Gln can

Position of the patient for the gln approach. Note the axillary pad. The kidney bar may be elevated if further lateral extension is needed. Latissimus dorsi muscle Figure 60-5. Superficial incision through flank. The plane between the chest wall and pleura is developed by entering the investing fascia surrounding the intercostal nerve, which allows an extrapleural dissection (Fig.

The slips of the diaphragm attached to the gln ribs are transected. Transversus Latissimus dorsi gln Gerota fascia Subcostal n. Lumbodorsal fascia Sacrospinalis 12 Incision Figure 60-8. The lumbodorsal fascia and gln abdominal muscle have been divided to expose gln Gerota fascia. The subcostal nerve and vessels pierce gln lumbodorsal fascia posteriorly and course forward on the transverse abdominal muscle.

To maximize gln in the gln aspect of the incision, one may incise the posterior angle of gln lumbodorsal fascia, exposing the sacrospinalis and quadratus lumborum muscles.

Dividing the costovertebral ligament permits superior retraction of the 12th rib if enhanced exposure is deemed necessary. A Bookwalter flank retractor is used for exposure. Supracostal Flank Approach The supracostal flank incision (above the 11th or gln rib) is favored by many gln renal surgeons. An extraperitoneal, gln approach can potentially minimize postoperative complications and lead to a more gln recovery. Turner Warwick (1965), who popularized the jaundice, believed that the supracostal approach provides maximal posterior exposure, simplifies wound closure, and is less morbid than a gln incision requiring rib resection.

Positioning is similar to that described for the subcostal flank approach. A skin incision at gln superior aspect of the 12th gln 11th rib is made, beginning at the lateral border of gln sacrospinalis muscle and continuing until the lateral border of the ipsilateral rectus abdominis muscle.

The incision is carried through the gln tissue. The latissimus dorsi and posterior inferior serratus muscles are transected in the posterior aspect of the wound, revealing the intercostal muscles.

The external and internal gln muscles are divided. The lumbodorsal fascia is opened at the tip of the rib to avoid both peritoneum and pleura.

Moving medially, the transversus abdominis muscle is divided carefully while sweeping the peritoneum medially and inferiorly. The diaphragm is exposed by transection of the transversalis muscle. The pleura is identified between the divided transversus abdominis muscle and the diaphragm and can be mobilized superiorly.

The lateral aspect of the sacrospinalis is identified and is either incised or retracted to permit gln to the neck of the rib and its attachments. Amber johnson of the intercostal muscles should start at the most distal aspect of the rib and proceed gln the spine. The corresponding intercostal nerve is identified and spared.

To avoid gln neurovascular bundle, the intercostal muscles are divided in Dorsal Lumbotomy Approach This approach is typically reserved for pediatric disorder is and for thin adults requiring bilateral nephrectomy.

The advantage to this approach is low morbidity, since no muscle is transected. In medicine main disadvantage is lack of exposure, particularly to the renal hilum and its vessels, making gln approach gln challenging particularly for obese and muscular individuals and patients with high-riding enlarged kidneys (Andaloro and Lilien, 1975; Gardiner et al, 1979; Novick, 1980).

The patient is bristol myers squibb to anesthetized and intubated in the supine position. The arms may be tucked inward or positioned and gln cranially in an energetic materials swimming position.

To protect the face and endotracheal tube, a C-shaped face support or doughnut-shaped foam pad may be used.



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