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Re: The Dorsal Lumbotomy Incision in Pediatric Urological Surgery, by S.M. Orland, H.M. Snyder and J.W. Duckett, J. Urol., part 2, 138: 963–966, 1987
0022-534 7/89/1416-1434$02.00/0 Vol. 141 June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1989 by Williams & Wilkins
Letter to the Editor RE: THE DORSAL LUMBOTOMY INCISION IN PEDIATRIC UROLOGICAL SURGERY
adequate relaxation of the musculature. It is particularly true in the patient with kyphoscliosis in whom the concave side can be reached easily by these means. 3 If these important details are remembered the vertical posterior lumbotomy results in a comfortable surgical approach.
S. M. Orland, H. M. Snyder and J. W. Duckett J. Urol., part 2, 138: 963-966, 1987
To the Editor. The wide experience in our department during the last 20 years' with more than 1,000 vertical posterior lumbotomies agrees with that of the authors, that is a reliable, safe, excellent approach with short hospital stay, low analgesic requirement and early resumption of oral intake. However, some important premises should not be forgotten or this approach might turn against the surgeon. It is mentioned in the Abstract that a modification of the Gil-Vernet vertical lumbotomy incision was used in all patients? We believe that such a modification, that is to incise along the external edge instead of along the middle of the sacrospinalis muscle, might not be helpful in many cases, since this is not the straighter approach to the renal pelvis and vascular pedicle. The idea described by Gil-Vernet shows that the latter incision with retraction of the sacrospinalis muscle gives rise to a straight, and thus the shortest, approach. (This is demonstrated clearly in any computerized tomography scan at the Ll to L2 level.) Also, there is the advantage that at operation the anatomical planes will close themselves merely by retiring the retractor, thus, permitt(ng easy closure and avoiding eventration. A special self-retaining retractor has been developed for this incision. Another important feature is that positioning of the patient should be directed to relax the sacrospinalis muscle, otherwise the operating field size might be reduced. We advocate the dorsolateral position in older children without any lumbar support and with the legs flexed to override the physiological lumbar lordosis. This position produces
Respectfully, J. M. Malla/re, R. Gutierrez del Pozo and Jorge A. Campos C. Hospital Clinic I Provincial Barcelona, Spain 1. Gil-Vernet, J.M.: La lombotomie vertical posterieure. Considerations apropos de 366 cas. Acta Urol. Belg., 32: 391, 1964 2. Gil-Vernet, J.: New surgical concepts in removing renal calculi. Urol. Int., 20: 255, 1965. 3. Gil-Vernet, J. M., Carretero, P. and Ballesteros, J. J.: A new approach to the kidney in kyphoscoliosis. Eur. Urol., 2: 105, 1976.
Reply by Authors. The figure from our article (part A of figure) showing the initial incision is confusing in that the dotted line refers only to the skin incision. The skin incision is a transverse one to follow Langer's lines (part B of figure) and, thus, to avoid spreading of the incision postoperatively. This method much improves the cosmetic aspects of the incision. After the skin incision has been made flaps are developed superiorly and inferiorly to permit a fascia! incision vertically, as is shown by the solid line. This follows the edge of the sacrospinalis and quadratus lumborum muscles for the reasons given by Doctor Mallafre and his associates. We apologize for confusion that may have arisen out of our original artwork.
A
B S:ACROSPINALIS SACROSPINALIS
. .~ ·
1434
THE JOURNAL OF UROLOGY
Copyright © 1989 by Williams & Wilkins
Letter to the Editor RE: THE DORSAL LUMBOTOMY INCISION IN PEDIATRIC UROLOGICAL SURGERY
adequate relaxation of the musculature. It is particularly true in the patient with kyphoscliosis in whom the concave side can be reached easily by these means. 3 If these important details are remembered the vertical posterior lumbotomy results in a comfortable surgical approach.
S. M. Orland, H. M. Snyder and J. W. Duckett J. Urol., part 2, 138: 963-966, 1987
To the Editor. The wide experience in our department during the last 20 years' with more than 1,000 vertical posterior lumbotomies agrees with that of the authors, that is a reliable, safe, excellent approach with short hospital stay, low analgesic requirement and early resumption of oral intake. However, some important premises should not be forgotten or this approach might turn against the surgeon. It is mentioned in the Abstract that a modification of the Gil-Vernet vertical lumbotomy incision was used in all patients? We believe that such a modification, that is to incise along the external edge instead of along the middle of the sacrospinalis muscle, might not be helpful in many cases, since this is not the straighter approach to the renal pelvis and vascular pedicle. The idea described by Gil-Vernet shows that the latter incision with retraction of the sacrospinalis muscle gives rise to a straight, and thus the shortest, approach. (This is demonstrated clearly in any computerized tomography scan at the Ll to L2 level.) Also, there is the advantage that at operation the anatomical planes will close themselves merely by retiring the retractor, thus, permitt(ng easy closure and avoiding eventration. A special self-retaining retractor has been developed for this incision. Another important feature is that positioning of the patient should be directed to relax the sacrospinalis muscle, otherwise the operating field size might be reduced. We advocate the dorsolateral position in older children without any lumbar support and with the legs flexed to override the physiological lumbar lordosis. This position produces
Respectfully, J. M. Malla/re, R. Gutierrez del Pozo and Jorge A. Campos C. Hospital Clinic I Provincial Barcelona, Spain 1. Gil-Vernet, J.M.: La lombotomie vertical posterieure. Considerations apropos de 366 cas. Acta Urol. Belg., 32: 391, 1964 2. Gil-Vernet, J.: New surgical concepts in removing renal calculi. Urol. Int., 20: 255, 1965. 3. Gil-Vernet, J. M., Carretero, P. and Ballesteros, J. J.: A new approach to the kidney in kyphoscoliosis. Eur. Urol., 2: 105, 1976.
Reply by Authors. The figure from our article (part A of figure) showing the initial incision is confusing in that the dotted line refers only to the skin incision. The skin incision is a transverse one to follow Langer's lines (part B of figure) and, thus, to avoid spreading of the incision postoperatively. This method much improves the cosmetic aspects of the incision. After the skin incision has been made flaps are developed superiorly and inferiorly to permit a fascia! incision vertically, as is shown by the solid line. This follows the edge of the sacrospinalis and quadratus lumborum muscles for the reasons given by Doctor Mallafre and his associates. We apologize for confusion that may have arisen out of our original artwork.
A
B S:ACROSPINALIS SACROSPINALIS
. .~ ·
1434