches at T12/L1 and 12th rib
- must take down diaphragm if need to instrument or cross T12/L1
L2 - L5
- anterolateral flank / retroperitoneal approach
- incision below 12th rib
- patient on side
L5/S1
- anterior / transabdominal approach
- pelvis blocks flank approach
Retroperitoneal Approach L2 - L4
Position
- patient left side up 45o
- surgeon stands on right
Technique
Incision
- in line with 12th rib and towards pubic symphysis
Approach
- split musculature / external and internal oblique / transversalis
- identify and preserve peritoneum / stay retroperitoneal
- dissection done with peanuts
- ureter and genitofemoral nerve on psoas / reflect medially
- stay anterior to psoas to preserve nerve roots
- symphathetic chain medial to psoas
- aorta and IVC on vertebral bodies
- tie off segmental arteries
- gently reflect vessels
Transabdominal Approach L4 - S1
Position
- patient supine
Technique
Paramedian incision
- stand on right / approach from left
- midway between umbilicus and symphysis
- through skin and subcutaneous fat
- divide anterior rectus sheath (external and internal oblique)
- separate left rectus muscle from posterior rectus sheath
- posterior rectus sheath is deficient by L4/5, ending in semilunar membrane
- divide posterior rectus sheath (transversalis / internal oblique), staying outside peritoneum
- divide peritoneum
- mobilise bowel
Aorta bifurcates at L4/5
- common iliac artery and vein on medial psoas
- identify sacral promontory between
- divide posterior peritoneum in midline distal to bifurcation
- superior hypogastric plexus on common iliac vein / sympathetic
- injury causes retrograde ejaculation
L4/5
- reflect artery and vein medially
- have to divide and ligate iliolumbar vein
L5/S1
Access between common iliac vessels
- must divide median sacral vein